the term hepatic cyst usually refers to solitary nonparasitic cysts of the liver , also known as simple cysts .
the precise frequency of liver cysts is not known because most do not cause symptoms , but liver cysts have been estimated to occur in 2.5% to 5% of the population . if the whole liver is involved , polycystic liver disease ( pcld ) is presumed to exist .
the cysts are lined with epithelium , and because liver cysts seldom contain bile , the current hypothesis is that they fail to develop normal connections with the biliary tree .
the majority of patients afflicted with adult polycystic liver disease are asymptomatic . for those who are symptomatic ,
the choice of surgical procedure is related to the severity of the disease and morphology of the cysts within the liver .
most case series in the literature are relatively small , reporting fewer than 50 patients each . when the cysts become large and cause symptoms like pain , treatment is warranted . today
we present our series of 12 patients who underwent laparoscopic surgery for symptomatic polycystic disease of the liver .
we have managed 12 patients with large , nonparasitic , simple hepatic cysts laparoscopically , from 1996 to 2006 .
there were 7 males and 5 females ; average age was 65 years ( range , 58 to 72 ) .
eight patients had isolated cysts of both lobes of the liver , and the other 4 cases had associated ( asymptomatic ) polycystic renal disease .
all the patients in this series had nonparasitic cysts in both lobes of the liver , the largest measuring 20149 cm in a 72-year - old lady .
routine laboratory investigations including liver function tests and bleeding profile , chest radio - gram , and electrocardiogram were done in all patients .
the initial imaging modality was the ultrasonogram in all cases , followed by ct scan .
the 8 cases with the isolated multiple cysts underwent laparoscopic deroofing of the larger cysts and puncturing of the smaller cysts .
pneumoperitoneum was established by veress needle , and pressure was maintained at 13 mm hg .
the patient was positioned supine with both legs apart , the head - end raised to 30. the chief surgeon stood in between the legs , camera surgeon stood to the right of the patient , an assistant and scrub nurse stood on the left side .
the monitor was placed on the head - end of the patient , directly opposite the chief surgeon .
four ports were used : ( 1 ) a 10 mm port 2 cm above the umbilicus for the laparoscope ; ( 2 ) a 5 mm port in the left midclavicular line for right - hand working ; ( 3)a5 mm port in the right midclavicular line for left - hand working ; ( 4 ) and a 5 mm port in the epigastrium for liver retraction . in all the patients ,
there was always at least one large ( dominant ) cyst with other smaller cysts .
the first step was to introduce the 5 mm left - hand working port directly into the largest cyst and suck out the contents without any spillage ( figure 1 ) .
this causes the cyst to collapse ( figure 2 ) . through the cystotomy opening , a harmonic ace scalpel (
ethicon endosurgery , cincinnati , oh , usa ) was used to cut out the cyst wall ( figure 3 ) . in patients where the cysts were more exophytic ,
the laparoscope was turned to the left of the falciform ligament and the cysts excised ( figure 4 ) .
complete resection of the cysts was achieved by keeping the dissection close to the cyst wall and was performed in 8 cases .
the harmonic ace scalpel was used for these resections and found to be very effective . in 3 patients with pcld ,
the greater omentum was packed into the bigger cavities to obliterate dead space and prevent fluid collection .
frozen section examination of tissue bits from the cyst wall revealed no evidence of cystadenoma or carcinoma in any case .
liquids were started on the same evening as surgery , and a normal diet was started on the first postoperative day ( pod ) .
parenteral analgesics were administered for 1 pod , and thereafter , oral analgesia was sufficient .
fluid drainage was present for 8 days to 12 days . between 25 ml and 350 ml of fluid
these 4 patients were discharged between the third and fifth pod with the drain tube and were advised to empty and measure the fluid daily .
follow - up was for 12 months to 48 months ; 6 patients were followed up with regular ultrasonograms .
up to 5% of the population has one or more liver cysts ; with a sharp rise in incidence with age . women ( age 50 to 60 years ) are more commonly affected than men are .
most cysts are thought to arise as a congenital aberration of bile duct development and are termed simple cysts .
