ANORECTAL MALFORMATIONS

PRESENTED BY :

DR. DEBANGA SARMA

P.G. DEPARTMENT OF SURGERY
GAUHATI MEDICAL COLLEGE
GUWAHATI-32

Anorectal malformations comprise a wide spectrum of disease affecting male and

female and can involve malformations of the distal anus and rectum, as well as the
urinary and genital tracts.
Malformations range from minor easily treated defects that have an excellent
functional prognosis to complex defects that are difficult to manage, are often associated
with other anomalies, and have a poor functional prognosis.

FREQUENCY:
Anorectal malformations occur in approximately 1 in 5000 live births.

EMBROYOLOGY :
The terminal part of hind gut enters into the cloaca, an endoderm- lined cavity in
direct contact with surface ectoderm. A transverse ridge, the urorectal septum arises in
the angle between allantois and hind gut. The septum grows caudally thereby
dividing the cloaca into an anterior portion, the primitive urogenital sinus and a posterior
anorectal canal. The cloacal membrane is then divided into posterior anal membrane and
anterior urogenital membrane.
In the meantime the anal membrane is surrounded by mesenchymal swelling and
in the eighth weeks it is located at the bottom of and ectodermal dipression known as anal
pit or proctodeum in the ninth weeks anal membrane ruptures and open pathway with
outside is formed. Any abnormality in the above proccess leads to the various anorectal
malformations.
CLASSIFICATION :
1. Wingspread classification :
The most common previous international classification was referred to as the
Wingspread classification of anorectal malformations, elaborated in Wingspread, Wis, in
1984. This classification distinguished between high, intermediate, and low anomalies in
the male and female, with special groups established for cloacal and rare malformations.
High-type anorectal malformations were subdivided into anorectal agenesis with and
without fistula, and rectal atresis. The intermediate malformations were classified as
rectovestibular and rectovaginal fistula in the female and rectobulbar fistula in the male
as well as anal agenesis without fistula in both sexes. The low-type malformations were
classified as anvovestibular fistula in the female and, both saxes, as anocutaneous fistula
and anal stenosis.
2. Pena’s classification :
In 1995, pena proposed a classification based on the type of the fistula present. He
distinguished between perineal, vestibular, bulbar, postatic, and bladder neck fistulas;
imperforate anus without fistula; vaginal fistulas; cloacal fistulas; and rectal atresia or
stenosis.

3. Krickenbeck classification :
A modification of the classification of Pena according to the type of the fistula
and including rare/regional variants was proposed. The major clinical groups were
classified as perineal (cutaneous) fistulas, rectourethral fistulas (prostatic and bulbar),
rectovesical fistulas, vestibular fistulas, cloacal malformations, patients with no fistula,
and anal stenosis. Rare/regional variants were subclassified as puch colon, rectal atresia/
stenosis, rectovaginal fistulas, H-type fistulas and other.
The new international classification enables the different operative procedures to
be more comparable to each other than with the Wingspread classification.
Initial assessment:

Early treatment for neonates born with an anorectal anomaly is crucial.

During the first 24-48 hours of life in a baby born with an anorectal malformation, answer the following 2 questions:

· Are any associated anomalies present that threaten the baby’s life and need to be addressed immediately?

Should the infant undergo a primary procedure with no protective colostomy or a protective colostomy with a definitive repair
at a later date?

For babies born with persistent cloaca, the surgeon must also determine whether a dilated vagina is present and if it should
be drained and whether urinary diversion is required. These maneuvers are intended to prevent sepsis or metabolic
acidosis.

Colostomy versus anoplasty

The decision to perform an anoplasty in the newborn period or to delay the repair and perform a colostomy is based
on the infant’s physical examination findings, the appearance of the perineum, and any changes that occur over the first 24
hours of life.

Operating earlier and in a single stage is potentially beneficial to the patient, but this should be decided carefully, weighing
the specific circumstances of the baby and the experience of the surgeon. A more conservative approach is warranted in
babies with low birth weight and associated cardiac or respiratory conditions. Indications for colostomy versus anoplasty
based on sex are as follows:

· Males

· Anoplasty - Rectoperineal fistula

· Colostomy - Recto-bulbar urethral fistula, recto-prostatic urethral fistula, rectovesical fistula, imperforate anus without
fistula, rectal atresia
· Females

· Anoplasty - Rectoperineal fistula

· Colostomy - Rectovestibular fistula, imperforate anus without fistula, persistent cloaca, rectal atresia, rectovaginal
fistula

Imaging Studies:

In neonatal period :

Invertogram

Indication : when the perinel inspection and urin analysis are inconclusive wheather the diffect is high or low.

