laproscopic treatment of hydatid cyst

1. Case presentation
• DR SUJAN SHRESTHA
• 2ND YEAR ,RESIDENT
• SURGERY,MCOMS

2. PATIENT WAS ADMITTED WITH THE CHIEF COMPLAIN OF
-PAIN ABDOMEN SINCE 1 MONTH
 NO H/O OF VOMITING,WT LOSS,ANORXIA,FEVER,TRAUMA
 NORMAL BLADDER AND BOWEL H/O
• Epigastric region
• Insidious onset
• Mild and continuous
• Dull type
• No aggravating and relieving factors
Associated with epigastric fullness
• Spontaneous onset
• Non progessive

3. PAST H/O:
 NO PAST SURGICAL H/O
 NO PAST MEDICAL H/O
PERSONAL H/O:
• NON VEG
• SOCIAL DRINKER [LOCAL SPIRIT]
• NON SMOKER
• NORMAL BLADDER AND BOWEL H/O
• NO H/O OF SIMILAR COMPLAIN AMONG FAMILY MEMBERS
• HAVE 2 DOGS AS PETS.
DRUG AND ALLERGIC H/O:
 NO KNOWN ALLERGIC H/O

4. GENERAL EXAMINATION:
• PATIENT NOT ILLLOOKING ,THIN BUILT,COMFORTABLY LYING IN BED
• ORIENTED TO TIME PLACE AND PERSON
VITALS:
 T=AFEBRIL
 P=80 BEATS /MIN REGULAR IN RT RADIAL ARTERY
 BP=110 / 70 MMHG IN RT ARM
 RR=16 BREATH /MIN
 SPO2=97% IN ROOM AIR
SYSTEMIC EXAMINATION:
CHEST:NORMAL VESICULAR BREATH SOUND B/L
CVS:S1 S2 NORMAL ,NO ADDED SOUND
CNS:GROSSLY INTACT

5. LOCAL ABDOMINAL EXAMINATION:
INSPECTION:
 LOOKS DISTENDED
 ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION
 NORMAL OVERLYING SKIN
 NO SUPERFICIAL DILATED VEINS
 NO VISIBLE PERISTALSIS OF PULSATION
 UMBILICUS SHIFTED DOWNWARD AND INVERTED
 HERNIAL ORIFICES INTACT
INSPECTION OF THE MASS
• SWELLING PRESENT IN EPIGASTRIUM EXTENDING UPTO MEDIAL HALF OF LEFT
HYPOCHONDRIUM AND CRANIAL HALF OF THE UMBILICAL REGION
• APPROXIMATELY 10 *15 CM
• MARGIN NOT CLEARLY DEFINED
• MOVEMENT WITH RESPIRATION PRESENT

6. PALPATION:
 NO LOCAL RISE OF TEMPERATURE
 NO SUPERFICIAL OR DEEP TENDERNESS OR REBOUND TENDERNESS
PALPATION OF THE SWELLING:
 10 * 14 CM SWELLING IN EPIGASTRIUM
 EXTENDED LATERALY UPTO LEFT HYPOCHONDRIUM AND INFERIORLY UPTO UMILICAL
REGION
 SUPERIOR ENTENSION COULD NOT BE DETERMINED
 SMOOTH SURFACE
 INFERIOR AND LATERAL MARGIN WELL DEFINED
 UPPER MARGIN IS NOT FELT
 NO CHANGE IN LOCATION OF MASS ON PATIENT CHANGE IN POSITION
 ON RAISING HEAD MASS IS LESS PROMINENT

7. PERCUSSION:
PERCUSSION OVER THE SWELLING
 DULL ON PERCUSSION
 NON SHIFTING DULLNESS
 HYDATID THRILL POSITIVE
 NORMAL BOWEL RESONANCE IN OTHER QUADRANTS OF ABDOMEN
AUSCULTATION:
 NORMAL BOWEL SOUND
 NO BRUIT HEARD

8. PATIENT WAS ADMITTED AND RELEVANT INVESTIGATIONS WERE SENT
LAB INVESTIGATIONS:
CBC:
 TLC-7200/UL
 DLC-N64L32M1E3
 HB-10.3 GM/DL
 PLATELETS-327000/UL
RENAL FUNCTION TEST:
 UR-27 MG/DL
 CR-1 MG/DL
 Na- 141 MG/DL
 K- 4 MG/DL
LIVER FUNCTION TEST:
o TOTAL PROTEIN-6.8
o ALBUMIN-3.5
o TOTAL BILIRUBIN-0.3 MG/DL
o DIRECT BILIRUBIN-0.1 MG/DL
o AST/ALT-12/10 U/L
o ALK PO4-73 U/L
URINE RME:
 NORMAL FINDINGS

