Original Article
Spillage-free laparoscopic management of hepatic hydatid disease using the hydatid trocar canula Kalpesh Jani Superspeciality Institute of Gastrointestinal and Minimal Access Surgery, Manjalpur, Vadodara, Gujarat, India Address for Correspondence: Dr. Kalpesh Jani, Superspeciality Institute of Gastrointestinal and Minimal Access Surgery, Abhishek House, Opp. Tulsidham Appt., Manjalpur, Vadodara - 390 011, Gujarat, India. E-mail: [email protected]
Abstract INTRODUCTION: This study was undertaken to demonstrate the efficacy of the Hydatid Trocar Canula system for safe and effective treatment of hepatic hydatid cysts. MATERIALS AND METHODS: All cases presenting to our centre for treatment of hydatid cyst of the liver with certain exceptions were considered for laparoscopic management using the specifi cally designed Hydatid Trocar Canula system. The technique of surgery and the step wise sequence of deployment of the device are described. RESULTS: Since January 2007, 16 patients compromising six males and 10 females underwent this procedure at our centre. The average age of the patients was 37.6 years and all of them had a single cyst. The average duration of surgery was 86 minutes. None of the cases suffered intraoperative mishap like spillage or anaphylaxis. Till date, follow-up has been maintained in 81.3% of the patients and no recurrence has been detected. CONCLUSION: The correct use of the Hydatid Trocar Canula system allows for spillage-free and complete evacuation of hepatic hydatid cysts. Key words: Echinococcal cyst, hydatid cyst, Hydatid Trocar Canula system, laparoscopic surgery, laparoscopy
INTRODUCTION When afflicted by hydatid disease, humans are accidental intermediate host for the cestode parasite Echinococcus granulosus. [1] The liver is the organ Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.134873
affected most commonly by the parasite.[2] Once lodged in the liver, the hydatid cyst grows steadily at a rate dependent on the resistance offered by the surrounding tissues.[3] Initially asymptomatic, clinical complaints arise as a result of compression of the adjacent organs due to the growing cyst or complications like rupture, infection or fistulisation.[4] Though, occasionally hydatid cysts are known to regress spontaneously, in the overwhelming majority, therapeutic intervention is necessary.[5] Conservative management in the form of medical therapy or percutaneous aspiration of cyst have been described.[6,7] However, the mainstay of treatment remains surgical. A variety of surgical procedures have been described using conventional open techniques, including pericystectomy, de-roofing the cyst with omentoplasty, marsupialisation and liver resection.[2,8,9] The techniques of minimally invasive surgery have also been adopted to treat this disease. [10] But one of the chief concerns during surgical treatment of hydatid cyst remains the possibility of cyst rupture and spillage and its containment. This poses a two-fold danger-an immediate one of anaphylactic reaction as the hydatid fluid is highly allergenic and a delayed risk of dissemination of the disease in the peritoneal cavity. The difficulty in containing spillage, should it occur, during laparoscopic management is much greater than in open conventional surgery. This factor has always been a deterrent to surgeons from widely adopting laparoscopic surgery as the mode to treat this disease.[11] We describe the correct technique to utilize a specialised hydatid trocar system, designed to allow spillage-free evacuation of hydatid cysts and also enable intra-cystic inspection for residual daughter cysts and cyst-biliary communications.
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MATERIALS AND METHODS This is a retrospective review of all cases of hydatid cyst presenting to us for management between January 2007 and December 2011. Laparoscopic management was offered to all patients diagnosed with hydatid cyst, except those in segments VII and upper VIII of the liver, totally intrahepatic cysts (small cysts, with no surface protruding beyond the liver) and patients unfit for surgery under general anaesthesia. The patients were evaluated clinically and routine laboratory tests were carried out including liver function tests. All patients were subjected to an initial screening ultrasonography followed by a computed tomography (CT) scan of the abdomen. In patients with features of obstructive jaundice and cholangitis, an endoscopic retrograde cholangiography with sphincterotomy and stenting was performed preoperatively. Patients were started on albendazole in a dose of 10 mg/kg body weight for 1 month pre-operatively and then posted for surgery. After surgery, two more cycles of albendazole were administered in the same dosage, each cycle lasting 4 weeks with a gap of 1 week between the two cycles. All patients were operated under general anaesthesia in a modified lithotomy position so that the thighs were parallel to the body, with the table in a reverse Trendelenburg position. The operating surgeon stood between the legs of the patient, the camera surgeon on the right side of the patient and the assistant surgeon on the left side of the patient. The monitor was placed at the head end of the patient.