several other small cysts within the liver usually accompany the dominant cyst , as we have seen in all the patients in this series .
multiple hepatic cysts are usually considered to be a part of a polycystic disease complex . in our series ,
polycystic liver disease can arise in childhood or adult life , sometimes associated with polycystic kidney disease .
liver cysts only rarely cause hepatic fibrosis and liver failure . occasionally , isolated polycystic liver disease has been reported .
although it is easy to attribute symptoms to the presence of a large hepatic cyst , the possibility of coexisting pathology must be excluded . despite improved imaging techniques ,
asymptomatic patients do not require therapy because the likelihood of developing complications related to the lesion is lower than the risks associated with treatment .
cyst aspiration with sclerosis , open or laparoscopic cyst fenestration , combined hepatic resection and fenestration , and liver transplantation are possible treatments .
percutaneous aspiration of symptomatic hepatic cysts is a simple option , but recurrence is invariable , not to mention lifethreatening infection .
several reports detail the efficacy of laparoscopic surgery for both multiple liver cysts and pcld .
if the gallbladder is closely adherent to the cysts , cholecystectomy may be indicated ; one such case occurred in our study where we managed to preserve the gallbladder ( figure 5 ) .
drainage of the operated site is not mandatory in all patients with large liver cysts ; it is advisable only if bile leakage is anticipated .
only 4 of our patients needed drainage , out of which none had bile leakage . ultimately , it is ideal to tailor the procedure in each individual case . in our series , 8 patients underwent laparoscopic radical excision of the cysts to prevent recurrence , and liver resection was not done in any case . in the 5 ( 41.66% ) patients who developed recurrence in our series , only 1 had undergone radical excision . based on this , we are tempted to think radical excision of cysts could reduce recurrence rates , though more studies are needed to confirm this .
martin et al11 compared the results of laparoscopic deroofing with open deroofing and open resection in 23 patients with simple cysts and 15 patients with polycystic disease .
they found that laparoscopic de - roofing of simple cysts was associated with a 20% morbidity rate .
the symptomatic recurrence rate was 8% for simple cysts and 71% for polycystic liver disease .
recurrence of symptoms was due to growth of the untreated cysts and not to re - expansion of the treated cysts .
lower recurrence rates were seen in a series of large dominant cysts in the anterior segment of the liver .
additional omen - toplasty and oversewing of the margins by a running suture appear to reduce the recurrence rate to between 0% and 14% .
liver transplantation has been performed in rare cases , especially when the above - mentioned interventions are not an option . collapsed cyst seen closely adherent to gall bladder .
laparoscopic radical excision and omentoplasty for all large polycystic lesions and deroofing with simple puncture of all the cysts in cases of non - pcld are highly effective procedures .
 background : liver cysts have been estimated to occur in 5% of the population . 
 multiple liver cysts can also be part of the polycystic disease complex . 
 only symptomatic or complicated cysts need surgery . traditionally , laparotomy is the procedure of choice . 
 we present our experiences with laparoscopic management of both symptomatic multiple liver cysts and polycystic liver disease.methods:between 1995 and 2006 , we treated 12 patients with large , multiple liver cysts , including 4 cases of polycystic liver disease . 
 most of the patients were elderly males . 
 the lung and other organs were not involved in any case . 
 laparoscopic deroofing or radical excision with omentoplasty was successfully performed in these patients.results:postoperatively , 4 patients had fluid draining through the drainage tube for an average of 10 days . 
 one patient had ascites that resolved spontaneously . 
 cysts recurred in 5 patients.discussion:there are not many reports in the literature regarding large series of patients , further confirming the rarity of the disease . 
 liver cysts can occur as a part of polycystic renal and lung disease or isolated to the liver alone . 
 laparoscopic deroofing is the ideal treatment for nonpolycystic liver disease , and laparoscopic radical excision is ideal for polycystic liver disease . 
 simple needle aspiration or sclerotherapy is inadequate as recurrence is almost 100%.conclusion : currently , laparoscopy scores over laparotomy for the treatment of nonparasitic liver cysts as evidenced by this and other studies . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION