Displacement of the Residual Liver Cavity in Laparoscopic Echinococcectomy

Aim: This article aimed to investigate the analysis of various methods for eliminating the residual liver cavity after laparoscopic echinococcectomy in patients. Methods: The authors used the following methods of eliminating the residual cavity: omentoplasty (36.8%), abdominalization (30%), drainage of the residual cavity (26.2%), and a combination of omentoplasty with drainage of the residual cavity (7%). Results: In the postoperative period, complications occurred in 2 (3.5%) cases in the form of bile leakage from the residual liver cavity. Conclusions: It is recommended to use abdominalization and omentoplasty when choosing a method for eliminating the residual liver cavity.


Introduction
Elimination of the residual liver cavity (RLC) as the final stage of echinococcectomy (EE) operation is one of the most controversial and topical issues in the surgical treatment of liver echinococcosis [1] [2] [3] [4]. This is due to the fact, that the results of the treatment of echinococcal hepatic cysts (EHC), which still do not satisfy surgeons depend on the choice of certain operational and technical solutions to eliminate RLC. The etiology of this study including treatment of the  [5].
In laparoscopic echinococcectomy (LEE), different authors have proposed various methods for eliminating the residual liver cavity such as radical excision of the fibrous cap (FC) [6] [7]. The partial pericystectomy, omentoplasty, and external drainage of RLC [8], omentoplasty, and external drainage of RLC [9] [10] performed. If the volume of RLC is more than 200 ml, a method of vacuum obliteration of the RLC proposed, where a wide silicone tube inserted into the RLC and a negative pressure about 250 mbar created. For the faster obliteration of RLC, the use of the RLC method for RLC vacuum obliteration is provided [10]. For large cysts up to 180 mm, the local application of a hemostatic sponge combined with external drainage of the RLC [11].
Omentoplasty is not recommended by many laparoscopic surgeons, but it is considered a fairly effective way to eliminate RLC. However, obliteration of the cavity with greater omentum previously reported to reduce complications and help to achieve obliteration in laparoscopic procedures [12]. The choice of the method for terminating LEE and eliminating RLC in many aspects depends on the priority of the surgeon, the size, number and location of the liver echinococcectomy, and the nature of complications. Laparoscopic surgeons have not yet finally developed a single, unified view on these issues. The purpose of this article is to analyze the various methods used to eliminate the RLC in the liver echinococcectomy.

Statistical Processing Methods
Statistical processing of the digital material carried out using the program "STATISTICA" Version 6. In the process of statistical analysis, quantitative values are indicated as the statistical mean (M) ± standard deviation (SD). Statistical processing of digital data in determining the reliability of differences in the quantitative values of the research results carried out using the Student's t-test.
Differences were considered statistically significant if the probability of a possible error was p (significance level) < 0.05. The number of omentoplasty, omentoplasty with drainage of residual liver cavity (RLC), abdominalization, drainage of RLC, number of patients with treatment results were collected as variables.

Results and Discussions
The following methods of the RLС elimination used: omentoplasty, abdominalization, river cavity drainage, and a combination of omentoplasty with the liver cavity drainage ( Table 1).
As can be seen from Total 57 100 Table 2 shows the chronological dynamics of various methods used for eliminating the RLC after LEE, which also shows that omentoplasty (on 25 patients) and abdominalization (on 17 patients) were preferred.

Omentoplasty
Omentoplasty in this work was performed by tamponing the RLC with a flap of the greater omentum, which was fixed to the edges of the FC by clipping (6 patients

Abdominisation
In 17 (30%) cases of the elimination, the RLC in LEE was performed by abdomi- In 15 (26.3%) patients, RLC was drained with one perforated drainage. 8 (53.3%) patients had EHCs that were suppurating. EHC suppuration excluded the possibility of RLC elimination, which was fraught with a high risk of developing purulent-inflammatory complications of RLC. As mentioned above, there were observations when omentoplasty and abdominalization used for suppurative EHCs.
In both groups of patients, there were no specific complications such as EHC perforation with the development of anaphylactic shock and intra-abdominal dissemination of the parasite elements.
In the postoperative period, complications occurred in 2 (3.5%) cases in the form of bile leakage from RLC, which independently ceased on days 12 and 20 after the operation. The daily flow rate of bile through drainage averaged 60-80 ml. Control ultrasound showed no free fluid in the abdominal cavity; the drains were in the RLC. And in the remaining 55 (96.5%) patients after LEE, there was no bile leakage and the duration of RLC drainage averaged 3.9 ± 2.5 days. The intensity of postoperative pain after LEE was minimal, 3.3 ± 1.2 mm, and did not require the use of narcotic analgesics.
It should be noted the early activation of patients after laparoscopic surgery. The patients became more active already, on average, 5.3 ± 1.6 hours after the operation. After LEE, the intestinal passage was restored 11.3 ± 3.4 hours after the operation. All of these indicators affected the duration of inpatient stay and the duration of labor rehabilitation of patients. The average hospital stay was 6.0 ± 3.1 bed-days.
When analyzing postoperative complications according to the Clavien-Dindo classification, grade I complications were observed in one (1.7%) patient in the form of bile leakage with a daily bile flow rate of up to 60 ml/day, which closed on its own on day 12 after LEE. Complications of the II degree also occurred in one (1.7%) patient (bile leakage from RLC), which led to an increase in the duration of the patient's stay in the hospital. Complications of III, IV, and V degree of complications according to Clavien-Dindo not observed. Long-term results were studied in all patients and presented in Table 3.
Analysis of long-term results of operated patients showed that most patients  patients with a satisfactory result in the long-term postoperative period, RLCs up to 2 -4 cm in size with homogeneous echo-negative contents, which clinically did not manifest themselves, were found sonographically.
In a dynamic study, within 4 -6 months, complete involution of the RLC occurred with the formation of an irregular shape of an echo-dense fibrous focus.
LEE in these 8 patients was completed by drainage of RLC without its elimination. The reason for choosing RLC drainage was the large size of the hydatid hepatic cyst (3 patients), as well as in the first cases of using laparoscopy in the surgical treatment of EHC (5 patients).

Conclusion
Thus, the analysis of the obtained results of the LEE allows making many rec- Abdominalization of RLC is applicable for both small and large EHC sizes. In the latter case, this method of eliminating RLC can be combined with external drainage. Omentoplasty of the RLC indicated for deep EHCs, cyst with diameter size 60 -90 mm, and solitary cysts. This method is contraindicated in patients with poor development of the omentum, with large (more than 90 mm) and multiple EHC, pronounced adhesive process.