TÇCD 2012 30th Annual Congress of Turkish Pediatric Surgical Association

İntroduction: Even in countries where it is considered endemic, splenic hydatid cyst is a very rare disease in childhood. Partial or total splenectomy has generally been the treatment of choice for this condition. A 10-year-old girl with isolated splenic hydatid cyst was successfully treated by laparoscopic cystectomy and splenic preservation.

Operative Technique: The patient was operated on under general anesthesia with endotracheal intubation. A nasogatric tube was inserted into the stomach before the veress needle insertion. A 1-cm curvilinear incision was made in the infraumblical region, where  a veress needle was inserted into the peritoneal space. A 9 mm Hg of intraabdominal pressure was established and maintained.  Firstly, a 10 mm trocar was inserted via same incision and a 10 mm, zeroation degree telescope was used through this cannule. Under the direct vision, a second 10 mm trocar was inserted via the 1 cm incision on the left lower quadrant, and 5 mm one was inserted in the middle of the midline extending from the umbilicus to the xiphoid process. On the intraperitoneal exploration, a medium sized cyst, which has a tensile and thin wall and an omental attachment was found in the lower pole of the spleen Other organs such as liver, stomach, omentum and intestine were found to be normal. A rolled sponge moistened with hypertonic NaCl was placed around the cyst for the prevention of potential contamination and anaphylaxic reaction. Omentum was detached from the cyst by using LigaSure device (Valleylab,USA).Then, needle was inserted into the cyst, a 60 ml clear cyst fluid was aspirated, and the same volume of hypertonic NaCl was injected into the cystic cavity. After a five-minute waiting period, hypertonic solution was aspirated from the cystic cavity. After the setting, a sling suture on the top of the cyst, cystotomy was applied with laparoscopic bipolar scissor and germinative membrane was extracted, then it was put into the endobag and taken out the abdominal cavity via 10 mm trocar. Circumferential partial cystectomy was performed by using a LigaSure device (Valleylab,USA) and it was extracted by endobag . Then, omentopexy was performed, and operation was ended. No perioperative complications occured. The duration of the operative procedure was 66 minutes. Postoperative period was un-eventful with no analgesic requirement, as the post-operative pain score of the patient was ranged from one to two according to the verbal rating scale. She was discharged on  postoperative second day. At 34-month follow-up, with 3-6 month-intervals, she did not have an abdominal pain and no recurrent lesion of spleen was found in the ultrasonographic examination of the abdomen. Post-op cosmetic appearance is good.

Conclusion: We found that the laparoscopic approach for managing splenic hydatid cyst is technically feasible, safe and is associated with a good cosmetic appearance and shorter hospital stay.

Giriş: Endemik olduğu düşünülen bölgelerde bile çocuklarda dalak hidatik kisti çok nadir bir hastalıktır. Bu durumda genellikle parsiyel veya total splenektomi önerilir. İzole dalak hidatik kisti olan 10 yaşındaki kız çocuğu dalak korunarak ve laparoskopik kistektomi ile başarılı bir şekilde tedavi edilmiştir.

Cerrahi Teknik: Hasta endotrakeal genel anestezi altında opere edildi. Veress iğnesi yerleştirmeden önce mideye nazogastrik sonda konuldu. Göbek altından 1 cm curvilinear insizyon yapıldı ve buradan Veress iğnesi peritoneal boşluğa sokuldu. 9 mm Hg intraabdominal basınç oluşturuldu ve devam ettirildi. Bu insizyondan 10 mm trokar yerleştirildi ve 10 mm  0 derece teleskop için kullanıldı. İkinci 10 mm trokar sol alt kadrandan, 5 mm lik trokar ise göbek xphoid arası hattın ortasından direk görüş altında yerleştirildiler. Karın içi eksplorasyonda dalak alt polde, orta büyüklükte gergin, duvarı incelmiş ve üzerine omentum yapışmış kist bulundu. Karaciğer, mide, omentum ve intestinal segmentler normaldi. Olası bir kontaminasyonu ve anaflaktik reaksiyonu önlemek amacıyla hipertonik NaCl ile ıslatılmış spanç kist çevresine yerleştirildi. Ligasure (Valleylab,USA) kullanarak omentum kistten ayrıldı. Sonra kist içine iğne ile girilerek 60 ml berrak kaya suyu aspire edildi ve aynı miktarda hipertonik NaCl kist içine verildi. 5 dk bekledikten sonra hipertonik sıvı aspire edildi. Kistin tepesine askı süturu konduktan sonra bipolar makas ile kistotomi yapıldı, germitatif membran çıkarıldı ve endobag içine konarak 10 mm trokardan karın dışına alındı. Ligasure (Valleylab,USA) kullanarak çepeçevre parsiyel kistektomi yapıldı ve endobag ile çıkarıldı. Sonra omentopeksi yapıldı ve operasyon sonlandırıldı. Postoperatif dönemde sorun olmadı ve ağrı skoruna göre analjezik gerekmedi. Postoperatif 2. gün oral albendazol ile taburcu edildi. Operasyon süresi 66 dakikaydı. 3-6 aylık aralıklarla 34 ay takip edildi. Karın ağrısı şikayeti yok ve ultrasonografik incelemede nüks tespit edilmedi. Postoperatif kozmetik görünümü iyi.

Sonuç:  Biz dalak kist hidatiği tedavisinde laparoskopik yaklaşımı teknik olarak uygulanabilir, güvenli, ve hastanede kısa yatış ve iyi bir kozmetik görünümle ilişkili bulduk.