Single incision laparoscopic surgery for a life-threatening, cyst of liver.

INTRODUCTIONMost liver cysts are found incidentally during imag-ing studies and tend to have a benign clinical course [1]. Some large cysts may be symptomatic and cause complications such as spontaneous hemorrhage [2], rupture into the peritoneal cavity or bile duct [3, 4], infection [5], and compression of the biliary tree [6]. Surgical intervention is required sometimes for such complications [7, 8]. We performed single incision lap-aroscopic surgery (SILS) for a case of life-threatening liver cyst with inferior vena cava (IVC) thrombosis and chronic heart failure.CASE REPORTAn 83 year-old female presented with a month-long history of general fatigue and loss of appetite. She had a history of a huge liver cyst with chronic heart failure and had been treated by aspiration therapy, with injec-tion of a sclerosing agent, eight months previously in another hospital. She denied any history of abdominal trauma. Physical examination revealed a huge palpable mass in the right upper abdomen without local ten-derness or any peritoneal signs. Her external jugular veins were dilated on her neck and bilateral leg edema with gait disturbance was observed in the clinic. Serum blood test showed a hypo-nutritional and anemic condition (total protein: 5.6 g/dl and hemoglo-bin: 9.1g/dl). The white blood cell count and C-reactive protein were not elevated. Total bilirubin, asparate aminotransferase and alanine aminotransferase were normal. Fibrin degradation product (FDP) and D-dimer were elevated, indicating hypercoagulabil-ity of the blood. The serum CEA was normal and CA19-9 was elevated (2827U/ml). A serum echinococ-cus serologic test was negative.A CT scan showed huge cystic mass of the liver, which compressed the right ventricle and inferior vena cava (Fig. 1). There was no sign of local wall thicken-ing, septum or solid part in this huge cyst. IVC throm-bosis was continued to the bilateral femoral veins (Fig. 2). We carried out a fine needle aspiration to con-firm the cytology and character of the contents after systemic heparin infusion. The cytology was normal. The CEA and CA19-9 of the contents were elevated (458.3ng/µl and 810 x 10