laparoscopic management of benign solid and cystic lesions of the

-I o g i:IL : [*lUJANNALS OF SURGERYVol. 229, No. 4, 460-466© 1999 Lippincott Willims & WiMns, Inc.

Laparoscopic Management of Benign Solid andCystic Lesions of the LiverNamir Katkhouda, MD,* Michael Hurwitz, MD,* Jean Gugenheim, MD,t Eli Mavor,* Rodney J. Mason,* Donald J. Waldrep, MD,*Raymond T. Rivera, MD,* Mudjianto Chandra, MD,* Guilherme M.R. Campos, MD,* Steven Offerman, BS,*Andrew Trussler, BS,* Pascal Fabiani, MD,t and Jean Mouiel, MDt

From the *Division of Emergency Non-Trauma and Minimally Invasive Surgery, Department of Surgery,University of Southern California School of Medicine, Los Angeles, California, and the tDepartment of Surgery,University of Nice School of Medicine, Nice, France

ObjectiveThe authors present their experience in the laparoscopicmanagement of benign liver disease. The aim of the study isto analyze technical feasibility and evaluate immediate andlong-term outcome.

Summary Background DataIndications for the laparoscopic management of varied ab-dominal conditions have evolved. Although the minimally inva-sive treatment of liver cysts has been reported, the laparo-scopic approach to other liver lesions remains undefined.

MethodsBetween September 1990 and October 1997, 43 patientsunderwent laparoscopic liver surgery. There were twogroups of benign lesions: cysts (n = 31) and solid tumors(n = 12). Indications were solitary giant liver cysts (n = 16),polycystic liver disease (n = 9), hydatid cyst (n = 6), focalnodular hyperplasia (n = 3), and adenoma (n = 9). Onlysolid tumors, hydatid cysts, and patients with polycysticdisease and large dominant cysts located in anterior liversegments were included. All giant solitary liver cysts wereconsidered for laparoscopy. Patients with cholangitis, cir-rhosis, and significant cardiac disease were excluded. Datawere collected prospectively.

ResultsThe procedures were completed laparoscopically in 40 pa-tients. Median size was 4 cm for solid nodules and 14 cm forsolitary liver cysts. Conversion occurred in three patients (7%),for bleeding (n = 2) and impingement of a solid tumor on theinferior vena cava (n = 1). The median operative time was 179minutes. All solitary liver cysts were fenestrated in less than 1hour. There were no deaths. Complications occurred in 6cases (14.1 %). Two hemorrhagic and two infectious compli-cations were noted after management of hydatid cysts. Therewere no complications after resection of solid tumors. Threepatients received transfusions (7%). The median length of staywas 4.7 days. Median follow-up was 30 months. There wasno recurrence of solitary liver or hydatid cysts. One patientwith polycystic disease had symptomatic recurrent cysts at 6months requiring laparotomy.

ConclusionLaparoscopic liver surgery can be accomplished safely in se-lected patients with small benign solid tumors located in theanterior liver segments and giant solitary cysts. The laparo-scopic management of polycystic liver disease should be re-served for patients with a limited number of large, anteriorlylocated cysts. Hydatid disease is best treated through anopen approach.

Benign liver tumors and hepatic cysts are rare lesions butare found more frequently today because of improvementsin imaging modalities and the widespread use of ultrasoundas a screening tool in patients with abdominal symptoms.'Surgery is indicated when they become highly symptomaticor complicated or demonstrate rapid growth.>4

Correspondence: Namir Katkhouda, MD, USC Department of Surgery,Healthcare Consultation Center, 1510 San Pablo Street, Los Angeles,CA 90033.

Accepted for publication October 13, 1998.