Procedure:it is done after18 hours of birth,so that the meconium reaches the rectum and with sufficient pressure that it can
negotiate the pressure exerted bylevator muscle complex. A radio opaque object is placed in the anal pit of the baby. Baby
is inverted for about three minutes and lateral view x-ray is taken .

Interpretation:if the lenght of the aircolumn is more than 1 cm, than a high anorectal maleformation is diagnosed. If it is less
than 1cm a low type of arm is diagnosed.

Disadvantages : Respiratory distress occcurs in the baby because of the position .

: Intracranial hammorhage can occur in the baby.

Crosstable lateral film: This procedure is same as invertogram expect the position of the baby, which is prone here. Thus
the disadvantages of invertogram because of the position is not here.

Other investigations :

Ultrasonography abdomen: This is done to rule out any associated urological anomalies.

X-ray spine : Anteroposterior and lateral films are taken to rule out any congenital spinal abnormalities like spina bifida.

Colostomy cases :

High pressure colostography : This is done to delineate the acurate anatomy of the anorectal malformation.

Associated malformations

· Genitourinary defects

· Approximately 50% of all patients with anorectal malformations have an associated urogenital anomaly, which
frequently varies with the type of anorectal defect.

· A list of anorectal defects and the percentages of patients with associated urogenital anomalies is as follows (Rich,
1988):

· Cloaca - 81%

· Rectovesical defect - 52%

· Recto-prostatic - 40%
· Rectovestibular - 9%

· Recto-bulbar - 4%

· Rectoperineal - 0%

· Overall - 48%

· All patients must be examined at birth to evaluate for one of these defects; the most valuable screening test is
abdominal and pelvic ultrasonography.

· Urologic evaluation before colostomy provides the surgeon the necessary information needed to address the
urologic problem at the time of the colostomy. The surgeon must be prepared to perform a urologic diversion if necessary.

· Tethered cord

· A tethered spinal cord refers to the intravertebral fixation of the phylum terminale.

· Tethered cord has a known association with anorectal malformation; approximately 25% of patients with anorectal
malformation have a tethered spinal cord.

· The prevalence of this anomaly increases with increasing height and complexity of the anorectal anomaly. In
addition, patients with a hypodeveloped sacrum and associated urologic problems have a higher likelihood of having
tethered cord.

· Motor and sensory disturbances of the lower extremities may result.

· Untethering the cord is indicated in the neurosurgical literature to avoid motor and sensory problems. No evidence
exists to suggest that this operation has an impact on the functional prognosis for patients with anorectal malformation.

· Spinal ultrasonography in the first 3 months of life and MRI thereafter are useful radiologic modalities to establish the
diagnosis.

· Sacral and spinal defects

· The sacrum is the most frequently affected bony structure. Traditionally, to evaluate the degree of sacral deficiency,
the number of sacral vertebral bodies was counted. A more objective assessment of the sacrum can be obtained by
calculating a sacral ratio. The sacrum

is measured and its length is compared with bony parameters of the pelvis. The lateral view is more accurate than the
anteroposterior view because its calculation is not affected by the tilt of the pelvis.

· Assessment of the hypodevelopment of the sacrum correlates with the patient’s functional prognosis. Normal sacra
have a calculated sacral ratio of 0.77. Bowel control has never been observed in patients with calculated sacral ratios less
than 0.3.

Rough assessment of post operative continence can be done on the basis of presence of number of sacral vertebras like
>3 sacral vertebras-- continence expected.

= 3 sacral vertebras -- intermediate continence

expected.

< 3sacral vertebras -- in continence expected.

· A hemisacrum is always associated with a presacral mass, which commonly includes dermoids, teratomas, or
anterior meningoceles.
· Hemivertebrae may also affect the lumbar and thoracic spine, leading to scoliosis.

· Patients may have spinal anomalies other than tethered cord, such as syringomyelia and myelomeningocele.

Management :

: As discussed previously, the surgeon must decide in the newborn period whether the child will need colostomy or primary
procedure.