(one for the laparoscopic view and one for the intracystic view) would be needed. However, one can perform this procedure even with a single camera system. Two laparoscopes are needed-a 30° one for the laparoscopic view and a 0° one for the intracystic view. Care should be taken that the scope used for the intracystic view is not inserted laparoscopically to avoid anaphylactic reaction from the contaminating hydatid fluid. The Hydatid Trocar system, also known as the Palanivelu Hydatid System (Om Surgicals, Mumbai, India) consists of a canula and trocar set, which have been modified for the purpose of this particular surgery. The canula is 26 cm. long and has an inner diameter of 12 mm [Figure 1]. It has a standard attachment for gas insufflations labelled B in the photograph. In addition, it has a 10 mm outlet for attaching the suction pipe, labelled A in the photograph. The trocar is 29 cm long and is hollow. Its tip is faceted and each facet bears a fenestration, labelled E. Its shaft also has two fenestrations, labelled D, opposite to each other approximately in the middle of its length. At its other end, there is an attachment for connecting the suction apparatus, labelled C in the photograph. The port positions are depicted in Figure 2. Depending on the size of the cyst, the camera port is placed supraumbilically in the midline. Right hand and left hand working ports are placed in the respective hypochondriums. An additional port may be required for retraction of gall bladder, which is placed in the right flank. The hydatid trocar is inserted over the most prominent non-dependent part of the hydatid cyst.
Apart from the standard laparoscopic equipment, for hydatid cyst surgery, certain special provisions are made. Two powerful suction machines are required in the operation theatre. Ideally, two separate camera systems and monitors
Once the Hydatid Trocar Canula system is introduced inside the abdominal cavity, the trocar is removed and the canula
Figure 1: Hydatid trocar canula
Figure 2: Port positions
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is advanced till its surface is in firm contact with the cyst surface [Figure 3a]. A gauze piece soaked in 0.5% cetrimide solution is arranged around the hydatid canula on the liver surface. The outlet A is connected to a suction machine which is turned on, creating a firm vacuum seal between the canula and the hydatid cyst [Figure 3b]. The trocar is inserted inside till its tip just touches the cyst wall without penetrating it. Its outlet C is connected to another suction machine which is turned on [Figure 3c]. With a firm thrust, the trocar is pushed into the cyst. Cyst contents flow into the hollow trocar through the fenestrations E and are suctioned away [Figure 3d]. The canula is slid over the trocar into the cyst. Part of the cyst contents will flow through the trocar into the canula via the mid-shaft fenestrations at D and are suctioned off through the canula outlet A [Figure 3e]. The trocar is removed and the canula keeps on suctioning contents. When the flow lessens, a regular 10 mm suction canula is introduced through the hydatid canula and further cyst contents are evacuated [Figure 3f]. When no further material is coming, the carbon dioxide insufflation is attached to the hydatid canula at B and gas is allowed to flow at a pressure setting of 2-3 mm of Hg. A 0° scope is introduced into the cyst and the interior of the cyst wall is inspected to confirm that it is denuded of all germinal epithelium [Figure 4]. If remnant daughter cysts are seen, the canula is stabilized such that its end is directly over the cysts; the scope is withdrawn and replaced with a suction canula. By repeating this manoeuvre patiently, the entire cyst is cleared off daughter cysts and germinal epithelium. Then the cyst is filled with 0.5% cetrimide solution (if the initial fluid was clear and bile-free), which is allowed to remain inside for 10 minutes and then suctioned off. Thereafter, the hydatid canula is removed; the cyst wall is opened up and excised, placed in a specimen bag and removed. The cavity is checked for bile leak and cyst-biliary
a
c
e
communication. If any such are identified, they are overrun with interrupted sutures of 3-0 polyglactin 910. The cavity is packed with omentum, which is held in place by stitches taken to liver edge. A wide bore drain is kept close to the cavity. Generous saline irrigation of the abdominal cavity is done. The fascia of all ports larger than 5 mm is closed before exsufflation. Patients are started liquids orally after 12 hours and discharged once they are afebrile and with nil drainage. Patients were called for follow-up at 7 days, 30 days, 6 months and yearly thereafter. Ultra-sonography was performed 6 months after the surgery and yearly thereafter.
RESULTS A total of 16 patients were eligible to be included in this analysis. There were six males (37.5%) and 10 females (62.5%). The average age of the patient was 37.6 years (range: 23-58 years). Of the total, 14 patients (87.5%) had a rural agrarian background while two patients (12.5%) were coming from an urban setting. The commonest presenting complaint was abdominal pain or heaviness, exacerbated by meals, a symptom reported by 11 (68.8%) of the patients. Nausea and dyspepsia was reported by 10 patients (6.25%). An upper abdominal swelling or mass was noticed only by 5 patients (31.3%). One patient had features of cholangitis with pain, fever and jaundice while one patient (6.3%) was diagnosed while being investigated for unrelated complaints. All the patients had a single cyst. The right lobe of the liver was involved in 12 cases (75%), the left lobe of liver in four cases
b
d
f
Figure 3: Correct use of the hydatid trocar canula
Figure 4: Intracystic view
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(25%) and cyst-biliary communication was diagnosed preoperatively in one patient (who had presented with features of cholangitis). The patient underwent sphincterotomy and stenting. During the procedure, purulent material and daughter cysts could be seen draining out of the sphincter. All patients were started on albendazole orally and were scheduled for surgery a month later. The duration of surgery ranged from 55 min to 120 min (mean: 86 minutes). There were no intra-operative mishaps or emergencies like anaphylaxis. Post-operatively, port site infection was reported in three patients (18.8%). A minor biliary leak was found in two patients (12.5%). The range of hospital stay was from 3 days to 15 days (average: 6.8 days). Out of the 16 patients, 13 (81.3%) have remained in regular follow-up. No recurrence has been reported till date.