460

Despite recent advances in laparoscopic techniques andinstrumentation, minimal-access surgery for treatment ofbenign liver disease has not gained widespread acceptance.Laparoscopic fenestration of solitary giant cysts has beenreported,5-9 but few studies have included management oflarger numbers of patients with polycystic liver disease(PLD)6,I 0, Ior benign solid tumors. 12-17 Lack of referrals,the complexity of the laparoscopic procedures, and unde-fined selection criteria are contributing factors. The aim ofthis study is to evaluate prospectively the immediate andlong-term outcomes of laparoscopic management of two

Laparoscopic Management of Benign Liver Lesions 461

Figure 1. Couinaud classification. "Safe" anterolateral segments are

shaded.

types of benign lesions (hepatic cysts and solid tumors)during a 7-year period, with special reference to technicalfeasibility. An original "four-hand" approach for resectionof solid tumors is described.

PATIENTS AND METHODSBetween September 1990 and October 1997, 43 patients

(11 men and 32 women) with a median age of 47 years

(range, 22 to 88 years) and a median weight of 59 kg (range,46 to 101 kg) were selected for laparoscopic liver surgery

following preestablished inclusion criteria. For patients withbenign solid tumors and hydatid cysts, only lesions locatedin anterolateral segments 2 through 6 (Couinaud classifica-tion) were considered for laparoscopic treatment (Fig. 1).All patients with solitary liver cysts, regardless of their sizeand anatomic location, were considered for laparoscopy.Patients with PLD and dominant cysts located in anteriorsegments were included. Cholangitis resulting from com-

munication of a hydatid cyst with the intrahepatic biliarytree, cirrhosis, and poor cardiac function were contraindi-cations to laparoscopy. No ruptured lesions were included.Of patients with cystic disease of the liver, pathology in-cluded solitary giant liver cyst (n = 16), PLD (n = 9), andhydatid cysts (n = 6). Solid tumors consisted of adenoma(n = 9) and focal nodular hyperplasia (n = 3). All patientsunderwent preoperative ultrasonography and computed to-mography (CT). Hepatic angiography was performed selec-tively when liver resection was planned. Data were col-lected prospectively, and all patients gave informed writtenconsent.

TechniqueThe patient is positioned in the inverted-Y position with

the surgeon between the legs and the assistants at the sides.

This allows the surgeon to work comfortably bimanuallywithout contortions while facing the monitor. The basic portplacement includes the introduction of the 300 high-qualitydigital three-chip videolaparoscope (Karl Storz, Tutlingen,Germany) at the umbilicus using a 10- to 12-mm trocar(Ethicon Endo Surgery Inc., Cincinnati, OH). Two 10-mmports surround the umbilicus in a 900 V-shaped fashion toavoid the "knitting needle" effect of the surgical instru-ments, and a subxiphoid trocar is used for the fan retractoror the irrigation/suction device. For resection of solid tu-mors, this basic technique can be modified to a "four-hand"approach, where two additional trocars allow two surgeonsto work simultaneously (Fig. 2). The first surgeon operatesa grasper with the left hand and the laparoscopic ultrasonicdissector with the right, performing an instrumental fractureof the liver parenchyma and selectively exposing all bileducts and vessels. The second surgeon controls all thevasculobiliary pedicles with clips or other hemostatic tools,thus hastening the operation while reducing the risk ofhemorrhage and carbon dioxide gas embolism.The approach to resection of solid tumors begins with

division of the round ligament and the right or left triangularligament for lesions located in the corresponding lobe. The"four-hand" technique is used to resect benign solid tumorssuch as adenomas and focal nodular hyperplasia. Glisson'scapsule is scored 2 cm away from the lesion using electro-cautery. An ultrasonic dissector (CUSA, Valley Lab, Inc.,Boulder, CO) is used by the first surgeon to dissect theparenchyma, while the left hand retracts the exposed liver

GCQ

Figure 2. The "four-hand" approach for laparoscopic resection of solidliver tumors. (A) Use of the ultrasonic dissector by the first surgeon. (B)Division of vasculobiliary pedicles by the second surgeon.

