Summary
Background
Laparoscopic cholecystectomy (LC) is usually done using four trocars; techniques to further reduce surgical trauma have been developed. Nonparasitic hepatic cysts (HC) are only treated if symptomatic or malignancy is suspected with laparoscopy becoming the preferred approach.
Case report
A 41-year-old African American male presented with recurrent right (R) upper quadrant (UQ) pain. He was found to have cholecystolithiasis and multiple HCs with the largest located dorsally to segments 4, 5, 8 being >10 cm in diameter. A 5 mm trocar in the left (L) UQ, a 10–12 mm umbilical trocar, and a Teleflex needle grasper between the two trocars were placed. The gallbladder (GB) was removed using a modified dome down technique due to difficult access to the hilum due to the bulging large HC. Following LC, the HC was dissected off the duodenum, gerota fascia, right adrenal gland and inferior vena cava (IVC) and thereafter, the roof was resected using a harmonic scalpel. Resection was incomplete medially due to close proximity with the hilar structures and the IVC. Also a liver wedge biopsy was done. The intra- and postoperative course were uneventful and the patient was discharged after a 23 h observation period. Pathology confirmed chronic cholecystitis, mild hepatic steatosis and inflammation and benign HC wall with chronic inflammation. The patient was asymptomatic for more than 2 years when he developed RUQ pain. On the computed tomography scan, a small recurrent HC close to the liver hilum was identified; however the cause of his pain was a kidney stone.
Conclusions
Combined LC and HC deroofing is a rare procedure. A minimally invasive technique should be the preferred approach. In our case only two trocars were required and the Teleflex minigrasper completely replaced a trocar-based instrument.
References
Society of American Gastrointestinal and Endoscopic Surgeons. Laparoscopic cholecystectomy. 2016. https://www.sages.org/wiki/laparoscopic-cholecystectomy/. Accessed 11/13/2017.
Al-Azawi D, Houssein N, Rayis AB, McMahon D, Hehir DJ. Three-port versus four-port laparoscopic cholecystectomy in acute and chronic cholecystitis. BMC Surg. 2007;7:8.
Gaillard M, Tranchart H, Lainas P, Dagher I. New minimally invasive approaches for cholecystectomy: review of literature. World J Gastrointest Surg. 2015;7(10):243–8.
Li L, Tian J, Tian H, Sun R, Wang Q, Yang K. The efficacy and safety of different kinds of laparoscopic cholecystectomy: a network meta analysis of 43 randomized controlled trials. PLOS ONE. 2014;9(2):e90313.
Haribhakti SP, Mistry JH. Techniques of laparoscopic cholecystectomy: nomenclature and selection. J Minim Access Surg. 2015;11(2):113–8.
Agrusa A, Romano G, Cucinella G, Cocorullo G, Bonventre S, Salamone G, et al. Laparoscopic, three-port and SILS cholecystectomy: a retrospective study. G Chir. 2013;34(9–10):249–53.
Chamberlain RS, Sakpal SV. A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg. 2009;13(9):1733–40.
Chalkoo M, Ahangar S, Patloo AM, Matoo AR, Baqal FS, Iqbal S. A medical school experience with three port laparoscopic cholecystectomy with a new modification in technique. Int J Surg. 2013;11(1):37–40.
Ciftci A, Yazicioglu MB, Tiryaki C, Turgut HT, Subasi O, Ilgoz M, et al. Is the fourth port routinely required for laparoscopic cholecystectomy? Our three-port laparoscopic cholecystectomy experience. Ir J Med Sci. 2016;185(4):909–12.
Drenth JP, Chrispijn M, Nagorney DM, Kamath PS, Torres VE. Medical and surgical treatment options for polycystic liver disease. Hepatology. 2010;52(6):2223–30.
Debs T, Kassir R, Reccia I, Elias B, Ben Amor I, Iannelli A, et al. Technical challenges in treating recurrent non-parasitic hepatic cysts. Int J Surg. 2016;25:44–8.
Antonacci N, Ricci C, Taffurelli G, Casadei R, Minni F. Systematic review of laparoscopic versus open surgery in the treatment of non-parasitic liver cysts. Updates Surg. 2014;66(4):231–8.
Donati M, Stavrou GA, Wellmann A, Flemming P, Donati A, Oldhafer KJ. Laparoscopic deroofing of hepatic cysts: the most effective treatment option. Clin Ter. 2010;161(4):345–8.
Zacherl J, Scheuba C, Imhof M, Jakesz R, Fugger R. Long-term results after laparoscopic unroofing of solitary symptomatic congenital liver cysts. Surg Endosc. 2000;14(1):59–62.
Tagaya N, Abe A, Kubota K. Needlescopic surgery for liver, gallbladder and spleen diseases. J Hepatobiliary Pancreat Sci. 2011;18(4):516–24.
Kim MJ, Kim TS, Kim KH, An CH, Kim JS. Safety and feasibility of needlescopic grasper-assisted single-incision laparoscopic cholecystectomy in patients with acute cholecystitis: comparison with three-port laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A. 2014;24(8):523–7.
Lee KW, Poon CM, Leung KF, Lee DW, Ko CW. Two-port needlescopic cholecystectomy: prospective study of 100 cases. Hong Kong Med J. 2005;11(1):30–5.
Mantke R, Wicht S. Single-port liver cyst fenestration combined with single-port laparoscopic cholecystectomy using completely reusable instruments. Surg Laparosc Endosc Percutan Tech. 2010;20(1):e28–e30.
Nota CL, Molenaar IQ, Borel Rinkes IH, Hagendoorn J. Robot-assisted laparoscopic fenestration of giant hepatic cysts. Surg Laparosc Endosc Percutan Tech. 2015;25(5):e163–5.
Poon CM, Chan KW, Lee DW, Chan KC, Ko CW, Cheung HY, et al. Two-port versus four-port laparoscopic cholecystectomy. Surg Endosc. 2003;17(10):1624–7.
Gurusamy KS, Vaughan J, Rossi M, Davidson BR. Fewer-than-four ports versus four ports for laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2014;2:CD7109.
Philip Rothman J, Burcharth J, Pommergaard HC, Viereck S, Rosenberg J. Preoperative risk factors for conversion of laparoscopic cholecystectomy to open surgery – A systematic review and meta-analysis of observational studies. Dig Surg. 2016;33(5):414–23.
Connor S, Garden OJ. Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg. 2006;93(2):158–68.
van Det MJ, Meijerink WJ, Hoff C, Totte ER, Pierie JP. Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines. Surg Endosc. 2009;23(6):1279–85.
Wauben LS, van Veelen MA, Gossot D, Goossens RH. Application of ergonomic guidelines during minimally invasive surgery: a questionnaire survey of 284 surgeons. Surg Endosc. 2006;20(8):1268–74.
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H. Bonatti and M.J. Fisher declare that they have no competing interests.
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Bonatti, H., Fisher, M.J. Combined laparoscopic cholecystectomy and deroofing of a large liver cyst with a two trocar technique and use of a needle grasper. Eur Surg 49, 288–292 (2017). https://doi.org/10.1007/s10353-017-0499-4
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DOI: https://doi.org/10.1007/s10353-017-0499-4