Abstract
Large hepatic cysts can cause abdominal pain, pressure symptoms, or liver dysfunction. Although laparoscopic fenestration is the standard surgical approach, recurrence remains a concern. As laparoscopic hepatectomy techniques have advanced, we have adopted laparoscopic left lateral segmentectomy as a curative treatment for symptomatic cysts located in the left lateral segment. Between 2018 and 2023, 4 patients underwent laparoscopic left lateral segmentectomy for symptomatic hepatic cysts at our institution. All procedures were performed using five ports. Cystic fluid was aspirated as much as possible, and hepatic transection was conducted under the total Pringle maneuver using ultrasonic dissectors. Small vessels were sealed, while larger vessels and Glissonean pedicles were clipped or divided with linear staplers. Resected specimens were retrieved via an extended umbilical incision. Surgical and postoperative parameters were analyzed to evaluate the safety and efficacy of the procedure. The cohort included 1 male and 3 female patients, with a mean age of 63 years. Presenting symptoms included abdominal pressure (3 cases) and epigastric pain (1 case). The mean maximum cyst diameter was 16.3 cm, and the average aspirated volume was 950 mL. The mean operative time was 232 minutes, and the mean blood loss was 48 g. No postoperative complications were observed. The average postoperative hospital stay was 6 days. All patients experienced symptom resolution without delayed complications during follow-up. Laparoscopic left lateral segmentectomy might be a safe and curative surgical option for symptomatic hepatic cysts located in the left lateral segment.
Keywords
Introduction
Hepatic cysts are frequently encountered benign lesions of the liver, with a reported prevalence of up to 18% in the general population detected by imaging studies such as ultrasonography or computed tomography (CT). 1 Most hepatic cysts are simple, asymptomatic, and incidentally discovered. However, large cysts can cause symptoms including abdominal pain, pressure sensation, early satiety, or even liver dysfunction due to mass effect. In such symptomatic cases, surgical intervention is warranted. 2
Laparoscopic fenestration has become the standard surgical approach for symptomatic hepatic cysts, owing to its minimally invasive nature, short recovery time, and low perioperative morbidity. 3 Nevertheless, recurrence rates of up to 20%–30% have been reported, especially in patients with large or deep-seated cysts or in cases with incomplete excision of the cyst wall. 4 Recurrence can lead to reappearance of symptoms and the need for repeat intervention.
With the advancement of laparoscopic hepatectomy techniques, including improved instrumentation, enhanced visualization, and refined anatomical understanding, laparoscopic anatomical liver resection has become increasingly feasible and safe. 5 As laparoscopic hepatectomy techniques have advanced, we have adopted laparoscopic left lateral segmentectomy as a curative treatment for symptomatic cysts located in the left lateral segment. This approach allows for complete removal of the cyst-bearing liver parenchyma, eliminating the risk of recurrence and offering definitive treatment.
The present study aims to evaluate the safety and feasibility of laparoscopic left lateral segmentectomy for symptomatic hepatic cysts located in segments II and III, based on a retrospective review of cases performed at our institution.
Materials and Methods
Patients
From January 2018 to December 2023, 4 patients with symptomatic hepatic cysts located in segments II and III underwent laparoscopic left lateral segmentectomy at our department. All patients were diagnosed as having hepatic cysts extending from the lateral segment on CT (Fig. 1a) and presented with clinical symptoms attributable to the cysts, including abdominal pressure or pain.
Presentation of representative case and intraoperative views of laparoscopic left lateral segmentectomy.
Surgical procedure
The procedure was performed under general anesthesia with the patient in a supine position. Five ports were placed under laparoscopic guidance (Fig. 1b). Figure 1c showed a cystic lesion in laparoscopy. After aspirating cystic fluid to decompress the lesion (Fig. 1d), hepatic transection was initiated under intermittent total Pringle maneuver (Fig. 1e). Cavitron ultrasonic surgical aspirators (CUSA) were used for parenchymal dissection (Fig. 1f). Small vessels were coagulated and divided using vessel sealing devices, while larger structures such as Glissonean pedicles and hepatic veins (G2, G3, and the left hepatic vein) were divided using endoscopic linear staplers (Fig. 1g). The resected specimen (Fig. 1h) was placed in an endo-bag and retrieved through an extended umbilical incision.
Postoperative management
In all cases, drains were inserted into the resected surface to obtain information on bleeding. The drain fluid was evaluated for total bilirubin concentration, and drain removal was performed. In cases with clinical concern for bile leakage, postoperative CT was obtained prior to drain removal. After discharge, all patients underwent follow-up imaging (ultrasonography or CT) at 3 or 6 months to confirm the absence of recurrence or new cyst formation (Fig. 1i).
