Laparoscopic partial pericystectomy for a giant hepatic hydatid cyst in an 8-year-old child: a case report

Abstract

Introduction:

Hydatid cyst of the liver is a zoonotic disease caused by the larvae of Echinococcus granulosus. It is endemic in countries like South America, Africa, Asia, and China. Giant hepatic hydatid cysts are rare in children and carry a higher risk of complications. We report a similar case of a giant hepatic hydatid cyst in an 8-year-old child managed successfully with laparoscopic surgery.

Case presentation:

An 8-year-old boy from a remote village of Nepal presented with fever, upper abdominal pain, and a sensation of heaviness in the abdomen for 6 months. Imaging revealed a giant hepatic hydatid cyst measuring 12.6 cm × 11.3 cm × 10.7 cm on the right lobe of the liver. The child underwent laparoscopic partial pericystectomy and recovered well. Postoperative albendazole therapy was continued, and there was no evidence of recurrence at 3 months of follow-up.

Discussion:

Hydatid disease commonly affects the liver in adults and lungs in children, with giant cysts posing a high risk of rupture, infection, and other complications. Imaging with ultrasonography and computed tomography is essential for diagnosis. Surgery remains the mainstay of treatment, with laparoscopic techniques offering faster recovery, smaller incisions, and fewer complications. Postoperative albendazole therapy and regular follow-up are crucial. This case highlights the effectiveness and safety of laparoscopic partial pericystectomy in a child, even in resource-limited settings.

Conclusion:

Laparoscopic surgery is a safe and effective option for managing giant hepatic hydatid cysts in children, even in resource-limited settings. Early diagnosis and intervention are crucial to reduce morbidity, mortality, and recurrence.

Introduction and importance

Hydatid cyst is a zoonotic disease caused by larvae of Echinococcus spp., most commonly E. granulosus, with dogs being the primary host, sheep and cattle being the secondary host, and humans as accidental hosts through the feco-oral route of transmission[1]. The annual incidence is >50 per 100,000 population-year in endemic zones like Argentina, Peru, East Africa, Central Asia, and China[2]. In adults, the liver is the most commonly affected organ (75%), followed by the lungs (15%), whereas in children, the lungs are more commonly involved than the liver[3]. Hepatic hydatid cysts usually occur in adults (19−64 years) and are relatively uncommon in children[4].

HIGHLIGHTS

• Giant hepatic hydatid cysts are very rare in pediatric populations.

• Radiological evaluation with USG and CT abdomen helps in diagnosis and planning appropriate management.

• Laparoscopic partial pericystectomy can be safely performed in the pediatric population.

• Laparoscopic surgery offers the advantages of minimal invasiveness, shorter hospital stays, and faster recovery.

• Postoperative albendazole therapy and regular surveillance help in preventing recurrence.

Giant cysts are prone to complications such as infection, hemorrhage, spontaneous rupture, pressure effect on adjacent structures, and peritonitis with secondary hydatidosis, leading to higher morbidity and mortality[5]. Surgery remains the mainstay of treatment of giant cysts, and laparoscopic methods are increasingly being adopted worldwide[6]. We are reporting an intriguing case of a giant hepatic hydatid cyst in an 8-year-old child from an urban village, which was managed successfully by a laparoscopic approach.

This case is important as it highlights the feasibility and safety of laparoscopic management of a giant hepatic hydatid cyst in a pediatric patient from a rural, resource-limited setting. It adds to the limited literature on minimally invasive surgery in children with hydatid disease. Moreover, it underscores the need for early diagnosis, capacity building, and advanced care access in endemic regions like Nepal.

This work has been reported in line with the revised SCARE criteria, 2025[7].

Case presentation

An 8-year-old boy, a resident of Jumla, presented to the outpatient department with fever and right upper abdominal pain associated with a feeling of heaviness and loss of appetite for 6 months. There was no history of jaundice or vomiting. There was no significant past history and illness in the family. No history of animal husbandry, including the rearing of sheep. On clinical examination, there was non-tender hepatomegaly with a liver span of 14 cm. He was initially diagnosed with a suspected hepatic hydatid cyst based on ultrasonography (USG) of the abdomen and pelvis in Jumla 1 month back, and was under Tab albendazole. Despite the management, his symptoms did not improve and hence was referred to our center. Laboratory reports were within normal limits except for leucocytosis (total leukocyte count of 10,510 cells/mm³⁾ and eosinophilia (6%). Abdominal USG demonstrated a well-defined cystic lesion in the right lobe of the liver measuring 12.1 cm × 10.5 cm × 11.3 cm with a few floating membranes, suggesting features of a hydatid cyst. Contrast-enhanced computed tomographic scan of abdomen and pelvis showed an enlarged liver (15.6 cm) with a well-defined thin-walled homogenous cystic lesion measuring 12.6 cm× 11.3 cm× 10.7 cm in the right lobe without any solid components and foci of calcification. On post-contrast study, the undulating membrane showed mild enhancement, suggesting a hepatic hydatid cyst (CE1, WHO-IWGE) (Fig. 1). The Echinococcus IgG was negative (0.073).

