Key messages

• It is unclear whether laparoscopy for hepatic hydatid cyst reduces mortality, morbidity or recurrence compared with open surgery because the certainty of the evidence is very low.

What is the evidence.
See evidence matrix  in Epistemonikos later

We found three systematic reviews [2],[3],[4], which include four studies relevant to our question, none of them randomized. Three were retrospective [6],[7],[8] and one prospective [5].

What types of patients were included

The studies included patients older than 10 years with active liver hydatid cyst (cysts type I to IV or CE1 to CE4).

One study [8] excluded patients with cysts located in segment 1 and 7 and with evidence of intrabiliary rupture.

None of the studies included emergency surgery for complicated cyst.

What types of interventions were included

All studies compared laparoscopy versus open surgery [5],[6],[7],[8].

Regarding the different types of surgery, studies divided it into conservative surgery where only the membrane was removed and pericystic parasite remained in the liver, and radical procedures including pericystectomy and liver resection. Two studies [6],[8] included only conservative laparoscopic management in the laparoscopy group, and one study [8] did not include radical surgery in the open surgery group.

What types of outcomes
were measured

Perioperative mortality and morbidity, relapse and hospital stay were compared across studies included in the summary.

They also measured general complications such as fever of unknown origin, subcutaneous hematoma, pleural effusion or empyema, pneumonia, atelectasis, drug induced fever and hyperosmolar coma.

We found three systematic reviews [5], [6], [7], including 14 studies   reported in 21 references [8], [9], [10], [11], [12], [13], [14], [15], [16],   [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28]. Eight   studies correspond to randomized controlled trials (15 references [9], [10],   [11], [12], [13], [14], [16], [17], [19], [21], [22], [23], [24], [26], [27]).   This table and the summary in general are based on the latter. One study [15]   did not contribute data to any of the outcomes of interest.

To whom this evidence does and does not apply

• This summary applies to patients > 10 years with hydatid cyst, excluding patients with inactive cysts (type V Gharbi or type CE5 WHO).
• Does not apply to patients with complicated hydatid cyst that require emergency surgery .

• The outcomes included are those considered critical for decision making by the authors of this summary. Hospital stay and postoperative pain were not included because there is wide consensus in the literature about the benefit of laparoscopy on these outcomes.

• It is not possible to make an appropriate balance between risks and benefits because the certainty of the evidence is very low.
• If there was a clear reduction of morbidity and mortality the balance would surely favor the intervention. If the benefit was only on hospitalization or other outcomes the balance would not be so clear.

• It is highly likely that patients and their doctors would be inclined to minimally invasive surgery because it has proven to be a safe procedure for many conditions. It is particularly important to inform about the certainty of the evidence.

• Since there is uncertainty about the benefits because the certainty of the evidence is very low, it is not possible to make an adequate cost/benefit balance.

Differences between this summary and other sources

• The conclusion of this summary are consistent with those of the systematic reviews identified, that is laparoscopic approach is as or safer than conventional surgery, in terms of mortality and morbidity, but the certainty of the evidence is very low.
• No relevant clinical guidelines relevant for this question were identified.

• The likelihood that the information presented in this summary change with future evidence is very high due to the very low certainty of the evidence.
• There is at least one retrospective study [9] not included in the systematic reviews identified, which included 353 patients, with 60 participants receiving laparoscopic surgery and 293 conventional surgery. The study shows no difference in morbidity or mortality between the groups.