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among various types of treatment options for a liver cyst , deroofing of the cyst is recommended as a safe and reliable procedure .
recently , it has been possible to perform deroofing laparoscopically because of the advances in laparoscopic techniques .
however , the place of laparoscopic deroofing is controversial when the cyst has a biliary communication . besides
, it is difficult to diagnose the presence of the cystobiliary communication preoperatively or even during operation . overlooking the cystobiliary communication leads to postoperative bile leakage , which is a serious complication .
we , herein , present the case of a liver cyst with biliary communication diagnosed intraoperatively and successfully treated by laparoscopic procedures .
a 71-year - old japanese woman presented with right upper abdominal fullness and pain of 18-months duration . when a huge cyst , measuring 14 cm in diameter , was pointed out in the right lobe of the liver at a nearby hospital , percutaneous aspiration was performed and resulted in disappearance of the cyst . however , the patient noted right upper abdominal distention again in 11 months and was admitted to the department of surgery i , kyushu university hospital .
computed tomography indicated a cyst in the right lobe of the liver , showing homogeneous water density without any mural nodules and measuring 16 cm at its largest diameter ( figure 1 ) .
1.3 cm in diameter , was found at the splenic flexure of the transverse colon .
the patient underwent laparoscopic deroofing of the liver cyst , together with laparoscopy assisted transverse colectomy for transverse colon cancer and laparoscopic resection of paraovarian tumor . at operation , the huge liver cyst was seen to protrude extrahepatically with mild adhesion to the surrounding tissue ( figure 2 ) .
after the cyst was deroofed with laparoscopic coagulating shears ( harmonic scalpel , ethicon endo - surgery , inc . ,
cincinnati , oh ) ( figure 3 ) , however , laparoscopic inspection of the inner surface of the cyst cavity revealed a small orifice of bile leakage ( figure 4 ) .
a catheter was inserted into the orifice for cholangiography , which demonstrated a communication of the cyst with the right anterior inferior hepatic branch of the bile duct ( figure 5 ) .
indocyanine green diluted in saline was subsequently injected to detect any other leakage points , but no other communications were found .
the orifice was closed with interrupted sutures by using a laparoscopic suturing device ( endostitch , tyco healthcare japan , tokyo , japan ) ( figure 6 ) .
the inner surface of the remaining cavity as well as the resected margin was coagulated with an argon beam coagulator .
total operation time was 9 hours 15 minutes , and that for the deroofing of the liver cyst was 5 hours 30 minutes .
total blood loss was approximately 500 grams , and that for the deroofing of the liver cyst was approximately 300 grams . according to the pathological examination of the resected specimen ,
the liver cyst was deemed consistent with a simple cyst , which was lined with cuboidal epithelial cells .
the tumor of the transverse colon was adenocarcinoma , invading submucosa , and the paraovarian tumor was cellular fibroma .
the patient was discharged on postoperative day 27 and had no recurrence of the liver cyst during the 13-month follow - up .
computed tomography reveals a liver cyst in the right lobe , measuring 16 cm in diameter .
the liver cyst protrudes extrahepatically with mild adhesion to the surrounding tissues . the cyst being deroofed with laparoscopic coagulating shears . macroscopic inspection of the cyst cavity shows bile leakage ( arrow ) .
cholangiography via the orifice ( arrow ) demonstrates the communication to a branch of the anterior inferior segmental duct .
various therapeutic options for a symptomatic liver cyst have been described , including percutaneous aspiration , cystojejunostomy , deroofing or excision of the cyst , partial liver resection , and even liver transplantation . among them , deroofing of the cyst is now recommended as the gold standard treatment in cases of nonpolycystic liver diseases , because of its simplicity , effectiveness , and low morbidity .
this procedure was introduced by lin et al in 1968 and was performed laparoscopically by paterson - brown and garden for the first time in 1991 .
the laparoscopic technique is not only less invasive than the conventional counterpart , causing less pain and promoting faster recovery , but also is as reliable as open surgery in terms of recurrence rates .
however , deroofing has been considered a contraindication for cysts with cystobiliary communication , for which cystojejunostomy has often been used . because postoperative bile leakage can lead to serious complications ,
endoscopic retrograde cholangiography , which was unsuccessful in the present patient , is considered a standard method for detection of cystobiliary communication .
however , it is not always useful because high intracystic pressure might prevent opacification of the cavity through the biliary tract .
meanwhile , percutaneous aspiration and inspection of the content of the cyst is a direct diagnostic tool to prove bile contamination .
however , even when aspirated fluid reveals no bile content , the cyst can still demonstrate leakage from an intrahepatic duct , just as in this case .
these suggest that very careful intraoperative examination is necessary so as not to overlook the possible existence of biliary communication . for intraoperative detection of the cystobiliary communication , meticulous inspection of the cyst cavity
is most reliable as stated by lai and wong and hodgson et al . in our patient ,
the cystobiliary communication was found by careful laparoscopic observation , which was very useful as a sensitive new tool .
operative cholangiography or cystography is another valuable examination for detecting biliary communication and defining the anatomic relationship between the cyst and major bile ducts .
injection of methylene blue through a transcystic catheter has also been reported to be useful . when an orifice of the biliary communication has been detected , the dye injection is helpful to further demonstrate other possible communications . once recognized , laparoscopic closure of the biliary communication is not technically difficult because of the recent advances in surgical instruments .
cystojejunostomy , recommended by longmire et al as an excellent alternative for a cyst with cystobiliary communication , might possibly be complicated by sepsis when the previously sterile cyst becomes infected with enteric organisms after the operation .
laparoscopic deroofing is recommended as the first choice for treatment of simple liver cysts even in the presence of cystobiliary communication , which can be closed by laparoscopic suturing .
a 71-year - old japanese woman complained of right upper abdominal fullness and pain . computed tomography revealed a huge cyst in the right lobe of the liver , measuring 16 cm in diameter . 
 she underwent laparoscopic deroofing of the liver cyst . on operation , 
 needle aspiration of the cyst yielded clear serous fluid without any bile contamination . 
 however , after the cyst was deroofed with laparoscopic coagulating shears , bile leakage was recognized from a tiny orifice in the cyst cavity . 
 a catheter was inserted via the orifice for cholangiography , which demonstrated a communication with the biliary tract . 
 the orifice was easily closed with a laparoscopic suturing device . 
 operation time was 5 hours and 30 minutes , and blood loss was 300 grams . 
 pathological examination of the liver cyst was consistent with a simple cyst . 
 the postoperative course was uneventful , and the patient has had no recurrence to date at 13 months . 
 laparoscopic deroofing is a recommended treatment for a liver cyst even in the presence of cystobiliary communication .