An optimal approach for major liver resections in patients with cystic echinococcosis

Introduction

Echinococcal liver disease is a dangerous parasitic disease characterized by a long course and progression in the absence of proper treatment for patients (1). Historically, numerous laparotomy variants were the sole standard for managing hydatid liver disease (2). Since the early 1990s, the advent of laparoscopic and robotic technologies has significantly expanded the application of minimally invasive liver resections, initiated by Katkhouda et al.’s pioneering laparoscopic pericystectomy (3). A comprehensive 2014 review, encompassing over 900 cases of cystic liver echinococcosis, reported reduced wound complications and postoperative pain with laparoscopic techniques compared to open surgery (4). However, laparoscopic major liver resections remain challenging for hepatobiliary surgeons due to the technical complexity of manipulating a cyst-laden right liver lobe. Modern minimally invasive surgery (MIS) offer hope for improving outcomes in cystic echinococcosis (CE) treatment (5). To address these challenges, an anterior approach has been developed (6-8), characterized by initial vascular inflow control (total or partial), complete hepatic parenchymal transection, and frequent ligation of hepatic vein branches before fully mobilizing the right lobe, thereby minimizing the risk of scolex dissemination. We report our experience with total laparoscopic right hemihepatectomy via an anterior approach, a novel application in CE management, demonstrating its feasibility and safety. We present this article in accordance with the SUPER reporting checklist (available at https://ls.amegroups.com/article/view/10.21037/ls-24-19/rc).

Preoperative preparations and requirements

Between December 2021 and January 2024, 13 patients underwent total laparoscopic right liver resection using the anterior approach for liver CE. The data were collected prospectively and analyzed. Data collected included cyst volume (measured in cm³ via preoperative imaging) and a “cyst ratio”, defined as the average number of cysts per patient, to assess disease burden. Perioperative, short-term, and long-term outcomes were recorded. Two hepatopancreatobiliary (HPB) surgeons performed all 13 operations in the Botkin Hospital HPB Department. The Medical Ethics Committee of Botkin Hospital granted approval for this study and determined that the requirement for informed consent could be waived (approval ID Number 47). The study protocol was approved by the Ethics Committee in accordance with the Declaration of Helsinki and its subsequent amendments.

Step-by-step description

Patient selection included assessment of the future functional liver remnant (fFLR), defined as the percentage of liver volume remaining after resection, calculated by preoperative computed tomographic (CT) volumetry (threshold >30% to ensure adequate postoperative function). Patients were positioned supine in a split-leg reverse Trendelenburg position, with a small cushion typically placed beneath the right side to optimize exposure. Trocar placement is illustrated in Figure 1. The procedure commenced with dissection of the right hepatic artery (RHA), right portal vein (RPV) branches, and bile duct, which were looped with colored silicone tapes and clipped (Figure 2). Parenchymal transection was performed using a LigaSure (Covidien LLC, Mansfield, USA), bipolar forceps, and an ultrasonic dissector (Soring Sonoca 300; Soring GmbH, Quickborn, Germany). The anesthesiologist maintained low central venous pressure (<5 cm H₂O) to minimize bleeding. Transection began at the anterior liver surface, progressing to the anterior and lateral aspects of the inferior vena cava (IVC) (Figures 3,4), with bleeding controlled primarily via bipolar coagulation. Middle hepatic vein (MHV) branches were secured with Hem-o-Lock clips (Weck Surgical Instruments, Teleflex Medical, Durham, NC, USA) (Figure 5). The right portal structures were divided using a Hem-o-Lock clip (hepatic artery) and a 25 or 40 mm vascular stapling device (Ethicon Endo-Surgery, Cincinnati, OH, USA) for the portal vein branch and bile duct. Short hepatic veins draining into the IVC were clipped with titanium or Hem-o-Lock clips. The right hepatic vein was subsequently controlled with a 40 mm vascular stapler. Following complete dissection of the right hemiliver from the IVC, residual ligaments were divided using LigaSure (Video S1). The specimen was extracted in a 1500 mL endobag through a Pfannenstiel incision, and a multi-perforated drain was placed along the resection margin (Figure 6).

Figure 1 Trocar placement sites during laparoscopic right hemihepatectomy.

Figure 2 RPV looped with blue silicone tape, alongside the clipped RHA and CD. CD, cystic duct; RHA, right hepatic artery; RPV, right portal vein.

Figure 3 Initiation of hepatic parenchymal transection from the anterior surface extending toward the right hilar region.

Figure 4 Exposed surface of the IVC. IVC, inferior vena cava.

