Laparoscopy for Liver Hydatid Disease: Where Do We Stand Today? Deborshi Sharma, MS, MRCS(Ed), FMAS,* Raghavendra Babu, MBBS,* Saurabh Borgharia, MBBS, MS,* Dhiraj Baruah, MD, PDCC,w Shaji Thomas, MS, DNB, FAIS,* and Ajay Kumar, MS, MCh, FICS* Abstract: Hydatid disease mostly affects the liver with Echinococcus granulosus being the most common organism. Surgery remains the gold standard in terms of therapy for patients with echinococcosis of the liver despite significant economic costs, advances in medical treatment, and interventional radiology. Laparoscopy, as a mini- mally invasive surgery, has well-known clinical advantages over traditional surgery. Several reports have confirmed the benefit of a laparoscopic approach to liver hydatid disease. We describe our technique and analyze numerous reports of laparoscopic hydatid liver surgery along with our results. Key Words: hydatid disease, liver cysts, laparoscopy, minimally invasive technique, newer techniques (Surg Laparosc Endosc Percutan Tech 2009;19:419–423) H ydatid disease mostly affects the liver, with Echinoco- ccus granulosus being the most common organism. A mature cyst consists of a layer of living tissue, which includes the germinal layer that surrounds the fluid-filled central hydatid cavity and the laminated membrane together forming endocyst. The compression of the host tissue around the endocyst produces a fibrous layer called ecto- cyst or pericyst. 1 The only live material that should be the target for any treatment modality is the germinative membrane and the fluid it contains together with live and infective protoscoleces or daughter cysts. 2 Surgery remains the gold standard in terms of therapy for patients with echinococcosis of the liver despite significant advances in medical treatment and interven- tional radiology. 3–5 Liver hydatid cysts have been subjected to laparoscopic surgery since 1992. 6 Laparoscopy, as a minimally invasive surgery, has well-known clinical advan- tages over traditional surgery. 5,7,8 However, some contro- versies still exist about the role of laparoscopy in the management of the liver hydatid cyst. Most issues have not been resolved because of scarce laparoscopic experience worldwide for liver hydatid disease. These controversies include selection of patient, exact laparoscopic technique, and maintaining the standards of established safety of procedures during liver hydatid surgery. 9 OUR TECHNIQUE OF LAPAROSCOPIC LIVER HYDATID CYST SURGERY In all patients, diagnosis was made on history, physical examination, ultrasound (Fig. 1), and computed tomogra- phy (Fig. 2). All patients underwent biochemical analysis to rule out evidence of intrabiliary communications and anti- echinococcal IgG was done in all patients. The patients were put on albendazole (800 mg/d) for 2 courses of 21 days each with a gap of 7 days between the two courses. Carbon dioxide pneumoperitoneum pressure was maintained between 12 and 14mm Hg depending on the patient’s weight. The patients were operated in a 30-degree reverse Trendelenberg position. The monitor was kept at the head end of the patient with the surgeon standing between the legs. The camera assistant was toward the left side of the patient in cases of right lobe lesions and vice versa. Supra umbilical camera port (5mm) was inserted and the abdo- minal cavity was inspected. The superficial area of the cyst was identified and 2 working trocars were inserted (10mm, right and 5 mm left) 2.5 cm below the subcostal margins maintaining triangulation. Adhesiolysis was done, if re- quired, followed by a careful reassessment of the surface anatomy of the liver and its relation with the diaphragm (Fig. 3A). About 300 to 400 mL of hypertonic saline (10%) was poured into the peritoneal cavity through one of the ports and 3 to 4-gauze pieces soaked in hypertonic saline were inserted into the cavity to pack the perihepatic area next to the cyst. The cyst was punctured with a laparoscopic FIGURE 1. Ultrasound image showing the large cyst with multiple daughter cysts showing the characteristic spoke wheel appearance. Copyright r 2009 by Lippincott Williams & Wilkins Received for publication June 5, 2009; accepted September 25, 2009. From the Departments of *Surgery; and wRadiology, Lady Hardinge Medical College, New Delhi, India. Reprints: Dr Deborshi Sharma, MS, MRCS(Ed), FMAS, Department of Surgery, Lady Hardinge Medical College, New Delhi 110001, India (e-mail: deborshi_sh@yahoo.com; drdeborshi@gmail.com). REVIEW ARTICLE Surg Laparosc Endosc Percutan Tech  Volume 19, Number 6, December 2009 www.surgical-laparoscopy.com | 419