Technical Report of a Novel Surgical Technique: Laparoscopic Cyst Fenestration and Falciform Ligament Pedicle Graft for Treatment of Symptomatic Simple Hepatic Cysts

Introduction

Large, symptomatic simple hepatic cysts are a rare cause of chronic abdominal pain. Symptoms, when they occur, are amenable to surgical therapy.^1,2 Following the initial description of a laparoscopic approach to the symptomatic simple hepatic cyst by Patterson-Brown and colleagues in 1991, operative therapy have continued to evolve from open resection to minimally invasive techniques. ³ The limiting factor of minimally invasive therapy for simple hepatic cysts has been recurrence of symptoms. To reduce the incidence of persistent or recurrent symptoms, authors have suggested the use of an omental plug to fill the residual cyst cavity after marsupialization.^2,4–7 Despite the use of the omental plug, recurrent symptoms have been reported in over 30% of patients.^2,8 Our experience with over 200 symptomatic simple hepatic cysts has lead to the development of a laparoscopic mini-fenestration technique with placement of a vascular falciform ligament pedicle graft into the residual cyst cavity. The use of the falciform ligament graft facilitates cyst drainage and prevents formation of adhesions to surrounding structures that may contribute to the recurrence of symptoms. We believe that this mini-fenestration technique, combined with the falciform ligament graft, is a novel treatment strategy that reduces recurrent symptoms in the treatment of symptomatic simple hepatic cysts. The goal of this technical report is to describe the technique of laparoscopic cyst fenestration and falciform ligament pedicle graft placement for treatment of symptomatic simple hepatic cysts.

Procedure

After decompression of the stomach with a nasogastric tube, a 5 mm trocar is placed in the left upper quadrant of the abdomen using a modified Veress needle technique. A complete laparoscopic examination of the abdomen is carried out and the hepatic parenchyma is inspected (Fig. 1). Two additional 5 mm ports are placed; one in the para-umbilical area and one in the right upper quadrant. If intra-operative ultrasonography is required, the para-umbilical port is upsized to a 12 mm port. The camera is moved to the para-umbilical port and the right and left upper quadrant ports become the operative ports. The cyst is identified and carefully inspected. The location for the entrance to the cyst cavity is chosen to allow for tension-free placement of the falciform ligament pedicle graft (Fig. 2). A 3–5-cm-diameter area of the cyst wall is excised and sent for frozen section. The cyst contents are evacuated through this site and the cyst cavity is carefully inspected. While awaiting the results of the frozen section, the falciform ligament is mobilized from the umbilicus to the liver, taking care to preserve the blood supply and venous drainage of the pedicle graft. The falciform pedicle graft is placed into the cyst cavity and the edges of the pedicle graft are secured to the edge of the cyst with intracorporeal sutures or clips (Fig. 3). Care is taken to avoid disrupting the cyst near the peritoneal reflections at the diaphragm, colon, and gallbladder.

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FIG. 1.

Laparoscopic view of cyst in left lobe of the liver before fenestration.

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FIG. 2.

View of cyst cavity after fenestration before placement of falciform pedicle graft.

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FIG. 3.

View of cyst cavity with falciform pedicle graft within residual cavity. Falciform pedicle graft secured to liver edge with two 10 mm clips.

Patients and Methods

To assess this new technique, we prospectively collected data on consecutive patients with symptomatic simple hepatic cysts commencing January 2009 (Table 1). All patients undergoing fenestration of simple hepatic cysts (single or multiple) were included in the study. Demographic information, presenting complaints, as well as biochemical and radiographic investigations were collected. Postoperatively, clinic records were followed to document postoperative recovery, final pathology results and monitor for recurrence of symptoms. Six patients were identified who required definitive management of simple hepatic cysts. Presenting complaints were right upper quadrant abdominal pain in 4 patients, back pain in 1 patient, and recurrence of a cyst after acute rupture in 1 patient. The patient who had suffered an acute rupture felt she would not tolerate the pain of another rupture and favored definitive surgical management of her cyst. At our institution cyst fenestration is generally attempted laparoscopically and is booked as a day-care procedure, with patients discharged home the day of surgery.

Four of 6 patients had previous abdominal surgery. Three patients had previous open hysterectomies and 1 patient had a laparoscopic removal of an ovarian cyst. The mean age of patients undergoing laparoscopic cyst fenestration was 63.2 years, with a range of 39–78 years. Co-morbid illnesses included coronary artery disease, chronic renal failure, and the presence of an abdominal aortic aneurysm. A patient had a history of postoperative nausea and vomiting, which had previously required hospitalization for symptom control.

All Patients are assessed in a multidisciplinary preoperative assessment clinic headed by an anesthesiologist before operation. Computed tomography was performed in all patients (Fig. 4). The greatest diameter of each cyst was measured with a mean value of 11.3 cm (range 7–16 cm). Cysts were located in the right lobe in 4 patients and left lobe in 2 patients. There was radiographic evidence of previous hemorrhage in 1 patient, but no septae or papillae were demonstrated on the computed tomography in any of the patients.

