|Year : 2015 | Volume
| Issue : 1 | Page : 49-51
Combined abdomino-thoracic approach to hydatid cyst in superior-posterior segments of the liver
VD Goyal1, A Mahajan2, S Sood3, S Rana4, R Kumar5
1 Assistant Professor, Cardiothoracic and Vascular Surgery, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India
2 Associate Professor, Surgery, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India
3 Assistant Professor, Surgery, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India
4 Associate Professor, Anesthesia, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India
5 Junior Resident, Surgery, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India
|Date of Web Publication
V D Goyal
Assistant Professor, Cardiothoracic and Vascular Surgery, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda - 176 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Hydatid disease of the liver is a common problem in developing countries. We present a case of huge hydatid cyst in the superior-posterior segments of liver, which was managed through combined abdominothoracic approach. Surgical intervention was done first through subcostal incision followed by anterolateral thoracotomy through sixth intercostal space with circumferential incision in the diaphragm as exposure through the abdominal approach was inadequate. The cyst was drained and the cavity filled with omentum to obliterate the residual space. Patient recovered well and was discharged after 1 week. This approach is useful when access is inadequate to hydatid cysts in the superior and posterior parts of the liver.
Keywords: Abdominothoracic approach, hydatid cyst liver, superior-posterior segments of liver
|How to cite this article:
Goyal V D, Mahajan A, Sood S, Rana S, Kumar R. Combined abdomino-thoracic approach to hydatid cyst in superior-posterior segments of the liver. Arch Int Surg 2015;5:49-51
|How to cite this URL:
Goyal V D, Mahajan A, Sood S, Rana S, Kumar R. Combined abdomino-thoracic approach to hydatid cyst in superior-posterior segments of the liver. Arch Int Surg [serial online] 2015 [cited 2024 Mar 1];5:49-51. Available from: https://www.archintsurg.org/text.asp?2015/5/1/49/153163
Hydatid disease is a zoonosis caused by Echinococcus granulosus and cystic hydatid disease is the most common presentation. Cystic echinococcosis (CE) has been classified by World Health Organization (WHO) on the basis of ultrasonographic appearance of the cyst,  CE1 - active unilocular cyst, CE2 - active multilocular cysts, CE3-separation of laminated membrane, CE 4-degenerative changes with absence of daughter cysts, and CE 5-degenerative, thick calcified wall. Majority of the liver hydatid cysts can be easily managed through the subcostal or midline abdominal approach and only rarely is thoracic approach  required for management of liver cysts. In the last decade, laparoscopic techniques and ultrasonographic-guided percutaneous techniques are also increasingly being used in the management of hepatic hydatid cysts. In some patients hydatid cysts in the superior-posterior segments of the liver may be relatively poorly accessible through the abdominal approach and in those cases additional thoracotomy maybe required. Transdiaphragmatic approach is mostly used for resection of liver tumors ,, in segment VI, VII, and VIII, and resection of large adrenal masses;  but is rarely required in the management of hydatid cysts in liver and should be used only when other options are either unsuccessful or are not feasible. We present a case of huge hydatid cyst in the superior-posterior segments of liver, which was managed through an abdominothoracic approach.