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462 Katkhouda and Others

Figure 3. Laparoscopic left lateral segmentectomy demonstrating thePringle maneuver and division of the left hepatic vein.

surface. Simultaneously, the second surgeon divides allexposed vascular and biliary pedicles between large hemo-static clips. Argon beam coagulation provides hemostasis ofthe raw liver surface. Small vessels and biliary radicles maybe sealed with harmonic shears (LCS, Ethicon Endo Sur-gery). Clips are used for hemostasis of larger structures, andlinear endovascular cutters are reserved for the hepaticveins. The cutter with vascular staples may also be used tocontrol segmental vascular and biliary pedicles. A flexiblelaparoscopic ultrasound probe is useful in locating anatomiclandmarks or vasculobiliary connections. Application offibrin sealant (Tisseel, Baxter, Deerfield, IL) will improvehemostasis and may prevent bile leaks.

Left lateral segmentectomy is initiated by dividing thefalciform and left triangular ligaments until the inferior venacava is identified. A fan retractor displaces the liver inferi-orly, and the left hepatic vein is carefully exposed at thejunction with the inferior vena cava using the right-angledand peanut dissectors. If the retrohepatic course of thehepatic vein is too short, and the dissection deemed tooperilous, no attempt is made to pursue the extrahepaticcontrol of the vein. The hepatoduodenal ligament is dis-sected using a blunt right-angled dissector, and a rubbertourniquet is passed around the porta hepatis to prepare fora Pringle maneuver in the event of an intraoperative hem-orrhage. An 0 silk tie is placed on the hepatic vein and thevein is ligated using intracorporeal knot-tying techniquesbut is not divided. The liver capsule is then scored on theanterior and inferior surface 1 cm to the left of the falciformligament. The "four-hand" approach is used to fracture theparenchyma using long atraumatic flat forceps or the ultra-sonic dissector in a technique similar to the open finger-fracture method. The vasculobiliary pedicles of segments 3and 2 are always clearly identified and serially ligated usinghemostatic clips, and divided. Division of the pretied left

hepatic vein is performed within the liver parenchyma usinga vascular endolinear cutter (Fig. 3).

Carbon dioxide embolism poses at least a theoretical riskduring surgery, particularly in the presence of-divided pa-renchyma or hepatic venotomies. Constant monitoring ofhemodynamic status and end tidal CO2 and 02 saturation isessential for early diagnosis and correction. Drains areplaced in the residual space. The specimen is placed in apuncture-resistant bag (Cook Surgical, Bloomington, IN),sliced into two or three fragments with scissors, and broughtout through the enlarged umbilical port.

Solitary nonparasitic liver cysts are fenestrated. The bluedome of the cyst is opened using scissors, and the fluid isaspirated. The cystic cavity is thoroughly examined for thepresence of indentations indicating neoplastic changes thatwould prompt an open resection of the lesion. The wall ofthe cyst is excised to within 3 mm of the liver parenchymaand is sent for pathology. The presence of bile at the cysticedge, indicating an injury to septal bile ducts, is assessed,and a hemostatic clip or a tie is applied when needed.Careful hemostasis of the cyst edge is performed withelectrocautery. In PLD, deeper cysts appear blue whenilluminated across septae; they must be distinguished fromportal or hepatic veins before transcystic fenestration. Lapa-roscopic ultrasound with color Doppler is helpful to delin-eate cysts from vascular structures. No drain is placed at thecompletion of the procedure. Fascia of all wounds is care-fully closed to prevent postoperative leakage of cystic fluid.Management of hydatid cysts proceeds in three stages.

First, cholecystectomy is performed and a cholangiographycatheter is placed in the cystic duct; possible intrahepaticbiliary fistula or the presence of parasitic debris in thecommon duct (despite the absence of cholangitis) is iden-tified on cholangiography. Next, the parasitic content issterilized and evacuated: a percutaneous spinal needle isintroduced and 10 to 20 cc of hypertonic saline is instilledfor 10 minutes. A large-bore trocar is used to aspirate thesterilized parasitic debris. Care is taken to prevent the spill-age of parasitic material to avoid secondary echinococcalinfestation or anaphylactic shock. Two 4X4" pieces ofgauze marked with a radiopaque strip and Prolene suture foreasy retrieval are soaked with hypertonic saline and placedaround the cyst, and the cyst is opened and inspected.Biliary leaks present on intraoperative cholangiography arefurther demonstrated by the injection of methylene bluethrough the transcystic catheter. These can be closed lapa-roscopically. Finally, the residual cavity is filled withomentum.

