Laparoscopic fenestration of liver cyst

Laparoscopic hepatic cyst fenestration is used for the surgical treatment of hepatic cysts. Hepatic cyst is a common benign liver disease. The detection rate in abdominal B-ultrasound was reported to be 1.74% (90/5184). In Shanghai Changhai Hospital, 320 cases of hepatic cyst were detected in 2679 cases of liver CT. Hepatic cysts can be divided into parasitic and non-parasitic hepatic cysts. The former is more common with hepatic hydatid disease; the latter can be divided into congenital, traumatic, inflammatory and neoplastic cysts, of which congenital liver Cysts are the most common. Some people also refer to congenital cysts as true cysts, while other cysts are called pseudocysts. Usually referred to as liver cysts refers to congenital hepatic cysts. Congenital hepatic cysts can be divided into single and multiple. The treatment of hepatic cysts is mainly surgical and non-surgical treatment. For small cysts and asymptomatic people do not need special treatment, but for large and oppressive symptoms, appropriate treatment should be given. Treating diseases: liver cysts Indication 1. Single or single-shot multi-atrial, symptomatic hepatic cyst, the cyst is shallow, and the thickness from the surface of the liver tissue is not more than 1mm. 2. Hepatic cysts found during laparoscopic cholecystectomy. Contraindications 1. Both traffic and neoplastic hepatic cysts are contraindicated, such as cysts communicating with the biliary tract, co-infection or suspected cancer. 2. Multiple cysts, cysts located in the right posterior lobe or extensively adherent with the diaphragm. 3. The cyst inside the liver parenchyma cannot be revealed under laparoscopy. 4. Have a history of upper abdominal surgery. 5. Serious dysfunction of important organs. Preoperative preparation 1. Same as preoperative routine preparation for open surgery. 2. Liver B ultrasonography, CT or MRI examination is an indispensable important examination, which can clarify the thickness of liver tissue on the surface of the cyst, the relationship between cysts and intrahepatic vessels, bile ducts and body surface location. 3. Functional measurement of important organs (heart, lung, liver, kidney, etc.). 4. Excluding liver echinococcosis, hepatic cystic tumor. If the cyst cannot be excluded from communicating with the biliary tract, retrograde cholangiopancreatography should be performed. Surgical procedure 1. Establish a belly Cut 1cm along the lower edge of the umbilicus, place the pneumoperitoneum needle, confirm that it is behind the abdominal cavity, connect the automatic pneumoperitone machine, so that the intra-abdominal pressure reaches 13~15mmHg; after taking out the pneumoperitoneum, hold the cannula with diameter 1cm The needle is slowly rotated into the abdominal cavity, and the needle core is taken out to confirm the posterior abdominal cavity, and the laparoscope is placed therethrough. The position of other trocars should be based on the results of the exploration combined with preoperative examination, and the location of the cyst and the position of the drainage tube after surgery should be determined. The cyst is located on the left hepatic and right lower hepatic margin, and the puncture site of the trocar is as follows. For example, the cyst is located only in the left liver, and its puncture position is as follows. If the cyst is located on the right hepatic sacral surface, the trocar of the anterior iliac crest and the midline of the clavicle can be punctured between the 8th and 9th ribs. Generally, the puncture of the 7th intercostal space should be avoided to avoid getting into the chest cavity. The selection of each puncture site should be close to the lesion site, and the operation is convenient. 2. Exploration and positioning Laparoscopy is extended into the right upper abdomen and directly to the front of the liver. The location, size and number of cysts are observed. Superficial cysts often see a thin layer of cystic cells protruding from the surface of the liver. The fluid inside is visible through the wall of the capsule. If the wall of the capsule is thick, the surface of the liver is often the part of the cyst. Difficulties should be combined with CT or other imaging examinations. If the preoperative imaging examination indicates that the cyst is located in the left lobe of the liver, the laparoscope should be extended to the left side of the sacral ligament and explored directly to the left septum. 