DISCUSSION Hydatid disease is an endemic entity in several parts of the Indian sub-continent.[1] The life-cycle of the parasite is such that human infestation is likely in areas where they live in proximity to the intermediate hosts (sheep, goat, etc) as well as the definitive hosts (dogs). Thus, usually, patients belong to rural agrarian communities where livestock are maintained. However, in areas where there is a population of stray dogs, adults as well as children coming in contact with infected strays can get infested with the parasite.[12] This may explain the reason for the disease in two of our patients who belonged to an urban background with no history of contact with livestock but contact with stray dogs was present in both these cases. In our study, more females were involved than males. This has been corroborated by other researchers too.[13] However, a few studies have shown the parasite to have equal predilection for either sexes.[14,15] The disease is known to progress asymptomatically for several years due to the slow growth of the cyst, before manifesting with symptoms related to pressure effects on surrounding organs, infection or rupture.[5] Rupture of the cyst into the biliary tree releases the daughter cysts into the biliary system, causing obstruction, jaundice and infection, as was seen in one of our patients.[16] Both ultrasonography and CT scan are reported to be highly effective in diagnosing liver hydatid disease.[17] These modalities can even detects signs of overt or impending rupture and cyst-biliary communication.[3] 116
Predilection for the right lobe of liver was seen in our series. A similar finding has also been noted by other researchers.[13,18] Amongst the agents available for medical treatment, albendazole is by far the most popular due to its greater absorption and penetration.[19] However, it has a doubtful role as a standalone treatment of hydatid disease.[20] It has a well-defined role as an adjunct to surgery, to reduce post-operative recurrence, as also in disseminated disease and inoperable cases.[19] At our institute, it is a standard practice to give all patients a 3 months course of albendazole, preferably posting the patient for surgery after completion of the first month of drug therapy. While surgery has established itself as the definitive therapeutic modality for this disease, laparoscopic surgery has its own limitations. Minimal invasive surgery is not suitable for cysts located intra-parenchymally in the liver, or located in the posterior segments of the right lobe of livers or in recurrent disease due to the extensive adhesions involved. Large calcified cysts will not collapse by simple drainage and partial excision, but may require pericystectomy.[21] Such radical procedures are associated with higher intra-operative blood loss, prolonged operative time and higher post-operative morbidity.[22] Multiple cysts can be managed individually, as long as their surfaces are accessible to the hydatid trocar canula or they are interconnected. The main concern in laparoscopic drainage of hepatic hydatid cyst is regarding spillage of hydatid fluid. To reduce this possibility, surgeons in different parts of the world have developed specialized devices.[23-26] The device that we utilize, the Palanivelu Hydatid system, allows maintaining a seal while draining the cyst, preventing any leakage of cyst fluid. It also allows complete evacuation of the cyst and its contents and facilitates intra-cystic inspection of the cyst. The affectivity of the device can be gauged from the fact that we did not encounter a single case of anaphylaxis or delayed abdominal recurrence, both evidence of spillage while draining the cyst, in our series. We carry out intracystic inspection of the hydatid cyst by inserting the scope into the hydatid canula and expanding the cyst wall using insufflation at a pressure of 2-3 mm of Hg. This manoeuvre has been described in a previous paper by Palanivelu et al.,[27] and we confirm its efficacy in allowing inspection of the intracystic contents and clearance of remnant germinal epithelium and daughter cysts. We also perform omental packing of the cyst to reduce dead space and problems associated with it.
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Frank intrabiliary rupture was present in one case of our series. The patient presented with features of obstructive cholangitis and was treated with initial endoscopic retrograde drainage of common bile duct with evacuation of pus and daughter cysts and subsequent laparoscopic drainage of hydatid cyst. This condition occurs when the rupture is present on the sides, the cyst wall as well as the adjoining biliary channel with interchange of contents. Patients with such frank intrabiliary rupture may not always have biliary obstruction but may simply have presence of bile in the cyst before surgical intervention. Acarli also describes a simple cyst-biliary communication in with the rupture is only on the side of the biliary channel while the cyst wall is intact.[22] In such cases, there is no bile in the cyst prior to surgical intervention. When the cyst wall is punctured and it collapses, the bile may then leak into the remnant cavity. In these patients, an observant surgeon sees that after introducing the drainage channel into the cyst, the initial effluent is colourless hydatid fluid and bile staining appears after some time. In several cases, there may not be any overt bile staining per operatively but minor biliary leak may appear in the drainage tube in the post-operative period, almost always responding to conservative management. This explains the presence of bile-stained effluent in the drainage tube in two of our patients, both of which stopped spontaneously.
and correct technique, it is possible to treat most of these parasitic cysts using minimal invasive techniques both safely and effectively.
