Abstract
A 44-year-old woman presented with a two-day history of sudden, severe right upper quadrant abdominal pain. Her medical history included hypothyroidism managed with thyroxine. Eight months prior, she had undergone imaging for bilateral flank pain, which revealed a left ureteric stone with hydronephrosis (managed conservatively) and a large right hepatic lobe cystic lesion. Serologic testing later confirmed echinococcal antibodies, and the hepatic cyst was initially managed non-operatively as the patient refused surgery. The patient also reported contact with dogs, sheep, and cats in Syria one year before presentation. Repeat imaging revealed a thick-walled hepatic cyst involving segment VIII of the right lobe and segment IV of the left lobe (measuring 9x10.6x8.5 cm), along with a left distal ureteric stone. A combined surgical approach was planned. First, the urology team performed ureteroscopic extraction of the stone with stent placement. This was followed by laparoscopic deroofing of the hepatic hydatid cyst. Intraoperatively, the cyst was aspirated and irrigated with 20% hypertonic saline, and then de-roofed, and the germinal layer was removed, followed by a second hypertonic saline irrigation. The cavity was covered with an omental flap to reduce the risk of bile leakage and bleeding. Histopathology confirmed an echinococcal cyst. Postoperatively, the patient received albendazole and recovered uneventfully. She was discharged on postoperative day four with instructions to complete two additional albendazole courses. The location of the hydatid cyst posed a significant technical challenge, as it was situated at the hepatic dome with associated liver enlargement, leaving minimal to no space between the liver and diaphragm for safe manipulation. This case highlights the importance of surgical expertise in managing hepatic hydatid disease, particularly in low-prevalence regions where specialists and resident surgeons may have limited exposure to such cases. In addition, we encourage the use of a multidisciplinary approach in surgical planning, particularly for patients with multiple surgical pathologies, for better patient-centered outcomes.