Wanita, 61 tahun, dengan perut

membesar perlahan sejak 6 tahun lalu,

kadang-kadang disertai nyeri perut
sebelah kanan.
Tidak ada riwayat trauma.
Pemeriksaan fisik perut membesar,
dengan gambaran pelebaran vena-vena
serta teraba massa tumor sisteus
terutama pada perut sisi kanan.
Foto pasien
Laboratorium
Tidak ada kelainan
USG
CT scan
Diagnosis ?
Penanganan

?
KISTA HEPAR
Pendahuluan
Insidens
Anatomi Fisiologi
Anatomi Fisiologi
Klasifikasi
Etiopatogenesis
Etiopatogenesis
Etiopatogenesis
Etiopatogenesis
 Etiopatogenesis
Kista Hidatid (Ecchinoccus
Granulosus)
Etiopatogenesis
Manifestasi klinis
Diagnosa
Pemeriksaan
Penunjang
 Pemeriksaan
Penunjang
Pemeriksaan Radiologi
Simple kista PCLD

Tampak gambaran homogen, garis CT-Scan menunjukkan lesi multipel,

tepi yang halus dan tipis hingga homogen, hipoattenuasi dengan garis
dinding tidak dapat terlihat regular
 Pemeriksaan Penunjang

Gambaran CT Scan Abdomen Pada Gambaran CT-Scan kista hepar

Kista hepar Piogenik. amubik, tampak lesi hipodens,
Tampak abses multifokal dinding tebal
 Pemeriksaan Penunjang
Kista Hydatid Kista hepar Neoplastik

Gambaran CT Scan Abdomen Pada

Gambaran CT Scan Abdomen Pada
Kista hepar hydatid,
Kista hepar neoplastik, tampak lesi
Tampak lesi hipodens dengan dua
hipodens dengan tepi irreguler
anak kista
 Pemeriksaan Penunjang
Pyogenic Amebic Hydatid Congenital Neoplasma

Number Tunggal atau Satu atau Biasanya Tunggal atau Tunggal

multipel sedikit tunggal multipel dengan
lokulasi

Ketebalan Tebal Tebal Tebal Tipis Bervariasi

dinding

Karakter dinding Seragam atau Biasanya Seragam, Seragam Bersepta,

multiloculasi seragam anak kista; umumnya
50% irregular
kalsifikasi
Indeks Kista Biasanya pus Merah-coklat Bersih; Biasanya Biasanya
dengan darah seperti agar- densitas water hijau
agar kecoklatan
mucinous
Penatalaksanaan
Penatalaksanaan
Laparascopic Surgery in
Liver Cystic Disease

Benny Philippi ( Indonesia )

 Liver Cyst

Liver cysts are not uncommon

Rarerly become symptomatic
and require intervention
Surgery is usually the treatment
Laparascopic cyst unroofing
 Diagnostic

Before ultrasonography (US)

and computed tomography
(CT) liver cyst were thought
rare lesions
Asymptomatic hepatic cyst are
quite common, 4.7% and sharp
rise in incidence with age
Klinger 1977
 Liver cyst clasification

Pseudo cyst :
Traumatic lesion, neoplastic growth
True cyst :
Non parasitic and parasitic types
(echinococcus)
Non-parasitic cyst :
Single, multiple
Simple cyst :
Aberrant bile duct with cystic dilatation
Therapeutic strategies

Relief of symptoms
Definitive treatment ( incl.
removal of the lesion )
Non surgical therapy ( non
parasitic cyst )

Percutaneous aspiration
(recurrence )
Percutaneous aspiration +
instillation of sclerosing agent :
Pantopaque, ethanol, minocycline
HCl
Treatment of simple liver
cyst

