Taurine Levels in Human Aqueous Humour MEDICAL SCIENCES (2000), 2, 125–126 © 2000 SULTAN QABOOS UNIVERSITY Department of Surgery, College of Medicine, Sultan Qaboos University, P O Box 35 Al-Khod, Muscat 123, Sultanate of Oman. *To whom correspondence should be addressed. 125 Laparoscopic deroofing of hepatic cyst *Al Kindy N M, Grant C S, Daar A S أزالة سقف آيس آبدي بواسطة المنظار داعر عبداهللا غرانت، توفرآريس الكندي، نائل وعندها أعراض الى األآياس هذه تؤدي ما نادراو عالج الى تحتاج وال جانبية أعراض بدون المعزولة الالطفيلية الكبدية األآياس تكون ما عادة: الملخص الكيس سقف بإزالة بالمنظار عالجناها حالةنعرض . لجد موضع اليزال لألعراض المسببة األآياس لهذه جراحي عالج وأفضل. جراحيا أستئصالها يفضل .ومؤثرة سليمة الطريقة جدليا وهذه ABSTRACT: Solitary non-parasitic cysts of the liver are commonly asymptomatic and do not require treatment. Rarely, the cysts be- come symptomatic and are then best treated surgically. The optimal surgical treatment is debatable. We report a case treated by laparo- scopic deroofing which is arguably a safe and effective approach. KEY WORDS: solitary non-parasitic liver cysts; laparoscopic deroofing ost non-parasitic solitary liver cysts are asymp- tomatic and need no treatment. Symptoms result from either an increase in the size of the cyst or the development of complications.1 Symptomatic or large solitary non-parasitic hepatic cysts are best treated surgically, though this in the past meant open sur- gery with its attendant morbidity and long hospital stay. The minimally invasive laparoscopic approach is of late being reported to be a safe and effective alternative.2–5 We report the case of a symptomatic large solitary non-para- sitic hepatic cyst treated by laparoscopic deroofing of the external part of the cyst wall. PATIENT AND METHOD A 46-year-old Omani woman presented with an 8- month history of progressive right hypochondrial pain. The liver edge was palpable 10 cm below the costal mar- gin. Abdominal ultrasound and CT scan showed a large, solitary smooth-walled unilocular cyst, 17 cm in diameter, located in the right lobe of the liver (Figure 1). The cyst had been aspirated once in another local hospital 6 months prior to her presentation, and cytology of the fluid had been reported as negative. Serological tests for hydatid liver disease were negative and an upper gastroin- testinal endoscopy was normal. Under general anaesthesia and carbon dioxide pneu- moperitoneum, a 30-degree laparoscope was introduced through a 10-mm cannula inserted through a subumbili- cal incision. The cyst was clearly seen. A second 10-mm cannula was inserted in the epigastrium to the right of the midline and a further 5-mm cannula was inserted in the right subcostal region just lateral to the midclavicular line. Laparoscopy-guided percutaneous needle aspiration was carried out to decompress the cyst and to avoid leakage of the cystic fluid into the abdominal cavity. A total of 1,200 ml of clear serous fluid was aspirated. Urgent cytol- ogy of the cystic fluid showed no malignant cells or scolices. The cyst wall was next widely deroofed using diathermy scissors and hook, excising all of the non- parenchymal cyst wall. Bleeding from the cut edge was minimal and easily controlled with diathermy. The excised cyst wall (6.5 x 9 cm) was then removed through the epi- gastric port. A small suction drain was inserted through the right subcostal 5-mm cannula, and placed within the cavity of the cyst, after which the pneumoperitoneum was deflated. The instruments were then removed and the wounds closed. Total operating time was 90 minutes. The patient's recovery was rapid and uneventful; the drain was removed on the second postoperative day, and the patient discharged home on the third postoperative day. Twelve months after the operation, she remains asympto- matic with no recurrence. Histology of the cyst wall showed only a dense fibrovascular tissue, lined with cu- boidal cells, confirming the benign nature. DISCUSSION Non-parasitic solitary hepatic cysts are considered to be retention cysts, which result from inflammatory