Total pericystectomy without aspiration is reserved forsmall, partially calcified cysts favorably located in an ante-rior hepatic segment. It consists of sequential vascular con-trol of all the pedicles, using the pericystic layer as the planeof dissection.

All patients are given perioperative albendazole to helpprevent recurrence of echinococcal disease in the event ofan unrecognized spillage of hydatid debris.

Ann. Surg. * April 1999


Table 1. OPERATIVE INDICATIONS ANDCORRESPONDING PROCEDURES

Operative Procedures Number of Cases

Cyst fenestration 28Giant liver cysts 16Polycystic liver disease 9*Hydatid cysts 3

Pericystectomy 3Hydatid cysts 3*

Wedge resection 9Adenoma 6Focal nodular hyperplasia 3

Left lateral segmentectomy 3Adenoma 3*

Includes one conversion to laparotomy.

RESULTSMedian size was 4 cm for solid nodules (range, 2 to 7 cm)

and 14 cm for solitary liver cysts (range, 7 to 22 cm).Patients with PLD had a median of 8 cysts (range, 6 to 12cysts), and the median diameter of the cysts measured on

CT scan was 8 cm (range, 4 to 16 cm). Forty-one patientswere symptomatic. Two asymptomatic patients were foundto have solid liver masses of 6 and 7 cm on ultrasonographyperformed for unrelated reasons. Excision was performed torule out malignancy and confirmed diagnoses of adenomaand focal nodular hyperplasia.

Presenting complaints included right upper quadrant pain(68%) and symptoms related to compression of adjacentorgans (22%), sepsis (6%), and refractory pleural effusion(4%). Five patients with adenomas attributed to oral con-

traceptive use did not demonstrate tumor regression on

cessation of therapy and remained symptomatic. Prothrom-bin time and total bilirubin level were normal in all patients.Alkaline phosphatase was mildly elevated in 20% of pa-tients with PLD. Serum creatinine levels were normal in allpatients. Three patients (33%) with PLD had associatedcysts in the kidney and a family history of autosomaldominant polycystic kidney disease. The operative indica-tions and corresponding procedures are shown in Table 1.

In three patients (7.1%), the operation was converted tolaparotomy. A left lateral segmentectomy for adenoma was

converted electively after intraoperative ultrasound showedthe mass to be impinging on the inferior vena cava, despitefavorable preoperative mapping. Conversion to controlbleeding occurred during fenestration of a polycystic liverand during total pericystectomy of a hydatid cyst. Bothhemorrhagic events resulted from injuries to hepatic venous

branches. During fenestration of a polycystic liver, thehepatic vessels were indistinguishable from the second layerof deeply located cysts; this resulted in venous bleeding. Inthe second instance, pericystic inflammation of an activehydatid cyst did not allow for differentiation of a clear planeof dissection and resulted in hemorrhage, requiring rapidconversion.Median operative time was 179 minutes (range, 45 to 325

minutes). The operative time was longer for the resection ofsolid tumors, exceeding 5 hours for the first left lateralsegmentectomy. All solitary liver cysts were fenestrated inless than 1 hour (Table 2).