Data collection
Patient demographics, operative parameters, perioperative outcomes, and postoperative course were reviewed retrospectively from medical records.
Results
Table 1 showed the patient characteristics and clinical presentations of 4 cases. The patient cohort consisted of 1 male and 3 females, with a mean age of 63 years (range 58–68). Presenting symptoms were abdominal pressure in 3 patients and epigastric pain in 1. In case 3, the primary disease is polycystic liver disease, and aspiration of the cystic fluid was not performed during surgery. The mean operative time was 232 minutes (range 210–260), and the mean intraoperative blood loss was 48 grams (range 30–60). There were no intraoperative complications or conversions to open surgery. No postoperative complications occurred, and the average length of hospital stay was 6 days. All patients experienced resolution of their symptoms, and no late complications or cyst recurrence was observed during the follow-up period.
Patient Characteristics and Clinical Presentations
Discussion
While laparoscopic fenestration is the standard treatment for symptomatic hepatic cysts, the recurrence rate is not negligible, especially in cases involving large or multilocular cysts. 6 Laparoscopic liver resection, particularly in the left lateral segment, has become an increasingly safe and standardized procedure. In our series, laparoscopic left lateral segmentectomy provided definitive treatment without complications or recurrence. Operative time and blood loss were acceptable, and recovery was smooth in all cases. Compared to fenestration, resection might be more invasive. However, in well-selected patients with localized large cysts and available surgical expertise, the benefits of curative resection outweigh the risks.
Historically, laparoscopic fenestration has been widely adopted as the first-line treatment for symptomatic simple hepatic cysts. 5 This technique is associated with low perioperative morbidity and short hospital stay. However, recurrence rates ranging from 10% to 30% have been reported, particularly when the cyst wall is incompletely excised or when the cyst is located in deep hepatic parenchyma. 7 In recurrent cases, repeated surgery may be technically more challenging due to adhesions, and patients may experience a significant impact on quality of life.
Laparoscopic left lateral segmentectomy has evolved into a standardized and highly reproducible anatomical resection. The left lateral segment is anatomically well-defined, with clear demarcation between segments II/III and segment IV, making it ideally suited for anatomical resection. The development of advanced laparoscopic instruments, improved imaging technology, and refined surgical techniques has enabled safe vascular control and precise parenchymal transection. According to international consensus statements, laparoscopic left lateral segmentectomy is one of the most widely accepted anatomical liver resections for the laparoscopic approach, with consistently low rates of blood loss, morbidity, and conversion. 8 In our series, the procedure was performed with minimal blood loss, no postoperative complications, and prompt recovery, supporting its role as a mature, curative technique for appropriately selected patients.
Compared with fenestration, laparoscopic left lateral segmentectomy offers the advantage of definitive removal of the cyst-bearing parenchyma, virtually eliminating recurrence risk. While the surgical procedure is more invasive than fenestration, laparoscopic left lateral segmentectomy might be an attractive option for large cysts with localized symptoms because they eliminate the risk of reoperation and recurrence. 3 Nevertheless, the choice between fenestration and resection should be individualized. Hepatic resection is essentially more invasive and might not be justified for small cysts, patients with significant comorbidities, or those with diffuse cystic disease. In our series, the indication for hepatic resection was large cysts confined to the left lateral segment with significant symptoms, where complete excision was feasible and expected to provide long-term relief.
Conclusions
In the present series, laparoscopic left lateral segmentectomy for symptomatic hepatic cysts resulted in complete symptom resolution without recurrence, perioperative complications, and conversion to open surgery. These findings highlight the potential role of anatomical resection as a definitive treatment option for selected patients.
Authors’ Contributions
M.Y.: Investigation, data curation, analysis, writing draft. K.F.: Conceptualization, editing draft. K.H., T.T., Y.S., S.O., M.M., N.O., and M.T.: Investigation. T.I.: Supervision. All authors have read and approved the final manuscript.
Footnotes
Funding Information
This work was supported by Japan Society for the Promotion of Science (JSPS) KAKENHI Grants (23K08222 to K.F., and 24K19377 to M.Y.) and by YOKOYAMA Foundation for Clinical Pharmacology (to M.Y.).
Statement of Ethics
The present study adhered to the Declaration of Helsinki, and the patient gave her consent for the case report to be published.
Disclosure Statement
No competing financial interests exist.