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The post-operative morbidity rate has been reported in a range varying from 6% to 47%.[28] In our series, the postoperative morbidity, in addition to the two cases of minor biliary leakage, consisted of three cases of port site infection. All the cases were managed conservatively. Except for one case of biliary leak, which persisted for 12 days, the other complications did not affect the length of stay of the patient. Recurrence can be local due to incomplete evacuation of the cyst or abdominal due to spillage of cyst contents during evacuation.[5] Recurrence rate with cyst evacuation and omentoplasty has been reported in the range of 6-25%. Radical surgeries like total pericystectomy or hepatectomy are associated with lower recurrence rates but higher complications.[2] While none of the patients in our series show evidence of recurrence, one has to remember the slow growth rate of the cyst and absence of symptomatology in early disease. This implies that these patients require prolonged follow-up with yearly ultrasonography as late manifestation of recurrence is known.
CONCLUSION
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Huizinga WK, Grant CS, Daar AS. Hydatid disease. In: Morris PJ, Wood WC, editors. Oxford Textbook of Surgery. 2nd ed. New York: Oxford University Press; 2000. p. 3298-305. Safioleas M, Misiakos EP, Kakisis J, Manti C, Papachristodoulou A, Lambrou P, et al. Surgical treatment of human echinococossis. Int Surg 2000;85:358-65. Pedrosa I, Saiz A, Arrazola J, Ferreirós J, Pedrosa CS. Hydatid disease: Radiologic and pathologic features and complications. Radiographics 2000;20:795-817. Pawlowski ZS. Critical points in the clinical management of cystic echinococcosis. In: Andersen FL, Chai J, Liu F, editors. Compendium on Cystic Echinococcosis with Special Reference to Xinjiang Uygur Autonomous Region of the People’s Republic of China. Provo: Brigham Young University; 1993. p. 119-34. Safioleas MC, Misiakos EP, Kouvaraki M, Stamatakos MK, Manti CP, Felekouras ES. Hydatid disease of the liver: A continuing surgical problem. Arch Surg 2006;141:1101-8. Mohamed AE, Yasawy MI, Al Karawi MA. Combined albendazole and praziquantel versus albendazole alone in the treatment of hydatid disease. Hepatogastroenterology 1998;45:1690-4. World Health Organization. PAIR: Puncture, Aspiration, Injection, ReAspiration. An option for the treatment of Cystic Echinococcosis. Geneva, Switzerland. Available from: http://www.who.int/emc-documents/zoonoses/ whocdscsraph20016.html [Last accessed on 2010 Oct 15]. Filippou DK, Kolimpiris C, Anemodouras N, Rizos S. Modified capitonage in partial cystectomy performed for liver hydatid disease: Report of 2 cases. BMC Surg 2004;4:8. Langer JC, Rose DB, Keystone JS, Taylor BR, Langer B. Diagnosis and management of hydatid disease of the liver. A 15-year North American experience. Ann Surg 1984;199:412-7. Bickel A, Daud G, Urbach D, Lefler E, Barasch EF, Eitan A. Laparoscopic approach to hydatid liver cysts. Is it logical? Physical, experimental, and practical aspects. Surg Endosc 1998;12:1073-7. Yaghan R, Heis H, Bani-Hani K, Matalka I, Shatanawi N, Gharaibeh K, et al. Is fear of anaphylactic shock discouraging surgeons from more widely adopting percutaneous and laparoscopic techniques in the treatment of liver hydatid cyst? Am J Surg 2004;187:533-7. Suarez Grau JM, Gomeg Bravo MA, Alamo Martinez JM, Rubio Cháves C, Marín Gómez LM, Suárez Artacho G, et al. Giant hydatid cyst involving the right hepatic lobe. Rev Esp Enferm Dig 2009;101:133-4, 135. Nahmias J, Goldsmith R, Soibelman M, el-On J. Three to seven year followup after albendazole treatment of 68 patients with cystic echinococcosis (hydatid disease). Ann Trop Med Parasitol 1994;88:295-304. Niscigorska J, Sluzar T, Marczewska M, Karpin´ska E, Boron´-Kaczmarska A, Moran´ska I, et al. Parasitic cysts of the liver-practical approach to diagnosis and differentiation. Med Sci Monit 2001;7:737-41. Cohen H, Paolillo E, Bonifacino R, Botta B, Parada L, Cabrera P, et al. Human cystic echinococcosis in a Uruguayan community: A sonographic, serologic, and epidemiologic study. Am J Trop Med Hyg 1998;59:620-7. Lewall DB, Nyak P. Hydatid cysts of the liver: Two cautionary signs. Br J Radiol 1998;71:37-41. Ovnat A, Peiser J, Avinoah E, Barki Y, Charuzi I. Acute cholangitis caused by ruptured hydatic cyst. Surgery 1984;95:497-500. Beecherl EE, Bigam DL, Langer B, et al. Cystic diseases of the liver. In: Zuidema GD, Yeo CJ, editors. Shackelford’s Surgery of the Alimentary Tract. 5th ed, vol 3. Philadelphia, PA: WB Saunders Company; 2000. p. 452-60. Erdem LO, Erdem CZ, Karlioguz K, Uner C. Radiologic aspects of abdominal hydatidosis in children: A study of 31 cases in Turkey. Clin Imaging 2004;28:196-200. Aktan AO, Yalin R. Preoperative albendazole treatment for liver hydatid disease decreases the viability of the cyst. Eur J Gastroenterol Hepatol 1996;8:877-9. Teggi A, Lastilla MG, De Rosa F. Therapy of human hydatid disease with mebendazole and albendazole. Antimicrob Agents Chemother 1993;37:1679-84.
