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BENIGN CONDITIONS
203
employed). Finally, the residual cavity must be treated to ensure there are no
viable residual organisms.
In the preoperative treatment, we use one of the available antihelminthic
agents and personal preference and often the availability will determine which.
We use albendazole or mebendazole for 3–4 weeks before any surgery and
have experienced no major side effects with these agents (Wen et al . 1994 ;
Schipper et al ., 2000 ; Saimot, 2001 ).
The operative strategy depends upon the number, size, and position of the
cysts. The patients are given hydrocortisone (200mg IV) at induction in case of
anaphylactic reactions. When cysts are confined to the left lobe (segments II
and III) or multiple cysts have replaced the right lobe (segments V–VIII), we
prefer formal resection in fit patients. In unfit patients where the cysts are
widely distributed, or when a single large cyst in the right lobe only affects one
or two segments, we will decompress and evacuate the cyst.
Laparotomy is through a right subcostal or rooftop incision depending on
the situation of the cyst(s) and build of the patient. The liver is mobilized and
particular care is taken with the surface of the cyst which may be adherent and
the underlying contents under considerable pressure. The cyst to be treated is
identified with ultrasound and comparison with the CT scans. The area is pre-
pared by isolating a small central portion with packs soaked in twice-normal
saline. We do not inject scolicidal agents into the cyst as all of these can cause
biliary tract problems if there is communication. Two large suckers are required
and we use a conventional device and either an Aaron’s cone or the instrument
used for the termination of pregnancy. The latter sucker is a very wide-bore,
high-pressure suction device and has a nozzle design which is ideal for evacu-
ating the cyst contents. The cyst is then carefully opened between stay sutures
which are kept under traction to prevent overflow and suction commenced
immediately until the cavity is emptied of free contents. The incision is then
enlarged and the cavity examined for the presence of daughter cysts and bile
staining. The laminated membrane and daughter cysts must then be com-
pletely removed by a combination of suction, dissection between layers, and
traction. The redundant portion of the wall around the incision is also excised
and the edges oversewn with a continuous PDS suture. The presence of bile
should always initiate the search for a communication but frequently this is
not apparent. If bile is present after the cyst is excised we leave a hypertonic
(twice-normal) saline soaked pack in the cavity and then gently remove it after
10 minutes looking for the position of any bile staining on the pack. This occa-
sionally indicates a source which is oversewn. If no communication is demon-
strated, or after it is found and oversewn, the cyst is filled with twice-normal
saline for a further 10 minutes to complete the sterilization. If there are other
LIVER
204
cysts, they are then treated similarly and the abdomen closed after thorough
washout (again with twice-normal saline) and two tube drains inserted to the
areas that have been treated.
Polycystic liver disease ( Fig. 3.94 )
Polycystic liver disease is a term for a heterogeneous group of conditions.
Multiple liver cysts are frequently associated with the adult polycystic kidney
disease but they may also occur alone (Drenth et al ., 2004 ; Everson et al ., 2004 ).
In many patients the cysts are completely asymptomatic but when extensive
may produce symptoms from stretching of the liver capsule, pressure effects
on the stomach when the left side is involved, and gross abdominal distension
related to the increase in the size of the liver. These latter patients may
have livers which extend into the pelvis and the usual association of this group
with polycystic kidneys, which can also be very large, causes major morbidity.
Cysts can also become infected but this normally follows ill-advised aspiration
of what is felt to be a dominant cyst responsible for the patient’s symptoms.
Biliary obstruction can also occur due to distortion or compression by
the cysts, which can be very tense. The majority of patients should be managed
conservatively but in some the symptoms or complications mandate
treatment. It is worth noting that 10% of patients with polycystic liver disease
also have cerebral aneurysms and some authors recommend screening for
these (Russell and Pinson, 2007 ). Surgical treatment is usually employed to
produce bulk reduction or treat a mechanical problem (Gigot et al ., 1996 ,
1997 ; Hansman et al ., 2001 ). Biliary obstruction in this context cannot
be treated surgically and must be managed endoscopically by ERCP and
stenting.