Destroy or reduce the size of

the secreting cyst wall
 Laparascopic therapy
Twenty one reports on a total of 61
patients
Position and entry cannula were
similar to those of laparascopic
cholecystectomy
Procedure : unroofing, excision,
aspiration and external drainage,
omentum transposition flap
(omentoplasty)
 Destructing of the remaining
part of the secreting cyst wall
by electro coagulation
Examining the inner surface of
the cyst
Advantages : Less stressful,
less pain and earlier recovery
 Patients and methods
From Jan 2003 to Dec 2003, in St. Carolus
Hospital
Laparascopic wide unroofing, drainage and
omentoplasty we performed in 3 patients :
Age range : 55 65 years old
Simple cystic diameter : 12, 15, and 18 cm
Location : 2 in the right lobe and 1 in the
left
 Conclusion
Applicability of laparascopic surgery
in liver cyst is determined by :
1. type, size and location
2. Accurate diagnosis is essential
3. Assessment of content, bleeding,
infection, biliary communication
4. Investigation of possible
malignancy
5. Methods of choice : wide cyst,
unroofing and cyst excision
THANK YOU
 Bali, October 4, 2013

Management of
Hepatic Cyst
Ibrahim Labeda
Dept of Surgery, Wahidin Sudirohusodo Hospital
Faculty of Medicine University of Hasanuddin
Makassar
 Garre
Enucleative Techniques For Hydatid Cyst
Morgagni
Seats & cause of disease
Couirouds
Keen Concept of segmental anatomy
37/76 Liver Resection Bening

1991 1992
1761 1890 1899 1907 1911 1954 1958

Lin
Tiffani Finger fracture technique
Resection of liver tumor
Paterson-Braun S
Wendell Laser Assisted Laparoscopic
Hepatic lobar resection Exsicion of cyst

Blumgarts. Surgery of the Liver, Biliaty Tract, Gagneretal

and Pancreas 2012 Laparoscopy Partial Hepatectomy
Br J. Surg. 1991, 78 ; 1047
Incidence
An overall incidence of 4.7%
(Surg Laparosc Endosc Percutan Tech 2006;16:6872 )
Varies from 0.1% to 4.5%
(Tokai J. Exp Clin Med; Vol.36, No.1,pp.13-16, 2011)
The prevalence 0.1 to 0.5% on autopsy and 2.5% based on USG
examinations (Eur J Surg Sci 2010;1(2):53-57)
They account for only 5% of all solitary cystic lesions of the liver

(World J Gastroenterol 2008 June 21; 14(23): 3616-3620 )

Polycystic livers is 0.9%-3.2%
(DRENTH et al. HEPATOLOGY, December 2010)
Classificatio
n
Congenital
Hepatic cysts are classified into Neoplastic
four main group Inflammatory
Traumatic
Eur J Surg Sci 2010;1(2):53-57
 Simple congenital cysts
Solitary
Multiple cyst (> 20 cyst are present)
(Drenth et al. HEPATOLOGY, December 2010)
Are believed to arise from the abnormal development of
intrahepatic bile ducts in utero
Non-parasitic hepatic cysts
Are asymptomatic
May be found incidentally at laparotomy
or with abdominal imaging.
Can be single or multiple
Range in size from mm - 20 cm in diameter
Although symptoms of the cysts are rare
Can occur if the cyst becomes complicated
Compression of adjacent structures

Eur J Surg Sci 2010;1(2):53-57

 Polycystic Liver Disease
Hereditary
Inheritance is autosomal dominant
Frequently associated with congenital renal malformation
Caused by PRKCSH or SEC63 gen mutations (21%)
Meyenburg complexes : Disconnected intralobular bile
ductules
Pathogenesis : Abnormalities in biliary cell proliferation
Apoptosis
Enhanched fluid secretion
Activation of several signal transduction pathways
Drenth et al. HEPATOLOGY, December 2010
Figure. Four types of the cystic liver; 1.Liver with one or a few dominant cysts;
2.Liver with multiple cysts, clustered and limited to one part of the liver;
3. the polycystic liver that has cyst spread through several segments of the liver, but
there are still some segments that are relatively free from cysts;
4. the extensive polycystic liver, that has cysts scattered throughout the whole liver.
 Neoplastic cysts
Cystadenoma/Cystadenocarcinoma is
a rare tumor
Strong tendency to recur
Has malignant potential
Pathogenes is unknown, a Congenital
origin From abnormal intrahepatic
duct
From misplaced germ cell
Diagnosis is based mainly on USG & CT
Serum CA 19-9 level may be elevated
Journal of the New Zealand Medical
Association, 4-7-2008, Vol 121 No 1277
Post-contrast CT scan with a complex, multiloculated cyst and
pathological examination shows multi-loculated structure containing
mucin with histopathology confirming a biliary cystadenoma
 Tabel. Distinctive Charasteristics of Cystadenoma
and Simple Cyst of the Liver