APPROACH TO A MALE CHILD WITH ANORECTAL MALFORAMTION

APPROACH TO A FEMALE CHILD WITH ANORECTAL MALFORAMTION

Colostomy
· A descending colostomy with separated stomas is recommended.
· The advantages of this type of colostomy include the following:
· It defunctionalizes only a small portion of distal colon.
· In cases of large rectourinary fistulae in which the patient passes urine into the
bowel, the urine comes out easily through the mucous fistula, avoiding problems of
hyperchloremic acidosis caused by urine absorption. Urinary tract infections are also
avoided.
· Washing and cleaning the portion of the colon distal to the colostomy is relatively
easy.
· Distal colostography is easy to perform.
· The sigmoid loop is kept distal to the colostomy, which provides enough length to
reach the perineum during the definitive pull-through procedure.
· The separated stomas prevent spillage of stool from proximal to distal bowel,
which avoids impacted distal stool and urinary tract infections.
· A low incidence of prolapse exists with this technique. Proximal stoma prolapse
in a normally rotated colon should not occur with this technique because the colon is well
fixed to the retroperitoneum just before the colostomy rises to the skin level. The distal
stoma may prolapse because it is in a mobile portion of the colon. To avoid this, the distal
stoma must be made intentionally small because it is used only for irrigations and
radiologic studies.
· When performing the colostomy in the newborn, the distal bowel should be
irrigated to remove all the meconium. This prevents formation of a megasigmoid, which
may be responsible for the future development of constipation.

DEFINITIVE REPAIR

OPERATIVE STEPS OF POSTERIOR SAGGITAL ANORECTOPLASTY (PSARP)

· Repair of an anorectal malformation requires a meticulous and delicate technique

and a surgeon with experience in the management of these defects.
· The posterior sagittal approach is an ideal method of defining and repairing
anorectal anomalies.
· Anorectal abnormalities in 90% of male patients can be repaired with a posterior
sagittal approach alone, whereas 10% require an additional abdominal component (with
laparotomy or laparoscopy) to mobilize a very high rectum.
· All female anorectal malformations, with the exception of approximately 30% of
persistent cloaca, can be repaired with the posterior sagittal approach. In 30% of
persistent cloaca, the rectum or vagina is so high that an abdominal approach is required
as well.
· Patients are placed in the prone position with the pelvis elevated. A Foley catheter
is placed before the prone positioning.
· The posterior sagittal incision length varies with anorectal defect. Perineal fistulas
are repaired with a minimal posterior sagittal incision that is large enough to divide the
external sphincter and to mobilize the anus back to the center of the external sphincter.
The sphincter mechanism is always located posterior to the fistula site. This operation can
be performed in the neonatal period without a protective colostomy.
· The posterior sagittal approach is based on the fact that nerves do not cross the
midline. By remaining exactly in the midline, the surgeon preserves the innervation of all
the important pelvic structures.
· An electrical stimulator helps identify the location of the sphincteric mechanism.
The parasagittal fibers, the muscle complex, and the levators are identified during the
dissection. The external sphincter is represented by muscle fibers that run parallel to the
midline in a parasagittal fashion. Medial to these fibers, a muscle structure exists, which
represents the lower end of the funnellike voluntary muscle, which is traditionally known
as the levator mechanism.
· The levator mechanism extends in continuum down to the skin, but this was not
known before the use of the posterior sagittal approach. Electrically stimulated, the
parasagittal fibers elicit a contraction that results in shortening of the same fibers. A
pushing forward of the rectum toward the pubic bone occurs when the upper portion of
the levators are stimulated. Stimulating the lower part of the funnellike muscle structure
elevates the anal dimple. This group of muscle fibers that extend from the levator
mechanism down to the skin and are located immediately medial to the parasagittal fibers
can be called the muscle complex.
· The surgeon opens the posterior sagittally. The skin and subcutaneous tissue are