There were no deaths in this series. The median bloodloss was 156 ml (range, 90 to 980 ml). Three patientsreceived blood transfusions, including two conversions andone hydatid cyst resection completed laparoscopically.Complications occurred in six cases (14%): pleural effu-sions developed in two patients after treatment of PLD, andone empyema occurred after total pericystectomy for hyda-tid disease, which required drainage. In one patient withPLD, recurrent ascites developed and was managed conser-

vatively. Abscesses developed in two patients after fenes-tration of a giant liver cyst and pericystectomy for a hydatidcyst. The giant liver cyst had been previously sclerosedpercutaneously with alcohol under CT scan guidance andpresented at surgery with a thick, multiloculated envelope.The abscess developed in the residual cavity. A subphrenicabscess occurred after resection of a hydatid cyst. Both were

drained under CT scan guidance and showed the presence ofbile, indicating an injury to septal ducts. They resolvedwithout requiring an operation. No complications occurredafter completed laparoscopic resection of 11 solid tumors.There were no wound infections or hernias. Bowel functionreturned after a median of 31 hours (range, 27 to 47 hours),

Table 2. OPERATIVE TIME FOR ALL COMPLETED PROCEDURES

Indication Number of Cases Operative Time (min)

CystsGiant solitary cysts 16 48 (45-56)Polycystic liver disease 8 141 (94-165)Hydatid cysts 5 179(88-211)

Tumors (adenomas and focal nodular hyperplasia)Wedge resections 9 144 (91-158)Left lateral segmentectomy 2 260(196-325)

Numbers indicate median and range.

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and diet was resumed on the first postoperative day. Themedian length of stay was 4.7 days (range, 1 to 17 days).The longest hospital stay involved the patient who under-went CT-guided drainage of the subphrenic abscess afterresection of a hydatid cyst.

Follow-up was obtained in all but two patients withhydatid disease, who returned to their country of origin.Median follow-up was 30 months (range, 3 to 78 months).All patients underwent a routine CT scan 6 months aftersurgery. CT scans were obtained subsequently only if pa-tients were symptomatic.One patient with PLD had recurrent right upper quadrant

pain. CT scan showed an increased size of preexistingposterior cysts. He subsequently underwent an uneventfulopen cyst fenestration. CT scan of patients with solid tumorsshowed no residual lesions. Patients remained asymptom-atic on follow-up. Four patients with hydatid disease did notdemonstrate an increase of hydatid serologic titers andremained symptom-free at the last follow-up.

DISCUSSIONA combined extensive experience in advanced laparo-

scopic and hepatobiliary surgery has enabled us to developthe following parameters for the safe inclusion of patientswith liver cysts and benign solid tumors:

. Laparoscopic operations must conform to standardsemployed in open surgery.

. Only lesions favorably located should be approached.

. Appropriate laparoscopic skills and technology shouldbe available.

Our data, involving 43 patients and compiled during 7years, show that laparoscopic liver surgery is technicallyfeasible in selected cases and that the outcome depends onthe type of pathology involved.

Nonparasitic hepatic cysts are usually asymptomatic andare not associated with defects in hepatic function. Thesecysts have been recognized with increased frequency asincidental findings on abdominal ultrasonography and CT,and do not require treatment.1'8 However, as they expand,they may become symptomatic. Complications such as rup-ture, infection, or intracystic hemorrhage can occur.3 Sur-gical management of symptomatic cysts has replaced non-operative management. Simple aspiration results in 100%recurrence and has been abandoned.'9 Aspiration combinedwith sclerotherapy has had limited short-term success.20The goal of surgical treatment of giant solitary cysts is todecompress the cyst and avoid recurrence. The currentmanagement involves cyst fenestration,21 a technique intro-duced by Lin et al in 1968 for treatment of PLD22 and nowperformed laparoscopically.59The laparoscopic approach does not require specific in-

strumentation or advanced skills. The cystic wall shouldalways be examined during surgery for possible septationsor irregularities that might indicate neoplastic changes (e.g.,

cystadenoma). An open total cyst excision would be indi-cated in this situation. Our results show minimal complica-tions and no recurrence and concur with published re-sults.6'9 10 The laparoscopic approach should become thetreatment of choice for this indication.

