Comparing The Effect Of Deroofing Of Congenital Liver Cysts With Open Surgery Or Laparoscopic Approach

Objective: To Compare the effect of deroofing of congenital liver cysts with open surgery or laparoscopic approach.Methods: Fifty-one consecutive patients with congenital liver cysts at our department between Sep-2000 and Jun 2007 were rendered to receive open surgery (29 patients,group 1) or laparoscopic fenestration (22 patients,group 2). Comparing the operation time,the quantity of blooding,the time of recovering, the hospital stay, the complication rate, the symptom recurrence rate, the cyst recurrence rate of the two methods.Results: There are significant differences in the operation time, the quantity of blooding, the time of recovering, the hospital stay between deroofing of congenital liver cysts with open surgery or laparoscopic fenestration (P<0.01), there are no significant differences in the complication rate, symptom recurrence rate, cyst recurrence rate between the two groups.Discuss: The congenital disorders of the bile duct growth and development lead to the disease liver cyst, and the literature[1,2]reported the disease was particularly prevalent in women, in particular, more in older women, the incidence ratio of male and female is 1:4 . The liver cyst can be divided into two categories, the congenital cyst and the acquired cyst, and the congenital cysts account for the majority. The first contains the isolated cyst, the benign cyst, the non-parasitic cyst cyst, the polycystic liver and the bile duct cysts Caroli's disease, the latter contains the new biological cyst, the traumatic cyst, the parasitic cyst and so on. With the wide use of the B ultrasound and other imaging diagnosis methords, the liver cyst had been rare in the past has become common disease now.The traditional surgical treatments of the liver cyst are the open surgery fenestration or the puncture, drainage by ultrasound-guiding,and the latter is more suited to smaller cyst, the deficiency of it is easy to relapse,which needs to repeat[17]. There have been reports saying the recurrence rate is as high as 100%[18], so the fenestration is better for the cyst greater than 6 cm[19]. The treatment should be taken for the congenital cysts with symptoms or corresponding complications, the surgical indications:①Single small cyst, diameter<5cm, and asymptomatic, generally without surgery, but to observe, because the single cyst may sometimes gradually increase in diameter;②Single cyst, diameter in the range of 5cm-10cm, if the chronic abdominal pain and the upper abdominal compression exist, surgery may be considered, if without any symptoms, we may continue to observe;③Diameter>10cm,upper abdominal compression symptoms and abdominal mass should be regarded as surgical indications;④Intracystic hemorrhage, infection or suspected tumorous cyst should be taken into account of surgical treatment.The open fenestration of the liver cyst can get exact effect because it can complete the surgery on the open,and fully deroof, strip, drainage, wall damage, cyst remove for the cyst. The 29 patients of the laparotomy group all get satisfactory results,but it has the shortcomings of long operation time, great trauma, more bleeding, long time of recovering and the hospital stay. With the extensive application of the laparoscopic technology because of its less trauma, less pain, quicker recovery and so on, this minimally invasive technique also be used in the fenestration of the liver cyst. The operation time, blood loss in the operation, recovering time,hospital stay of the 22 patients of the laparoscopic group are significantly shorter than the laparotomy group. Comparing the two surgical fenestration methods,the laparoscopic fenestration is minimally invasive, painless, quick recovery of the obvious advantage. As long as suitable patients are choosed,and seriously operate in accordance with the actual situation, the laparoscopic fenestration of the liver cyst is an ideal, worth recommending treatment.But not any liver cysts are suitable for laparoscopic fenestration, there are certain taboos:①Cyst in the deep, thick surface of liver tissue (1cm above from the liver surface), there are dangerous in injuring the bile duct and the vascular, leading to the bile leakage or the vascular hemorrhage;②The huge cyst with thickening wall;③Generalized,diffuse intrahepatic congenital cyst;④Cyst puncture in recent history;⑤Traffic hepatic cyst[4];⑥The history of upper abdominal surgery;⑦The cyst locates in the right posterior lobe of the liver or there are extensive adhesion between the liver and the diaphragm,and the laparoscopic inaccessible;⑧Parasitic hepatic cyst and suspicious malignant cyst[14]. In the case of the following situations,it should be timely transfer to the laparotomy:①There is significant bile leakage,and the laparoscopic can not deal with;②Massive intraoperative bleeding;③Tumorous cysts,in particular malignant tumor, although the incidence is very low, but we should also pay attention;④Cyst exposed unclear during the operation,and it is difficult for the laparoscopic to deal with.Although the laparoscopic fenestration of the liver cyst has the hemorrhage, ascites, pleural effusion[21], dyspnea,bile leakage[22] and other related complications, ascites and bile leakage are the most common postoperative complications[4,23], but a large number of clinical data showed that the incidence of these complications is not high, and can be controlled by appropriate measures[22]. Literature[2]reported that the recurrence rate of the laparoscopic fenestration of the liver cyst is 0~25%.Recurrent reasons:①Only deal with one of the multiple cysts[4];②Only deal with the superficial cyst,and the deep cyst isn't dealt with;③Didn't open the divide of the cyst;④The cyst is big and deep,and the fenestration position is too high, drainage is poor,particularly prevalent in theⅦ,Ⅷof the cyst;⑤The fenestration scope is smaller,although the fenestration site is at the lowest point of the cyst bottom, but the rigid connective tissue structure of the cyst wall can't make the cyst completely shrink during a short period of time, and postoperative adhesions lead to the close of the window and the cyst form again;⑥Although the cyst wall will be inverted and stitched after fenestration, which aims to eliminate the cyst cavity, which also forms a thick layer of narrow ring,and the ring will be closed because of the adhesion,which will lead to the cyst form again. While the above reasons may also lead to the cyst recur,but too small cyst wall fenestration and adhesion is in the most common,occurred most in the top phrenic of the right liver lobe (ⅥⅦ). For the prevention and reduction of cyst recurrence, we should pay attention to the following points:①Fenestration should be big enough, the top of the cyst wall should be removed fully, reserved the cyst wall link to liver tissue, in order to avoid postoperative adhesions and cysts occlusion;②Inspecting carefully the multi-cyst or deep cyst to avoid omission, if conditions are feasible, we can use the B ultrasound in the operation, and the divide should be removed;③The cyst wall should be dealt with iodine and ethanol;④We should fenestrate at the lowest site of the cyst when the cyst cavity is big or the cyst is deep, to ensure smooth drainage. Conclusions: Laparoscopic fenestration is better than open surgery because it has shorter operation time, less quantity of blooding,qu-icker recovering and shorter hospital stay,and the long effect is the same.