Hepatic Cysts

Introduction The term hepatic cyst usually refers to solitary nonparasitic cysts of the liver, also known as simple cysts. Most simple cysts asymptomatic and require no treatment. When the cysts become large and cause symptoms, treatment is warranted. Today, laparoscopic unroofing（去顶术） of large simple cysts has become the preferred treatment option.

History of the Procedure Diagnosis confirmation: an abdominal mass or an incidental finding during laparotomy ultrasonography and computed tomography scans Treatment ：laparotomy laparoscopic approach Frequency: 5% , less than 10-15% symptomatic

Classification nonparasitic cysts congenital cysts simple cyst multiple cysts inflammatory cysts cystic tumors traumatic cysts parasitic(echinococcal、棘球蚴) cysts

Etiology simple cysts ：unknown, congenital in origin. perhaps progressive dilatation of biliary microhamartomas（微错构瘤）. seldom contain bile？Hypothesis？ polycystic liver disease : congenital echinococcal cysts:infestation with E granulosus.

Pathophysiology simple cyst: fluid secretion by the epithelial lining ,needle aspiration ? echinococcal cysts: life history of E granulosus

Clinical presentation simple cyst dull right upper quadrant pain, satiety(饱涨感），a palpable abdominal mass polycystic liver disease hepatomegaly , hepatic fibrosis, portal hypertension, and liver failure echinococcal cysts similar to patients with simple cysts. rupture into different sites (the biliary tree, the chest, the peritoneal cavity) ； secondary infection

Auxiliary inspection 1、Lab Studies: liver (renal) function test ,PT,KPTT; BR (eosinophilia 嗜红细胞增多) , echinococcal antibody titers 2、Imaging Studies: Ultrasonography Computed tomography MRI

Imaging Studies Ultrasound appearance of a patient with a large simple hepatic cyst.

Imaging Studies CT scan appearance of a large hepatic cyst. MRI reconstruction in a patient with a large echinococcal cyst; note daughter cysts in interior.

Auxiliary inspection 3、Percutaneous Aspiration avoided cytologic evaluation of the cyst fluid is nondiagnostic a small risk exists of inducing anaphylaxis from leakage from the hydatid cyst. 4、Histologic Findings: routinely, suspected neoplasm

Differentiatial diagnosis based on the patient symptoms and the radiographic appearance of the lesion Simple cysts tend to have thin and uniform walls ,homogenous low-density interiors. Cystic neoplasms tend to have thicker, irregular, hypervascular walls and heterogeneous interiors with septa（隔膜） and papillary extrusions（乳头状突起）. echinococcal cysts can be identified by the presence of daughter cysts within a thick-walled main cavity.

Indications and Contraindications nonparasitic cysts : symptomatic patients echinococcal cysts: complications related to cyst growth and rupture contraindications to treatment of symptomatic liver cysts relate mainly to underlying comorbid(伴随） illnesses that increase surgical risk.

Clinical Therapy Medical therapy : Percutaneous aspiration under US or CT guidance , recurrence rates nearly 100% Percutaneous aspiration combined with sclerosis ，therapeutic effect? Albendazole（阿苯达坐） or mebendazole for echinococcal cysts

Surgical therapy: simple cyst: laparoscopical cyst unroofing polycystic liver disease : laparoscopical cyst unroofing laparoscopical fenestration（开窗术） liver resection liver transplantation

Surgical therapy: echinococcal cysts: 2 technical problems Strategy 1. anaphylaxis（过敏） ： spillage（溢出） of cyst fluid containing eggs and larvae into the peritoneal cavity 2. recurrence ： residual eggs in incompletely removed germinal membranes(生发层） Strategy cyst contents aspirated and replaced with a hypertonic saline solution before unroofing and pericystectomy

Surgical therapy 1. laparoscopic view of the initial hepatic cyst puncture before unroofing. 2. Laparoscopic view of the beginning of unroofing a large simple hepatic cyst 3. Drawing of final result of laparoscopic unroofing of a large simple hepatic cyst in the right lobe of the liver 1 3 2

Postoperative complications and Follow-up care trocar site infection a subhepatic or subphrenic fluid collection bile ascites anaphylaxis Follow-up care 2 weeks and again 6 weeks after surgery to assess symptomatic relief and identify complications Routine radiographic studies are not obtained unless symptoms recur.

Emphasis should be grasped ? The definition and classification of hepatic cyst? Differentiatial diagnosis of hepatic cyst? The tchnical points of laparoscopical cyst unroofing? How to prevent anaphylaxis and recurrence of echinococcal cysts during laparotomy?

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