divided, and the parasagittal fibers below are divided in the midline, as is the muscle
complex.
· The levator muscle is then opened, and the rectum is found, except in cases of a
true supralevator malformation (10% of cases) in which the surgeon instead finds a
genitourinary structure.
· When the rectum is located, its posterior wall is opened in the midline to
demonstrate that a fistula is present. This posterior incision in the rectum is carried down
to the fistula site.
· The rectum and urethra share a common wall. Meticulous dissection is required to
separate the distal rectum from the urethra. A submucosal dissection must be performed
in · The rectum is separated from the urinary tract. This dissection is facilitated by
placing multiple 6-0 silk sutures in the rectal mucosa to exert uniform traction.
· The opening in the urethra is then closed with absorbable suture.
· Once the rectum is separated, it is then mobilized down so it can reach the
perineum. This is accomplished by circumferentially dividing the bands and vessels that
hold the rectum up in the pelvis. The intramural blood supply of the rectum is excellent,
and, thus, the rectum remains viable. Because of the dependence on this intramural blood
supply, not damaging the rectal wall is vital.
· Once the rectum is fully mobilized, the size of the rectum and the available space
must be assessed. The rectum may occasionally require tapering to fit the limits of the
sphincteric mechanism. The tapering should take place on the posterior wall so that the
suture lines of the tapered rectum and the closed urethral fistula do not lie next to each
other.
· The rectum is placed in the limits of the sphincter mechanism, which is
reconstructed in the midline. The rectum is sutured to the perineal skin (anoplasty).
· In the rare case of a true supralevator malformation (recto–bladder neck fistula),
the operation involves a posterior sagittal incision and an abdominal component. All the
muscle structures are divided in the midline, leaving the urinary tract untouched. A
rubber tube is placed in the presacral space in front of the levator mechanism and within
the limits of the muscle complex and external sphincter. The muscle structures are then
reconstructed around this tube. The tube forms the path through which the rectum is
pulled down. The entire wound is closed, and the patient is turned supine. The abdomen
is opened, and the retroperitoneum is exposed to find the rubber tube. The sigmoid is
dissected below the peritoneal reflection, where the bowel opens into the bladder neck.
Great care must be taken at this step to avoid injury to the ureters and the vas deferens.
To avoid this, the plane of dissection is made close to the bowel wall of the rectosigmoid,
2-3 cm above the peritoneal reflection.
· The fistula is divided and sutured with absorbable material. The rectum is
anchored to the rubber tube, and the tube and distal rectum are pulled through, along the
path of the tube. An anoplasty is performed.
· Some authors advocate using laparoscopy to perform this abdominal portion. A
trocar is passed through the perineum and the sphincter mechanism into the pelvis, an
instrument is passed through it, and the mobilized distal rectum is grabbed.
· In patients with imperforate anus without fistula, the same meticulous dissection
is required to separate the distal rectum from the urinary tract as in patients with
rectourinary fistulae because the rectum and urethra still share a common wall.
· In cases of rectovestibular fistula, the posterior sagittal incision can be shorter
than in male patients with rectourethral fistulae. Often, the entire levator mechanism does
not need to be divided; only the external sphincter, muscle complex, and part of the lower
portion of the levator mechanism need dividing. The rectum and posterior vagina share a
common wall; this separation is the most difficult part of the operation. Once the rectum
is completely mobilized, a perineal body is constructed, and the rectum is placed within
the limits of the sphincter mechanism.
· A very rare malformation, rectal atresia, occurs in 1% of cases. The anal canal is
normal, and externally, the anus appears normal. However, a blockage exists 1-2 cm from
the anal skin and is usually found when the nurse tries to pass a thermometer. These
babies should undergo colostomy at birth; definitive repair involves a posterior sagittal
approachand an end-to-end anastomosis between the upper rectal pouch and the anal
canal.

