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INDICATIONS

Nonparasitic liver cysts are a frequently encountered entity for most surgeons. Although these are rarely large enough to warrant operation, most cases that require surgical intervention can be managed safely and effectively using standard laparoscopic techniques. These lesions are typically discovered incidentally on abdominal imaging performed for other indications. On occasion, symptoms related to stretch of the liver capsule can lead to complaints of epigastric or right upper quadrant pain. Other symptoms that might prompt workup and discovery of these lesions are related to compression of adjacent organs, particularly the stomach. Patients may complain of early satiety, bloating, or upper abdominal fullness. Hepatic cysts may become secondarily infected, but should be differentiated from hepatic abscess. Pain symptoms, especially if abrupt in onset, might indicate hemorrhage into the cyst cavity and require careful patient monitoring. Women are far more likely to present with symptomatic liver cysts. Most solitary, simple cysts can be managed conservatively; operative intervention is indicated for large (>8 cm) cysts with symptoms attributable to the hepatic cyst.

The differential diagnosis for solitary hepatic cysts includes solitary bile duct cyst, ciliated hepatic foregut cyst, hepatobiliary cystadenoma, cystadenocarcinoma, peribiliary cysts, mesothelial cyst, pancreatic pseudocyst, endometrial cyst, and metastatic carcinoma with cystic features. In the setting of a simple hepatic cyst, solitary bile duct cyst and hepatobiliary cystadenoma remain most likely. The vast majority of these lesions are benign; however, surgeons treating these patients must always send resected cyst wall for histologic evaluation to rule out malignant features. Cystadenocarcinoma is a potential risk, especially in the very large and long-standing cyst, or if there has been hemorrhage into the cyst cavity. If cystadenocarcinoma is identified on final pathologic analysis, formal, anatomic hepatic resection should be performed. The presence of septations on imaging is the best noninvasive method for differentiation of simple cysts from these other entities, unless multiple confluent cysts are present wherein adjacent cyst walls can mimic septations.

Echinococcal cysts and cysts in the setting of autosomal dominant polycystic liver disease (ADPLD) are unique clinical problems that require specific interventions beyond the scope of this chapter. It should be noted that the echinococcal cyst has unique imaging characteristics (septations and calcifications) that help differentiate it from simple cysts. Additionally, these patients should all have serum echinococcal titers sent. Extreme care must be taken in the operative management of these cysts, as anaphylaxis can result from cyst rupture into the peritoneal cavity. Cystic disease in ADPLD is typically associated with polycystic kidney disease. These lesions are best managed by combination cyst marsupialization and resection for symptoms. Liver transplantation may be the only therapeutic option in some of these patients.

ANESTHESIA

General anesthesia with endotracheal intubation is required for laparoscopic liver surgery. Complete neuromuscular blockade is necessary. Intravenous antibiotics with broad coverage (including Enterococcus) are given prior to skin incision. To minimize the risk of deep vein thrombosis, compression stockings ...

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