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FIG. 4.

Preoperative computed tomography scan showing suspected simple hepatic cyst.

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FIG. 5.

Postoperative computed tomography scan demonstrating complete drainage of the cyst with the falciform graft within the residual cyst cavity.

Results

All 6 consecutive patients were treated with laparoscopic cyst fenestration. There were no immediate operative complications, and there were no conversions to open procedures. In each case the cyst was identifiable on the liver surface, and therefore intra-operative ultrasonography was not performed. Four patients were discharged home within 6 hours of the procedure and 2 patients required hospital admission, for a total of 3 and 4 days, respectively. One of these patients required admission for symptomatic control of anticipated postoperative nausea and vomiting, and one for management of postoperative dyspnea secondary to a pleural effusion. This patient had a significant history of coronary artery disease, and there was concern that the pleural effusion may represent a postoperative coronary event (Table 2).

Laparoscopic cyst fenestration was the primary procedure in 5 of 6 patients. A single patient, initially investigated at a peripheral hospital, had undergone percutaneous drainage of a large hepatic cyst. The cyst re-accumulated and symptoms recurred within 2 weeks of drainage; therefore, the patient was referred for surgical management. Occasionally, to determine if the symptoms are attributable to the cyst, ultrasound-guided large volume cyst aspiration is completed. Improvement in symptomatology indicates that the patients symptoms are likely related to the cyst and not to other pathology. Frozen sections were sent to pathology for preliminary diagnosis in all cases. In each case the report of the frozen section confirmed simple hepatic cysts. Preoperative serology for echinococcus did not reveal any positive results. Final pathology confirmed simple hepatic cysts in 5 of 6 patients. In 1 case, despite a reported benign frozen section, final pathology revealed findings suspicious for biliary cystadenoma. In light of this diagnosis the patient underwent elective open resection of the residual cyst.

There was one complication in our series of 6 patients. A single patient developed postoperative dyspnea with chest radiograph demonstrating atelectasis of the right lower lobe of the lung. In light of the patients underlying coronary artery disease, the patient was assessed by the medicine consultation service. This patient required hospital admission and chest physiotherapy but did not require further invasive diagnostic procedures. A repeat chest radiograph on postoperative day 2 showed the presence of a pleural effusion that was drained via thoracocentesis. This completely resolved the patient's dyspnea and allowed for discharge home on postoperative day 4 without any further complaints at 13 month follow-up.

Follow-up ranges from 3 to 13 months with a mean of 9.6 months. There have been no complications in any of the patients to date and symptoms have resolved in all patients. A single patient required an elective hepatic resection based on the results of final pathology showing biliary cystadenoma. This diagnosis was in spite of a frozen section demonstrating a simple hepatic cyst.

Discussion

Hepatic cysts are estimated to occur in 1%–7% percent of the population and are most frequently encountered as an incidental finding of abdominal radiographic examinations.^1,5,9,10 Simple hepatic cysts form ∼37% of all hepatic cysts, of which a minority will be symptomatic.^11,12 Symptomatic simple hepatic cysts occur most commonly in female patients and incidence increases with age. ¹⁰ Symptoms, when they occur, are most frequently abdominal pain or distension, although acute complications, including hemorrhage, infection, and rupture, are described.^1,9,10 In our series 5 of 6 patients suffered chronic abdominal pain. Four patients described constant right upper quadrant pain and 1 patient described pain radiating to the back. One patient had suffered a ruptured cyst and had radiographic evidence of cyst recurrence and strongly favored definitive management of the cyst. In our series of 6 patients, symptoms have been completely resolved by laparoscopic cyst fenestration without any clinical evidence of recurrence to date.

Management options for the symptomatic cyst include observation, percutaneous therapy, minimally invasive fenestration, and open resection. The utility of percutaneous therapy is hampered by a recurrence rate of ∼50%. ¹¹ Recurrence may be decreased by the addition of a sclerosant such as alcohol, but the safety of sclerosant therapy has been questioned. ⁵ Percutaneous techniques can be useful in patients with co-morbid conditions that prohibit general anesthesia. The single patient in our series who underwent percutaneous drainage had recurrence of symptoms and radiographic evidence of cyst recurrence within 2 weeks of attempted drainage. We continue to advocate surgical management for all patients with symptomatic simple hepatic cysts and reserve percutaneous therapy for those patients that cannot tolerate surgery.

Laparoscopic management of the simple hepatic cyst was first described by Paterson-Brown and colleagues in 1991. ³ Since then, multiple successful case series have demonstrated the safety and definitive nature of laparoscopic management of simple hepatic cysts.^4–6,9 Some authors have suggested that open cyst resection is associated with a lower rate of recurrence and favor this operation.^11,13 Although the risks of hepatic resection are small when performed in a major hepatobiliary center, we feel that laparoscopic fenestration allows a less invasive definitive operation.