Figure 5 Clipped branches of MHV. MHV, middle hepatic vein.

Figure 6 Final intraoperative view of the operative field (white absorbable haemostat is placed in the zone of transection).

Postoperative considerations and tasks

The study enrolled 13 patients with CE (Table 1). Preoperative fFLR exceeded 30% in all cases. Median values included: age, 43.8 years (range, 26–65 years); cyst volume, 686 cm³ (range, 330–1,500 cm³); and cyst ratio, 3.7 (range, 2–7). Two patients exhibited satellite cysts in the left liver. Mean peak values for bilirubin, plasma albumin, and international normalized ratio (INR) were 39.6 µmol/L (range, 22–54 µmol/L), 33.26 g/L (range, 29–36.5 g/L), and 1.28 (range, 1.22–1.89), respectively. The median operative time was 422 minutes (range, 345–485 minutes), with a mean blood loss of 490 mL (range, 400–600 mL). No patient required transfusions of blood, plasma, or cryoprecipitate. No conversions to open or hand-assisted surgery occurred, and there were no instances of liver failure, bile fistulae, or mortality (9,10). The mean hospital stay was 12.4 days (range, 9–14 days). All patients achieved radical resection, with no recurrence observed to date. Perioperative outcomes are summarized in Table 2.

Discussion

Laparoscopic major hepatectomy remains an evolving technique, with ongoing research to ensure postoperative safety (11). Such procedures should be introduced cautiously and limited to expert hepatobiliary centers. They demand advanced minimally invasive surgical skills (12),

particularly as mobilizing the voluminous right liver lobe laparoscopically is technically demanding due to its size and weight. Manipulation of thin-walled cysts increases the risk of rupture and protoscolex dissemination into the abdominal cavity (13). Additionally, cyst rupture may precipitate anaphylactic shock due to hydatid antigen release, requiring meticulous technique (14). While CE is benign, major resection may be warranted in select cases. While pericystectomy or endocystectomy are preferred for CE due to their conservative nature, major hepatectomy was indicated in our cohort due to extensive cystic replacement of the right lobe (median volume 686 cm³, range, 330–1,500 cm³), involvement of portal veins (4 patients), hepatic veins (3 patients), and bile ducts (2 patients), and parenchymal destruction (Table 1). These conditions precluded pericystectomy or endocystectomy, as partial resection risked incomplete cyst removal, recurrence, or injury to critical structures. Our aim was to achieve radical resection while leveraging the anterior approach’s safety in minimizing cyst rupture risks. Long-term outcomes of such radical resections require randomized studies (15). We propose that open or minimally invasive hepatectomy for hepatic CE is feasible under the following conditions: (I) multiple cysts confined to one lobe, with or without solitary cysts in the contralateral lobe; (II) sufficient residual liver volume (fFLR ≥30%); (III) involvement of portal or hepatic vein branches; (IV) involvement of or compromise of bile ducts; and (V) extensive replacement of lobe parenchyma by parasitic cysts (e.g., volumes up to 1,500 cm³) (Figure 7).

Figure 7 Multiple echinococcal cysts confined to a single hepatic lobe.

Historically, surgeons mobilized the right lobe via J-incision before parenchymal division for safety and simplicity (16-18). However, mobilizing a large, cyst-altered liver is particularly difficult in laparoscopic or robotic approaches. The anterior approach has been successfully applied in other MIS contexts, such as laparoscopic donor right hepatectomy (19) and resection of giant liver tumors exceeding 10 cm (20), supporting its versatility and safety for complex cases like CE. In rare instances, cyst rupture may trigger anaphylactic shock due to hydatid antigen release, necessitating meticulous operative technique. Our study highlights the applicability of this technique to a unique patient cohort with CE, and we found no prior reports of its use for laparoscopic right hemihepatectomy in this context.

Conclusions

A laparoscopic anterior approach for major liver resection in patients with CE is both feasible and safe in well-selected cases. Larger, multicenter trials are necessary to fully assess the long-term benefits and risks. Nonetheless, our findings demonstrate promising short-term outcomes with radical resection and no disease recurrence to date.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://ls.amegroups.com/article/view/10.21037/ls-24-19/rc

Peer Review File: Available at https://ls.amegroups.com/article/view/10.21037/ls-24-19/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ls.amegroups.com/article/view/10.21037/ls-24-19/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study protocol was approved by the Ethics Committee in accordance with the Declaration of Helsinki and its subsequent amendments. The Medical Ethics Committee of Botkin Hospital granted approval for this study and determined that the requirement for informed consent could be waived (approval ID Number 47).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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