| Case Report
A 40-year-old male patient presented with pain abdomen and dyspepsia. Ultrasonography of the abdomen revealed large cyst in the liver, computed tomography (CT) confirmed the findings of huge liver cyst with possibility of hydatid cyst [Figure 1]a and b]. Serology of the patient was positive for echinococcus and also eosinophil count was raised; therefore, provisional diagnosis of hydatid cyst was made. Percutaneous drainage under ultrasonographic guidance was avoided to prevent risk of anaphylaxis. Surgical intervention was initially planned through the subcostal abdominal approach. Initial exploration as done through the right-sided subcostal abdominal incision provided inadequate exposure of the superior-posterior surface of the liver. Enlarged liver had pushed the diaphragm up and mobilization of the liver from diaphragm and division of ligaments attaching the liver to the diaphragm was not possible under vision. Also the liver was tense and not compressible, which further hindered the mobilization of liver. As the abdominal approach was not adequate for proper exposure and management, additional thoracotomy (anterolateral thoracotomy) was done through the sixth intercostal space; the diaphragm was incised in the anterolateral part in a circumferential fashion [Figure 2]a]. After incising the diaphragm, stay sutures were taken in the diaphragm at both the edges and retraction of edges of the diaphragm brought the superior surface of the liver in excellent view. The cyst was initially aspirated and drained and was found to be infected hydatid cyst. After drainage of the cyst along with removal of the germinal epithelium and membranes, the omentum was mobilized through the subcostal incision and residual cavity in the liver [Figure 2]b] was filled with omentum and abdominal drain was inserted. Incision in the diaphragm was repaired with nonabsorbable sutures in a continuous fashion and further supported with few interrupted sutures. Standard thoracotomy closure was done after inserting a chest drain followed by closure of the subcostal abdominal incision with drain in the Morrison's pouch. The patient recovered well without any complications and was discharged after 1 week with complete resolution of symptoms. Albendazole was given postoperatively for 1 month. Ultrasonographic examination was done after 1 month and at 6-month follow-up, and there was no evidence of fluid collection or recurrence of the disease.
|Figure 1: (a) CT abdomen (coronal section) showing huge cyst in liver occupying the superior-posterior segments.(b) CT abdomen (sagittal section) showing huge cyst in liver occupying the superior-posterior segments. CT = Computed tomography
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|Figure 2: (a) Intraoperative photograph showing approach to the liver through circumferential incision in the diaphragm. (b) Intraoperative photograph showing residual cavity after drainage of the cyst
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Adequate exposure of the superior-posterior segment of the liver through subcostal/midline abdominal approach depends on presence or absence of various factors like hepatomegaly, obesity, adhesions, previous surgery, and also on body habitus. When the liver is not enlarged, even the superior-posterior segment can be easily approached through the subcostal incision after dividing the triangular and coronary ligaments attaching the liver to the diaphragm; however, in cases with hepatomegaly the mobilization of liver under vision becomes difficult or is sometimes not possible as happened in this case. Mobilization of the liver requires compression of the liver and in cases with tense noncompressible liver its mobilization is difficult through the abdominal approach. The exposure of the superior-posterior segment of liver through thoracic approach is excellent, although with the disadvantage of incision in the diaphragm. Preservation of the branches of phrenic nerve and inferior phrenic artery is of utmost importance and circumferential incision in the diaphragm away from central tendon and near to its insertion in the costal margin is quite safe; however, radial incisions in the diaphragm are avoided as there is risk of diaphragmatic palsy and increased morbidity. Disadvantages of transthoracic-transdiaphragmatic approach can be i) phrenic nerve damage leading to diaphragmatic palsy, ii) pulmonary complications (like lung collapse, consolidation, and pneumonitis), iii) empyema, and iv) biliary-pleural fistula. There are conflicting reports in literature on the usefulness of transthoracic approach. Athanassiadi et al.,  found the transthoracic approach to be good and safe choice in the management of intrathoracic cyst and upper lobe liver cysts; however, Smyrniotis et al.,  compared transthoracic versus transabdominal surgical approach for echinococcal cysts located over the superoposterior aspect of the right lobe of the liver and they preferred the transabdominal approach over the transthoracic approach and recommended transabdominal approach to cyst located in any of the segments of the liver. In our opinion, combined abdominothoracic approach should be used when the exposure through the initial abdominal approach is not satisfactory. Additional thoracotomy increases the exposure of the relatively inaccessible areas of the liver, and is also required when there are cysts in the lungs also. Minimal invasive techniques are also being used in the management of liver cysts, SabaͲu et al.,  have successfully used the transpleurodiaphragmatic laparoscopic approach for management of rear dome liver cysts.
Combined abdominothoracic approach may be required for management of superior-posterior liver cysts not adequately exposed through the abdominal approach alone.
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