9. ULTRASONOGRAPHY:
 CYSTIC LESION WITH DOUBLE MEMBRANE VISUALIZED IN LEFT LOBE
OF LIVER
CECT ABDOMEN AND PELVIS:
TWO WELL DEFINED CYSTIC LESION IN LEFT LOBE OF LIVER
 ONE IS 10.8*14.1*12 CM
 OTHER IS 4*2.8 CM
HYDATID CYST OF LIVER

10. PATIENT WAS ADMITTED IN SURGERY WARD WITH DIAGNOSIS OF
HYDATID CYST OF LIVER
LAPROSCOPIC PARTIALPERICYSTECTOMY USING PANALIVELU HYDATID
SYSTEM

11. OT FINDINGS:
 AROUND 15 *10 CM CYST PRESENT IN LEFT LOBE OF LIVER
 ANT,LATERAL,UPPER AND LOWER MARGINS WERE FREE
 POSTERIORLY WAS ATTACHED WITH ANT AND INF LEFT LOBE OF
LIVER
 AROUND 1 LITER OF CLEAR FLUID WAS PRESENT IN CYST
 NO DAUGHTER CYSTED WAS PRESENT
 LAMINATED MEMBRANE WAS EASLY SEPARABLE
 NO BILIARY OR ORTHER COMMUNICATION NOTED
LIVER
CYST
FALCIFORM

12. TOPIC FOR DISCUSSION
LAPROSCOPIC MANGEMENTOF HYDATID CYST
USING PALANIVELU HYDATID SYSTEM

13. The laproscopic legend
 1st PERSON TO INTRODUCE LAP SURGERY IN SOUTH INDIA
 FOUNDER PRESIDENT OF ASSOCIATION MINIMAL ACCESS SURGEONS
OF INDIA(AMASI)
 PURE VISION FOR CARE AND TEACH WITHOUT ECONOMICAL DOOR

14. INDICATION:
 GARBI I AND II HYDATID CYST
CONTAINDICATION:
o PATIENT DOES NOT TOLERATE CAPNOPERITONEUM
o SEVERE ASCITIES
o PEDIATRIC PATIENT
o PREGNANCY AFTER 2ND TRIMESTER
o CENTRALLY LOCATED CYST
o POSTERIORLY LOCATED CYST
o CALCIFIED CYST WALL

15. PREOPERATIVE PLANNING
TRAINED SURGEON
TRAINED ASSISTANT
TRAINED SCRUB NURSE
ROUTINE LAPROSCOPIC INSTRUMENTS:
 LAPROSCOPE 30 AND 0 DEGREE
 1 MARYLAND DISSECTORS
 1 GRASPER
 1 METZENBAUM SCISSIORS
 10 MM AND 5 MM SUCTIONS
 TWO 10 MM AND TWO 5 MM TROCAR AND CANNULA
 PALANIVELU HYDATID SYSTEM

16. PATIENT PREPARATION
FOLEY CATHETERISATION
PROPHYLACTIC ANTIBIOTICPART PREPARATION

17. CHEMOTHERAPY
• ALBENDAZOLE=10-15 MG/KG BD
• MEBENDAZOLE=40-50 MG/KG TDS
• CHEMOTHERAPY SHOULD BE STARTED AT LEAST 4
DAYS PRIOR TO OPERATION

18. Pulse therapy vs continuous therapy
• Postoperatively given for 3 cycles
• Each cycle of 28 days
• 2 wks. gap between each cycle
Some study suggest continuous chemotherapy
o Continuous long-term albendazole therapy in intraabdominal cystic echinococcosis.
Chin Med J (Engl). 2000; 113(9):827-32 (ISSN: 0366-6999)

19. PALANIVELU HYDATID SYSTEM(PHS)
CANNULA
TROCAR
FOR CO2
SUCTION
SUCTION CANNULA FENESTRATION

20. TECHNIQUE
CREATE PNEUMOPERITONEUM
INSERTIONS OF CAMERA FROM UMBILICAL PORT
VISUALISATION OF HYDATID CYST
INSERTION OF PHS TROCAR AND CANNULA DIRECTELY OVER HYDATID
CYST

