Traumatic Ruptured Hepatic Cyst Managed by Laparoscopic Fenestration Assisted With Indocyanine Green (ICG) Fluorescence: A Case Report

Nonparasitic hepatic cysts are common and generally asymptomatic. However, complications such as infection, hemorrhage, or rupture of the cyst necessitate therapeutic intervention. We report a rare case of traumatic rupture of a large hepatic cyst managed laparoscopically with the assistance of indocyanine green (ICG) fluorescence. A 57-year-old woman had been followed for 2 years for a large cystic lesion in segments 4 (S4) and 8 (S8) of the liver, suspected to be a mucinous cystic neoplasm (MCN). As the S4 cyst grew to 15 cm, surgical resection was planned. However, she presented to our emergency department after blunt abdominal trauma sustained from a fall at home. Computed tomography (CT) revealed rupture of the S4 cyst with massive ascites. Although initially managed conservatively with little abdominal symptoms, she developed worsening abdominal pain and progressive anemia 2 days postadmission, raising concern for cyst-related hemorrhage and possible bile leakage. Emergent laparoscopic surgery revealed hemoperitoneum and bleeding from the ruptured cyst wall. ICG was administered intravenously immediately after anesthesia induction to visualize the communication between the cyst and the biliary tract by fluorescence imaging. Then, laparoscopic fenestration was performed under ICG guidance. The patient was discharged on postoperative day (POD) 6 without any complications. We successfully treated a rare case of traumatic hepatic cyst rupture by laparoscopic fenestration with ICG imaging. ICG fluorescence was a helpful adjunct for intraoperative assessment of the potential bile duct in the cyst, ensuring the safety of the operative procedure.