human hydatid disease is caused by echinococcus granulosus , a cestode that is commonly lodged in the liver . several endemic regions exist ; however , the disease may be observed anywhere in the world . surgery remains the main modality of treatment , despite advances in medical and minimally invasive radiological therapies . in the last decade , laparoscopic surgery has become a part of the discussion of this issue , and several studies have reported encouraging results . whatever the technique , surgeons should focus on safe evacuation and sterilization of the cyst 's cavity . on the other hand , obliteration of the cavity with greater omentum herein , we report our series of patients with hydatid disease of the liver who underwent laparoscopic surgery , including omentoplasty and fixation of the omentum with helical fasteners . between january 1998 and april 2000 , 13 patients ( 5 men and 8 women ) , mean age 36 years ( range 23 to 63 years ) with hydatid disease of the liver were considered for laparoscopic surgery at our department . in the patient who had two , both of the cysts were in the right lobe . the cysts ' localizations were as follows : five in segment 8 , five in segment 5 , three in segment 4 , and one in segment 2 . the diagnoses were made with computerized tomography ( ct ) , ultrasonography ( us ) , and specific serological examinations . five patients were primarily diagnosed with us and 8 with ct . nevertheless , ct studies were added to the first group to have an optimum morphological evaluation . no evidence or suspicion existed of biliary rupture upon clinical findings and radiological studies ( history of cholangitis or jaundice , evidence of dilatation of the biliary tree , or connection with the cyst ) . indirect hemagglutination tests ( iht ) and elisa tests were done as serological tests and were positive in all patients . the patients who had evidence of biliary rupture , a history of recurrence , cysts deep or difficult to access in liver ( central or posterior localizations ) , multiple cysts ( more than two with unfavorable localizations ) , large cysts ( > 15 cm in diameter ) , and cysts with thick , calcified walls were not considered candidates for laparoscopy . the urinary bladder was catheterized , a nasogastric tube was placed , and antibiotics were administered half an hour prior to the operation . the first trocar was inserted at the umbilicus and a 30 laparoscope was used to visualize the peritoneal cavity . the operating surgeon stood at the patient 's left side ; the camera assistant managed the laparoscope from the left for right - sided cysts and from the right for left - sided cysts . the patient was placed in deep trendelenburg position and the subdiaphragmatic area was filled with 200 to 300 cc of 10% povidone - iodine for right - sided cysts . the cyst then was punctured with a veress needle and the cyst 's fluid was aspirated as much as possible . the cyst was refilled with 20% hypertonic saline , which is a potent scolocidal agent and left for 5 minutes . during this procedure , a 5-mm aspirator was placed beside the puncture point to prevent any fluid spillage into the peritoneal cavity . the insertion of the locking trocar into the cavity to minimize the contamination by the cyst 's fluid . worth , texas , usa ) was inserted from a point nearest to the cyst that was immobilized with a grasper . then this trocar , which was primarily designed to avoid inward and outward movement through the abdominal wall , was inserted into the cyst , and the umbrella - like lock was opened immediately . the cyst was pulled upwards and pinched between the abdominal wall and the umbrella lock of the trocar ( figure 1 ) . a 10-mm aspirator was inserted through the trocar and the cyst 's contents , including germinative membrane and daughter cysts , were aspirated . the superficial and visible part of the cystic wall was excised with an electrosurgical hook or shears , and the specimen was removed from the abdominal cavity within an endobag . the cystic cavity was then explored with a laparoscope to check whether any remnants of the cyst , biliary rupture , or hemorrhage were present . an adequate portion of greater omentum was pulled and inserted into the cyst 's cavity . the omentum was fixed to the cut edges of the cyst wall with a helical fastener ( pro tack , auto suture , norwalk , connecticut , usa ) , an instrument designed to fix mesh patches in endoscopic hernia surgery ( figure 2 ) . the drain was removed and the patient was discharged if no bile or ascites drainage were present . albendazole was administered , 10 mg / kg / day , for 6 months postoperatively , and an intermittent therapy regimen was planned as a 4-week course of drug therapy and 2 weeks of no treatment . radiological controls with ct and us were performed in the sixth month , and then annually . no perioperative complications such as bleeding occurred during application of the helical fasteners . in 1 case , with a single