Laparoscopic Treatment of a Perforated Hydatic Cyst

Echinococcosis is a zoonosis transmitted by dogs and accidentally affects man. Worldwide, Echinococcus granulosus occurs most frequently. This relatively benign parasitic disease is characterised by slowly growing cysts, most commonly in the liver, less frequently in lungs and rarely elsewhere in the body. Seeding of cyst content into the peritoneal cavity is a serious secondary complication of cyst rupture. The complex of parasitic cyst with fibrous capsule is called Echinococcus cyst or hydatid cyst. The ruptured cysts can cause anaphylactic reaction, abdominal pain and implantation of the new cyst material. Intraperitoneal rupture of hydatid cyst results in dissemination of hydatid fluid, broad capsules, and scolices into the peritoneum, leading to a transient peritoneal irritation of varying severity. Viable protoscoleces may develop into new hydatid cysts causing substantial morbidity in the future. The reproductive elements usually initiate the formation of new cysts in the peritoneal cavity.1
We present herein a case of spontan perforated hepatic hydatid cyst that operated laparoscopically.

CASE
A 65 years old woman with nonspesific symptoms admitted to the Ýnternal medicine department.
Physical examination revealed an epigastric mass. Ultrasonography demonstrated a 18x14x11 cm cyst in the left lobe of the liver. CT demostrated the same cyst with the signs of hydatic cyst The result of Elisa was 1/640 positive. Ýn the thirteenth day of the hospitalisation a hypotansion and syncop occured and spontaneously regulated only with ringer lactat infusion. The MRI on the next day of the syncope demostrated that the cyst had perforated While the surgical consultation on the same day she had tenderness on the upper quadrants, vomiting and 14.800/mm white blood cell count. Other hematological and biochemical tests were within normal limits. These findings suggested an hydatid cyst rupture. Emergency laparoscopy was performed. Ýn abdominal exploration free intrabdominal fluid mixed with hydatid cyst material, peritonitis and dense adhesions between omentum, hydatid cyst, stomach, colon and liver After blunt dissection we see that cyst was ruptured throught its superiolateral wall. Fig.5 In operation total cystectomy, intraflexion – capitonage and drainage of the cyst performed Germinal Capsule extracted by using endobag . Bridectomy done with blunt and sharp dissection then remove cyst content by aspiration and abdominal cavity irrigated with povidone iodine in order to kill viable scolecs. Two drains put into subdiaphragmatic and douglas regions. Drain fluids are dedected microscopically for viable scolecs everyday and all of them were negative. Albendazole was prescribed in order of 10 mg/kg, to prevent recurrence on the second day postoperatively. On 9th day postoperatively control USG demostrated that cyst totally collapsed and 100 cc liquid at douglas. Douglas punctioned and sample dedected microscopically for viable scolecs and result was negative. Postoperative period was uneventful and the patient was discharged on tenth day. It’s planned to use Albendazole for 6 months post-treatment prophylaxis.

DISCUSSION
spontaneously hydatid cyst rupture is very rare. Great care should be taken to prevent the spillage of hydatid cyst contents during the operation. In cases of intraperitoneal traumatic or spontaneous rupture, all of the cyst contents should be removed.1 Abdominal cavity should be irrigated with appropriate scolocidal solutions in order to kill all scolex and prevent recurrence. 1
Anaphylactic shock, cyst infection and rupture are the most severe complications. Anaphylactic shock due to spontaneous or traumatic cyst rupture or during surgery is a rare and severe complication. Patients may die when diagnosis is not recognised, appropriate treatment is not immediately at hand or anaphylaxis is refractory to treatment. 3.4.5.6

When a peritoneal cyst ruptures into the abdomen, complaints of the patient are not so severe. Mild tenderness is found, but signs of acute abdomen not seen. 2
Ultrasonography (US) is the preferred diagnostic tool for hepatic hydatid cysts. Computed tomography is currently the most sensitive tool for demonstrating hydatid cyst rupture of the liver. 7 MRI is not indicated for routine diagnosis but only when complications are suspected. 1 ELISA is used as a screening test and IE (immuno-electrophoresis) as confirmation test. Serology may be negative in 10 -15% of cases, especially in well encapsulated cysts and pulmonary cysts.1
The core principles of hydatid surgery are total removal of all infective cyst parts and avoidance of intra-abdominal spillage of cyst content. In the view of experts, cystectomy is the procedure of choice. Cystectomy involves removal of the parasitic cyst or endocyst: laminar layer, germinal layer and cyst content. The pericyst (the fibrous capsule) is not resected. 8.9.10

Laparoscopic (peri)cystectomy or drainage of anteriorly located cysts was introduced as a new surgical technique. 1 Compared to the classical approach by laparotomy, this method is less traumatic for the patient, requires a shorter hospital stay and recovery is faster. Results are encouraging even in 6 complicated cases. During long-term follow-up, high success rates (77-100%) and low complication (0-17%) and recurrence rates (0-9%) were reported. However, this technique is limited to laparoscopically accessable cysts, mainly those located anteriorly in the liver. Expert consensus on indications and contraindications is needed. 11.12.13

In hydatid liver disease, the risk of dissemination of the cyst contents can be avoided by injection of scolicidal agents such as; cetrimide, hydrogen peroxide, povidone iodine, nitrate de argent, hypersonic saline or praziquantel.14,16

Povidone iodine was recommended as scolocidal agent against peritoneal hydatidosis but cetrimide and hipertonic saline was found to be not effective. 15,16

Albendazole medication: definite cure, reduction of cyst viability, preoperative treatment and
perioperative prophylaxis. In urgent cases immediately before or after the intervention. Advises for post-treatment prophylaxis range from 3-8 weeks for uncomplicated cases. In complicated cases with higher risk for spillage of cyst content 3-6 months are arbitrarily advised. 1


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