Robotic Cystotomy and Capitonnage Technique for a Pulmonary Hydatid Cyst

The zoonotic infection known as hydatid cyst is caused by the larval stages (metacestodes) of cestode species belonging to the genus Echinococcus (1). Lung parenchyma is the most commonly affected organ after liver infection (1). Hydatid lung cysts can become serious due to the late onset of symptoms. Surgery is the safest curative treatment for pulmonary hydatid cysts. The first approach is complete resection of the cyst with maximal preservation of the lung tissue (2). Despite the development of thoracoscopic surgery in recent years, many surgeons are concerned about the difficulty of controlling the contents of the cyst during the operation and the possibility of the cyst bursting into the pleural cavity and causing contamination or anaphylactic reaction in the surgical approach to pulmonary hydatid cysts. Therefore, the thoracotomy is still preferred because it is considered a safer option. However, thoracoscopic treatment of pulmonary hydatid cysts has started to be published, though research is limited (3). Also, there has been an increase in the use of robotic-assisted surgical methods in thoracic surgery for performing complex lung resections. However, there is a lack of studies documenting the use of robotic-assisted thoracic surgery in cases of lung hydatid cysts. The advent of robotic-assisted surgery offers a new approach to these complex cases allowing the benefits of minimally invasive surgery with greater precision and control. 

Case Presentation 

A twenty-five-year-old woman was admitted to the hospital with complaints of progressive dyspnea and blunt chest pain. On general examination, her pulse rate was 78 beats per minute with a respiratory rate of 13. Her blood pressure was 110/70 mmHg and her oxygen saturation was 98 percent on room air. A blood investigation showed elevated levels of C-reactive protein (44.3 mg/L), ALT (41 U/L), ALP (123 U/L), and GGT (61 U/L). There was a nonspecific opacity appearance on the chest radiography. A high-resolution computed tomography scan of the chest and abdomen revealed a 7-centimeter pulmonary cystic lesion in the left lung lower lobe and a 10-centimeter cystic lesion in the liver, which were suspected to be hydatid cysts. Hydatid disease was confirmed by a strongly positive serum enzyme-linked immunosorbent assay (ELISA) for Echinococcus. The patient did not report any respiratory symptoms before this and her past medical and drug history were unremarkable. She denied smoking or alcohol consumption, and previous exposure to pets. Her family history was also unremarkable and her body mass index was 22.3. Forced expiratory volume in one second (FEV1) was 2,68 (86 percent). General surgery consulted with the patient for a liver hydatid cyst, and it was decided to first perform a lung operation, followed by albendazole treatment. Robotic-assisted left lower lobe cystotomy, and capitonnage were performed, and the cyst was totally excised. Histopathological results of the specimen confirmed the previous diagnosis. 

Case Management 

Operative management included a cystotomy and capitonnage approach via robotic surgery using the DaVinci XI system. The patient was placed in the right lateral decubitus position. A port site was opened at the intersection of the 6th intercostal space and the anterior axillary line, where caddiere forceps would be used. An 8-mm camera port was placed at the intersection of the left 7th intercostal space and the humeral head. The third port was an 8-mm port on the scapula tip in the 7th dorsal intercostal space. This port was placed in the Maryland dissector that was handled by the surgeon's right hand. The assistant port was a 12-mm port on the anterior axillary line in the 8th intercostal space. After inserting the robotic ports, the DaVinci XI robot was introduced into the field. Carbon dioxide was then pumped at 6 mmHg. After opening the inferior pulmonary ligament, 200 cc of iodopovidone was administered into the thoracic cavity to prevent contamination due to the cystic fluid spillage. The cyst fluid was aspirated using a handmade thoracoscopic needle through the assistant port. The cyst wall was opened with a Maryland dissector, and the cystic cavity was irrigated with iodopovidone. Then, the cystic membrane was placed in an endobag and removed from the thorax. Next, capitonnage was applied by robotic suturing with 2-0 absorbable vicryl sutures. There was no air leakage. A single chest drain (24 F) was then inserted. The surgical time was 42 minutes, and the blood loss volume was 0 mL. The procedure was completed without any complications. There was no postoperative air leakage or drainage, and the chest x-ray was normal. Postoperative pain was managed with oral analgesia, and the patient was mobile on the same day. The patient was discharged from the hospital 16 hours after the surgery, with the thorax drain removed. The postoperative course was uneventful. The diagnosis of an Echinococcosis cyst measuring 7.4x6x0.3 cm was confirmed through pathological examination. The examination also revealed traces of the scolices and a laminated membrane. 

Discussion 

This case demonstrates the feasibility and safety of robotic-assisted cystectomy and capitonnage for the management of a pulmonary hydatid cyst. The robotic approach offered several advantages over traditional methods, including enhanced visualization, greater precision in dissection and suturing, reduced postoperative pain, and reduced recovery time. Additionally, the risk of cyst rupture and spillage—a major concern in hydatid cyst surgery —was minimized through careful robotic manipulation. This experience suggests that with adequate preoperative preparation and surgical expertise, robotic-assisted surgery can be an effective and safe option for select patients with pulmonary hydatid disease. 

Conclusion 

Robotic cystectomy and capitonnage represent a promising advancement in the surgical management of pulmonary hydatid cysts. This technique combines the benefits of minimally invasive laparoscopic surgery with the enhanced dexterity and precision of robotic-assisted systems, which can potentially reduce the morbidity associated with traditional surgical approaches. Further studies with larger patient cohorts and long-term follow-ups are necessary to fully evaluate this approach, its outcomes and benefits. Nonetheless, this case adds valuable evidence supporting the use of robotic-assisted surgery in the treatment of complex thoracic infections and suggests a new frontier in the management of pulmonary hydatid disease. 

References

1. Eckert J, Deplazes P. Biological, epidemiological, and clinical aspects of echinococcosis, a zoonosis of increasing concern. Clin Microbiol Rev. 2004 Jan;17(1):107-35. doi: 10.1128/CMR.17.1.107-135.2004. PMID: 14726458; PMCID: PMC321468.
2. Kuzucu A, Soysal O, Ozgel M et al. Complicated hydatid cysts of the lung: clinical and therapeutic issues. Ann Thorac Surg. 2004 Apr;77(4):1200-4. doi: 10.1016/j.athoracsur.2003.09.046. PMID: 15063234.
3. Abu Akar F, Gonzalez-Rivas D, Shaqqura B, et al. Uniportal video assisted thoracoscopy versus open surgery for pulmonary hydatid disease-a single center experience. J Thorac Dis. 2020 Mar;12(3):794-802. doi: 10.21037/jtd.2019.12.73. PMID: 32274146; PMCID: PMC7139009.

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