**7.1 Surgical treatment indications**

	- a.In spite of the possibility of spontaneous or traumatic rupture in superficially located and large single cysts.
	- b.Infected cysts.

## **7.2 Conservative surgical procedures**

The basic principles of conservative surgical treatment are to clean all the contents inside the cyst and sterilize the cavity and to excise the pericyst as much as possible. Conservative surgical procedures are more simple and easier to perform than radical procedures. It is possible to perform these procedures in daily general surgical practice (**Figure 5**).

In conservative surgery, the basic principle is to open the cyst and sterilize the interior and then to manage the cavity. Various scolicidal agents are preferred for emptying the cyst content and for sterilizing the cavity interior. NaCl,

*An example of biliary duct connection of the cyst shown during the operation. A photo from our collection.*

**107**

*The Surgical Management of Hydatid Cyst of the Liver: What is New?*

and closure of the cyst after opening and emptying.

tract from the cyst to the skin like an ostomy is done.

beyond the common portion of the incision line and sphincter.

chlorhexidine, povidone iodine, ethyl alcohol, and hydrogen peroxide are used as scolicidal agents. The administration time of these agents is 5–15 min. Hypertonic NaCl and cetrimide are the most commonly used agents [15]. Different concentrations have been reported for hypertonic NaCl. Both clinical and experimental studies suggest that the scolicidal efficacy of a concentration below 10% is not sufficient. The ideal concentration is 20%. Each scolicidal agent must be prevented from contact with the bile duct, because they all have the potential to cause caustic sclerosing cholangitis. After emptying of the cavity, bile control should be performed. Bile leakage can be seen directly with the eye, or some researchers recommend to wash the cystic duct or choledochus with isotonic NaCl for detection of the bile duct invasion. It is recommended that all detectable bile ducts be carefully closed without damaging the common bile ducts. In cysts with large bile duct openings, caution is needed when using scolicidal agents and closing the fistula

The second main part of cavity management is how to reduce or close the cavity. The cyst wall outside the liver parenchyma should be excised as much as possible, which is defined as partial cystectomy. After the cyst cavity has been minimized, the methods for the remaining cavity are unroofing, marsupialization, tube drainage, Posadas surgery and modifications (Llobet-Varsi modification), Roux-En-Y cystojejunostomy, and omentoplasty [16]. In the marsupialization technique, the edges of the cyst are sutured to the abdominal wall, and the cyst contents are drained out, which is now a historical approach. The technique that has been adapted to current surgical approaches is tube drainage, in which the cyst cavity is drained out of the tube, but postoperative complications are high. Posadas surgery and its modifications are used in small peripheral cysts with no biliary involvement

The current techniques used in the treatment of liver hydatid cysts are changing from simply unroofing the cyst to hepatic resections; the important part is to define the techniques. The cystectomy is basically opening the dome of the cyst and removing the germinative membranes and vesicles, whereas in pericystectomy, radical surgery is done by resection of the cyst with some liver tissue surrounding. Unroofing stands for the excision of the part of the cyst located outside the liver. Apart from the germinative membrane, parts of the cyst within the liver parenchyma are not touched when unroofing is done. The placement of a visceral organ, usually the omentum, into the cavity after unroofing is done is defined as quilting technique, whereas marsupialization is a historical technique in which building a

Although the most common indications for transduodenal sphincteroplasty are related to bile duct stones and cholangitis, this technique can also be used in hydatid cyst residues and membranes extracted from the common bile duct. The procedure may extend to the left and right hepatic channels, and angled Randall forceps are useful for this purpose. Sphincteroplasty involves suturing both sides or edges of the surgical sphincterotomy to prevent future stenosis of the incision. The sutures provide hemostasis in the incision margins and lead to the risk of retroduodenal perforation but also help prevent leakage of the duodenal content if it extends

Recent studies have reported postoperative morbidity and mortality rates of conservative techniques as 3–24% and 0–4% [17]. Although conservative surgical treatments are safer than radical procedures, they have become controversial due to the complications occurring in the postoperative period and the length of hospitalization. The most common complications are biliary fistula and cavity infection. Apart from these complications, bile peritonitis, cholangitis, and rarely sepsis and anaphylaxis can be observed in the preoperative period. Although anaphylaxis is

*DOI: http://dx.doi.org/10.5772/intechopen.90726*

openings.

#### *The Surgical Management of Hydatid Cyst of the Liver: What is New? DOI: http://dx.doi.org/10.5772/intechopen.90726*

*Overview on Echinococcosis*

**7.1 Surgical treatment indications**

female vesicles [14].

b.Infected cysts.