Figure 1.

CECT abdomen and pelvis (a: coronal section) and (b: axial section) showing a thin-walled homogenous cystic lesion in the right lobe of the liver (red arrow) without any solid component or calcification. CECT, contrast-enhanced computed tomographic scan.

The patient was planned for laparoscopic partial pericystectomy for the hydatid cyst of the liver. He was kept in a supine position. Pneumoperitoneum was established using an open (Hasson) technique at the umbilicus, and intra-abdominal pressure was maintained at 8–10 mmHg. A 10-mm camera port was placed in an infraumbilical position. The hydatid cyst was identified on the surface of the right lobe of the liver. Under laparoscopic guidance (with a 30° laparoscope), two 5-mm working ports were inserted in the right hypochondrium and epigastric region, respectively, to facilitate access to the right hepatic lobe. Gauzes soaked in 10% betadine were placed around the cyst to prevent spillage and dissemination of content. The cyst cavity was punctured, aspirated, infiltrated with 20% hypertonic saline, and left for 6 min to inactivate the parasite. The cyst cavity was then opened, and its contents were aspirated. Partial pericystectomy was done using a harmonic scalpel, and the cystic membrane was retrieved using a self-made endobag (Fig. 2). There was no evidence of cystobiliary communication. A single 20-Fr abdominal drain was placed at Morrison’s pouch. The postoperative period was uneventful. Oral feeding started after 6 h of surgery, and the drain was monitored for any evidence of bile leaks. Albendazole (10 mg/kg/day) therapy was initiated on the first postoperative day and was continued. Drain was removed on the fourth postoperative day, and the patient was discharged on the sixth postoperative day.

Figure 2.

Intraoperative image (a: during removal of content from cyst cavity), (b: after removal of content from cyst cavity) showing laminated membrane (blue arrow) and cyst cavity (white arrow).

Histological examination revealed cystic structures lined by an outer thick, avascular, eosinophilic, lamellated layer and an inner germinal layer with the presence of scolexes and daughter cysts. Additionally, dense inflammatory infiltrates composed of neutrophils, lymphocytes, and plasma cells, along with thickened and congested blood vessels, were also evident (Fig. 3). At 3 months of follow-up, there were no clinical and radiological signs of recurrence.

Figure 3.

Hematoxylin and eosin stain (a: 4×, b: 40×). Cyst lined by an outer layer of avascular eosinophilic laminated chitinous layer (black arrow), an innermost germinal layer with protoscolices (red arrow) containing multiple hooklets (blue arrow).

The child’s parents expressed gratitude and relief after prompt diagnosis and successful treatment, as the child had been symptomatic for several months. They were grateful for the efforts of our surgical team in performing minimally invasive surgery, which allowed a faster recovery and shorter hospital stay. It subsequently reduced the travel frequency and associated costs for a family from a remote village, facilitated an earlier return to school for the child, and minimized disruption to parental work responsibilities. They emphasized the importance of timely referral and access to advanced surgical care, especially in remote areas of Nepal.

The sequence of key clinical events is outlined in the following timeline (Table 1).

Table 1.

Timeline of events.

Day/Time	Event	Details
6 months before presentation	Symptom onset	Patient developed fever, right upper abdominal pain, feeling of heaviness, and loss of appetite
1 month before presentation	Suspected as a case of hydatid cyst of the liver	Visited the nearby hospital, USG of the abdomen showed features suggestive of a hydatid cyst of the liver, and started on albendazole therapy.
Day 0	Presentation to our outpatient department	Symptoms did not improve on albendazole therapy.
Day 2	Preparation for surgery,	A giant liver cyst at the surface of the right lobe of the liver
	Preanesthetic checkup
	Minimally invasive laparoscopic surgery	Partial pericystectomy
		No evidence of cystobiliary communication
0th POD	Postoperative care	Feeding was started
1st, 2nd, and 3rd POD	Diet progression	Soft to normal diet, Albendazole started,
4th POD	Continued recovery	Tolerated normal diet
		Drain was removed
6th POD	Discharged	Patient was discharged with stable vitals
1st and 2nd -week follow-up	Postoperative check	No complaints, the stapler was removed from the port site
3-month follow-up	Surveillance	Asymptomatic, no signs of recurrence

Discussion

Hydatid cyst is a zoonotic disease that affects people involved in livestock farming worldwide and can affect many organs, notably the liver and lungs[5]. In children, it typically affects the lungs, possibly due to the lower density of liver tissue, which enables the scoleces to traverse liver barriers. In contrast, in adults, the liver is the most commonly affected site[4]. Males are more commonly affected than females due to behavioral differences and outdoor exposure of boys in the age-group from 1 to 14 years[8] (as in our case).

