International Journal of Surgery Science 2020; 4(1): 419-422

E-ISSN: 2616-3470
P-ISSN: 2616-3462
© Surgery Science Surgical techniques for management hepatic hydatid
www.surgeryscience.com
2020; 4(1): 419-422
cysts in fallujah teaching hospital: A prospective study
Received: 04-11-2019
Accepted: 06-12-2019
Abdulhadi Meryud Abood and Duraid Dawood Mahmood
Abdulhadi Meryud Abood
Deportment of Surgery, Fallujah
Teaching Hospital, Fallujah,
DOI: https://doi.org/10.33545/surgery.2020.v4.i1h.371
Anbar, Iraq
Abstract
Duraid Dawood Mahmood Background: Hepatic hydatid cysts (HHCs) are a parasitic infestation caused by several species of
Deportment of Surgery, Fallujah Echinococcus, even though surgery is the mainstay in the management of hydatid disease of the liver,
Teaching Hospital, Fallujah, controversies still exist about the preferred operating technique.
Anbar, Iraq Aim of study: To assess the effectiveness of different surgical procedures for managing the hepatic hydatid
cyst at Baghdad Teaching Hospital and study the incidence of post-operative complications.
Patients and Method: Sixty-four patients aged between12 and 60 years underwent surgery for HHCs
within a one-year period from the first of January 2018 to end of December 2018.
We recorded demographic data, location of the cysts in liver, surgical procedures used, postoperative
complication, morbidity, mortality and hospital stay.
Results: Most of the patients were females 48(75%) from rural area and the mean age was 40 years, the
most common symptom was abdominal pain in 51 patients (79.6%) and the right lobe of the liver was
mostly affected 39(60.9%).
The External drainage technique was used in 28 patients (43.3%). Omentoplasy technique was used in 19
patients (29.6%)
Conclusion: The morbidity and hospital stay were highest in external drainage method and least in
omentoplasty. The method of omentoplasty is simple and can be performed in the majority of patients.

Keywords: Cyst. echinococcus hydatid disease liver

Introduction
Human cystic echinococcosis or hydatid cyst disease is a zoonosis caused mainly by the larval
cestode of Echinococcus granulosus of taenia Hippocrates recognized hydatid disease over 2000
years ago who referred to (a liver full of water) [1].
T The disease is relatively common in the sheep and cattle-raising areas of the world [2].
Hydatid cyst disease in Iraq is endemic mainly in the central and southern between Tigris and
Euphrates rivers which is inhabited by farmers who raised sheep's in large numbers [3].
Hydatid is a zoonetic infection in which the human is an alternative to intermediate host of the
larval stage of this parasite which is referred to hydatid cyst, the intermediate host are
herbivorous mammals and the definitive host are carnivore animals [4].
In human the liver is infected in about (60%) of patients, the lung in about (20%) and other
organs such as the kidney, brain, bone, and muscles in about (20%) [5].

The cyst consist of three layers [6]

1. The outer coat (pseudocyst or pericyst).
2. Laminated membrane (ectocyst).
3. Germinal layer (endocyst).

Hydatid fluid is thick colorless, odorless, ph (6.7-7.2), highly antigenic and the pressure can be
as high as 300ml H2O [6].

Corresponding Author: Symptom & sign: [7]

Duraid Dawood Mahmood 1. The cyst may be silent (asymptomatic).
Deportment of Surgery, Fallujah 2. Chronic abdominal pain.
Teaching Hospital, Fallujah, 3. Abdominal mass.
Anbar, Iraq
4. Nausea, vomiting and weight lose.

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5. Fever (infected hydatid cyst). 2. To study the incidence of post-operative complications and
6. Hepatomegaly. compare with other studies.
7. Jaundice (obstructed) due to pressure effect or rupture
hydatid cyst into biliary tree. Patientas and Methods
8. Acute abdomen or death due to rupture hydatid cyst This is Prospective study of 64 patients who underwent surgical
[17]
(anaphylactic shock). treatment for HHC at Fallujah Teaching Hospital over period
from the first of January 2018 to end of December 2018 (one
Investigation [7] year period). Patients with liver hydatid were included as
1. Imaging: plain x-ray. elective cases or emergency case (acute abdomen).
2. Abdominal ultrasonography (U/S) and abdominal (CT). Are We recorded the main symptoms, preoperative radio- logical
uses to classify the cysts to the five categories according to investigations, location of the cysts, surgical procedures
Gharbi classification? performed, postoperative complications, morbidity, and mean
3. Liver function tests. hospitalization period after surgery.
4. Serological tests to detect antibody in the serum, ELISA and Preoperative diagnosis was established by a history followed by
complement fixation test. clinical examination and the main clinical features were (chronic
5. Confirmation of the diagnosis is possible only by abdominal pain, abdominal mass, acute abdomen, asymptomatic
examination of the cyst content after surgical removal [7, 9]. and jaundice).

