Laparoscopic Liver Cyst Unroofing
What Is Laparoscopic Liver Cyst Unroofing
When a large hepatic cyst becomes symptomatic, patients often present with right upper quadrant pain, shoulder discomfort, nausea, epigastric fullness, and acid reflux-like feelings. The symptoms are caused by a mechanical stretch to the Glissonean capsule covering the liver or mechanical compression to the surrounding organs such as stomach, diaphragm, intestines, and chest wall. In this situation, a surgical unroofing or fenestration of the large liver cyst is necessary. A diagnosis can be easily made based on a CT scan or MRI. It is important to rule out a premalignant cystic mass/lesion of the liver such as mucinous cystic neoplasm or parasitic hydatid cyst, which should instead be resected. A percutaneous liver cyst aspiration by an interventional radiologist is commonly discussed and falsely performed, however it is well known to fail in more than 95% of patients due to rapid fluid reaccumulation within the hepatic cyst. The futile percutaneous liver cyst aspiration is therefore, not recommended.
In the modern era of liver surgery, laparoscopic liver cyst unroofing has become the standard treatment for symptomatic large hepatic cysts. It is a technically straightforward operation with excellent efficacy and long-term outcomes. An open liver operation is now obsolete for this disease. Liver transplant surgery is not a part of treatment algorithm for large symptomatic liver cysts, since it is rarely associated with liver dysfunction.
To definitively treat symptomatic large hepatic cysts, removal/resection of a large portion of the cyst wall is mandatory. This may include partial liver resection of adjacent attenuated liver parenchyma. When the operation is performed properly, the incidence of cyst recurrence is minimized. Recognition of the intrahepatic biliary and vascular anatomy is important to avoid bile leak or bleeding intraoperatively. The resected cyst wall is then sent to pathology for a frozen-section evaluation to identify or rule out presence of any premalignant/malignant cells. When premalignant or malignant cells are identified, a formal oncologic liver resection is needed to gain negative margins.
While the majority of liver surgeon/liver specialist/transplant surgeon perform the liver cyst unroofing operation using the multiport conventional laparoscopic technique, Dr. Iswanto Sucandy performs this operation through a single incision in the umbilicus. This is called laparoendoscopic single site liver cyst unroofing. By creating only a single incision in the umbilicus, physiologic insults to the body can be minimized and cosmetic results can be optimized. Laparoscopic instruments including camera, graspers, cutting device, stapler, and liver ultrasound can be inserted through this single opening. Excellent outcome, remnant liver hypertrophy, and resolution of symptoms are expected after this operation. Only a single dressing in the umbilicus will be needed postoperatively.
Most patients can be discharged to home on the same day of the operation. Placement of an abdominal drain is usually not needed after this procedure. A small percentage of patients require an overnight stay in the hospital mainly due to medical problems. It is important to see an experienced liver surgeon to treat large symptomatic hepatic cysts. In our liver surgery center, Dr. Iswanto Sucandy and his team perform this operation frequently. Even in patients with prior multiple abdominal operations (including open operations), minimally invasive technique can still be offered safely with excellent outcomes.