**6.2 Laparoscopic subtotal cystectomy**

Laparoscopic subtotal hepatic cystectomy has all the advantages of minimally invasive procedures (**Figures 22**–**24**). It offers magnified vision with better appreciation of the cyst, residual cavity, and biliary communications. In addition, it presents less postoperative pain and earlier discharge. Comparative studies are reported

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**Figure 23.**

*Protection of the surgical field, iodine povidone.*

between the two techniques, and the future trend seems to prefer laparoscopic technique [50]. However, technical difficulties currently persist to avoid the spillage of fertile hydatid material into the peritoneal cavity with anaphylactic reactions and secondary hydatid implants. For this reason, and to prevent this complication and

*Subtotal cystectomy. Giant hydatid cyst. Retrohepatic cava vein (yellow-dotted arrow).*

*Laparoscopic subtotal pericystectomy. Dissection of diaphragm adhesion.*

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

**Figure 21.**

**Figure 22.**

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

#### **Figure 21.**

*Liver Disease and Surgery*

**Figure 18.**

**Figure 19.**

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

*Hepatic mobilization. Subcostal laparotomy.*

**6.2 Laparoscopic subtotal cystectomy**

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

Laparoscopic subtotal hepatic cystectomy has all the advantages of minimally invasive procedures (**Figures 22**–**24**). It offers magnified vision with better appreciation of the cyst, residual cavity, and biliary communications. In addition, it presents less postoperative pain and earlier discharge. Comparative studies are reported

**162**

**Figure 20.**

*Subtotal cystectomy. Giant hydatid cyst. Retrohepatic cava vein (yellow-dotted arrow).*

#### **Figure 22.**

*Laparoscopic subtotal pericystectomy. Dissection of diaphragm adhesion.*

#### **Figure 23.** *Protection of the surgical field, iodine povidone.*

between the two techniques, and the future trend seems to prefer laparoscopic technique [50]. However, technical difficulties currently persist to avoid the spillage of fertile hydatid material into the peritoneal cavity with anaphylactic reactions and secondary hydatid implants. For this reason, and to prevent this complication and

**Figure 24.** *Partial resection of adventitia.*

a possible uncontrollable bleeding, the laparoscopic approach is contraindicated in the following situations:


Following the rules of laparoscopic liver surgery, the location of the entrance ports depends on the anatomical location of the cysts. To prevent the spillage of hydatid material into the peritoneal cavity, it is necessary to have a good puncture and aspiration system, similar to Perforator-Grinder [51].

## **6.3 Pericystectomy**

Open or laparoscopic pericystectomy is based on the concept of complete parasite removal. This technique consists of resecting the cyst by a plane through the hepatic parenchyma adjacent to the adventitia, thus achieving avoidance of recurrence due to the presence of daughter vesicles in the adventitia or in the surrounding hepatic parenchyma [52]. In cases of complicated cysts, pericystectomy is not recommended due to the risk of further bleeding or bile duct injuries. Previous radiological studies are crucial to determine the relationship of these structures with the cysts. Currently, laparoscopic pericystectomy helps to prevent the aforementioned risks thanks to its magnified vision, more efficient hepatic transection instruments, and widespread access (**Figure 25**). Well-trained surgeons in laparoscopic hepatic surgery have a better chance of successfully performing this technique [53].

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**6.4 Hepatic resection**

*Steps of laparoscopic pericystectomy.*

**Figure 25.**

Sometimes it is necessary to carry out liver resections, e.g., when there are hydatid recurrences in the same lobe previously operated or in residual cavities, which have the risk of subsequent infection with development of liver abscesses and cholangitis. When the infection is controlled by antibiotic therapy or percutaneous drainages, it is recommended to resect the compromised lobe, which is usually more atrophic. This surgery will be consequently more laborious. Nevertheless, the compensatory hypertrophy of the unaffected lobe determines a lower risk of postoperative hepatic failure. With the aim of completely eradicating the parasite and preventing recurrence, several surgical centers perform hepatic resection more frequently by both open and laparoscopic surgeries with acceptable morbidity and very low mortality. Liver resection is more indicated in alveolar echinococcosis by higher frequency of recurrence and infiltrative behavior similar to malignant neoplasms. There are recent reports of liver transplantation and also ex vivo resection surgery with autotransplantation for this type of echinococcosis [54]. Summarizing, hepatic resection, not very used in the past, now appears as

a viable alternative for selected cases carried out in specialized reference centers.

The morbidity of resective surgery depends on the complexity of the hydatidosis and the magnitude of the surgery performed. Among the most difficult to treat are biliary fistulas, bleeding, and infections. For example, for patients with fistulization of the cyst toward the bile duct and thorax, it is advisable to work in stages, e.g., treating cholangitis first, and then, when the patient is stabilized, a pleural empyema is drained. Once general conditions have been recovered, the resective surgery is indicated. In relation to morbidity and mortality rates, what has been reported so far shows a great disparity of figures. A surgeon from our university conducted a

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

the following situations:

*Partial resection of adventitia.*

**Figure 24.**

peritoneum

migration

**6.3 Pericystectomy**

• Cyst diameter more than 10 cm

• Very thin or calcified adventitia

a possible uncontrollable bleeding, the laparoscopic approach is contraindicated in

• More than three cysts and/or presence of peritoneal cysts or in other organs

• Cysts located in the dome and central locations of the liver

• Imaging signs of accentuated pericystic inflammation

and aspiration system, similar to Perforator-Grinder [51].

better chance of successfully performing this technique [53].

• Complicated cysts with rupture and emptying on the biliary tree or

• Cysts with fibrous adhesions to the diaphragm on the way to a thoracic

Following the rules of laparoscopic liver surgery, the location of the entrance ports depends on the anatomical location of the cysts. To prevent the spillage of hydatid material into the peritoneal cavity, it is necessary to have a good puncture

Open or laparoscopic pericystectomy is based on the concept of complete parasite removal. This technique consists of resecting the cyst by a plane through the hepatic parenchyma adjacent to the adventitia, thus achieving avoidance of recurrence due to the presence of daughter vesicles in the adventitia or in the surrounding hepatic parenchyma [52]. In cases of complicated cysts, pericystectomy is not recommended due to the risk of further bleeding or bile duct injuries. Previous radiological studies are crucial to determine the relationship of these structures with the cysts. Currently, laparoscopic pericystectomy helps to prevent the aforementioned risks thanks to its magnified vision, more efficient hepatic transection instruments, and widespread access (**Figure 25**). Well-trained surgeons in laparoscopic hepatic surgery have a

**164**

**Figure 25.** *Steps of laparoscopic pericystectomy.*