Treatment [10] Imaging studies including

Surgery is definitive treatment and the medical treat- ment of 1. Ultrasonography was done routinely in all patients to
hydatid cysts with mebendazole or albendazole alone is determine the location, number, and morphol- ogy of cysts
controversial and the medical treatment is usu- ally reserved for within the liver. Unfortunately Gharbi classification was not
disseminated systemic disease, inop- erable disease, patient unfit used at Baghdad teaching hospital.
for surgery and prophylaxis during surgery. 2. CT scan were needed for further anatomical details,
especially in patients with recurrent disease and presence of
Surgical treatment includes [10] multiple hydatid cysts.
1. Radical operation. 3. All patients underwent chest radiography to exclude
2. Conservative operation. pulmonary hydatid cyst.
4. Other investigation were complete blood picture and liver
Radical operation [10] function test.
1. Cysto-pericyst ectomy.
2. Segmental resection. All patients kept on albendazol (10mg/kg/day) for 2 week before
3. Hepatic lobectomy. surgery. During surgery the principle incision was the right
subcostal and midline incision used in emergency cases and
Conservative operation includes [11] multiple hydatid cyst, the operative field was packed with 20%
Evacuate the content of the cyst without removal of the pericyst, hypertonic saline compresses to protect the surrounding tissues,
management the residual pericystic cavity is very important the cyst was punctured and decompressed as much as possible if
because the operative morbidity and mortality depend on how there was no bile in fluid then (20%) hypertonic saline injected
the pericystic cavity is managed. in the cyst and kept for 5 minute then aspirated, after that the
There is a lot of method of handling residual cavity of HHC cyst opened. If the aspirate contained bile, no irrigation was
(Capsulorrhaphy, Extraperitoneal drainage, Marsupialazation, performed and the containing is evacuated after that laminated
Left opened to the peritoneal cavity, Omentoplasty, membrane removed with sponge-holding forceps then the visible
Capitonnage, Overlapping, External drainage and Myoplasty) biliary communications were sutured individually with
[12]
. absorbable material. Some time for adjacent multiple hydatid
cyst we open one to other after that finally hypertonic saline
Recently [13] used on wall of cyst then remaining cavity was dealt with by one
1. Laparoscopic deroofing, when cyst present in accessible of these procedure.
place. 1. Closed-tube drainage (external drainage). This method use
2. PAIR technique (puncture, a spirtion, ninjection and for large cyst >16cm and infected hydatid.
respiration). 2. Omental flap was placed over the residual cavity
3. PAIR was proposed in 1986 by Tunisian team and Guideline (omentoplasty), patch of omentum is brought to rest within
for the treatment of hydatid disease include PAIR have been the cavity and the omentum loosely with 3-4 stitches of
proposed by WHO in 1996 13. absorbable suture to widely open mouth cavity. This method
4. DPAI (double percutaneous aspiration and injection of used for size of cyst between (7-16cm) and bile stained
alcohol). content.
5. Water jet dissector used to deeply located cyst, cyst cavity is 3. Combination of procedures (omentoplasty and external
filled with gelatin sponge which induce fibroblast response drainage). This method used infected cyst and bile stained
and assist rapid and effective obliteration of cavity [14]. and some of multiple hydatid cysts.
6. Nd-YAG laser: photocoagulation used for residual cavity [14]. 4. Postoperatively all patients were followed up during their
admission and kept on albendazole (10mg/kg/day) for four
The aim of the study weeks this cycle is re- peated three time by 2 week intervals.
1. To assess the effectiveness of different surgical procedures Information regarding the demographic features of the
for managing the hepatic hydatid cysts in Baghdad teaching patients, operative details and immediate post-operative
hospital. complications were recorded.

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Results Table 3: Post-operative complications and period of hospital stay for