**7.2 Conservative surgical procedures**

relationship.

surgical practice (**Figure 5**).

The main question here is: Is it necessary to remove the entire cyst, or is it sufficient to remove only the cyst? Two treatment modalities have therefore been proposed: radical and conservative surgery. The choice of surgical treatment depends on the number, localization, diameter, and complexity of the hydatid cysts, as well as the age and comorbidities of the patient, and the experience of the surgeon.

1.In large-scale uncomplicated CE2 and CE3b cysts with a large number of

a.In spite of the possibility of spontaneous or traumatic rupture in

4.An alternative to percutaneous treatment in cysts with cystobiliary

The basic principles of conservative surgical treatment are to clean all the contents inside the cyst and sterilize the cavity and to excise the pericyst as much as possible. Conservative surgical procedures are more simple and easier to perform than radical procedures. It is possible to perform these procedures in daily general

In conservative surgery, the basic principle is to open the cyst and sterilize the interior and then to manage the cavity. Various scolicidal agents are preferred for emptying the cyst content and for sterilizing the cavity interior. NaCl,

*An example of biliary duct connection of the cyst shown during the operation. A photo from our collection.*

2.In uncomplicated large cysts compressing adjacent vital organs.

3.In cases where percutaneous treatment is not possible.

superficially located and large single cysts.

**106**

**Figure 5.**

chlorhexidine, povidone iodine, ethyl alcohol, and hydrogen peroxide are used as scolicidal agents. The administration time of these agents is 5–15 min. Hypertonic NaCl and cetrimide are the most commonly used agents [15]. Different concentrations have been reported for hypertonic NaCl. Both clinical and experimental studies suggest that the scolicidal efficacy of a concentration below 10% is not sufficient. The ideal concentration is 20%. Each scolicidal agent must be prevented from contact with the bile duct, because they all have the potential to cause caustic sclerosing cholangitis. After emptying of the cavity, bile control should be performed. Bile leakage can be seen directly with the eye, or some researchers recommend to wash the cystic duct or choledochus with isotonic NaCl for detection of the bile duct invasion. It is recommended that all detectable bile ducts be carefully closed without damaging the common bile ducts. In cysts with large bile duct openings, caution is needed when using scolicidal agents and closing the fistula openings.

The second main part of cavity management is how to reduce or close the cavity. The cyst wall outside the liver parenchyma should be excised as much as possible, which is defined as partial cystectomy. After the cyst cavity has been minimized, the methods for the remaining cavity are unroofing, marsupialization, tube drainage, Posadas surgery and modifications (Llobet-Varsi modification), Roux-En-Y cystojejunostomy, and omentoplasty [16]. In the marsupialization technique, the edges of the cyst are sutured to the abdominal wall, and the cyst contents are drained out, which is now a historical approach. The technique that has been adapted to current surgical approaches is tube drainage, in which the cyst cavity is drained out of the tube, but postoperative complications are high. Posadas surgery and its modifications are used in small peripheral cysts with no biliary involvement and closure of the cyst after opening and emptying.

The current techniques used in the treatment of liver hydatid cysts are changing from simply unroofing the cyst to hepatic resections; the important part is to define the techniques. The cystectomy is basically opening the dome of the cyst and removing the germinative membranes and vesicles, whereas in pericystectomy, radical surgery is done by resection of the cyst with some liver tissue surrounding. Unroofing stands for the excision of the part of the cyst located outside the liver. Apart from the germinative membrane, parts of the cyst within the liver parenchyma are not touched when unroofing is done. The placement of a visceral organ, usually the omentum, into the cavity after unroofing is done is defined as quilting technique, whereas marsupialization is a historical technique in which building a tract from the cyst to the skin like an ostomy is done.

Although the most common indications for transduodenal sphincteroplasty are related to bile duct stones and cholangitis, this technique can also be used in hydatid cyst residues and membranes extracted from the common bile duct. The procedure may extend to the left and right hepatic channels, and angled Randall forceps are useful for this purpose. Sphincteroplasty involves suturing both sides or edges of the surgical sphincterotomy to prevent future stenosis of the incision. The sutures provide hemostasis in the incision margins and lead to the risk of retroduodenal perforation but also help prevent leakage of the duodenal content if it extends beyond the common portion of the incision line and sphincter.

