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Video-assisted Thoracoscopic Surgery (VATS) with mini-thoracotomy for the management of pulmonary hydatid cysts
© The Author(s). 2018
Received: 14 May 2017
Accepted: 5 April 2018
Published: 2 May 2018
Hydatid cyst is an endemic infectious disease. Various modalities have been provided to approach hydatosis. This article reports a 20-years-experience of a new minimally invasive technique for the management of solitary pulmonary hydatid cysts using video-assisted thoracoscopic surgery (VATS) with mini-thoracotomy.
We reviewed the medical records of patients who underwent unilateral or bilateral single pulmonary hydatid cyst excision using VATS with mini-thoracotomy. All patients were managed by the same surgeon over the period from January 1996 till January 2015.
The study involved 120 patients aged between 11 and 74 years (median age = 30 years). The overall number of conducted surgeries was 130 (10 patients needed two surgeries). No deaths were reported during or after surgery. No recurrences were seen in the follow-up period that ranged between 10 and 30 months. Three patients (2.3% out of the 130 surgeries) developed post-operative complications: one patient had prolonged air leak and two patients developed empyema.
VATS with mini-thoracotomy is an effective and safe option for managing intact or ruptured solitary pulmonary hydatid cysts. Further studies in controlled prospective design are needed to compare this approach to other modalities of management.
Hydatid cyst is a parasitic infectious disease, which is endemic in many places around the world, such as the Mediterranean countries, Iran, India, Australia and South America. According to World Health Organization (WHO), the annual incidence of Cystic Echinococcus is up to 220 per 100,000 inhabitants in these countries .
The causal parasite of the disease is Echinococcus Granulosus. Humans can serve as intermediate hosts for this organism. It usually infects human organs separately or in groups, especially the liver and the lungs. The hydatid cyst grows slowly and asymptomatically in most of the cases to an extent that some cysts may exceed 20 cm in diameter. This expansive growth can seriously damage the tissue of the hosting organ, and makes spontaneous, traumatic, or intra-operative rupture of the cyst easier. The optimal treatment targets are: complete elimination of the parasite, preservation of the utmost of the healthy tissue, and prevention of recurrence by avoiding the spillage of the cystic fluid and dissemination of the cyst contents [1, 2].
Medical treatment attempts with Benzimidazoles to manage hydatid cysts are countless and persistent. Although this management spares patients the risks of surgery, its efficacy is still limited to specific cases such as hydatid cysts that are smaller than 6 cm, and in inoperable patients, and it is given after surgery to prevent recurrence and secondary echinococcosis [1, 3, 4]. Also, aspiration of cystic fluid yields high risks and small benefits, and is still limited to liver cysts [3, 5].
Surgery with open thoracic surgery, sternotomy or right thoraco-abdominal approach, is the first and the best choice to manage large, multiple or complicated cysts in the lung or the liver [6–8]. Although this surgical approach allows delivering the cysts or removing them along with the damaged tissue without cystic rupture, it is a traumatic and highly invasive procedure for patients [6–8].
Surgical removal using video-assisted thoracoscopic surgery (VATS) has been used to minimize the risks of open surgery. However, it is limited to few clinical entities because of the high risk of postoperative complications such as cyst rupture, cystic fluid spillage and difficulties in controlling bronchial fistulas associated with cysts [9–16].
In this article, we report a series of cases of solitary pulmonary hydatid cyst managed with a new minimally invasive technique using video-assisted thoracoscopic surgery with mini-thoracotomy in order to prevent spillage and facilitate management of the residual cavity and control of the associated bronchial fistulas.
This is a case-series study. We reviewed the medical records of 120 patients with unilateral or bilateral single pulmonary hydatid cyst, whether it was intact, ruptured, or infected, and those who were managed with thoracoscopic surgery by the same surgeon, who applied the exact same technique for all patients, during the period from January 1996 till January 2015. All consecutive cases which met the inclusion criteria were included. We aimed to investigate operative time, duration of hospital stay, postoperative complications, morbidity, mortality, and recurrence rate.
Big hydatid cysts that are > 15 cm in diameter. Because it might need lung resection.
Multiple cysts in a single lung. Thoracotomy provides a better access in these cases.
Children under the age of 10 years, due to technical reasons related to anesthetic and thoracoscopic equipment.
Applied surgical procedure
In the event of bilateral hydatid cysts, surgery was performed first on the larger cysts. Preoperative chest radiography and CT scanning were performed on all patients. In patients presented with combined pulmonary and hepatic hydatid cysts, we proceeded with simultaneous combined resection of hydatid cysts in one stage through midsternotomy along with laparotomy or transdiaphragmatic removal of liver cysts in order to avoid three-stage operation of two thoracotomies and a laparotomy.
