Management of Hepatic Cysts
(Including Hydatid Disease)
Juan M. Sarmiento, MD and David M. Nagorney, MD
epatic cysts are classically divided into parasitic and
H .nonparasitic types, with the latter most prevalent
worldwide. Typically cysts cause no symptoms and sel-
dom lead to liver dysfunction. Their clinical presence is
precipitated by hemorrhage, infection, bile duct compres-
sion, portal hypertension, or, most commonly, expan-
sion. The treatment of hepatic cysts should be individu-
alized by cyst type and symptomatology. Cyst-related
complications of jaundice, infection, or hemorrhage must
be addressed during treatment. Because malignant poten-
tial is rare (with the exception of cystadenomas), malig-
nancy should not be a prima~y concern. Our approach to
treatment is based on these premises. 1
Many diagnostic modalities can define the presence
and the extent of hepatic cysts. Ultrasonography (US),
computed tomography (CT), and magnetic resonance
imaging (MRI) are the most useful imaging tests. US and
CT are used routinely in the workup of these patients,
with MRI reserved for complicated cases and polycystic
liver disease. Treatment is undertaken based on cyst type
by imaging, cyst number, intrahepatic site, and any com-
plications present.
Simple Cysts
Simple cysts occur in 1% to 5% of the general population.
Most are diagnosed in women, in whom symptoms are
also more common. The indication for treatment is based
on the presence of symptoms or complications. Asymp-
tomatic patients require no therapy, regardless of the size
of the cyst.
Percutaneous cyst aspiration and alcohol sclerosis un-
der US or CT guidance has evolved as an effective treat-
ment for uncomplicated hepatic cysts. 2 Complicated
cysts are best approached by an open method. Cyst aspi-
ration and sclerosis is preferable for cysts with no or
minimal capsular involvement or cysts in segments 7 and
8. When interventional radiologic expertise is unavail-
able, laparoscopic partial cystectomy (unroofing) is war-
From the Division of General and Gastroenterologic Surgery, Mayo Clinic and
Mayo Foundation, Rochester. MN.
Address reprint requests to David M Nagorney, MD, Professor of Surge U,
Department of Surgery., Mayo Clinic, 200 First Street SW, Rochester, MN 55905
Copyright 2002, ElsevierScience(USA).All rights reserved.
1524 153X/02/0401-0006535.00/0
doi:10 1053/otgn.2002 30032
76 Operative T e c h n i q u e s in General Surgery, Vol 4, No 1 (March), 2002: pp 76-87
ranted. Laparoscopy is preferred for anterior hepatic cysts
(segments 2 to 6) or for cysts with at least 50% capsular
surface area. Laparoscopic management has become the
treatment of choice based on its applicability, efficacy,
and low morbidity) Importantly, unroofing of cystade-
nomas, which are usually multiloculated but can be
unilocular, should be avoided because of the high recur-
rence rate. Biopsy of the cyst wall provides the distinction.
Biliary Cystadenoma and
Cystadenocarcinoma
These cysts are true neoplastic cysts. They can either be
serous or mucinous, with the latter more common. They
differ from simple cysts in their imaging features and
prognosis. Cystadenomas can be differentiated radiolog-
ically from simple cysts by thicker walls and more prom-
inent intraluminal septae. Cystadenocarcinomas are fur-
ther characterized by mural nodularity. Cystadenomas
are best treated by complete excision at laparotomy. 4
Echinococcal Cysts
Echinococcus, or hydatid disease, is characterized by a
worldwide distribution and frequent hepatic involve-
ment. This disease is not prevalent in the United States.
The capsule of the hydatid cysts in the liver comprises
three different layers: the host capsule, consisting of com-
pressed liver tissue and fibrous scar; the actual parasitic
cysts, consisting of an outer laminated membrane of pro-
teinaceous material of the cyst; and a germinal epithelium
that gives rise to brood capsules that contain numerous
protoscolices. These cysts are at high pressure, making
them prone to enlargement or bile duct erosion.
Patients are frequently asymptomatic. Often a routine
chest x-ray that raises the suspicion of a cyst due to ele-
vation of the right hemidiaphragm or the presence of
subdiaphragmatic calcifications. Once the diagnosis is
confirmed by further imaging and serology, treatment
must be initiated. In general, all symptomatic patients and
probably those patients with large asymptomatic cysts
with minimal or no calcifications should be treated. Small
or centrally located cysts are best observed. Recently,
percutaneous aspiration and injection of scolicidal agents
have proven safe and effective. 5 Operative or percutane-
ous intervention is indicated for symptomatic cysts; large,
peripherally located, noncalcified hydatid cysts are ap-
Hepatic Cysts
proached operatively because of the unpredictable risk of
major complications. If operation is indicated, preopera-
tive antihistamines should be administered to prevent
anaphylaxis. Albendazole or mebendazole also are ad-
ministered preoperatively, e
Adult Polycystic Kidney and Liver Disease
Adult polycystic kidney and liver disease (APKLD) is an
autosomal dominant disease that adversely affects clinical
performance status by producing progressive hepatomeg-
aly in some patients. The cysts are variable in size and
numerous, have a simple epithelial layer, and only rarely
communicate with the biliary tree. Cyst distribution and
extent varies from a few small cysts to total hepatic in-
volvement, although nearly all patients have some paren-
chymal sparing. Although the cysts compress the hepatic
parenchyma and produce hepatomegaly, liver function is
preserved almost uniformly. Increased liver volume and
adjacent visceral compression produce symptoms.
Surgical treatment is dictated for patients who exhibit
77
significant impairment in clinical performance from mas-
sive hepatomegaly or patients with complications (e.g.,
bleeding, rupture, infection, jaundice). About 10% of pa-
tients with APKLD have intracranial aneurysms that
should be addressed preoperatively, r In some patients
with few dominant cysts (the minority), percutaneous
cyst aspiration with alcohol sclerosis is appropriate. In
patients with more diffuse disease, operative intervention
is warranted. 8
The role of laparoscopy in this setting is limited to
patients harboring only a few large peripheral cysts or
some patients with medium-size cysts located anteriorly
in the liver. 9 The surgical technique is the same as that
described for simple cysts. However, most symptomatic
patients require more extensive therapy.
The choice between resection/fenestration and liver
transplantation is undefined. We favor liver transplanta-
tion in patients who lack segmental sparing. If at least two
adjacent segments are spared, we prefer resection/fenes-
tration. ]
78 Sarmiento and Nagorney