21. TOUCH WITH WALL
SUCTION ON
SEAL CREATED
TROCAR WITH SUCTION INSERTED
CONTENT ASPIRATED
WAY FOR SPILLED CONTENT

22. AFTER ASPIRATION TAKE OUT CANNULA
CREATE INTRACYSTIC CAPNOPERITONEUM VIA PHS (3 TO 4 MMHG)
INSERT LAPROSCOPE
VISUALISE FOR ANY REMAINING CYST OR BILIARY COMMUNICATION
INSTILLATION OF SCOLICIDAL AGENT INTO THE CYST
WAIT FOR 10 MINS
REASPIRATION OF THE SCOLICIDAL AGENT

23. POSITION:
• SECURE BOTH ARM OF PATIENT
• 15 DEGREE REVERSE
TRENDELENBURG
• 15 DEGREE LATERAL TILT ON
THE OPPOSITE SIDE

24. SURGERY
ESTABLISHMENT OF CAPNOPERITONEUM:
VERESS NEDDLE/CLOSED TECHNIQUE
OPEN TECHNIQUE USING HASSON TROCAR

25. TROCAR PLACEMENT
UMBILICAL INCISION
• SUBUMBILICAL
• SUPRAUMBILICAL
• THROUGH UMBILICAL
SCAR
CAMERA/LAPROSCOPE PORT
WORKING PORTS
PALANIVENU HYDATID SYSTEM

26. LAPROSCOPE INSERTED
VISUALIZE THE SIZE AND POSITION OF CYST
RELATION TO SURROUNDING STRUCTURE
SELECT SITE FOR WORKING PORTS
GUIDE THE INSERTION OF OTHER PORTS

27. GAUZE
ISOLATION OF OPERATIVE FIELD
 CYST SURROUNDED BY GAUZE SOAKED WITH EITHER 3% HYPERTONIC SALINE OR SAVLON
 DONE TO PREVENT DESSIMINATION TO SURROUNDING STRUCTURES

28. ASPIRATION AND INJECTION
 VIA EPIGASTRIC PORT WIDE BORE NEEDLE INSERTED AND ABOUT 30 -50 % FLUID
ASPIRATED
 IF CLEAR FLUID INJECT EQUAL VOLUME OF SCOLICIDAL AGENT INTO THE CYST
 WAIT FOR 10 MINS
 REASPIRATE THE FLUID

29. CYSTOTOMY
CYSTOTOMY DONE USING HOOK OR SCISSORS
HOOK DIATHERMY
SCISSOR

30. REMOVAL OF LAMINATED MEMBRANE
SUCTION IT WITH WIDEBORE SUCTION OR
REMOVE USING ENDO BAG
ENDOBAG
LAMINATED MEMBRANE

31. INSPECTION OF CYST CAVITY
• INSERT 0 DEGREE CAMERA INSIDE THE CYST
• LOOK FOR ANY BILIARY COMMUNICATION
• LOOK FOR MISSED DAUGHTER CYST OR LAMINATED MEMBRANE

32. PARTIAL PERICYSTECTOMY
REMOVE REMAINING FREE WALL OF THE CYST
WITH THE HELP OF HOOK OR SCISSORS
MAINTAIN HEMOSTASIS

33. OMENTOPLASTY
o OBLITERATE THE CAVITY WITH OMENTUM
o FIX THE OMENTUM WITH THE CYST WALL WITH INTRACORPOREAL
ABSORABLE SUTURE
o INSERT DRAIN IT THE CAVITY
o IRRIGATED AND WASH THE ABD CAVITY WITH NORMAL SALINE

34. CLOSING THE ABDOMINAL INCISION
• RELEASING THE CO2
• WITHDRAW THE TROCARS
CLOSURE OF THE 10 MM WOUND IN 2 LAYERS
 CLOSING THE DEFECT IN SEATH USING PORT VICRYL
 CLOSING THE SKIN USING STAPLER
CLOSURE OF THE 5MM WOUND IN SINGLE LAYER USING STAPLER
PORTVICRYL
STAPLER

35. POST OPERATIVE CARE
IV FLUIDS ANALGESICS
IV ANTIBIOTICS :
THREE DOSES OF 1ST GENERATION
CEPHALOSPORIN

36. POST OPERATIVE CARE
FOLEY CATHETERISATION
LIGHT ACTIVITIES
1ST DAY REGULAR ACTIVITIES
1 WK
STERNOUS ACTIVITY
3RD WK
EARLY ENTERAL FEEDING

37. AFTER 7 DAYS
EVERY 4 MONTH FOR 3
YEARS
THEN EVERY ANUALLY OR SOS

38. THANK YOU