1. Hepatic Cysts

2. 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.

3. 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

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

5. 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.

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

7. 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

8. 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

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

10. 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.

11. 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

12. 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.

13. 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.

14. 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

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

16. 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

17. 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

18. 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.

19. 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?

20. Thank you