hyper- plasia and obstruction of congenital aberrant bile ducts.1 Most are small and remain asymptomatic, though a few cysts occasionally increase in size and eventually cause symptoms. In the absence of complications, symptoms M A L K I N D Y E T A L 126 from solitary non-parasitic liver cysts are almost always the result of a space-occupying effect of the cyst either on the liver itself or on adjacent viscera.1 FIGURE 1. Computed tomographic scan showing a large 17 cm diameter solitary unilocular cyst in the right lobe of the liver. Non-surgical treatment in the form of percutaneous ultrasound-guided aspiration of the cyst, followed by in- jection of a sclerosing agent, is associated with an unac- ceptably high recurrence rate.6 Current surgical manage- ment relies on fenestration or deroofing of the cyst as described by Lin in 1968,7 with or without placement of an omental flap into the residual cyst cavity to prevent the edges from co-apting. Recently, the laparoscopic ap- proach to this technique has been shown to be feasible and safe.3–5 Precise preoperative assessment of the loca- tion of the cyst with CT scans is necessary as cysts lo- cated posteriorly in segments VI and VII of the liver are difficult to approach laparoscopically.5 Intra-operative localization of the cyst is also crucial as the laparoscopic approach can be limited by the lack of manual palpation. Superficial cysts are obvious or easily localized by aspira- tion at laparoscopy as in our case. Intra-operative ultra- sound should be used to confirm the anatomy, especially where the cyst is not obvious on surface laparoscopy. Laparoscopic ultrasound provides accurate anatomical lo- calization of lesions and identifies adjacent vascular ped- icles.8 The wide deroofing of superficial cysts can be achieved by using diathermy which is satisfactory for both dissection and haemostasis3,4 but the ultrasonic co- agulating shears may be considered ideal because they provide excellent haemostasis in a relatively smoke-free environment.8 With careful selection of cases, laparoscopic deroof- ing of symptomatic solitary hepatic cysts is safe and ef- fective, and offers all the advantages of minimally invasive surgery.9,10 Patients with symptomatic polycystic liver dis- ease characterised by a limited number of large cysts mainly located on the liver surface have also been re- ported to benefit from the laparoscopic technique.2,3 REFERENCES 1. Jones WL, Mountain JC, Warren KW. Sympto- matic non-parasitic cysts of the liver. Br J Surg 1978, 61, 118–23. 2. Paterson-Brown S, Garden OJ. Laser-assisted laparoscopic excision of liver cyst. Br J Surg 1991, 78, 1047. 3. Morino M, DeGiuli M, Festa V, Garrone C. Laparoscopic management of symptomatic non- parasitic cysts of the liver. Ann Surg 1994, 219, 157– 64. 4. Ker CG, Chen JS, Lee KT, Sheen PC. Laparo- scopic fenestration for a giant liver cyst. Endoscopy 1994, 26, 754. 5. Krahenbuhl L, Baer HU, Renzulli P, Zgraggen K, Frei E, Buchler MW. Laparoscopic management of nonparasitic symptom-producing solitary hepatic cysts. J Am Coll surg 1996, 183, 493–8. 6. Saini S, Mueller PR, Ferrucci JT Jr, Simeone JF, Wittenberg J, Butch RJ. Percutaneous aspiration of hepatic cysts does not provide definitive therapy. Am J Roentgenol 1983, 141, 559–60. 7. Lin TY, Chen CC, Wang SM. Treatment of non- parasitic cystic disease of the liver: a new approach to therapy with polycystic liver. Ann Surg 1968, 921–7. 8. Martin I, Garden OJ. Laparoscopic radical deroof- ing of hepatic cysts using the ultrasonic scalpel. Aust NZ J Surg 1999, 69, 743–4. 9. Klinger PJ, Gadenstatter M, Schmid T, Bodner E, Schwelberger HG. Treatment of hepatic cysts in the era of laparoscopic surgery. Br J Surg 1997, 84, 438–44. 10. Martin IJ, McKinley AJ, Currie EJ, Holmes PH, Garden OJ. Tailoring the management of non-para- sitic liver cysts. Ann Surg 1998, 228, 167–72. Laparoscopic deroofing of hepatic cyst PATIENT AND METHOD DISCUSSION Figure 1. Computed tomographic scan showing a large 17 cm diameter solitary unilocular cyst in the right lobe of the liver. REFERENCES