Postoperative management
The posterior sagittal incision is relatively painless.
In patients with a rectourethral fistula, the Foley catheter usually stays in place for
approximately 5-7 days; however, occasionally, this period is longer.
If the colostomy is untouched during the operation and no laparotomy was necessary, oral
feedings may be started immediately postoperatively. If a laparotomy was necessary, the
patient may require a period of fasting and nasogastric decompression.
At 2 weeks’ postoperation, anal calibration is performed, followed by a program of anal
dilatations. The anus must be dilated twice daily, and the size of the dilator is increased
every week. The final size to be reached depends on the age of the patient.
Once the desired size is reached, the colostomy can be closed.
Dilatations are continued afterward according to a prescribed protocol.
Dilatations are a vital part of the postoperative management to avoid a stricture at the
anoplasty.
After colostomy closure, severe diaper rash is common because the perineal skin has
never before been exposed to stool.

Postoperative functional disorders

Constipation is the most frequent problem encountered after treatment for
imperforate anus in which the rectum has been preserved in female.
Constipation is the most important problem to avoid after definitive repair for female
patients with rectovestibular or rectoperineal fistula and for male patients with recto-
bulbar urethral fistula, imperforate anus without fistula, and rectoperineal fistula. Failure
to avoid constipation can result in megarectum and megasigmoid, and it can lead to fecal
impaction and overflow incontinence or further discussion.
The origin of the problem of constipation is unknown. Originally, the perirectal
dissection was thought to cause a degree of denervation that resulted in constipation.
However, on careful review of the largest series of these patients, those with the most
benign defects and, therefore, the least amount of perirectal dissection had the worst
constipation.
The presence of a megarectum before the pull-through correlates with postoperative
constipation. Megarectum is more common in patients who underwent a transverse or
loop colostomy during the newborn period.
Constipation appears to be a hypomotility disorder secondary to chronic bowel dilatation,
or perhaps the hypomotility causes the dilatation. Dilatation causes constipation, creating
a vicious cycle.
Patients who have undergone abdominoperineal operations for imperforate anus that
included resection of the rectum are prone to have diarrhea because of lack of a rectal
reservoir. Incontinence in these patients is much more difficult to manage because stool is
constantly passed.
Occasionally, constipation becomes so severe that patients develop chronic fecal
impaction and constant soiling. These patients are often referred to as having fecal
incontinence. However, if the patient has a type of anorectal anomaly with good
prognosis, often this incontinence is actually overflow pseudoincontinence. Once the
constipation is managed, the patients gain continence.
When constipation is very severe and the patient has a megasigmoid (and has been shown
to be fecally continent), resection of the sigmoid has been found to dramatically reduce
the patient’s laxative requirements. The descending colon with normal caliber and normal
motility is anastomosed to the rectum at the peritoneal reflection. This procedure is for
the select group of patients who require enormous amounts of daily laxatives to keep
their colons clean. Performance of a new pull-through operation should be avoided so
that the rectal reservoir is preserved. Loss of the rectal reservoir could lead to the worse
problem of incontinence related to diarrhea.

Complication :
Complications of surgery include dehiscence and infection. These complications
can be avoided by colostomy before the main repair.

A
SHORT NOTE ON

HYDATID DISEASE
 CONTENTS :
- INTRODUCTION
- CUSATIVE ORGANISM
- LIFE CYCLE
- MODE OF INFECTION
- EVOLUTION OF HYDATID CYST
- CHARACTERISTICS OF HYDATID FLUID
- CLINICAL FEATURES
- INVESTIGATIONS
- DIFFERENTIL DIAGNOSIS
- TREATMENT
- PREVENTION

DR. SANTANU KR. BORA , PG STUDENT , DEPTT. OF SURGERY

Echinococcosis (Hydatid Disease ) is an infection of human caused by the larval stage ofEchinococcus
granulosus , E. multilocularis or E. vogeli . The disease is world wide in distribution, prevalent in areas
where livestock ( cattle , sheep etc.) is raised in association with dogs .

CAUSATIVE ORGANISM : E. granulosus , the most common causative organism of hydatid disease ,
is a small tapeworm , measuring 3 to 6 mm in length comprises of a head ( scolex) , neck and strobila ,
consisting of three segments .

LIFECYCLE : The worm passes its life cycle in two hosts :

1. Definitive host: Dog (mc), wolf, fox, jackle
 2. Intermediate host: human, sheep, cattle, goats , camels,
horses etc.

The adult worms lives in the small intestine of definitive host and discharge large no.
of eggs in their feces .

These eggs are swallowed by the intermediate hosts . In their duodenum eggs are
hatched to form embryos .

Embryos penetrate the intestinal wall to enter radicles of portal vein .

Embryos are carried to the liver to get lodge in the sinusoidal capillaries ( the liver acts
as the first filter )

Some of the embryos pass through the hepatic capillaries , enter the pulmonary
circulation to get lodge in the lungs .( lungs act as the second filter )

A few embryos even pass the pulmonary circulation to enter the systemic circulation
and lodge in various organs of the body .

The embryos that get settled in liver , lung or other organ of the body , get transformed
into larval stage forming a hollow bladder like cavity containing fluid commonly known as hadatid
cyst .

From the inner side of the cyst , brood capsules with a number of scolices are
developed .

These fertile hydatids when ingested by a dog are capable of growing into adult worms
in the intestine .

Thus the cycle is repeated .

MODE OF INFECTION :

Infecting agent : Eggs in dog’s feces

Portal of entry : Alimentary tract
Process of entry: 1. By handling and fondling with infected dogs.
2. By taking uncooked vegetables contaminated with infected canine feces.

The infection is generally acquired in childhood but the disease usually manifest in adulthood only .

EVOLUTION OF HYDATID CYST:

The cyst wall secreted by the embryo consist of two layers .

