I. General knowledge of liver cysts Liver cysts are benign diseases of the liver and can be divided into two categories: parasitic and non-parasitic. The latter is common, mostly congenital, and a few are traumatic, inflammatory and neoplastic, and can occur at any age. Most patients with liver cysts are asymptomatic and are mostly detected during imaging examinations such as ultrasound or CT or other abdominal surgeries. However, when the cyst gradually increases in size and compresses the liver or adjacent organs, symptoms such as abdominal discomfort, abdominal pain, jaundice, and even portal hypertension may occur. B-mode ultrasonography is the preferred method to diagnose liver cysts, commonly used for routine physical examination and preliminary diagnosis, and is an economical, reliable and simple examination method, which shows a liquid dark area at the cyst, unlike liver cancer and hepatic hemangioma. x-ray examination may show signs such as significant enlargement of the liver, elevation of the diaphragm and displacement of the gastrointestinal pressure. Radionuclide hepatic blood pool scan shows an occupying hepatic lesion with well-defined borders, while the lesion area of hepatic cavernous hemangioma is radiologically enhanced and hepatocellular carcinoma is radiolucent. CT examination is very helpful in the diagnosis of hepatic cysts, which can detect 1-2 cm hepatic cysts. Enhanced CT with contrast injection helps to differentiate hepatic hemangioma from primary hepatocellular carcinoma. The lesion area remains unchanged after enhancement is hepatic cyst, the lesion area shrinks is hepatic hemangioma, and the lesion area is more obvious is hepatocellular carcinoma. Patients with multiple liver cysts should also have their kidneys, lungs, pancreas and other organs examined. Small liver cysts such as about 1-5cm in diameter without obvious symptoms do not need special treatment; large liver cysts such as 5 – 10cm in diameter with symptoms of compression should be given appropriate treatment. Liu Xuejun, General Surgery Department, Anyang Hospital of Traditional treatment of liver cysts Traditional treatment of non-parasitic liver cysts includes open cyst openings and ultrasound-guided percutaneous puncture cyst aspiration, the former with heavy trauma, pain, long course of disease and more surgical complications; the latter with no openings, light trauma and little pain, but easy to recur. In recent years, with the continuous development of laparoscopic technology, the field of laparoscopic surgery has been expanded, and liver cysts excluding parasitic liver cysts, tumorigenic liver cysts and cystic dilatation of intrahepatic bile ducts can be treated surgically under laparoscopy. Laparoscopic treatment of liver cysts has the advantages of exact efficacy, less trauma to patients, shorter course, less pain and faster recovery. The indications and contraindications of laparoscopic hepatic cystotomy The nature and location of the cyst should be fully understood before surgery, which is the main factor of whether laparoscopic hepatic cystotomy can be performed. For cases with clear diagnosis, excluding parasitic and neoplastic liver cysts and cystic extension of intrahepatic bile ducts, laparoscopic hepatic cyst windowing is feasible for single or multiple simple liver cysts and polycystic liver disease type I (large multiple cysts mainly located on the surface of liver II-IV) located on the liver surface within the laparoscopic field of view. Contraindications to surgery are mainly: (1) preoperative imaging reveals communication with the bile duct; (2) suspicion of cystic malignancy; (3) cyst located in the right posterior lobe of the liver or extensive adhesions between the cyst and the diaphragm, making it difficult to approach the cyst laparoscopically; (4) active bleeding from the cyst; (5) cyst located deep in the liver or thicker liver tissue on the surface of the cyst. In order to reduce the incidence of postoperative complications and enable patients to recover as soon as possible, the following points should be noted during surgery: (1) multiple liver cysts with extensive lesions should not be excised or opened too many windows at one time to prevent complications such as intractable ascites and liver failure after surgery, generally 4-5 larger cysts can be opened at one time.
(2) preoperative selection of cases and determination of cyst type can improve the efficacy and reduce the recurrence rate; (3) the free cyst wall should be fully revealed during surgery, and the free surface of the cyst wall should be completely excised immediately at the junction of the cyst wall and normal liver parenchyma to fully open the cystic cavity, and then the cystic cavity should be carefully electrocoagulated with an electrocoagulation rod or injected with anhydrous alcohol to destroy the epidermal cells of the inner wall, and the surface of the cystic wall should not be damaged during electrocoagulation. (4) for larger cystic cavity, the large omentum can be filled in the cavity and fixed with titanium clips or sutures to make the large omentum adhere to the cystic cavity to prevent recurrence; (5) for cysts suspected of malignancy, pathological examination should be performed intraoperatively. If there is malignant change, partial hepatectomy is feasible, and if necessary, the laparotomy should be opened in transit to avoid delaying treatment.