Recent studies have reported postoperative morbidity and mortality rates of conservative techniques as 3–24% and 0–4% [17]. Although conservative surgical treatments are safer than radical procedures, they have become controversial due to the complications occurring in the postoperative period and the length of hospitalization. The most common complications are biliary fistula and cavity infection. Apart from these complications, bile peritonitis, cholangitis, and rarely sepsis and anaphylaxis can be observed in the preoperative period. Although anaphylaxis is

extremely rare, it can be fatal. Hypernatremia is another complication that should be kept in mind in patients using hypertonic NaCl for cavity sterilization.

Although bile fistula is affected by various factors, it is observed in approximately 30–50% of cases. It is the most disturbing complication of conservative surgical treatment for the surgeon. The most predictive factor for postoperative bile fistula was found out to be the diameter of the cyst. Postoperative bile fistula rate increases in patients with a cyst diameter greater than 10 cm. Studies on the number, localization, and stage of the cysts on postoperative complications have yielded variable results, but localized cysts in the dome were definitely reported as a predictive factor. Postoperative bile fistula is defined as permanent bile fistula if it lasts more than 10 days. Endoscopic procedures are recommended primarily for the treatment of biliary fistulas. The cystobiliary fistula can be seen by ERCP, and endoscopic sphincterotomy, stenting, or nasobiliary drainage can be performed for therapeutic purposes.

An important problem during conservative surgery is the cavity infection. The rate of cavity infection in different series has been reported to be between 5.5 and 37%. Omentoplasty is thought to be useful in preventing cavity infection.

Mortality after conservative surgery can be seen up to 1.5%. Although higher mortality can be seen in patients with biliary involvement of the cyst, local recurrence rate is relatively higher in conservative methods than radical methods. Recurrences are reported to be caused by cysts growing from the pericyst to the liver parenchyma (exogenous vesiculation).

#### **7.3 Radical surgical procedures**

There are two radical procedures: pericystectomy and hepatectomy. In radical surgery, all the cysts can be performed with either excising the pericyst (pericystectomy—total cystectomy) or excising the parenchyma with the pericyst (hepatectomy) without opening the cyst. The rate of pericystectomy in radical surgery procedures is close to 90%. Unlike conservative procedures, radical procedures are more complex and difficult.

The pericystectomy is the preferred radical procedure because it is aimed to protect the healthy parenchyma as much as possible. There is a good dissection plan between liver tissue and cyst. Determining and progressing this plan will provide a comfortable dissection plan. When pericystectomy is performed laparoscopically, the operation is completed without emptying the cyst contents, and when the open method is performed, the pericyst is excised after the cyst is opened and the contents are emptied. Open method should be preferred especially in deeply located cysts adjacent to the hepatic artery or portal vein.

Indications for hepatectomy include the presence of large cysts that fill a lobe, multiple cysts, complicated cysts, and, according to some authors, being proximal to hilar vascular structures. This is an indication for hepatectomy if the large biliary tract is eroded. Particularly, lesions close to the inferior vena cava have been reported to be a partial contraindication. Caution is specifically needed for lesions adjacent to the right atrium and hepatic veins, especially the lesions in segments 1, 4, and 8. The radical resection is recommended for patients under age 75 only if the lesion is located with less than three segments of liver; if the residual liver function is sufficient to allow the surgery; if the vena cava, portal vein, hepatic artery, or biliary tract are suitable for repair; and if distant metastases are suitable for resection or do not cause life-threatening complications at least.

Complications vary according to the surgical method used in radical surgery. In general, complications related to liver surgery are observed and vary between 3 and 30% postoperatively. This rate is lower than conservative surgery. The advantage

**109**

*The Surgical Management of Hydatid Cyst of the Liver: What is New?*

of radical surgery is that there is no cavity infection and the risk of biliary fistula is less (0.7–7%). The rate of infection in the surgical site is less than 3% in patients who underwent radical surgery. The low postoperative morbidity reduces the length of hospital stay in patients who underwent radical surgery. In addition, the possibility of local recurrence is less in radical surgery. The rate of local recurrence in conservative methods has been reported to be 20–25% in the literature, while the

It should be done according to complication. Biliary tract problems should be solved primarily in cysts that are involved with bile ducts. For this, ERCP and endoscopic sphincterotomy can be performed. Conservative methods should be used rather than radical surgery in free ruptured cysts to the peritoneum.