cyst in the right lobe , bile leakage was observed postoperatively , whereas no evidence of biliary rupture had been found during exploration . the biliary drainage gradually tapered off and ceased spontaneously on postoperative day 9 without any further intervention . except for this case , no early or late complications occurred . no radiological recurrence was observed in an average length of follow - up of 17 months ( range 4 to 36 months ) . in the last decade , laparoscopic treatment of hydatid disease of the liver has been carried out in many centers . a variety of techniques have been suggested for the surgical treatment of hydatid disease , all to sterilize the cysts , but the most commonly performed ones , both conventional or laparoscopic , are pericystectomy , simple drainage , or unroofing with omentoplasty . however , regardless of the method , the surgical principles are sterilization of the cyst cavity , careful evacuation of the cyst 's content without intraperitoneal spread , investigation of the biliary rupture , and obliteration of the cyst 's cavity . to succeed in laparoscopic hydatid disease surgery , these objectives are best reached with the meticulous selection of patients . as for current opinion obliteration of the cyst 's cavity with greater omentum has been reported to provide further benefits concerning prevention of postoperative abdominal complications . for this purpose , we modified it by securing an omental flap to the edges of the excised cavity with helical fasteners that are designed to fix mesh patches in video endoscopic hernia surgery . this allows a better and faster fixation of greater omentum that may easily drop into the peritoneal cavity . a critical point while applying this method is to apply fasteners only to the edges of the remnant of the cyst wall and to avoid injury to the liver . the other hand , spread of cystic fluid into the peritoneal cavity may result in peritoneal hydatidosis . we have used a locking ( or umbrella ) trocar , as previously described by seven et al , and a 10-mm rigid aspirator to evacuate the cyst 's contents . when approaching right - sided cysts , we filled the subdiaphragmatic space with 10% povidone - iodine ( betadine ) , to take measures against intraperitoneal spread , and 20% hypertonic saline solution was used to sterilize the cystic cavity . the scolocidal effect of povidone - iodine has been demonstrated in several experimental studies . although the use of 20% hypertonic saline solution to sterilize the cavity is now widely accepted because of it 's safety and ease of application , we preferred povidone - iodine for filling the pericystic area . in our series , except for 1 patient with 2 cysts that allowed easy access , we excluded patients with multiple cysts . although not contraindicated , multiple cysts are not suitable for laparoscopy . in such cases , maneuver of laparoscopic devices becomes exceptionally difficult unless the surgeon uses an excessive number of ports . also , cysts deep into the liver have increased surgical risks , such as difficult identification , bleeding , or the inability to check for biliary rupture . khoury et al reported on a patient who developed anaphylaxis on laparoscopic evacuation of a hydatid cyst , localized deep into the liver . it should be kept in mind that even minimal contact of cystic fluid with blood or with the peritoneal surface may lead to anaphylactic shock , and this contact is not preventable in deep cysts . therefore , an open surgical technique must have priority in deep cysts because the surgeon 's ability to prevent cyst fluid from contact with blood is significantly more difficult . another question concerning difficult cases for laparoscopy is biliary rupture . in a series of 328 patients , erguney et al reported a biliary rupture rate of 10.3% . in the preoperative evaluation , evidence of jaundice , right upper quadrant abdominal pain , cholangitis , or dilated biliary tract must warn the surgeon of a possible biliary rupture and a decision in favor of laparoscopic surgery should be reconsidered . one patient was overlooked on preoperative assessment in our series and presented with biliary fistula during the postoperative course . nevertheless , biliary drainage ceased with conservative management . spiliadis et al performed endoscopic sphincterotomy for complicated hydatid disease of the liver and 80% of patients suffering from postoperative biliary fistulas were successfully treated . endoscopic sphincterotomy by ercp ( endoscopic retrograde cholangiopancreatography ) is the treatment of choice for persistent biliary fistulas . with growing experience , laparoscopy seems to be quite feasible in hydatid disease of the liver . however , laparoscopy should not limit the surgeon 's performance in every surgical step of hydatid disease surgery . in many instances , omentoplasty with helical fasteners provides an easy and effective obliteration of the cyst 's cavity during laparoscopic access .