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Mansy et al. Mini-invasive Surg 2018;2:36 I http://dx.doi.org/10.20517/2574-1225.2018.48 Page 7 of 9

should be focused on parasite elimination, and treatment of both the adventitia as well as the cavity.

Total or near total pericystectomy is the chosen treatment for hepatic hydatid cyst, because it is the only
[13]
management modality that treats the disease integrally with low morbidity and mortality . If we don’t resect
the infected adventitia well, which is known to contain exogenous vesicles, that may lead to relapse of the
disease. Due to this reason radical treatment prevents residual cavity disease and thus prevents relapse [9,13] . In
our study, radical procedure was done in 96.12% of the patients (liver resection in 14.59%, total pericystectomy
[6]
in 77.67% and laparoscopic total pericystectomy in 4.85%). In a study of Marco et al. , a radical treatment was
performed for 93%, and for 81% of these patients, total or near total cystectomy was done.

In addition to ordinary open surgical techniques, the laparoscopic approach has been used as a new
modality for hydatid cyst treatment.

The laparoscopic approach on open approach affords a short hospital stay, less invasiveness, lower incidence
[14]
of wound infection and less postoperative pain . Disadvantages of laparoscopic technique are limited
manipulation, difficult thick viscous content aspirating, increased risk of cyst content spillage and the
[15]
difficult approach deeply-seated lesions . Note that centrally located cysts carry a high risk of bleeding, so
[16]
we should think in conventional open method, for its management .
[17]
Radical hydatid cyst treatment showed better results and low risk for complications . In our study, the
average intra-operative bleeding was less than 600 mL, ranging from 300 mL to 2000 mL. About 31.07%
of the patients required an intraoperative blood transfusion. Less than 20% of the patients required
hospitalization in ICU during the first 24 h postoperatively.

[18]
Complicated hydatid liver cysts was found in 15% to 60% of patients at the time of diagnosis . We
managed 30 (29.13%) patients with complicated hydatid cyst. The most important cases were the 8 cases
that recurrent after incomplete resection (endocystectomy and drainage). Three of the cases were presented
with biliary complications (1 with biliary cyst and 2 with biliary fistula).

The type of surgery: either conservative method (deroofing, drainage) or radical surgery (pericystectomy
[18]
[19]
and hepatectomy) is the major factor for hydatid cyst recurrence . Aydin et al. comparative retrospective
study on 242 patients described significantly higher morbidity and recurrence rates in patients managed by
[20]
conservative surgery (11% vs. 3%; 24% vs. 3%). In another study by Tagliacozzo et al. , from 454 patients, 214
were managed with conservative surgery (external drainage, marsupialization or omentoplasty), while the
remaining 240 managed with radical surgery. Morbidity and recurrence rates were significantly higher in the
group that was managed conservatively. In our study no recurrence was detected during the follow up period.

Biliary leakage and fistulas are the main immediate post-operative complications after conservative
procedures, beside septic complications of the residual cavity. A pericyst left in situ (especially if thick and
calcified) represents two major obstacles. First, delay liver regeneration filling the residual cavity, leading to
serum and blood accumulation or liver abscess formation. Second, pericyst persistence may hide possible
biliary communication in the residual cavity leading to biliary fistula, which occurs in up to 50% of
[3]
patients after conservative managemenet .
However radical procedure advantages in this particular issue allow exact detection and safe suture of
biliary and vascular branches in the healthy parenchyma which definitely reduce the risk of biliary leak
[21]
and blood collection. Spontaneous reduction of the residual cavity by liver regeneration would happen .

Albendazole may play a role to prevent recurrences after surgery using 400 mg twice daily for 3-6 months.