SURGICAL TECHNIQUE

Simple Cysts

tllliu

1 Laparoscopic unroofing of a simple cyst. Usually three ports are

necessary, one each for the camera, grasper for the cyst wall, and cutting
instrument (cautery, harmonic scalpel, or scissors). One of the working
ports should be 10 mm to allow clip application. Placement varies accord-
ing to the anatomic location and size of the cyst. This illustration shows
the port sites that we use most often. After the laparoscope is introduced
and the abdominal cavity inspected, the dome of the cyst is elevated with
a grasper. The wall of the cyst is resected with electrocautery. We empha-
size excision as close as possible to the cyst-liver tissue interface.
Hepatic Cysts 79

2 After the cyst is incised, cyst contents are drained

making the flaccid cyst wall easier to handle. Cytology of
the aspirate is performed if indicated. It is important to
resect as much of the wall of the cyst as possible to enhance
retraction of the remnant edge of the cyst, thus preventing
reapproximation of the rim by contraction which leads to
cyst recurrence. Effaced ducts or vessels at the cyst-liver
interface should be stapled or clipped. The cyst wall is
removed and assessed microscopically.

3 After unroofing, the residual cyst wall is carefully in-

spected. Irregularities within the concavity of the cyst are
biopsied. When less than 50% of the cyst has been re-
moved, ablation of the remnant cyst lining by cautery,
argon beam coagulation, or topical sclerosant may reduce
the incidence of recurrence. Rarely, omentum can be
placed within the cyst remnant to prevent recurrence.