It is randomized prospective study which was carried out in the each operation method
surgical department in Fallujah Teaching Hospitals during the Post-operative External Omento- Combination
period of Jan. 20017-Dec. 2018. complication drainage plasty Procedures
The total series of 64 patients treated surgically during the one Biliary discharge 4 (14.2%) 1 (5.8%)
year period forms basis of this study, the females patients were Wound infection 7 (25%) 2 (10.5%) 4 (23.5%)
48(75%), mean age 40year and their ages range between 12-60 Abscess in cavity 2 (7.1%)
year. The males patients were 16(25%), mean age 34year, their Morbidity (46.4%) (10.5%) (29.4%)
ages range between 17-60 year and female to male ratio 3:1. Hospital stay 9 days 5 days 6 days
Age and gender distribution of 64 patients with HHC in table.1 Mean no. of day
Total No. (28) (19) (17)
Table 1: Age and gender distribution of 64 patients with hepatic
hydatid cyst. Discussion
We found that, the hydatid cyst has a maximum incidence in
Age in year Male Female
12-19 4 (6.2%) 6 (9.3%)
female’s patients. They were 48 (75%), mean age 40 year and
20-29 2 (3.1%) 10 (15.6%) their ages range 12-60 year.
30-39 2 (3.1%) 4 (6.2%) The external drainage was mostly used 28 patients (43.3%), but
40-49 6 (9.3%) 20 (31.2%) in study by Al-Janabi; 16 at Al-Rasheed Military Hospital this
50-60 2 (3.1%) 8 (12.5%) method was used in (34.4%) and in study in UK by STAVROSE
Total No. 16 48 et al [17], the external drainage was used in (25.5%) of patients
while in 15
The diagnosis was made by clinical features and imaging The incidence in the males patients were 16 (25%), mean age of
techniques. 34 year, their ages range 17-60 year and a study in Turkey by
The abdominal discomfort was the most frequent symptom and ERGUNERDEM et al method used in (12.7%) of patients., this
reported by 51(79.6%) patients. female to male ratio 3:1 and this is probably due to females deal
The rural people were more affected 38(59.3%), the right lobe of with infected vegetables. It agrees with study in Turkey by
the liver are more affected 39(60.9%) and the cyst was mostly ERGUNERDEM et al [15], the incidence was (74.5%) in females
solitary 40 (62.5%). and (25.5) in males, it is different from study by Al-Janabi; 16 at
The most operations were elective 61(95.3%) and the subcostal Al-Rasheed Military Hospital which revealed a high incidence
incision was mostly used 53 (82.8%). in males (87.9%) because most militaries were men and (12.1%)
Size, contains of HHC and Post-operative complications are in females but in study in UK by STAVROSE et al [17], the
summarized in Table 1. incidence was (56.2%) in females and (43.8%) in the males.
The external drainage procedures was mostly used in 28 patients Treatment of HHC is mainly surgical and it is directed toward
(43.3%), the omentoplasty was used in 19 patients (29.6%) and the cyst and the remaining cavity, the surgical approach may be
the combination of both procedures are used in 17 patients chosen on basis of local experience and the characteristics of
(26.5%). each individual case (e.g. number, size and location of cyst), so
in this study we assess the different surgical techniques in
Table 2: Size contains of HHC and Post-operative complications. general.
All patients diagnosed with HHC underwent laparoto- my,
External Omento- Combination which was performed through a right subcostal incision in
drainage plasty Procedures 28patients (43.7%), extended Right subcos- tal in 25 patients
Size of HHC(cm)
11.6 (7-21) 9.6 (7-16) 10.2 (8-13)
(39%) for cyst in left or both lobes and midline incision in 11
median and range patients (17.1%), 3 patients were emergency operations and 8
Contains of HHC patients multiple hydatid cyst.
Pure 25(89.2%) 13(68.4%) 16 (94.1%) In our series, patients are treated by three surgical procedures to
Bile 2(7.1%) 6 (31.5%) 1(5.8%) deal with the remaining cavity of HHC which included (external
Infected 1(3.5%) drainage, omentoplasty and combination of both procedure
Post-operative 13 patients 2 patients 5 patients
drainage and omento-plasty).
Complications (46.4%) (10.5%) (29.4%)
In external drainage procedur e, this method used for HHC size
No. of patient 28(43.3%) 19(29.6%) 17(26.5%)
(7-21) cm and the contains of cyst were pure hydatid fluid in 25
patients, bile stained in 2 patients and infected in 1 patient. A
The post-operative complications and period of hospital stay for
high morbidity (biliary discharge, wound infection and abscess
each operation method are summarized in table3.
in cavity) was found in external drainage in 13 patients (46.4%)
The highest morbidity was in external drainage in 13 patients
and long period of hospital stay 9 days (mean hospital stay), the
(46.4%), the least morbidity was in omentoplasty in 2 patients
high morbidity due to high wound infection rate in 7 patients
(10.5%), the longer mean hospital stay (days) were in external
(25%), biliary leak in 4patients (14.1%) and abscess in cavity in
drainage 9 days and 5 days in omentoplasty.
2 patients (7.1%).
Statistical analysis was performed using analysis of (ANOVA)
But in study by Al-Janabi; 16 at Al-Rasheed Military Hospital
variance for length of hospital stay and Fisher's exact test for
the morbidity was higher (55%) while in study in Turkey by
morbidity.
ERGUNERDEM et al [15], the morbidity was highest (58.3%)
Highest morbidity and hospital stay in external drainage
and hospital stay was 19 days (mean hospital stay).
(P<0.04) and least morbidity and hospital stay in omentoplasty
In omentoplast, this method was used in 19 patients (29.6%),
(P<0.02).
this method used for HHC size (7-16) cm and the contains of
A value of P<0.05 was considered statistically signifi- cant.
cyst were pure hydatid fluid in 13 patients, bile stained in 6

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patients and there is no infected cysts. The morbidity was in 2 7. Shaleen Agarwal, Sadiq Saleem, Ashok Kumar. Bile leaks
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