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Acarli K. Controversies in the laparoscopic treatment of hepatic hydatid disease. HPB (Oxford) 2004;6:213-21. Karavias DD, Vagianos CE, Bouboulis N, Rathosis S, Androulakis J. Improved techniques in the surgical management of hepatic hydatidosis. Surg Gynecol Obstet 1992;174:176-80. Alper A, Emre A, Acarli K, Bilge O, Ozden I, Ariogul O. Laparoscopic treatment of hepatic hydatid disease. J Laparoendosc Surg 1996;6:29-33. Bickel A, Eitan A. The use of a large, transparent cannula, with beveled tip, for safe laparoscopic management of hydatid cyst of the liver. Surg Endosc 1995;9:1304-5. Kayaalp C. Evacuation of hydatid cysts using laparoscopic trocar. World J Surg. 2002;26:1324-7.
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Palanivelu C, Jani K, Malladi V, Senthilkumar R, Rajan PS, Sendhilkumar K, et al. Laparoscopic management of hepatic hydatid disease. JSLS 2006;10:56-62. Vagianos CR, Karavias DD, Kakkos SK, Vagenas CA, Androulakis JA. Conservative surgery in the treatment of hepatic hydatidosis. Eur J Surg 1995;161:415-20.
Cite this article as: Jani K. Spillage-free laparoscopic management of hepatic hydatid disease using the hydatid trocar canula. J Min Access Surg 2014;10:113-8. Date of submission: 21/01/2013, Date of acceptance: 27/05/2013 Source of Support: Nil, Conflict of Interest: None declared.
Journal of Minimal Access Surgery | July-September 2014 | Volume 10 | Issue 3
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Spillage-free laparoscopic management of hepatic hydatid disease using the hydatid trocar canula Kalpesh Jani Superspeciality Institute of Gastrointestinal and Minimal Access Surgery, Manjalpur, Vadodara, Gujarat, India Address for Correspondence: Dr. Kalpesh Jani, Superspeciality Institute of Gastrointestinal and Minimal Access Surgery, Abhishek House, Opp. Tulsidham Appt., Manjalpur, Vadodara - 390 011, Gujarat, India. E-mail: [email protected]
Abstract INTRODUCTION: This study was undertaken to demonstrate the efficacy of the Hydatid Trocar Canula system for safe and effective treatment of hepatic hydatid cysts. MATERIALS AND METHODS: All cases presenting to our centre for treatment of hydatid cyst of the liver with certain exceptions were considered for laparoscopic management using the specifi cally designed Hydatid Trocar Canula system. The technique of surgery and the step wise sequence of deployment of the device are described. RESULTS: Since January 2007, 16 patients compromising six males and 10 females underwent this procedure at our centre. The average age of the patients was 37.6 years and all of them had a single cyst. The average duration of surgery was 86 minutes. None of the cases suffered intraoperative mishap like spillage or anaphylaxis. Till date, follow-up has been maintained in 81.3% of the patients and no recurrence has been detected. CONCLUSION: The correct use of the Hydatid Trocar Canula system allows for spillage-free and complete evacuation of hepatic hydatid cysts. Key words: Echinococcal cyst, hydatid cyst, Hydatid Trocar Canula system, laparoscopic surgery, laparoscopy
INTRODUCTION When afflicted by hydatid disease, humans are accidental intermediate host for the cestode parasite Echinococcus granulosus. [1] The liver is the organ Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.134873
affected most commonly by the parasite.[2] Once lodged in the liver, the hydatid cyst grows steadily at a rate dependent on the resistance offered by the surrounding tissues.[3] Initially asymptomatic, clinical complaints arise as a result of compression of the adjacent organs due to the growing cyst or complications like rupture, infection or fistulisation.[4] Though, occasionally hydatid cysts are known to regress spontaneously, in the overwhelming majority, therapeutic intervention is necessary.[5] Conservative management in the form of medical therapy or percutaneous aspiration of cyst have been described.[6,7] However, the mainstay of treatment remains surgical. A variety of surgical procedures have been described using conventional open techniques, including pericystectomy, de-roofing the cyst with omentoplasty, marsupialisation and liver resection.[2,8,9] The techniques of minimally invasive surgery have also been adopted to treat this disease. [10] But one of the chief concerns during surgical treatment of hydatid cyst remains the possibility of cyst rupture and spillage and its containment. This poses a two-fold danger-an immediate one of anaphylactic reaction as the hydatid fluid is highly allergenic and a delayed risk of dissemination of the disease in the peritoneal cavity. The difficulty in containing spillage, should it occur, during laparoscopic management is much greater than in open conventional surgery. This factor has always been a deterrent to surgeons from widely adopting laparoscopic surgery as the mode to treat this disease.[11] We describe the correct technique to utilize a specialised hydatid trocar system, designed to allow spillage-free evacuation of hydatid cysts and also enable intra-cystic inspection for residual daughter cysts and cyst-biliary communications.