~,~o
80 Sarmiento and Nagorney

4 Not all simple cysts are amenable to laparoscopic

therapy. Cysts located superiorly in segments 7 and 8
are very difficult to access without mobilizing the liverff
This illustration shows a cyst in the right posterior seg-
ment. A right subcostal incision is indicated in these
patients; we usually divide the triangular ligament and a
portion of the coronary ligament to rotate the liver and
bring the cyst closer to the wound. Using the nondomi-
nant hand, the surgeon pushes the liver toward the
midline to facilitate exposure of the cyst. Following the
same principles espoused in the laparoscopic approach,
the cyst is resected. Alternatively, the cyst can be enu-
cleated en toto.

5 The final result after resection shows a "clean" concavity of

the cyst with basically no cyst wall above the level of the hepatic
parenchyma. Occasionally, blood vessels or bile ducts can be
seen in the cavity. No drains are necessary after cyst excision.
Hepatic Cysts 81

Biliary Cystadenoma and Cystadenocarcinoma

6 A cystadenoma in the inferior portion

of the liver.

? ~ @ ~ , ~ ~ ~ ~ . . . . ~ ~ 7 84: ~ ~ 5 ~ : 84
~i~ ~'84 ~ ~!: ~ % ~ i ~ : i)4!i"~ ~ ~84184
84184184

tYS~tVO
2~01

7 After mobilization of the liver is achieved,

countertraction is imposed by the surgeon's
nondominant hand. The interface between the
cyst and the hepatic parenchyma is identified
and developed. The cyst wall is sufficiently
thick allowing the surgeon to dissect it away
from the liver without rupture. With deeper
dissection, compressed vessels and bile ducts
become evident and are preserved. This dissec-
tion is continued circumferentially with enu-
cleation of the cystadenoma. 1~ The cyst is sent
for histologic analysis to exclude occult cyst-
adenocarcinoma. If this finding is present, for-
real hepatic lobectomy is indicated. 11
82 Sarmiento and Nagorney

8 When inadvertent injury of the bile

ducts occurs, fine (4-0 or 5-0 absorbable)
interrupted suture is used for repair. Ab-
dominal drainage is optional. Complete
excision of the cystadenoma eliminates
the risk of recurrence. 4

Echinococcal Cysts

9 After routine abdominal exploration and liver expo-

sure, the cyst is identified and isolated with saline-soaked
gauze (20%) packs peripherally. This preventive measure
may reduce the risk of anaphylactic reactions if cyst con-
tents spill into the peritoneal cavity.

!i!~!:: ~:: ~i!~i~:: : : i~

~&'r
Hepatic Cysts 83

Cyst is Scolicidal
drained solution is
injected

~&YO
~001

l 0 The cyst is decompressed to avoid inadvertent rupture during manipulation. Once the cyst is
drained and bile duct communication is excluded, a scolicidal solution is instilled into the cyst.
Adequate duration of exposure to the agent is necessary. Scolicidal instillation is contraindicated with
bile duct rupture because of the risk of biliary sclerosis.

l 1 The cyst is opened, and the laminated cyst membrane and daughter cysts
are removed manually, again avoiding spillage.
84 Sarmiento and Nagorney

Fibrous
capsule

Risk of
injury to
underlying Prefered
vessels method

12 It is not our practice to perform a cystopericystectomy ~2 because of the risk of

hemorrhage and bile duct injury. We prefer to leave the host capsule behind, because it is
noninfectious and because excision may lead to vascular or bile duct injury. We advise
removal of the cyst, staying in the plane between the host capsule and the actual cyst to
avoid unnecessary complications.

13 Final appearance of the cyst after excision. One

must be very careful to identify bile duct injuries at this
stage.
Hepatic Cysts 85

14 The cyst cavity is obliterated with omen-

turn, and the site is drained externally by a suc-
tion catheter.