In all cases, the surgery is ended by repeated washing of the pleural cavity with warm saline, and placing a chest tube for drainage through the same entrance of the camera. Albendazole is administered at a dose of 10 mg/kg continuously for three consecutive months post-surgery.
The follow up was done by chest radiography every 3 months for at least 10 months postoperatively.
Clinical characteristics of the patients
Clinical type of cysts
Ruptured into the bronchi
Ruptured into the pleura
Mean operative time ranged from 75 to 100 min, including the time for anesthesia. Mean hospital stay was 2–3 days for all patients, except for the three patients who developed post-operative complications (2.3% out of the 130 surgeries). Prolonged air leakage (for more than 5 days) occurred in one of these three patients, and it needed an open thoracic surgery to close the bronchial fistulas. The two other patients with post-operative complications had infections: the first one had an empyema that required drainage and regular washing of the pleural cavity with antibiotic therapy according to culture and sensitivity test results, and the other one developed an abscess in the place of the removed cyst and required thoracotomy and lobectomy. The two patients who suffered from infectious postoperative complications had already had infected cysts before surgery.
No mortality was reported during or post-surgery, and no recurrences were seen during the follow-up period (10 to 36 months).
In this case-series, we found that using video-assisted thoracoscopic surgery (VATS) with mini-thoracotomy for the management of a certain group of patients with solitary pulmonary hydatid cysts allowed for total elimination of the parasite, maximum preservation of the healthy tissue, and prevention of recurrences by avoiding the spillage of the cystic fluid.
Results of various studies of VATS for pulmonary hydatid cysts
Year and country
Mean cyst diameter (cm)
Mean Operative time (min)
Mean Duration of hospital stay (day)
Mean period of follow up (month)
Mortality and recurrence
Abbas et al.
Median: 30 Range: 11–74
Alpay et al. 
Findikcioglu et al. 
Parelkar et al. 
Uchikov et al. 
Ettayebi et al. 
Our results showed that there was no cystic rupture or cystic fluid spillage during operations, which is supported by the absence of recurrences during the follow up period that lasted for up to 3 years. Moreover, the routine application of prophylactic pharmacological therapy with Albendazole after surgery had helped in preventing recurrence which reached zero in some studies [16, 20]. However, the follow up period in some of these studies was short (about 6 months) and not sufficient to detect all cases of recurrence [11, 14, 16].
The operative time in our study was shorter than that reported in some similar studies [9, 14] by virtue of the operative easiness through mini-thoracotomy. Giving the fact that those studies were limited to small cysts that are less than 7 cm in diameter, which are not usually accompanied by bronchial fistulas, while our study included large cysts that reached 15 cm in diameter.
Duration of hospital stay in our study was relatively short, due to the easiness of control over bronchial fistulas and closure of the residual cavity after cyst removal via mini-thoracotomy, and thus avoiding prolonged post-operative air leakage (a single case out of 130 operations). In some studies [2, 14, 16], where mini-thoracotomy approach was not used, prolonged post-operative air leakage was the most common complication which had led to a longer hospital stay and to an increased complications rate that reached 13.3% in Levent Alpay study .
The rate of infectious complications was high in our series, in which we reported two cases: empyema and abscess formation within the place of the removed cyst, in two out of four patients who already had infected cysts. This is consistent with the results of Milind study , and requires reconsideration of the role of thoracoscopic surgery in such cases, and looking for a better alternative.
In conclusion, the case series revealed that (VATS) with mini-thoracotomy is an effective and safe option for managing intact or ruptured solitary pulmonary hydatid cysts. Further studies in controlled prospective design are needed to compare this approach to other modalities of management.
Availability of data and materials
All data and materials are available upon request.
NA: developed the surgical technique, performed surgeries, and finalized the manuscript. SZ, FA, TA, IH, MA, TT: collected and analyzed the data, and participated in writing the manuscript. AA: helped NA in the surgical aspects, and participated in writing the manuscript. All authors approved the final manuscript as submitted, and agreed to be accountable for all aspects of the work.
Ethics approval and consent to participate
Ethical approval was obtained from the Research Ethics Committee of Faculty of Medicine of Damascus University. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The objectives of the study were explained to the participants who were informed that their participation was voluntary and anonymous. An informed consent was obtained from all participants.
Consent for publication
While explaining the study and obtaining consent for participation, participants were told that the results of this research will be published in an international journal.
The authors declare that they have no competing interests.
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