Treatment
When planning the surgery it is important to remember that the biliary radi-
cles and vessels run between cysts and can be difficult to separate from the wall.
Distortion of the liver can make planning difficult and the presence of the cysts
generally renders intraoperative imaging unhelpful. CT scanning can be very
valuable in assessing the areas of liver which are extensively affected to see if
there is any residual parenchyma. Surgical options are:
◆
Laparoscopy and deroofi ng of all accessible cysts
◆
Surgical resection of expanded areas causing pressure effect—generally the
left lobe to relieve gastric compression
◆
Combination of resection and deroofi ng of cysts ( Fig. 3.95 )
◆
A formal extensive fenestration resection ( Fig. 3.96 ).
BENIGN CONDITIONS
205
Fig. 3.94 Management of polycystic liver disease.
Polycystic
liver disease
Symptomatic
Pain
Pressure effects
(weight loss and
early satiety)
Consider
deroofing
dominant cysts
All areas equally
affected
Fenestration
One area almost
completely
replaced
Resection plus
fenestration
Gross abdominal
distension
• Combination
• Single area badly affected
• Dominant cyst
• Widespread disease
Resection and
deroof dominant cyst
(may be possible
laproscopicaly)
Asymptomatic No treatment
LIVER
206
In patients with widespread cysts of similar sizes and no area where liver
parenchyma is absent we would perform a laparoscopic deroofing of all acces-
sible cysts. When significant problems are experienced with gastric compres-
sion, particularly if little or no residual liver is present in the left lobe (Segments
II and III), we would resect this area and deroof all accessible cysts from the
right side ( Fig. 3.95 ).
The resection is technically easy due to the absence of liver and the tough
walls of the cysts, which take sutures extremely well. The resection can be per-
formed by simple clipping with haemostats and dividing across the conven-
tional resection line to the left of the falciform ligament. The remnant is then
oversewn as the haemostats are removed and, as long as care is taken to recog-
nize the area of the left hepatic vein and to check for bile leaks at the end of the
procedure, few problems should be encountered. We have never found it nec-
essary to employ a Pringle manoeuvre for these resections.
Fenestration resections Fenestration and resection is much more challenging
and requires careful planning. The results can however be dramatic and
patients with huge livers can experience an astonishing reduction in size with
commensurate improvement in their quality of life (Gigot et al ., 1997 ; Russell
and Pinson, 2007 ). As the name implies, the fenestration involves deroofing
the cyst and then exposing the posterior wall which is then opened into an
underlying cyst until all the large cysts communicate. The fenestration must be
done with the aim of avoiding Glissonian sheaths and their contained bile
ducts and vascular structures that travel between the cyst cavities. Surprisingly
this is usually more straightforward than it appears and the very thin walls to
Fig. 3.95 a) Dominant cysts in left lobe of liver with larger but fewer cysts on the
right side. b) Resection of the left lobe and deroofing of superficial cysts on the
right side.
(a) (b)
BENIGN CONDITIONS
207
the cysts make structures visible or palpable. This can be further aided by
removing one wall of the cyst to identify any intermediate structures and the
anterior wall of the underlying cyst and demonstrating that there were no
structures lying in-between.
Occasionally cysts will contain bile-stained fluid and it is important to locate
the source of the leak and oversew it with a small vascular suture (4/0, 5/0
Prolene). We find that in patients who require fenestration resections that
there is almost inevitably a significant portion of the liver which is completely
replaced by cysts and resection of this area together with the fenestration of the
remnant is well tolerated, removing virtually no functioning liver. A few
months postoperatively the procedure results in a liver which is simply large
and palpable as opposed to virtually filling the abdominal cavity. Symptomatic
results can be very rewarding but unfortunately a number of these patients will
develop recurrent cysts and although repeated surgery is possible, in our expe-
rience this cohort will continue to produce cysts in a relatively short time
frame (1–3 years). Repeated procedures are not justified because of this natu-
ral history and the rapidly rising risks inevitably associated with this type of
re-do surgery.