1 The outer cuticular layer ( ectocyst) : It is a laminated hyaline membrane having a thickness upto
1 mm
2 Inner or germinal layer ( endocyst) : This cellular layer is the vial layer of the cyst because
- it gives rise to brood capsules with scolices
- secretes the specific hydatid fluid
- forms the outer layer

CHARACTERISTICS OF HYDATID FLUID:

1.Clear colorless fluid

2. Specific gravity low 1.005 to 1.010
3. Slightly acidic ph 6.7
4.Antigenic , being used for immunological test
5.Highly toxic , gives rise to anaphylactic reaction when absorbed
6.Hydatid sand – a granular deposit of brood capsules , free scolices and loose ooklets
that settles at the bottom

CLINICAL FEATURES :

The disease usually involves both sexes equally and it generally manifest at an average age of 45 years
.About three fourth of hydatid cyst are located in the right liver and are unilocular .

For many years the disease remain asymptomatic . Symptoms arises only after ,
- cyst becomes large enough to have space occupying effect in the organs
involved
pressure effect on the surrounding structures .
- the cyst gets ruptured
- the cyst gets secondarily infected
Liver hydatid cyst often present with
-abdominal pain or a palpable mass in the right upper quadrant
-compression of the billiary duct can result in jaundice
-Rupture or episodic leakage from a hydatid cyst may produce fever, pruritus
urtiaria, eosinophilia or anaphylaxis

Pulmonary hydaid cyst often present with

-cough
-chest pain
- hemoptysis

INVESTIGATIONS:

1. Casoni test
2. Blood examination may reveal generalized eosinophilia
3. Serological test : Detection of antibody to specific ecchinococcal antigens by immunoblotting
has the highest degree of specificity
 4. Exploratory cyst puncture: examination of hydatid fluid under the microscope for scolices
or
hooklets gives an accurate diagnosis but it may have serious
consequences and so not advised .
5. X ray : Plain picture abdomen may miss a hydatid cyst of liver unless the cyst wall is calcified.
Chest x ray usually picks alveolar hydatid cyst as a irregular mass of uniform density .
6. Ultrasonography : most commonly applied radiological examination . It shows
- Well circumscribed cystic area with budding cystic membrane
- may show hyperechogenic hydatid sand
- a rossete appearance is seen when daughter cyst is present
7. CT scan : shows cystic area with no enhancement in contrast study . The most pathognomonic
finding in CT scan are
- presence of membrane like structure in the dependent part of the cavity
-daughter cyst within the mother cyst , if demonstrable.
8. MRI : same finding as CT scan . No added advantage over CT
9. ERCP or PTC : may be necessary in patients with suspected billiary involvement

DIFFERENTIAL DIAGNOSIS:

1. Congenital simple cyst of liver

2. Polycystic liver disease
3. Pyogenic liver abscess
4. Amoebic liver abscess
5. Hemangioma of the liver
6. Hepatic adenoma
7. Focal nodular hyperplasia
8. Hepato cellular carcinoma

TREATMENT:

a) Medical : Albendazole therapy is the mainstay of treatment in majority of the patients .Albendazole
is given at the dosage of 15mg/kg/day in two divided doses for 12 weeks to 6 months .
Response to treatment is assessed by serial imaging studies with attention to cyst size and
Consistency . It results in cure in 30% of the cases and improvement in another 50% of
the
cases .

b) PAIR treatment : It comprises of –percutaneous aspiration

 -infusion of scolicidal agents like hypertonic saline or ethanol
-respiration
PAIR treatment can be used in many cases of cystic echinococcosis instead of surgery
It is contraindicated in
- superficially located cysts for the fear of rupture
- cysts with honeycombing pattern
- cysts that has communication with the billiary tree
c) Surgical It is indicated
- when medical therapy fails
- PAIR is contraindicated
In surgical approach excision of the cyst is done. Now a days formal liver resection for removal of
the affected area is advocated.

Steps of operation :

-an incision is made through the liver parenchyma overlying the cyst until the ectocyst is
exposed
-the ectocyst is incised to expose the rubbery endocyst
-gently endocyst is removed with the parasites inside
-After the cyst has been excised , mobilized omentum is frequently packed into the liver cavity
but alternatively the area can be left open to the peritoneal cavity .

Precautions during operation

It is very important not to rupture the endocyst with subsequent spillage of viable parasites . To
reduce the consequences of such a mishap the liver is surrounded by packs which may be
soaked in scolicidal solution such as hypertonic saline .

PREVENTION
-dogs should be kept separated from livestock to break the life cycle of E. granulosus
-avoid intimate fondling of the dogs
-Praziquantal to infected dogs
-vaccination of sheep

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