The role of laparoscopy in the surgical treatment of liver hydatid cysts has always been discussed. The first studies were reported in the 1990s. The general advantages of laparoscopy, such as less hospital stay, less wound problems, and less pain, apply here. However, it is difficult to reach cysts in some localizations, and there are difficulties in aspiration of cyst contents and concerns about spreading of

Reaching the cysts in the posterior and superior segments of the liver poses some technical difficulties. However, access to cysts in segments II, III, IVB, V, and VI is more convenient [16]. This situation also provides patient selection in liver hydatid cyst. In other words, laparoscopic or minimally invasive surgical treatment seems more reasonable for patients with cysts in the anterior segments. It can even be interpreted that laparoscopy is a relative contraindication for cysts in segments I and VII. In addition, the cyst content is completely evacuated, and the possibility of spreading around while being evacuated is another problem. After the cavity is emptied and sterilized, it is aimed to perform cavity management with the same methods as in open cases [14]. After the cyst has been evacuated, laparoscopy can

In laparoscopic surgery, exposure is usually caused by inaccessibility of the cyst, calcifications, and other complications (bleeding, etc.). The conversion rate to open radical techniques was reported as 1.7% [16]. At present, there is no obstacle to the treatment of liver hydatid cysts with minimally invasive surgery. In the published series, the recurrence rate in patients undergoing minimally invasive surgery is not higher than in open-operated patients. However, the indications of laparoscopy should not be forced, and patients should be selected well. As minimal invasive hepatectomies become widespread, minimally invasive radical surgery for liver

Albendazole starting at 10 mg/kg/day should start to be used immediately for 6 months postoperatively. Hemogram and blood biochemistry should be performed every month (due to the risk of the toxicity of liver and bone marrow). Serological tests are not used in the early stages of follow-up (first few months), because none of them becomes negative in the early period. A control serological test (usually *Echinococcus*

IHA) should be performed at the end of the 6-month postoperative period.

be used to magnify the bile leakage and suture the sources of leakage.

*DOI: http://dx.doi.org/10.5772/intechopen.90726*

recurrence rate after radical surgery is 0.6–4%.

**7.4 Surgical treatment of complicated cysts**

content and question marks about laparoscopy.

**7.5 Minimal invasive surgery**

hydatid cyst will increase.

**8. Postop follow-up**

*The Surgical Management of Hydatid Cyst of the Liver: What is New? DOI: http://dx.doi.org/10.5772/intechopen.90726*

of radical surgery is that there is no cavity infection and the risk of biliary fistula is less (0.7–7%). The rate of infection in the surgical site is less than 3% in patients who underwent radical surgery. The low postoperative morbidity reduces the length of hospital stay in patients who underwent radical surgery. In addition, the possibility of local recurrence is less in radical surgery. The rate of local recurrence in conservative methods has been reported to be 20–25% in the literature, while the recurrence rate after radical surgery is 0.6–4%.

#### **7.4 Surgical treatment of complicated cysts**

It should be done according to complication. Biliary tract problems should be solved primarily in cysts that are involved with bile ducts. For this, ERCP and endoscopic sphincterotomy can be performed. Conservative methods should be used rather than radical surgery in free ruptured cysts to the peritoneum.

#### **7.5 Minimal invasive surgery**

*Overview on Echinococcosis*

therapeutic purposes.

liver parenchyma (exogenous vesiculation).

**7.3 Radical surgical procedures**

dures are more complex and difficult.

cysts adjacent to the hepatic artery or portal vein.

or do not cause life-threatening complications at least.

extremely rare, it can be fatal. Hypernatremia is another complication that should

Although bile fistula is affected by various factors, it is observed in approximately 30–50% of cases. It is the most disturbing complication of conservative surgical treatment for the surgeon. The most predictive factor for postoperative bile fistula was found out to be the diameter of the cyst. Postoperative bile fistula rate increases in patients with a cyst diameter greater than 10 cm. Studies on the number, localization, and stage of the cysts on postoperative complications have yielded variable results, but localized cysts in the dome were definitely reported as a predictive factor. Postoperative bile fistula is defined as permanent bile fistula if it lasts more than 10 days. Endoscopic procedures are recommended primarily for the treatment of biliary fistulas. The cystobiliary fistula can be seen by ERCP, and endoscopic sphincterotomy, stenting, or nasobiliary drainage can be performed for

An important problem during conservative surgery is the cavity infection. The rate of cavity infection in different series has been reported to be between 5.5 and

Mortality after conservative surgery can be seen up to 1.5%. Although higher mortality can be seen in patients with biliary involvement of the cyst, local recurrence rate is relatively higher in conservative methods than radical methods. Recurrences are reported to be caused by cysts growing from the pericyst to the