The majority of liver cysts are asymptomatic and diagnosed during USG of the abdomen during a routine checkup. The growth rate of a hydatid cyst is 1–2 cm per year in adults, whereas it can reach up to 4–5 cm per year in children due to various factors such as smaller organ size, increased tissue elasticity, and differences in immune responses[9]. Cysts larger than 10 cm are considered giant cysts[5]. As the cyst grows in size, it starts to manifest by causing right upper abdominal pain, abdominal distension, and discomfort, or presents with complications such as secondary infection, hemorrhage, pressure effect on the adjacent organ or tissue, and rupture, causing cystobillary communication, cholangitis, peritonitis, secondary hydatidosis, and rarely severe anaphylactic reaction[10].

USG of the abdomen and pelvis is the best initial modality of investigation for diagnosis, as it can detect daughter cysts, membranes, hydatid sand, and vesicles inside the hydatid cyst. It also helps in monitoring the response to therapy with up to 90% accuracy[11]. Computed tomography (CT) has sensitivity up to 94% with added advantage in detecting calcification in the cyst wall or septa, assessing complications, and in cases of obesity, excessive bowel gases, abdominal wall deformities, and previous surgery[12]. USG and CT also help to differentiate liver cyst from WHO type 1 hydatid cyst with sensitivity and specificity of 96%, 98% and 80%, 62%, respectively[13]. Magnetic resonance imaging is particularly important in the evaluation of the cystic component and in suspected cystobiliary communication[11].

Surgery is the mainstay of management of a giant cyst because of the increased risk of rupture. The principle of surgery is disease cure, reducing morbidity and preventing spillage, thus reducing the risk of severe anaphylaxis, secondary hydatidosis, and recurrence[6]. Both laparoscopic and open surgical intervention with anthelminthics is the treatment strategy of choice[14]. Laparoscopic surgery is gaining popularity in recent times due to early recovery, small incisions, short hospital stay, and better access to multiple and unusual locations, but still being held back due to the potential risk of intraperitoneal spillage as a result of poor suction control and technical difficulties in managing the residual cavity. In pediatric laparoscopy, low-pressure pneumoperitoneum (typically 5–8 mmHg in infants and 8–12 mmHg in older children) is preferred because it minimizes adverse cardiopulmonary and metabolic effects associated with CO₂ insufflation while providing adequate surgical workspace[15]. Minaev et al found that the laparoscopic technique was safe with shorter duration of surgical effects and markedly fewer postoperative complications compared to open surgery[16]. Similarly, a comparative study of laparoscopic and open surgery in hepatic hydatid disease in children by Masood et al demonstrated that laparoscopic surgery is a feasible and safe option with low morbidity, low conversion rate, and minimal complications[17]. Controlled suction of content and use of scolicidal agent rinsed gauzes around the potential spillage site lessens the chance of recurrence of disease[6]. Recently, there has been a single incision trocar less endoscopic technique, which is easy to conduct, prevents the intraperitoneal spillage, allows complete evacuation, and simplifies the obliteration of the residual cavity[18]. Postoperatively, chemotherapeutic agents like albendazole with or without praziquantel is continued for 3–6 months, as there is a risk of recurrence up to 12%[19]. Echinococcal IgG ELISA or indirect hemagglutination can be performed for surveillance. The patients are evaluated every 3 months for the first year, every 6 months for the second year, and annually thereafter for residual disease and recurrence[20].

In our patient, we chose laparoscopic partial pericystectomy because of availability, accessibility, and expertise in minimally invasive surgery. Low-pressure pneumoperitoneum of 8–10 mmHg was used in our case to minimize cardiopulmonary and metabolic complications[15]. The patient recovered well postoperatively without any major complications. In a growing child, timely surgical intervention helps in reducing potential morbidity and mortality associated with complications, and hence promotes proper growth and development of the child.

Conclusion

Laparoscopic management of giant hepatic hydatid cysts in children is a safe and feasible option, even in resource-limited settings. Early diagnosis and timely surgical intervention help prevent life-threatening complications and recurrence. This case highlights the importance of capacity building and accessibility of minimally invasive techniques in endemic regions to improve pediatric surgical outcomes.

Ethical approval

Ethical approval by the ethics committee is not required for a case report in our country.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

None.

Author contributions

Constructing hypothesis for the manuscript: R.J., S.K.G., S.K.K. Planning methodology to reach the conclusion: R.J., R.P., S.K.G., R.K.G., S.D. Organizing and supervising the course of the article and taking responsibility: R.J., S.K.G., S.K.K. Patient follow-up and reporting: R.J., S.K.G., R.P. Logical interpretation and presentation of the results: R.J., S.K.G., R.P., R.K.G., S.D. Construction of the whole or body of the manuscript: R.J., R.P., S.K.G., S.K.K. Reviewing the article before submission not only for spelling and grammar but also for its intellectual content: R.J., S.K.G., R.P., R.K.G., S.D.

Conflicts of interest disclosure

The authors declare that there is no conflict of interest regarding the publication of this paper.

Research registration unique identifying number (UIN)

Not Applicable.

Guarantor

Rahul Jha.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

Curated data that were analyzed are available from the corresponding author on request.