Fig. 3.96 a) Extensive polycystic liver disease in both lobes. b) Fenestration resection
in both lobes of the liver.
(a) (b)
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Section 4
Gallbladder
Gallstones ( Fig. 4.1 )
Gall stones are common throughout the world but particularly in developed
countries where the incidence is consistently quoted at about 10% (NIH
Consensus Statement, 1992 ). The incidence increases with age and patients
between 50 and 65 years of age are most at risk (GREPCO, 1984 , 1986 ; Angelico
et al ., 1997 ). Stones are twice as likely to occur in women and in certain ethnic
groups, such as Pima Indians in Arizona, USA where the incidence is believed
to be as high as 50% (Bennion et al ., 1979 ).
As a consequence of the frequency with which gall stones occur and surgery
is needed, even uncommon complications occur regularly and, if not managed
expeditiously and appropriately, the outcome can be disastrous. As well as the
consequences of the acute problem, long-term sequelae produce significant
morbidity and consume resources (American College of Physicians, 1993 ;
Quintana et al ., 2003 ). The aim should therefore be to avoid complications,
recognize them rapidly when they occur, and treat them appropriately to min-
imize these long-term problems. Effective treatment of complications often
requires transfer of patients at an early stage (or even importing surgical exper-
tise at the time of the problem) to an appropriate unit where all management
modalities are available. It is often stated that major biliary complications are
best managed by a second party who is able to take a more objective view. This
certainly has some merit but overlooks the fact that complications occur in
every hepatobiliary unit and unless units were to swap patients, complications
must inevitably be managed in house (but possibly by different personnel)
under these circumstances. Nevertheless, complications of gall bladder surgery
do remain very low and cholecystectomy by whatever means can be safely
offered to patients, both those with symptomatic and asymptomatic stones.
Controversy still exists about operating on patients with asymptomatic
stones, but with increasing longevity and well-recognized complications it is
clear that many of these patients have fewer risks associated with the surgery
than with a wait-and-see policy. Nevertheless, the exact age at which surgery
should be offered for asymptomatic stones remains unclear and will depend
on the fitness of the patient, the expertise available, and the resources of the
GALLBLADDER
210
Fig. 4.1 The management of gallstones.
>65 years age
<65 years age
Suspicious of
malignancy
Laparoscopic cholecystectomy
withl likelihood of open
procedure ± repair CBD
Abnormal LFTs/
dilated CBD on
US
Normal CBD
Normal LFTs
Cholecystectomy
Cholecystectomy
Mirizzi’s
syndrome
Stone in CBD
ERCP followed by
laparoscopic
cholecystectomy
and OTC
CT ±
laparoscopy
Symptomatic
Gallstones
Incidental
MRCP
Conservative
treatment
Unfit
Fit
GALLSTONES
211
healthcare system (Fendrick et al ., 1993 ; Ransohoff and Gracie, 1993 ; Dobbins,
2008 ).
The internet has certainly provided a large amount of information about
what is available but is less effective in allowing objective comparisons to be
made. Some patients may also express a strong preference for one treatment to
another and frequently ask about alternative modalities such as shock wave
lithotripsy and dissolution therapy. We do not offer either of these treatments
as we believe that cholecystectomy which is possible laparoscopically in the
majority of patients is now the gold standard treatment. Its main but crucial
advantages over other modalities are:
◆
It provides a permanent solution to the problem
◆
There is no requirement for continued medication or repeat treatments
◆
The risks associated with an intact gall bladder mucosa (particularly gall
bladder cancer) are removed
◆
Risks associated with the procedure in experienced hands are very low and
comparable to, or better than, other non-surgical treatments.