Surgical management of PLD is more complex becauseproliferating cysts can affect a significant portion of thehepatic parenchyma. Fenestration applied indiscriminatelyresults invariably in failure and symptomatic recurrence of

3 ~~~3,23,24 evnlertasthe disease.3 Hepatic resection and even liver transplantation25 has been proposed in highly symptomatic dif-fuse PLD or in patients in liver failure. The surgical ap-proach is determined, therefore, by the stage of the disease.PLD may be classified into two groups according to thenumber, distribution, and location of cysts, as defined byMorino et al.'0 Type 1 is characterized by a limited numberof large cysts predominantly located in the anterior seg-ments of the liver. Type 2 is characterized by multiple smallcysts distributed throughout the liver, including posteriorsegments ("Swiss cheese"). Gigot et al described three typesof lesions in patients with PLD: type 1 (<10 cysts of >10cm each), type 2 (multiple medium-sized cysts with someliver parenchyma present between cysts), and type 3 (type 2lesions without liver parenchyma between the cysts).26Type 1 in both classifications represents similar groups ofpatients with PLD, amenable to laparoscopic management.

Recurrences are a consequence of the underlying patho-physiology.' 0'1124 Expansion of deep cysts is restrained bythe pressure exerted by the surrounding cystic parenchyma,and unroofing allows untreated deep cysts to expand. Deepcysts that communicate with superficial cysts through a thinparenchymal wall are difficult to reach laparoscopically andmoreover are difficult to differentiate from hepatic venousstructures.The rate of recurrence depends on patient selection. In the

series by Morino et al,'0 global recurrence was 60% at 6months but included predominantly type 2 lesions. Kabbejet all" reported a high recurrence rate of 72% but includedboth type 1 and 2 lesions. The only patient with type 1lesions in another study showed no recurrent cysts on fol-low-up.26 Our low recurrence rate of 11% may reflect theinclusion of patients with only type 1 cysts. We believe thatlaparoscopic fenestration in this instance is the preferredmethod of treatment. Open fenestration with liver resectionshould be reserved for type 2 lesions. The postoperativemorbidity rate in our study was 33%, comparable to thereports of other laparoscopic series!011 Ascites and pleuraleffusion resulting from cyst fluid secretions are the mostcommon reported complications; this is confirmed in ourseries. Drainage at the completion of the laparoscopic pro-cedure will not prevent these complications and risks infec-tion of ascites.11Two surgical techniques are advocated for treatment of

hydatid cysts: either unroofing the sterilized cyst and omen-toplasty, or total pericystectomy, in which the outer cystcontaining the exogenous layer is removed and all biliary

Ann. Surg. * April 1999


communications are closed.27 Unroofing is reserved forlarge cysts or cysts in contact with venous branches of theinferior vena cava. Total pericystectomy is indicated foranterior cysts. Dissection may prove quite difficult becauseof the inflammatory response of the liver parenchyma to theparasitic cyst, the increased risk of intraabdominal compli-cations by spilled parasitic debris,28 the possibility of ana-phylactic shock, and the complex anatomy of biliary fistu-las. Management of hydatid cysts is challenging even forsurgeons with extensive open surgical experience and lapa-roscopic expertise.2831 Our series of six laparoscopicallytreated hydatid cysts resulted in two hemorrhagic and twoinfectious complications. One recent publication reported acase of anaphylactic shock after laparoscopic fenestration ofa hydatid cyst.32 Hydatid disease is infrequently encoun-tered in the United States, and surgical experience is lim-ited. Despite the small number of cases included in ourstudy, we cannot advocate routine laparoscopic manage-ment of echinococcal disease.The "four-hand" approach we have described for resec-