Cystadenoma Simple Cyst

No. Cysts 1 1
Septations Present Absent
Papillary projections Common Absent
Cystic fluid Mucinous Serous
Recurrent after partial excision Common Exceptional
Malignant transformation
Possible Exceptional
(cystadenocarcinoma)

Blumgart,LH. SURGERY of the LIVER, BILIARY TRACT,

and PANCREAS, 2007:1005-1018
 Traumatic cysts
Is a rare and single
Usually form after incomplete
resolution of subcapsular or intra
hepatic hematoma or biloma
A thick pseudocyst wall and contain
thick, bile salt stained and hematoma
Formed by parenchymal and ductal
disruption
No epithelial lining
Most resolve spontaneously

Blumgarts. Surgery of the Liver, Biliaty Tract, and Pancreas 2012

 Cystic metastases

Solid tumors & Cystic form is rare.

May be partial or total,
Arise fr neuroendocrine, sarcoma
melanoma, Bronchial, Breast tumor.
Ovarian, pancreatic cystadenoCa.
Anal Ca, very rare frequently cystic.
If the primary is unknown, the presence of
peripheral hypervascularization and multiplicity of
the lesions should raise the suspicion of this
diagnosis.
Blumgarts. Surgery of the Liver, Biliaty Tract,and Pancreas 2012

CT and MRI Scan : A 76 yo,m with locally advanced rectal cancer

 Hydatid Cyst

Caused by infection.
May be partial or total,
Arise fr neuroendocrine, sarcoma
melanoma, Bronchial, Breast tumor.
Ovarian, pancreatic cystadenoCa. USG of Hydatid cyst of the liver
type III (Gharbi).
Anal Ca, very rare frequently cystic.
If the primary is unknown, the presence of
peripheral hypervascularization and multiplicity of
the lesions should raise the suspicion of this
diagnosis.
Derbei F et al. Hydatid Cyst of the Liver-
INTECH, 2012
 Tabel Distinctive Charasteristics of Simple Cyst
and Hydatid Cyst of the Liver

Simple Cyst Hydatid Cyst

Septations Absent Common
Calcifications Absent Common
Split wall Absent Possible
Complication with biliary tree Absent Possible
Serologic tests for hydatid Negative Positive*
disease

* In most, but not all, patients with hydatid disease.

Blumgart,LH. SURGERY of the LIVER, BILIARY TRACT,

and PANCREAS, 2007:1005-1018
 Symptoms
They are usually asymptomatic
but may occasionally present as :
Abdominal pain
Nausea
Vomiting
Abdominal distention

Neri V et al. HPB,2006; 8: 306-310

 DIAGNOSIS : Radiologic
imaging
USG : Rounded, anechoic with
good-through transmission,imperceptible wall
CT :
Demonstrate homogenous lesion with low/
water attenuation, no enhancement of wall
or content following contrast
MRISame signal intensity as water (low attenuation
on T1-weighted images, and homogenous)
Very high signal attenuation on T2-weighted images
no enhancement following iv contrast material

* Eur J Surg Sci 2010;1(2):53-57

* Surgical Management of Hepatobiliary and Pancreatic Disorders.