Consequently, in our practice it is policy to offer cholecystectomy (after
a detailed discussion) to asymptomatic patients with gall stones discovered
incidentally if they are less than 65 years of age and fit. Many of these ‘asymp-
tomatic’ patients do have some dyspeptic problems which disappear after
cholecystectomy.
When patients present with gall stones they will fall into one of three groups:
◆
Uncomplicated with no liver function test abnormalities and a non-dilated
CBD on ultrasound
◆
Transient abnormalities of liver function tests or a documented attack of
pancreatitis, abnormalities on ultrasound or MRCP
◆
Documented ductal stones and obstructive jaundice.
Cholecystectomy for uncomplicated gallstones
Laparoscopic cholecystectomy ( Figs. 4.2 – 4.7 )
Laparoscopic cholecystectomy is now the standard and preferred treatment
for uncomplicated gall stones (Wu et al ., 1998 ; Lyass et al ., 2000 ; Avgerinos
et al ., 2009 ). Problems are rare but do occur and the complexity and variability
of the biliary anatomy means it is likely that this will continue. Classical anat-
omy (combined biliary tract and vascular) between the liver and upper border
of the pancreas is only present in about 40% of the patients and when biliary
and vascular abnormalities are taken together there are a large number of
well-recognized variations (Blumgart, 2007 ). The common abnormalities such
GALLBLADDER
212
as anomalies of the cystic duct and bile duct junction and a right hepatic artery
which forms a hump and gives off a very short cystic artery are well docu-
mented and are more likely to be recognized than rarer variations (Healey and
Schroy, 1953 ; Couinaud, 1957 ; Kune, 1970 ). The less common variations can
produce almost any pattern and surgeons must have a strategy and approach
which is able to deal with these. Although conversion to open surgery should
be uncommon, it is an increasingly under-used strategy that is invaluable for
patients with confusing anatomy and severely diseased gall bladders. This is
particularly the case when the gallbladder disease is associated with previous
ERCP, xanthogranulomatous cholecystitis, unrecognized Mirizzi’s syndrome,
an incidentally discovered possible malignancy, or if there are miscellaneous
technical problems encountered during the procedure. For this reason we do
not consent patients for ‘laparoscopic cholecystectomy’ but instead to have
‘their gallbladder removed, probably by key-hole surgery’. This approach is
explained together with the likely conversion rate but serves to stress to the
patient that the important thing is a safe removal of the gallbladder during the
operation not how this is achieved.
Our operative technique is a standard four-port method and we always enter
the peritoneal cavity by an open method (Hasson technique). After the pneu-
moperitoneum has been created, the abdominal cavity is examined for inci-
dental pathology and then we examine the gallbladder. The majority will be
unremarkable apart from the effects of inflammation which may cause adhe-
sions and occasionally require the duodenum to be carefully separated. When
the gallbladder is visualized and the table has been tilted foot down and to
right-side up, usually a clear view is obtained with the two standard ports
below the right costal margin and the gallbladder being held at two points: the
fundus and above the Hartmann’s pouch. Any abnormalities at this time, such
as irregularities of the gallbladder wall as opposed to smooth changes second-
ary to inflammatory processes, or any suggestion of dense fibrosis where the
cystic duct should enter the CBD, will be noted. Intraoperative ultrasound can
be an invaluable tool at this stage to examine the gallbladder wall and reassure
the operator that this is not a gallbladder carcinoma. If suspicion remains,
however, the procedure should be converted to an open operation with careful
examination of the gallbladder and removal if possible for frozen section (see
‘Open cholecystectomy’). Similarly, Mirizzi’s syndrome (Mirizzi, 1948 ) is dif-
ficult to safely deal with laparoscopically and if this is suggested by a trial dis-
section (or ultrasound) then conversion to an open procedure should occur.
In the large majority of patients, however, the gallbladder will be mobile
and only mildly diseased and the next step is to clearly define the anatomy
( Fig. 4.2 ).