tion of solid liver tumors combines the expertise of thehepatic and laparoscopic surgeon.15 The coordinated dissec-tion increases the visibility, safety, and expediency of theprocedure. The risks of intraoperative bleeding and CO2embolism are minimized if vessels are individually isolatedbefore division. The immediate availability of a clip applierwithin the area of resection reduces the time required tocontrol the vasculature. The goal of th& operative techniqueis to reproduce the open surgery fracture technique, whichbluntly exposes vascular and biliary structures. For eachliver resection, we used an ultrasonic dissector, which isprecise but has an unwieldy handpiece. Experience withdivision of the short gastric vessels during laparoscopicfundoplication and splenectomy, as well as laboratory workin the liver parenchyma, has proven the efficacy of theharmonic shears. This device uses acoustic energy to oscil-late blades at 55,000 cycles per second, generating local-ized heat, coagulating structural proteins, and sealing ves-sels up to 4 mm in diameter. It achieved satisfactoryvascular control and biliostasis during left lateral segmen-tectomy. The left hepatic vein was controlled using anendolinear cutter with vascular staples, an instrument alsoapplied to laparoscopic wedge biopsy.33 The argon beamcoagulator was effective in controlling raw surface oozingwithout complications, but death has been reported withthis device.34 The flow of argon gas may rapidly overpres-surize the abdominal compartment, resulting in argongas embolism and hemodynamic collapse. Surgeons usingargon must be familiar with published safety recommenda-tions, which advise using alarmed monitoring of abdomi-nal pressure, leaving one port vent open, and limiting argonflow. 13,34

In our series, no cases of CO2 gas embolism occurred.These accidents are exceedingly rare,35'36 with one seriesreporting 15 probable events in 113,253 cases (0.013%).37Despite these reassuring numbers, we took several precau-

tions to avoid embolic events, including the division of eachvessel between hemostatic clips.Our data support the literature12-17 and suggest that

laparoscopic resection of small benign tumors in selectedpatients is safe, provided the lesions are located in the leftlobe (segments 2, 3, and 4) or in the anterior segments ofthe right lobe (segments 5 and 6). We attempted threelaparoscopic left lateral segmentectomies for benign tu-mors, converting one deliberately because of the prox-imity of the lesion to the inferior vena cava. The twoother cases were completed laparoscopically withoutcomplication. The mean operating time was approxi-mately 4 hours and indicates a steep learning curve.Despite the long times, no intraoperative complicationoccurred, and the Pringle maneuver was not used. Thisprocedure is the ultimate challenge in abdominal laparo-scopic procedures and should be performed cautiouslyand only by a few experts.We did not include malignant lesions in our series be-

cause laparoscopic management of intraabdominal cancer iscontroversial.38'39 It is not inconceivable that wedge resec-tion of limited liver metastases could be an acceptablealternative to an open metastasectomy, pending trials as-sessing the safety and efficacy of laparoscopic managementof intraabdominal malignancy.

In summary, minimally invasive techniques may be usedfor treating a variety of benign hepatic lesions in selectedpatients. The size of the lesions is less important than theanatomic location in anterolateral regions. No patient withunderlying cirrhosis should be included. Laparoscopic un-roofing of solitary liver cysts is simple and safe and is theprocedure of choice for this indication. PLD should beapproached selectively, offering fenestration for patientswith predominantly large anterior symptomatic cysts. Ac-tive hydatid cysts present technical difficulties because oftheir complex biliovascular connections and the inherentnature of the parasite. The laparoscopic approach is chal-lenging, and previous open experience in the managementof echinococcal disease is mandatory. Our results do notsupport widespread use of laparoscopy in these cases. Un-complicated benign liver tumors located in the left lobe or inthe anterior segments of the right lobe can be resected safelyusing a "four-hand" technique.

Technologic advances may overcome some laparoscopicdifficulties, such as adequate liver exposure and vascularcontrol. Hand-assisted laparoscopy using a device to pre-vent air leakage (Handport, Smith and Nephew, Inc., Mans-field, MA) is one such promising innovation, allowing thesurgeon to introduce one hand to assist in the dissection.The incision is only large enough to accommodate thesurgeon's hand and exteriorize the specimen.40 In our insti-tution, open surgery remains the treatment of choice whentumors are malignant, are located posteriorly, or are inproximity to major hepatic vasculature.

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laparoscopic management of benign solid and cystic lesions of the

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