3. Cyst puncture Puncture cysts, such as the colorless or pale yellow non-biliary sap, can be confirmed as a simple hepatic cyst, can expand the puncture, and perform cystic fenestration. If the cyst fluid is yellow, it is suspected that the contrast agent should be injected into the biliary tract. Regardless of the nature of the cyst fluid, the fluid should be collected for routine fluid administration, bilirubin quantification, cytology, and bacterial culture. 4. Cyst opening window Gently press down on the liver to make the cysts in the best exposed state. At the thinnest part, the electrocoagulation hooks are burned and opened. At this time, there is a clear cyst fluid, and the assistant can place the aspirator in the open part of the cyst to attract the cyst fluid. After stopping the outflow, use the gallbladder grasping forceps to lift the wall of the capsule with electrocoagulation hooks or scissors to open the window at the top of the cyst. The window opening range depends on the size of the cyst, which is subject to smooth drainage, usually a cyst without liver tissue coverage. The top is completely removed. In the process of opening the window, bleeding at the edge of the cyst wall can be stopped by electrocoagulation, and larger blood vessels can be clipped with titanium clamps. Conditional use of ultrasonic scalpel can achieve "no blood" effect. When the cyst is opened, it is found that the bile contained in the cyst fluid should be converted to open surgery. According to the laparotomy, the appropriate procedure should be selected as appropriate. For giant hepatic cysts, the laparoscopic lens should be extended over the cystic cavity or into the lumen to observe the wall of the capsule when the cyst is removed. Single-occlusive polyhepatic cysts often have deep cysts on the inner wall of superficial cysts. After the puncture is confirmed, the diaphragm between the cysts or the thin-walled wall of the surface is removed according to the above method, but the blood vessels should be preserved. Bile duct structure. If there is a nodule in the wall of the capsule, a nodule should be taken for biopsy, and if necessary, a frozen section should be taken to exclude the possibility of cancer. If there is a malignant change, the cystectomy or partial hepatectomy should be performed immediately. 5. Drainage Remove the cut wall, rinse the cyst, check for active bleeding and bile leakage, and drain the fluid in the abdominal cavity. In patients with large cysts or multiple cysts, the drainage tube can be introduced into the capsule through the cannula under the rib. The capsule can also be filled with a large omentum and fixed with a titanium clip. The removal time of the drainage tube depends on the amount of drainage. In principle, the drainage fluid can be removed after drainage. If the cyst is small, the drainage should not be placed. complication Timid A small amount of biliary fistula can heal itself in a short time. If the timidity does not heal for a long time, the angiography can be performed through the drainage tube to clarify the reason. The biliary fistula connected with the larger bile duct should be treated with open surgery. 2. Cyst drainage is not smooth The huge hepatic cysts have poor drainage after fenestration, which may be due to insufficient coverage of the wall of the capsule wall or the formation of new adhesions. If the cyst is not large, no obvious symptoms can continue to be observed; if the cyst is large or symptomatic, you can take non-surgical treatment such as repeated puncture or injection of absolute ethanol into the cyst. If the effect is not good, laparoscopic or open surgery should be performed again. Cystopening. Prevention method: the cyst wall should be removed as much as possible to make the cyst cavity fully open; the inner surface of the capsule cavity can be coated with 10% iodine, destroying the endothelial cells secreting cystic fluid on the surface; filling the omentum in the cyst cavity to promote the cystic fluid. absorb. 3. Cyst residue Multiple hepatic cysts or cysts located deep behind the right hepatic loboscope are sometimes difficult to detect and lead to residual cysts. For suspected cysts, exploratory puncture or intraoperative B-ultrasound examination. Open surgery should be selected for those who are difficult to open the laparoscopic position. Postoperative diet 1. Give high protein, high vitamin and cellulose-rich digestible diet. 2, do not eat spicy spicy food.