Informa 2011;Sec ed:301-307

 Radiologic imaging for Hydatic Disease

of the liver
USG : - Non invasive, low cost, reproducible, suitable for po follow-up
- Precise information on the size, number, location and vascular
relationship on its structure
CT : Procedure of choice when considering radical surgery
- Identifying vascular relationships, number, site and type of the cyst : Dual, sand-glass like
with vesiculation
- Invaluable for recurring pattern
- Spiral CT : Gold Standard
MRI :
- Low sinyal intesnsity rim on T2-weighted images
- MRI Cholangiography : Good visualization intra/extra hepatic biliary tree and relationship
* Angiography : Some use for huge cyst
Percutaneous cholangiography is CI because risk perforation, dissemination contents
* ERCP : Most suitable for the characterization of CBD and the relationships

* Eur J Surg Sci 2010;1(2):53-57

Surgical Management of Hepatobiliary and Pancreatic
Disorders. Informa 2011;Sec ed:301-307
 Management
Nonsurgical
Surgical Management options include :
* Percutaneous aspiration
* Injection of sclerosing agents
* Laparoscopic or open fenestration
* Surgical cystectomy
Simple Percutaneous aspiration

Is not adequate
Risk of infection
Recurrence rate
With Sclerosis method results were better

Saini S, et al. Percutaneous aspiration of hepatic

cysts does not provide definitive therapy. AJR Am J
Roentgenol 1983; 141: 559-60
From 13 patients underwent radiologically guided percutaneous needle
aspiration of simple liver cyst recurrence in all patients within two years.
A 100% recurrence rate.
Surgical decompression was required for definitive therapy in three
cases.
They concluded that the usefulness of percutaneous aspiration as the
sole definitive therapeutic procedure is limited because of the certainty
of recurrence of the cyst fluid.

Saini S, et al. Percutaneous aspiration of hepatic cysts does not provide definitive
therapy. AJR Am J Roentgenol 1983; 141: 559-60.
 Laparoscopic vs Open surgery
a) Quality of live
b) Morbidity
c) Mortality
d) Length of postoperative hospital stay
e) Long term outcome
Laparoscopic approach did not offer better results
compared with open deroofing
Tocchi A et al. Symptomatic hepatic cysts options for and result of
surgical management. Arch Surg 2002; 137: 154-158
 Factors that predicted failure of the Procedure

o Deep-seated cysts
o Incomplete deroofing
o Location in segmen VII-VIII

Drenth et al. HEPATOLOGY, December 2010

Menna et al. Tranplantation at a Glance, Wiley-Blackwell, 2012
 Open surgery

o Malignant tumor
o Located in posteriorly
o Proximity to mayor hepatic vasculature
o Some selected cases

Eur J Surg Sci 2010; 12 53-57

From: Treatment Strategy for Patients With Cystic Lesions Mimicking a Liver Tumor: A Recent 10-Year
Surgical Experience in Japan
Arch Surg. 1998;133(6):643-646. doi:10.1001/archsurg.133.6.643

Figure Legend:
Preoperative and Postoperative Diagnoses, With Operative Variables, for Hepatic Cystic Lesions
Mimicking Liver Tumor in 10 Patients
Arch Surg. 1998;133(6
1998;133(
Arch Surg. 1998;133(6):643-646.
 Indication for Treatment
Increase in size in surveillance scans
Pain affecting quality of life
Symptoms due to compression of the
stomach, duodenum, biliary tree,
portal venous system or IVC
Intracystic hemorrhage
Spontaneous/traumatic rupture
Evidence of infection in the cyst
Diagnostic uncertainty
Figure. CT scan showing a central hepatic
cyst with vascular compression.

