Collection of pus in the liver is a common occurrence especially in alcoholics needing antibiotics and anti-amoebics and repeated aspiration by pushing a needle into it under ultrasound guidance. Some large abscesses located in inaccessible areas of the liver, multiple abscesses and those threatening to rupture will require surgical intervention.
There are three major types of liver abscesses namely pyogenic liver abscess, amoebic liver abscess and fungal abscess. Procedures for drainage of liver abscesses include needle aspiration, percutaneous catheter drainage, open and laparoscopic surgical drainage.
- Percutaneous needle aspiration: Material for microbiologic and pathologic evaluation can be done recovered with needle aspiration. Aspiration of the cavity material is done under CT scan and ultrasound guidance.
- Percutaneous catheter drainage: Percutaneous catheter drainage is usually performed for small cysts. Cysts greater than 5 mm, multiloculated cysts and ruptured cysts surgical drainage is preferred. A catheter is placed under Seldinger or trocar techniques under CT and ultrasound guidance. This method is used to drain multiple abscesses.
- Laparoscopic liver abscess drainage: A small cut below the umbilicus is made under general anesthesia. A laparoscope is then inserted into the peritoneal cavity after establishing the pneumoperitoneum. Pus is aspirated from the liver through paracentesis.
Open surgical drainage: The area is explored for abdominal lesions after making a right subcostal or a superior median abdominal incision. Once the position of the liver is established, hemostatic forceps are used to enter the cavity and remove the pus with a paracentric needle.
Simple cysts: Cysts of the liver are well encapsulated fluid collections. Most simple cysts are congenital and a symptomatic. They can usually be treated without surgery. But when they become large and cause symptoms, simple liver cysts are unroofed. The portion of the wall extending to the surface of the liver is excised. Large symptomatic cysts require laparoscopic puncture from time to time but cyst unroofing is also conducted laparoscopically.
Polycystic liver disease: The cystic liver is decompressed with a combination of unroofing, fenestration or resection of the liver. This procedure is considered only for patients displaying chronic and disabling pain.
Neoplastic cysts: Cystadenoma and cystadenocarcinoma are treated with complete ablation of the tumor. Enucleation, fenestration, formal resection and complete fulguration are also implemented.
Hydatid cysts: Common liver affliction in India, hydatid cyst is a parasitic disease caused by a certain tape worm carried by domestic dogs. Unlike Hydatid cysts can be life-threatening if untreated. Majority of these cysts require surgical treatment with either a marsupialization or a cysto-pericystectomy. Spillage of cyst contents can sometimes cause anaphylactic reaction and dissemination of hydatid disease.
- Marsupialization :A slit is cut into the abscess and the edges are stitched to form a continuous layer from the exterior to the interior surface. The site can then drain easily.
- Cystopericystectomy :Laparoscopic cystopericystectomy is almost the same as open surgery. It is a very difficult procedure where initially the cyst is punctured and the fluid aspirated so as to prevent spillage. This part of the surgery is very well controlled in an open surgery rather than a laparoscopic surgery.
Cancer of the liver is a dreaded condition affecting both young and the old. Primary liver cancer is called hepatocellular carcinoma and can be a congenital defect or even due to scarring of the liver due to alcohol abuse. Most cancers from different digestive organs in the abdomen spread to the liver causing secondary deposits. Secondary cancer deposits from colon cancer are amenable to liver resection. Surgeries for liver cancer include partial hepatectomy, liver resection and lobectomy and liver transplant. In partial hepatectomy part of the cancer affected liver is removed. In liver resection and lobectomy the lobe of the liver is removed or an attempt is made to remove the cancer surrounding the tissues of the liver.
Patients with injury to the liver often benefit from laparoscopy to evaluate the extent of the injury and decide on opening the abdomen for a definitive surgery.