Journal of Minimal Access Surgery | July-September 2014 | Volume 10 | Issue 3
113
Jani: Laparoscopic management of hepatic hydatid disease
MATERIALS AND METHODS This is a retrospective review of all cases of hydatid cyst presenting to us for management between January 2007 and December 2011. Laparoscopic management was offered to all patients diagnosed with hydatid cyst, except those in segments VII and upper VIII of the liver, totally intrahepatic cysts (small cysts, with no surface protruding beyond the liver) and patients unfit for surgery under general anaesthesia. The patients were evaluated clinically and routine laboratory tests were carried out including liver function tests. All patients were subjected to an initial screening ultrasonography followed by a computed tomography (CT) scan of the abdomen. In patients with features of obstructive jaundice and cholangitis, an endoscopic retrograde cholangiography with sphincterotomy and stenting was performed preoperatively. Patients were started on albendazole in a dose of 10 mg/kg body weight for 1 month pre-operatively and then posted for surgery. After surgery, two more cycles of albendazole were administered in the same dosage, each cycle lasting 4 weeks with a gap of 1 week between the two cycles. All patients were operated under general anaesthesia in a modified lithotomy position so that the thighs were parallel to the body, with the table in a reverse Trendelenburg position. The operating surgeon stood between the legs of the patient, the camera surgeon on the right side of the patient and the assistant surgeon on the left side of the patient. The monitor was placed at the head end of the patient.
(one for the laparoscopic view and one for the intracystic view) would be needed. However, one can perform this procedure even with a single camera system. Two laparoscopes are needed-a 30° one for the laparoscopic view and a 0° one for the intracystic view. Care should be taken that the scope used for the intracystic view is not inserted laparoscopically to avoid anaphylactic reaction from the contaminating hydatid fluid. The Hydatid Trocar system, also known as the Palanivelu Hydatid System (Om Surgicals, Mumbai, India) consists of a canula and trocar set, which have been modified for the purpose of this particular surgery. The canula is 26 cm. long and has an inner diameter of 12 mm [Figure 1]. It has a standard attachment for gas insufflations labelled B in the photograph. In addition, it has a 10 mm outlet for attaching the suction pipe, labelled A in the photograph. The trocar is 29 cm long and is hollow. Its tip is faceted and each facet bears a fenestration, labelled E. Its shaft also has two fenestrations, labelled D, opposite to each other approximately in the middle of its length. At its other end, there is an attachment for connecting the suction apparatus, labelled C in the photograph. The port positions are depicted in Figure 2. Depending on the size of the cyst, the camera port is placed supraumbilically in the midline. Right hand and left hand working ports are placed in the respective hypochondriums. An additional port may be required for retraction of gall bladder, which is placed in the right flank. The hydatid trocar is inserted over the most prominent non-dependent part of the hydatid cyst.