Adult Polycystic Kidney and Liver Disease

15 Diffuse involvement of the right lobe with some cysts in the left lobe
(i.e., lobar sparing). In this particular patient, resection of the right lobe and
fenestration of cysts in the left lobe is the procedure of choice. Generally, the
cysts on the right lobe are small, and almost no gross hepatic parenchyma
exists between the walls of the cysts. Resection of the involved lobe has only
a minimal affect on hepatic function.
86 Sarmiento and Nagorney

I~g01

16 Right hepatectomy in these patients follows the same principles as resection for other
conditions. The lobar hepatic artery and portal vein are divided initially, as is the right hepatic
vein if possible. Large adjacent lymphatics should also be ligated. Liberal cyst decompression
around the vasculature facilitates control of the major vessels. Moreover, reduction of liver size
by decompression improves mobility.

17 After vascular control is achieved, the liver is divided by sequential

cyst fenestration along the planned transection plane. This maneuver offers
the advantage of quick advancement through the liver. Use of a cavitron
ultrasonic suction aspirator (CUSA) enhances the dissection because of its
dual suction and cautery capability. Any vessel or duct encountered should
be ligated with sutures to reduce the risk of hemorrhage and bile leaks.
Hepatic Cysts 87

18 The location of the vessels and the bile ducts compressed in the
hepatic parenchyma surrounding the cysts (inset). These structures
must be suture ligated to prevent postoperative complications. After
resection is complete, central lobar cysts are unroofed. This illustra-
tion shows the final result of this procedure. Because the remnant cyst
wall maintains its secretory capacity, epithelial ablation by cautery or
an equivalent is performed to reduce postoperative drainage. More-
over, ensuring that the interior vena cava and the remaining hepatic
veins are free of cyst compression reduces the risk of postoperative
ascites.

Summary 4. Davies W, Chow M, Weiland L, et al: Intrahepatic biliary cystadeno-

The management of liver cysts should be individualized
by cyst type, symptoms, and associated complications.
Percutaneous aspiration/ablation therapy and laparo-
scopic approaches are used most commonly and have
proven efficacious for simple cysts. Management of spe-
cific diseases such as APKLD is more complicated and
dictates treatment in centers with hepatobiliary and trans-
plantation expertise.
REFERENCES
1. Nagorney DM: Surgical management of cystic disease of the liver.
In Blumgart LH, Fong Y (eds): Surgery of the Liver and Biliary
Tract. Philadelphia, PA, W.B. Saunders, 1995, pp 1261-1276
2. Van Sonnenberg E, Wroblicka JT, D'Agostin HB, et al: Symptom-
atic hepatic cysts: Percutaneous drainage and sclerosis. Radiology
190:387-392, 1994
3. Gigot JF, Legrand M, Hubens G, et al: Laparoscopic treatment of
nonparasitic livers cysts: Adequate selection of patients and sur-
gical technique. WorldJ Surg 20:556-561, 1996
mas: An institutional experience with 37 cases. HPB 1:141, 1999.
5. Men S, Hekimoglu B, Yucesoy C, et al: Percutaneous treatment of
hepatic hydatid cysts: An alternative to surgery. AmJ Roentgenol,
172:83-89, 1999
6. Turkcapar AG, Ersoz S, Gungor C, et al: Surgical treatment of
hepatic hydatidosis combined with perioperative treatment with
albendazol. EurJ Surg 163:923-928, 1997
7. Geevarghese SK, Powers T, Marsh J, et al: Screening for cerebral
aneurysms in patients with polycystic liver disease. South Med J
92:1167-1170, 1999
8. Que F, Nagorney DM, Gross JB Jr, et al: Liver resection and cyst
fenestration in the treatment of severe polycystic liver disease.
Gastroenterology 108:487-494, 1995
9. Martin IJ, McKinley AJ, Currie EJ, et al: Tailoring the management
of nonparasitic liver cysts. Ann Surg 228:167-172, 1998
10. Pinson CW, MunsonJL, Rossi RL, et al: Enucleation of intrahe-
patic biliary cystadenomas. Surg Gynecol Obstet 168:534-537,
1989
11. Ishak KG, Willis SGW, Cummins SD, et al: Biliary cystadenoma
and cystadenocarcinoma. Report of 14 cases and review of the
literature. Cancer 39:322-338, 1977
12. Mentes A: Hydatid liver disease: A perspective in treatment. Dig
Dis 12:150-160, 1994