Thoracic Approach for Removal of Hydatid Cysts of the Right Lung and the Liver

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
Thoracic Approach for
Removal of Hydatid Cysts of
the Right Lung and the Liver
Prof. Abdulsalam Y Taha
College of Medicine
University of Sulaimani
2022 1

2. The Case
 A 49-years old man was admitted to
Sulaymaniyah Teaching Hospital,
Sulaymaniyah, Region of Kurdistan, Iraq
on 24th of May 2009 because of frank
haemoptysis of several days duration.
He was a known case of liver hydatid
disease, for which a laparotomy was
done 15 years earlier. CXR (PA and
lateral views) revealed an elevated
right hemidiaphragm. 2

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4. 4

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6. Abdominal US revealed a complicated
hydatid cyst in the posterior part of the liver
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7. 7

8. Complete blood count showed leukocytosis and
neutrophilia consistent with infection
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9. Fiberoptic Bronchoscopy
 ..revealed old clots mixed with pus from the
right middle lobe (RML) and the superior
segment of the right lower lobe (RLL) besides
purulent secretions from the left bronchial
tree.
 The impression was (Suspected liver HC
communicating with the RLL through the
diaphragm).
 CT scan was requested prior to surgical
exploration.
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12. CT scan of the Chest and Upper
Abdomen revealed:
 A complicated HC in the right lower
pulmonary lobe (RLL); 7 x 5 cm in size;
in the posterior basal segment.
 An enlarged liver with multiple (at
least 3) complicated cysts with
calcified walls measuring 3 x 2.5 cm,
6.5 x 5 cm, and 12 x 9.5 cm.
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17. The Management
 The diagnosis was a PHC associated
with recurrent multiple liver HCs.
 The patient was initially managed
conservatively. Antibiotics and
expectorants were prescribed while
the patient was prepared to right
posterolateral thoracotomy. Trans-
thoracic approach was chosen as it
would be ideal for the RLL HC as
well as the liver HCs.
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18. Right thoracotomy for removal of
ruptured RLL PHC and trans-
diaphragmatic removal of 2 huge liver
HCs
1. Under GA, via a double lumen
endotracheal tube in a lateral position.
2. Right 6th space posterolateral
thoracotomy with resection of 1 inch of
the posterior 7th rib to improve exposure
was performed.
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19. Findings
3. Dense adhesions of the RLL to the
diaphragm with whitish external
appearance of RLL posterior segment
(HC) and 2 big bulges of right hemi-
diaphragm anteriorly and posteriorly.
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20. Operative Procedure
4 a: Release of adhesions of RLL to the
diaphragm was done by careful sharp
dissection.
4 b: The diseased posterior basal segment of
the RLL was incised by the electrocautery
and a friable laminated membrane of PHC
was evacuated. Three big bronchial fistulae
were closed by interrupted 2-0 silk sutures,
after which, a very good lung expansion was
achieved.
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21. Operative Procedure…
4 c: The diaphragm was then incised
over the posterior bulge. The area
was probed by the finger. Large
amount of a friable membrane and
mud-like material was evacuated.
The wall of the cyst was fibrosed,
calcified and hard like a bone.
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22. Operative Procedure…
4 d: Another incision was made over
the anterior bulge of the diaphragm.
A large amount of yellowish fluid
together with pieces of membrane
was aspirated. The cavity was very
big. It was cleaned by mopping with
a gauze and then irrigated by a
normal saline mixed with Povidone
Iodine (Betadine). There was no
biliary communication.
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23. Operative Procedure…
4 e: The calcified fibrotic septae were
excised.
4 f: A subphrenic tube drain was placed
in the cystic cavity.
4 g: The diaphragm was closed in 2
layers; interrupted mattress 0-silk and
continuous 0-silk sutures.
4 h: A chest tube was placed.
4 i: The chest wall was closed in layers.
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29. The postoperative course was smooth
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33. Comment
 Not infrequently, thoracic surgeons
are asked for the management of
hydatid cysts located at the upper
part (sub-diaphragmatic location) of
the liver. A thoracotomy provides
better exploration and access to the
cyst located in this area when
compared to the laparotomy.
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34. Comment…
 The principal of the resection of liver cyst
is similar with the pulmonary cyst;
however, there are important technical
differences between the two operations:
the hepatic cysts contain daughter vesicles
more commonly than the pulmonary cysts.
For this reason, a scolocidal agent (to kill
the parasite) such as hypertonic saline
solution or 10% povidone iodine must be
injected through the diaphragm into the
cyst to prevent the spreading of the living
vesicles in the abdomen or thorax before
opening and removal of the cyst.
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35. Comment…
 The diaphragm is cut using a scissors and
its muscle is separated from the cyst by
blunt and sharp dissections with no
pressure over the cyst. When the intra-
cystic pressure has been lowered, the cyst
is opened from the uppermost part of the
cyst and its content is aspirated by a large
holed suction device.
 As the cyst contains numerous daughter
vesicles that are not technically possible to
aspirate with a suction device or take out
by a grasper, a spoon is used to evacuate
the cavity completely.
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