Apart from the standard laparoscopic equipment, for hydatid cyst surgery, certain special provisions are made. Two powerful suction machines are required in the operation theatre. Ideally, two separate camera systems and monitors
Once the Hydatid Trocar Canula system is introduced inside the abdominal cavity, the trocar is removed and the canula
Figure 1: Hydatid trocar canula
Figure 2: Port positions
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Jani: Laparoscopic management of hepatic hydatid disease
is advanced till its surface is in firm contact with the cyst surface [Figure 3a]. A gauze piece soaked in 0.5% cetrimide solution is arranged around the hydatid canula on the liver surface. The outlet A is connected to a suction machine which is turned on, creating a firm vacuum seal between the canula and the hydatid cyst [Figure 3b]. The trocar is inserted inside till its tip just touches the cyst wall without penetrating it. Its outlet C is connected to another suction machine which is turned on [Figure 3c]. With a firm thrust, the trocar is pushed into the cyst. Cyst contents flow into the hollow trocar through the fenestrations E and are suctioned away [Figure 3d]. The canula is slid over the trocar into the cyst. Part of the cyst contents will flow through the trocar into the canula via the mid-shaft fenestrations at D and are suctioned off through the canula outlet A [Figure 3e]. The trocar is removed and the canula keeps on suctioning contents. When the flow lessens, a regular 10 mm suction canula is introduced through the hydatid canula and further cyst contents are evacuated [Figure 3f]. When no further material is coming, the carbon dioxide insufflation is attached to the hydatid canula at B and gas is allowed to flow at a pressure setting of 2-3 mm of Hg. A 0° scope is introduced into the cyst and the interior of the cyst wall is inspected to confirm that it is denuded of all germinal epithelium [Figure 4]. If remnant daughter cysts are seen, the canula is stabilized such that its end is directly over the cysts; the scope is withdrawn and replaced with a suction canula. By repeating this manoeuvre patiently, the entire cyst is cleared off daughter cysts and germinal epithelium. Then the cyst is filled with 0.5% cetrimide solution (if the initial fluid was clear and bile-free), which is allowed to remain inside for 10 minutes and then suctioned off. Thereafter, the hydatid canula is removed; the cyst wall is opened up and excised, placed in a specimen bag and removed. The cavity is checked for bile leak and cyst-biliary
a
c
e
communication. If any such are identified, they are overrun with interrupted sutures of 3-0 polyglactin 910. The cavity is packed with omentum, which is held in place by stitches taken to liver edge. A wide bore drain is kept close to the cavity. Generous saline irrigation of the abdominal cavity is done. The fascia of all ports larger than 5 mm is closed before exsufflation. Patients are started liquids orally after 12 hours and discharged once they are afebrile and with nil drainage. Patients were called for follow-up at 7 days, 30 days, 6 months and yearly thereafter. Ultra-sonography was performed 6 months after the surgery and yearly thereafter.
RESULTS A total of 16 patients were eligible to be included in this analysis. There were six males (37.5%) and 10 females (62.5%). The average age of the patient was 37.6 years (range: 23-58 years). Of the total, 14 patients (87.5%) had a rural agrarian background while two patients (12.5%) were coming from an urban setting. The commonest presenting complaint was abdominal pain or heaviness, exacerbated by meals, a symptom reported by 11 (68.8%) of the patients. Nausea and dyspepsia was reported by 10 patients (6.25%). An upper abdominal swelling or mass was noticed only by 5 patients (31.3%). One patient had features of cholangitis with pain, fever and jaundice while one patient (6.3%) was diagnosed while being investigated for unrelated complaints. All the patients had a single cyst. The right lobe of the liver was involved in 12 cases (75%), the left lobe of liver in four cases
b
d
f
Figure 3: Correct use of the hydatid trocar canula
Figure 4: Intracystic view
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(25%) and cyst-biliary communication was diagnosed preoperatively in one patient (who had presented with features of cholangitis). The patient underwent sphincterotomy and stenting. During the procedure, purulent material and daughter cysts could be seen draining out of the sphincter. All patients were started on albendazole orally and were scheduled for surgery a month later. The duration of surgery ranged from 55 min to 120 min (mean: 86 minutes). There were no intra-operative mishaps or emergencies like anaphylaxis. Post-operatively, port site infection was reported in three patients (18.8%). A minor biliary leak was found in two patients (12.5%). The range of hospital stay was from 3 days to 15 days (average: 6.8 days). Out of the 16 patients, 13 (81.3%) have remained in regular follow-up. No recurrence has been reported till date.
