**6. Surgical treatment**

The main objective of the treatment of hepatic hydatidosis is the eradication of the parasite and avoidance of recurrence. There is consensus, in considering surgery as the best option to achieve this purpose. It is currently possible to perform different surgical techniques with acceptable rates of morbidity and mortality, which are applied according to the pathological conditions of cysts. In cases of greater complexity, surgery can be complemented with other therapies such as minimally invasive procedures and chemotherapy. Surgical treatment has indications and contraindications depending on the patient's condition and the forms of disease presentation [6].

At the dawn of the surgery to treat hepatic hydatidosis, only conservative techniques were used. Among them, marsupialization consisted in the opening and extraction of the parasite followed by externalizing the residual cavity toward the abdominal wall, waiting for the closure by secondary intention. Cystoenteroanastomosis was also performed, anastomosing the hepatic residual cavity into the duodenum or a defunctionalized jejunal loop. Currently, these conservative techniques are not indicated due to the high risk of complications such as recurrences, liver abscesses, intestinal obstruction, biliary fistulas, biliomas, biliary peritonitis, cholangitis, and septicemia. However, there are surgical centers that report good results in cases with large cysts treated by laparoscopic cystojejunostomy [49].

There are various procedures of resective surgery performed in different surgical centers. When indicated, it is necessary to consider age, general condition of the patient, pathological state of the cysts and location in other organs, and the existence of important comorbidities difficult to control. Despite being a benign pathology, its evolution can sometimes be very complicated, requiring multiple surgeries and leading to a poor prognosis. The surgical resections are performed either through open or laparoscopic surgery. The following are the most used techniques from least to greatest complexity.

#### **6.1 Subtotal cystectomy by open surgery**

This technique, performed by open surgery, follows the steps below according to the location of the cysts (**Figures 18**–**21**):


**161**

**Figure 16.**

**Figure 17.**

*Surgical Treatment of Hepatic Hydatidosis DOI: http://dx.doi.org/10.5772/intechopen.86319*

• Wide resection of the adventitia and further revision to eliminate daughter

*MRI T2 coronal septated cysts. Multiple daughter vesicles (white star). Membranes in bile duct (white arrow).*

• Closure of the residual cavity by means of capitonnage or omentoplasty. In giant cysts, capitonnage is not recommended to avoid distortion of the biliary tree

• In some cases, to prevent postoperative biliary fistulae, a drain is placed in the

• When the cyst is close to the main bile duct or to the subhepatic and cava vein, the adjacent adventitia should be left in situ to prevent biliary fistulae or bleedings.

and intrahepatic vasculature with subsequent functional sequelae.

residual cavity, or a choledocostomy with a Kehr tube is performed.

vesicles in cavities located in the remaining adventitia.

• Identification and suture of biliary communications.

*MR cholangiography. Same findings as demonstrated in* **Figure 15***.*

*Surgical Treatment of Hepatic Hydatidosis DOI: http://dx.doi.org/10.5772/intechopen.86319*

*Liver Disease and Surgery*

**6. Surgical treatment**

presentation [6].

nostomy [49].

from least to greatest complexity.

**6.1 Subtotal cystectomy by open surgery**

the location of the cysts (**Figures 18**–**21**):

• Right or bilateral subcostal laparotomy.

• Rarely, cysts located adjacent to the retrohepatic vena cava can rupture and cause severe cardiorespiratory failure due to bilateral pulmonary arterial embolism with multiple pulmonar hydatid dissemination [48]. In that case, a CT angiography (CTA) is used to better diagnose this serious complication.

The main objective of the treatment of hepatic hydatidosis is the eradication of the parasite and avoidance of recurrence. There is consensus, in considering surgery as the best option to achieve this purpose. It is currently possible to perform different surgical techniques with acceptable rates of morbidity and mortality, which are applied according to the pathological conditions of cysts. In cases of greater complexity, surgery can be complemented with other therapies such as minimally invasive procedures and chemotherapy. Surgical treatment has indications and contraindications depending on the patient's condition and the forms of disease

At the dawn of the surgery to treat hepatic hydatidosis, only conservative techniques were used. Among them, marsupialization consisted in the opening and extraction of the parasite followed by externalizing the residual cavity toward

the abdominal wall, waiting for the closure by secondary intention. Cystoenteroanastomosis was also performed, anastomosing the hepatic residual cavity into the duodenum or a defunctionalized jejunal loop. Currently, these conservative techniques are not indicated due to the high risk of complications such as recurrences, liver abscesses, intestinal obstruction, biliary fistulas, biliomas, biliary peritonitis, cholangitis, and septicemia. However, there are surgical centers that report good results in cases with large cysts treated by laparoscopic cystojeju-

There are various procedures of resective surgery performed in different surgical centers. When indicated, it is necessary to consider age, general condition of the patient, pathological state of the cysts and location in other organs, and the existence of important comorbidities difficult to control. Despite being a benign pathology, its evolution can sometimes be very complicated, requiring multiple surgeries and leading to a poor prognosis. The surgical resections are performed either through open or laparoscopic surgery. The following are the most used techniques

This technique, performed by open surgery, follows the steps below according to

• In order to obtain a good access to the cyst, the section of the round ligament and the dissection of adhesions to the diaphragm or adjacent organs might be required. The use of intraoperative ultrasound is useful in posterior and central cyst locations, to avoid injuring the retrohepatic cava vein or hepatic veins.

• During puncture and removal of the fluid and hydatid membrane, it is necessary to isolate the surgical field with compresses embedded in scolicidal agents

(20% hypertonic saline solution or diluted povidone iodine).

**160**

*MRI T2 coronal septated cysts. Multiple daughter vesicles (white star). Membranes in bile duct (white arrow).*

**Figure 17.** *MR cholangiography. Same findings as demonstrated in* **Figure 15***.*


**Figure 18.** *Open surgery. Multiple cysts (yellow arrow).*

**Figure 19.** *Hepatic mobilization. Subcostal laparotomy.*

**Figure 20.** *Open surgery. Subtotal cystectomy biliary communications (yellow arrow).*