There are two radical procedures: pericystectomy and hepatectomy. In radical surgery, all the cysts can be performed with either excising the pericyst (pericystectomy—total cystectomy) or excising the parenchyma with the pericyst (hepatectomy) without opening the cyst. The rate of pericystectomy in radical surgery procedures is close to 90%. Unlike conservative procedures, radical proce-

The pericystectomy is the preferred radical procedure because it is aimed to protect the healthy parenchyma as much as possible. There is a good dissection plan between liver tissue and cyst. Determining and progressing this plan will provide a comfortable dissection plan. When pericystectomy is performed laparoscopically, the operation is completed without emptying the cyst contents, and when the open method is performed, the pericyst is excised after the cyst is opened and the contents are emptied. Open method should be preferred especially in deeply located

Indications for hepatectomy include the presence of large cysts that fill a lobe, multiple cysts, complicated cysts, and, according to some authors, being proximal to hilar vascular structures. This is an indication for hepatectomy if the large biliary tract is eroded. Particularly, lesions close to the inferior vena cava have been reported to be a partial contraindication. Caution is specifically needed for lesions adjacent to the right atrium and hepatic veins, especially the lesions in segments 1, 4, and 8. The radical resection is recommended for patients under age 75 only if the lesion is located with less than three segments of liver; if the residual liver function is sufficient to allow the surgery; if the vena cava, portal vein, hepatic artery, or biliary tract are suitable for repair; and if distant metastases are suitable for resection

Complications vary according to the surgical method used in radical surgery. In general, complications related to liver surgery are observed and vary between 3 and 30% postoperatively. This rate is lower than conservative surgery. The advantage

37%. Omentoplasty is thought to be useful in preventing cavity infection.

be kept in mind in patients using hypertonic NaCl for cavity sterilization.

**108**

The role of laparoscopy in the surgical treatment of liver hydatid cysts has always been discussed. The first studies were reported in the 1990s. The general advantages of laparoscopy, such as less hospital stay, less wound problems, and less pain, apply here. However, it is difficult to reach cysts in some localizations, and there are difficulties in aspiration of cyst contents and concerns about spreading of content and question marks about laparoscopy.

Reaching the cysts in the posterior and superior segments of the liver poses some technical difficulties. However, access to cysts in segments II, III, IVB, V, and VI is more convenient [16]. This situation also provides patient selection in liver hydatid cyst. In other words, laparoscopic or minimally invasive surgical treatment seems more reasonable for patients with cysts in the anterior segments. It can even be interpreted that laparoscopy is a relative contraindication for cysts in segments I and VII.

In addition, the cyst content is completely evacuated, and the possibility of spreading around while being evacuated is another problem. After the cavity is emptied and sterilized, it is aimed to perform cavity management with the same methods as in open cases [14]. After the cyst has been evacuated, laparoscopy can be used to magnify the bile leakage and suture the sources of leakage.

In laparoscopic surgery, exposure is usually caused by inaccessibility of the cyst, calcifications, and other complications (bleeding, etc.). The conversion rate to open radical techniques was reported as 1.7% [16]. At present, there is no obstacle to the treatment of liver hydatid cysts with minimally invasive surgery. In the published series, the recurrence rate in patients undergoing minimally invasive surgery is not higher than in open-operated patients. However, the indications of laparoscopy should not be forced, and patients should be selected well. As minimal invasive hepatectomies become widespread, minimally invasive radical surgery for liver hydatid cyst will increase.

#### **8. Postop follow-up**

Albendazole starting at 10 mg/kg/day should start to be used immediately for 6 months postoperatively. Hemogram and blood biochemistry should be performed every month (due to the risk of the toxicity of liver and bone marrow). Serological tests are not used in the early stages of follow-up (first few months), because none of them becomes negative in the early period. A control serological test (usually *Echinococcus* IHA) should be performed at the end of the 6-month postoperative period.

In this first 6 months postoperatively, USG is the main follow-up method. It shows both early recurrences and complications related to surgery. In the first few months, USG may show fluid accumulation in the cyst, which is usually seroma and will disappear afterwards. In recurrences, the fluid seen in the cavity in the previous USG will gradually increase.

Recurrence rates after surgery or invasive procedures range from 0 to 15%. The most common cause of recurrence is the scattering of living scolexes into the peritoneal cavity. Even if the patients is going to get operated, albendazole treatment is started 4–6 weeks preoperatively, which significantly reduces the risk of recurrence. The treatment of recurrent cysts is designed as in newly diagnosed cysts.