Surgical Management of Hepatobiliary and Pancreatic

Disorders. Informa 2011;Sec ed:301-307
Surgical Treatment of PCLD
* Cyst Fenestration
* Liver Resection
* Combination Fenestration and resection
* Liver transplantation

Treatment Decisions Based

on level 3 evidence :
Case report
Small case series
Experience of the treating physician

Surgical Management of Hepatobiliary and

Pancreatic Disorders. Informa 2011;Sec ed:301-307
Table. Results of Treatment of Recurrence According to the
Surgical Method Used

Blumgarts. Surgery of the Liver, Biliaty Tract, & Pancreas ,2012

 The WHO guidelines for indication
PAIR are as follows:

Holman H. Hepatic cysts Treatment and Management. October 2012.

 The WHO guidelines for
contraindication PAIR are as follows:

Holman H. Hepatic cysts Treatment and Management. October 2012.

 Hydatid Cysts Prosedure

Radical surgery : Partial cystectomy Drainage of the residual cavity after

partial cystectomy
Hydatid Cysts Prosedure

A 34 year old patient operated for Hydatid cyst of liver with portal
hydatid cyst of segment VIII. Partial hypertension: partial cystectomy
cystectomy and capitonnage
 Hydatid Cysts Prosedure

Transparieto-hepatic fistulization Internal drainage technique

(perdromo)
 47 Penderita : = 11, = 36. Journal of the New Zealand Medical
Umur : 61 Thn (37-86 thn) Association, 4-7-2008, Vol 121 No 1277
CYST TYPE SOLITER MULTIPLE NEOPLASTIC HYDATID
DISEASE
SEX 13 (: 11, : 2) 12 : 9 (: 5 : 4) 13 (: 7 : 6)
SIGN & Pain Abdominal distention: Upper abdominal Pain : 8
SYMPTOMS Abdominal 9 pain/ discomfort : 5 Fever and Jaundice :
distention Early satisfy : 1 Incidental : 4 1
Pain : 2 Incidental : 4
AGE 62 thn (45-73) 62 thn (37-80) 54 thn (45-78) 64 thn (52-86)
TUMOR MARKER CEA : 1,4 g/L (0- CEA : 3 g/L (0-3) CEA : 2 g/L (0-5) Serology test :(+)
3) Ca-199: 7 U/ml (3-15) Ca-199: 7 U/ml (5-
Ca-199: 5 U/ml (0- 12)
17)
TREATMENT Lap. Fenestration : Lap. Fenestration : Lap Fenestration 1 Albendazole : 6
13. 11. Segmental week
50 menit (27-67) 87 menit (63-130) Resection 4 2 Discontinued :
4 bln recurent 1 complex cyst R Hepatectomies 2 thrombocytopenia
Left hepatectomy resection benign L Hepatectomies 2 Cystectomy 10
cystadenoma. 3 po complications Hepatic Resection 3
I ascitic leak
2 biloma
FOLLOW UP All remain well 26 monts All 3 po complication 4 po complications
No sign of cyst alive,well. 1 ascitic leak 2 infection, 1 biloma
development 2 recurrent : Lap. 2 biloma 1 Incisional hernia
Management Of Hepatic Cyst
in Makassar
April 2012 September 2013
 Age and Sex Distribution

Patien Age(y) Radilogic

Sex
t no Imaging

1 F 50 USG / CT Scan

2 M 51 USG / CT Scan

3 M 45 USG / CT Scan

4 M 55 USG / CT Scan

5 F 73 USG / CT Scan

6 F 49 USG / CT Scan

7 F 47 USG / CT Scan
Age : 38 73 years 8 M 38 USG / CT Scan
Median : 55 years
9 F 53 USG / CT Scan
Tabel. Clinical Findings in patient with liver cyst
Cysts Location
Patien
size (segmen Symptoms
t no
(cm) )
1 8 VI Abdominal and right shoulder pain
2 9 IV Abdominal and right shoulder pain
3 13 VIII Epigastric pain, gall bladder lithiasis
4 10 V Abdominal pain, early satiety
5 5 VI Right shoulder pain
6 11 VI Epigastric pain, Discomfort
7 8 VII Epigastric pain, gall bladder lithiasis
8 12 V Right upper abdominal pain
9 11 VI Abdominal pain, abdominal disten
Surgical Management