DISCUSSION Hydatid disease is an endemic entity in several parts of the Indian sub-continent.[1] The life-cycle of the parasite is such that human infestation is likely in areas where they live in proximity to the intermediate hosts (sheep, goat, etc) as well as the definitive hosts (dogs). Thus, usually, patients belong to rural agrarian communities where livestock are maintained. However, in areas where there is a population of stray dogs, adults as well as children coming in contact with infected strays can get infested with the parasite.[12] This may explain the reason for the disease in two of our patients who belonged to an urban background with no history of contact with livestock but contact with stray dogs was present in both these cases. In our study, more females were involved than males. This has been corroborated by other researchers too.[13] However, a few studies have shown the parasite to have equal predilection for either sexes.[14,15] The disease is known to progress asymptomatically for several years due to the slow growth of the cyst, before manifesting with symptoms related to pressure effects on surrounding organs, infection or rupture.[5] Rupture of the cyst into the biliary tree releases the daughter cysts into the biliary system, causing obstruction, jaundice and infection, as was seen in one of our patients.[16] Both ultrasonography and CT scan are reported to be highly effective in diagnosing liver hydatid disease.[17] These modalities can even detects signs of overt or impending rupture and cyst-biliary communication.[3] 116
Predilection for the right lobe of liver was seen in our series. A similar finding has also been noted by other researchers.[13,18] Amongst the agents available for medical treatment, albendazole is by far the most popular due to its greater absorption and penetration.[19] However, it has a doubtful role as a standalone treatment of hydatid disease.[20] It has a well-defined role as an adjunct to surgery, to reduce post-operative recurrence, as also in disseminated disease and inoperable cases.[19] At our institute, it is a standard practice to give all patients a 3 months course of albendazole, preferably posting the patient for surgery after completion of the first month of drug therapy. While surgery has established itself as the definitive therapeutic modality for this disease, laparoscopic surgery has its own limitations. Minimal invasive surgery is not suitable for cysts located intra-parenchymally in the liver, or located in the posterior segments of the right lobe of livers or in recurrent disease due to the extensive adhesions involved. Large calcified cysts will not collapse by simple drainage and partial excision, but may require pericystectomy.[21] Such radical procedures are associated with higher intra-operative blood loss, prolonged operative time and higher post-operative morbidity.[22] Multiple cysts can be managed individually, as long as their surfaces are accessible to the hydatid trocar canula or they are interconnected. The main concern in laparoscopic drainage of hepatic hydatid cyst is regarding spillage of hydatid fluid. To reduce this possibility, surgeons in different parts of the world have developed specialized devices.[23-26] The device that we utilize, the Palanivelu Hydatid system, allows maintaining a seal while draining the cyst, preventing any leakage of cyst fluid. It also allows complete evacuation of the cyst and its contents and facilitates intra-cystic inspection of the cyst. The affectivity of the device can be gauged from the fact that we did not encounter a single case of anaphylaxis or delayed abdominal recurrence, both evidence of spillage while draining the cyst, in our series. We carry out intracystic inspection of the hydatid cyst by inserting the scope into the hydatid canula and expanding the cyst wall using insufflation at a pressure of 2-3 mm of Hg. This manoeuvre has been described in a previous paper by Palanivelu et al.,[27] and we confirm its efficacy in allowing inspection of the intracystic contents and clearance of remnant germinal epithelium and daughter cysts. We also perform omental packing of the cyst to reduce dead space and problems associated with it.
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Jani: Laparoscopic management of hepatic hydatid disease
Frank intrabiliary rupture was present in one case of our series. The patient presented with features of obstructive cholangitis and was treated with initial endoscopic retrograde drainage of common bile duct with evacuation of pus and daughter cysts and subsequent laparoscopic drainage of hydatid cyst. This condition occurs when the rupture is present on the sides, the cyst wall as well as the adjoining biliary channel with interchange of contents. Patients with such frank intrabiliary rupture may not always have biliary obstruction but may simply have presence of bile in the cyst before surgical intervention. Acarli also describes a simple cyst-biliary communication in with the rupture is only on the side of the biliary channel while the cyst wall is intact.[22] In such cases, there is no bile in the cyst prior to surgical intervention. When the cyst wall is punctured and it collapses, the bile may then leak into the remnant cavity. In these patients, an observant surgeon sees that after introducing the drainage channel into the cyst, the initial effluent is colourless hydatid fluid and bile staining appears after some time. In several cases, there may not be any overt bile staining per operatively but minor biliary leak may appear in the drainage tube in the post-operative period, almost always responding to conservative management. This explains the presence of bile-stained effluent in the drainage tube in two of our patients, both of which stopped spontaneously.
and correct technique, it is possible to treat most of these parasitic cysts using minimal invasive techniques both safely and effectively.
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The post-operative morbidity rate has been reported in a range varying from 6% to 47%.[28] In our series, the postoperative morbidity, in addition to the two cases of minor biliary leakage, consisted of three cases of port site infection. All the cases were managed conservatively. Except for one case of biliary leak, which persisted for 12 days, the other complications did not affect the length of stay of the patient. Recurrence can be local due to incomplete evacuation of the cyst or abdominal due to spillage of cyst contents during evacuation.[5] Recurrence rate with cyst evacuation and omentoplasty has been reported in the range of 6-25%. Radical surgeries like total pericystectomy or hepatectomy are associated with lower recurrence rates but higher complications.[2] While none of the patients in our series show evidence of recurrence, one has to remember the slow growth rate of the cyst and absence of symptomatology in early disease. This implies that these patients require prolonged follow-up with yearly ultrasonography as late manifestation of recurrence is known.
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Cite this article as: Jani K. Spillage-free laparoscopic management of hepatic hydatid disease using the hydatid trocar canula. J Min Access Surg 2014;10:113-8. Date of submission: 21/01/2013, Date of acceptance: 27/05/2013 Source of Support: Nil, Conflict of Interest: None declared.
Journal of Minimal Access Surgery | July-September 2014 | Volume 10 | Issue 3
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