PMC2248592_01
A) Anterior view of abdomen showing the globular cystic lump in the epigastrium. B) Left lateral view abdomen showing the lateral profile of the lump. C) Inset: Sutured incision with Foleys catheter in situ, draining the cyst cavity.
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F1
The patient had a huge lobulated liver (span 22 cm) occupying both hypochondria and the right lumbar, epigastrium and umbilical regions with a localized cystic subfascial projection in the epigastrium of 8 x 8 cm. (Figure-1A &1B) Laboratory investigations revealed haemoglobin 10 gm%, white blood cell count 7500/mul and eosinophils 900/mul. A 24 F self retaining Foleys catheter was then introduced into the cyst cavity as a drain, the course of which was routed with the help of a long Robert forceps passed though the opening into the cyst cavity and then rail-roaded into position. (Figure-1C inset) The trocar site on the cyst was closed by continuous 2-0 Polyglactin sutures.
A) & B) Axial spiral CT scan of abdomen through two different levels showing a hydatid cyst in the left lobe (Segments V, VI, VII, VIII) with a cystic projection anteriorly.
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F2
Spiral CT scan of the liver (Figure-2A &2B) confirmed a hydatid cyst in the right lobe (segments - V, VI, VII, VIII), with multiple daughter cysts within, compressing the portal vein, inferior vena cava, hepatic veins, gallbladder, intra and extra hepatic biliary tree and the right kidney.
A) Intraoperative view showing the exposed cystic projection of the hydatid cyst with a purse string all around. B) Daughter cysts being sucked through the laparoscopic trocar sheath. (Inset: suction bottle containing cyst contents.)
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F3
After dividing the linea alba a close continuous suture of 2-0 silk was taken all around between the divided fascial aponeurosis and the projecting cyst wall (Figure-3A) to prevent the spillage and entry of cyst contents into the peritoneal cavity during the process of evacuation. Alternate use of the suction tube applied to the mouth of the sleeve (Figure-3B) and a high pressure laparoscopic suction irrigation apparatus introduced into the cyst cavity resulted in a drainage of three liters of thick, viscid, cream-colored cyst contents containing abundant daughter cysts (Figure-3B inset).