Adjuvant techniques to laparoscopic fenestration aimed at reducing the rate of cyst recurrence include wide excision and coagulation of the cyst wall, the use of an argon coagulator to destroy the cyst wall epithelium, and placement of an omental patch within the residual cavity.^{1,2,4–6,8,9} Each adjunct is associated with complications that are avoided by performing the mini-fenestration and falciform patch technique. Wide deroofing of the cyst wall has been associated with hemorrhage from the cut surface of the liver. ¹³ We perform mini-fenestration, which allows complete observation of the cyst cavity to rule out malignancy, but do not advocate radical fenestration. Emmermann et al. questioned the safety of coagulation of the cyst wall with diathermy or argon beam because of the theoretical risk of thermal injury to the hepatic vasculature. ²

The use of an omental plug to facilitate drainage of the residual cyst cavity has been reported.^2,6–8 Failure to place such a plug has been described as a major factor in cases of recurrence after laparoscopic cyst deroofing. ⁸ The omental plug will facilitate drainage from the cyst in the same manner as our falciform ligament pedicle, but requires mobilization of the omentum and may lead to adhesions involving the stomach or colon to the cyst. Bleeding from torn omental vessels has been described after the placement of an omental patch. ¹⁴ Although mobilization of the omentum is a technically straight forward procedure, we believe that the falciform ligament pedicle offers a safer, more efficient, peritoneum-covered graft.

Emmerman and associates demonstrated the utility of an omental plug in 13 patients without evidence of cyst recurrence. ² In this series radical fenestration was performed with the addition of an omental flap. The authors believe that radical fenestration is an integral part of the success of this operation. An additional case series of patients undergoing laparoscopic cyst deroofing described the utility of an omental patch in 6 of 10 patients. ⁷ In this case series there was a single recurrence over a range of 6–36-month follow-up. This patient had polycystic liver disease and had only partial cyst deroofing at the time of operation. ⁷

Mobilization of the falciform ligament provides a vascular, peritoneum-covered graft useful in upper abdominal surgery. The utility of a falciform ligament graft to support an esophageal–jejunal anastamosis was described by Strode in 1950. ¹⁵ The successful use of the falciform ligament in the repair of perforated duodenal ulcers has also been well described.^15,16 Ozmen and associates presented a case series of 20 patients with hydatid cysts of the liver treated with partial cystectomy and falciformoplasty with positive initial short-term results. At a median follow-up of 9 months, ultrasonography revealed that all cyst cavities were fully collapsed and blood flow to the falciform ligament was persevered. ¹⁷ The use of the falciform ligament as a vascular pedicle graft to prevent cyst recurrence after fenestration of simple hepatic cysts has not been previously described.

Cyst recurrence has been attributed to development of adhesions between the area of fenestration and adjacent abdominal organs.^2,18 Tagaya and associates noted that adhesions between abdominal viscera and the fenestrated portion of the cyst had lead to recurrence in a single patient who required reoperation for recurrent symptoms. ¹⁸ The falciform pedicle graft used in our case series minimizes surgical dissection and does not involve manipulation of surrounding abdominal organs. This may lead to decreased adhesions to surrounding structures and is a theoretical advantage over the use of an omental plug.

Laparoscopic cyst fenestration is a planned day-care procedure at our institution. Two of our 6 patients required hospital admission, 1 for anticipated postoperative nausea and vomiting and the other for dyspnea. Hospital stay after laparoscopic cyst deroofing varies from institution to institution. A case series of 10 patients with laparoscopic fenestration of hepatic cysts had a mean postoperative stay of 4 days with a range of 3–6 days. ⁷ A series of 16 patients with laparoscopic deroofing published in 2003 had a mean length of stay of 4 days with a range of 3–7 days. ⁴ A retrospective review of a single institutions experience with both laparoscopic and open management of simple hepatic cysts demonstrated a reduction in length of stay from 8 days after open surgery to 3 days after laparoscopic surgery. ¹⁰ An additional retrospective review by Gigot et al. demonstrated a reduced length of stay from 9.2 days after an open approach to 5.3 days after laparoscopic fenestration. ⁹

As demonstrated in our series, conversion rates to open procedures remain low. There were no conversions to laparotomy in any of the patients in our series. In a case series of 16 patients with attempted laparoscopic deroofing, a single patient (6%) required conversion to an open procedure. This was in a patient with a large cyst in segment VIII in which it was found to be impossible to laparoscopically mobilize the right lobe. ⁴ Despite preoperative investigations it is impossible to completely exclude malignancy before surgery. Therefore, surgeons managing hepatic cysts must be able to manage all facets of hepatobiliary disease, including formal open hepatic resections if required.

In conclusion, we feel that laparoscopic mini-fenestration and placement of falciform pedicle graft into the residual cyst cavity is the safest treatment strategy for symptomatic simple hepatic cysts. The falciform graft facilitates drainage and prevents fluid re-accumulation while eliminating the potential morbidity associated with radical fenestration. Our case series has demonstrated the technical feasibility of this novel procedure and have shown encouraging early results. As with any new procedure the long term outcome is yet to be assessed.