4 Open procedures can be classiﬁed into (1) conservative tissue sparing techniques that remove the parasite and leave the majority of the pericyst in place and (2) radical procedures that extricate the entire pericyst. Conservative techniques include partial cystopericystectomy and near-total pericys- tectomy. Radical procedures such as cystopericystectomy, hepatic lobectomy, and hepatectomy have been used in the past. Currently, they are rarely used and are being replaced by cystotomy, partial cystectomy, and omentoplasty, which can all be done laparoscopically. Advantages of the laparoscopic procedures include less pain, good cosmetic results, rapid recovery, and decreased complications. The chosen operative procedure depends on the location, size, type of cyst, and the surgeon’s skills [14]. Total pericystectomy is often avoided if the pericystic area is near major vascular or biliary structures because of a high risk of severe bleeding and bile duct injury. A total pericystectomy, however, is considered by some to be preferable due to its low risk of recurrence, lower risk of biliary leakage, reduced inﬂammatory complications, and increased rate of detection of daughter cysts [15–17]. The higher risk of total pericystectomy limits some surgeons to recommend this only for small peritoneal cysts or cyst on the exterior surface of the liver [18]. Another radical surgical procedure is hepatic resection, but it is accompanied by a high morbidity rate [13]. Liver resection is suggested when a complete lobe is involved or when other procedures have failed [18]. Alonso Casado et al. suggested radical resection for hepatic hydatid cyst has better outcomes than puncture-aspiration-injection- re-aspiration (PAIR) or partial resection regarding morbidity and mortality with almost no recurrence rate [19]. Laparoscopic treatments that have been described in- clude cystotomy, partial pericystectomy, and total peri- cystectomy [11, 13]. Laparoscopic techniques are gaining popularity even though no fail-safe methodology has been devised to completely ensure the prevention of cyst spillage. A laparoscopic hand-assisted procedure has been suggested to prevent intra-abdominal spillage [20]. Others suggest using antiscolecoidal agents preoperatively and intraoper- atively to completely eradicate the parasite, but this may cause sclerosing cholangitis [21, 22]. In all procedures, it is the initial penetration and aspiration of the cyst ﬂuid that remains the most diﬃcult part of the procedure [22]. Some suggest using a special umbrella trocar to secure the cyst to the abdominal wall along with a special suction device. Another method uses an antiscolecoidal ﬂuid (Cetrimide) and Trendelenburg positioning, but has failed to prevent stray jets of ﬂuid from escaping [23]. The only cysts not removed laparoscopically are deep intraparenchymal cysts close to the vena cava, or cysts containing thick, calciﬁed walls [24, 25]. The decision is often made, to perform partial pericystectomy and not to treat thickly calciﬁed cysts in close approximation to major vascular and biliary structures due to the high risk of severe complications [13, 26]. Good laparoscopic candidates include those with super- ﬁcial and ﬂuid ﬁlled cysts, while deep cysts should be approached in an open manner due to the risk of hem- orrhage [27]. Additional exclusion criteria for laparoscopic intervention include the presence of more than three cysts, Case Reports in Gastrointestinal Medicine and cysts with thick and/or calciﬁed walls [13]. In 2000, Seven et al. established that laparoscopy could be used to treat hepatic echinococcal cysts with morbidity and recurrence rates comparable to those observed in open series [28]. In 2002, Kayaalp demonstrated that successful cyst evacuation could be accomplished at a rate of 92% in anteriorly located cysts and a rate of 73% in posterior- superiorly located cysts [29]. A series of 18 patients treated with laparoscopic surgical techniques similar to the ones instituted with our patient demonstrated safe results with low rates of conversion to open techniques [30]. A study out of Amsterdam demonstrated that laparoscopic treatment of anteriorly located hepatic cysts had a success rate of 77%– 100%, with low complication and recurrence rates (0%–17% and 1%–9%, resp.) [31]. However, lower complication and recurrence rates of the laparoscopic approach compared to open procedures can be misleading due to bias in patient selection criteria [32]. Lastly, percutaneous methods are becoming increas- ingly popular. The procedure, initially developed by Ben Amor et al. is called PAIR: puncture-aspiration-injection- re-aspiration [33]. The patient selection is crucial to its success. The increased popularity of percutaneous aspiration is due to the advances in imaging techniques such as CT and ultrasound, development of ﬁne needles and catheters, and the origination of the intercostal intrahepatic approach which have decreased the risk of peritoneal spillage and anaphylaxis [34]. Percutaneous drainage of hydatid cysts involves aspira- tion of the cyst ﬂuid and injection of contrast to ensure no large biliary tract communication. The cyst is then infused with an antiscolecoidal agent and drained with a catheter [13, 23]. Only type I and type II cysts and some of type III and type IV cysts can be managed using PAIR. In high surgical risk patients such as pregnant women and those with several cysts, percutaneous drainage might prove advantageous [13]. Beneﬁts of PAIR include a low recurrence rate, low morbidity rate, short hospitalization, and less scarring [23, 35, 36]. Some argue that the percutaneous methods produces equivalent results to laparoscopic surgery and that surgery should be reserved for situations when percutaneous treatment is not available or has failed [31]. Giorgio et al. presented a modiﬁed technique with a better overall outcome called double puncture-aspiration-injection (D-PAI) [37]. Fine-needle puncture of the hepatic liver cyst is repeated 3 days after the initial aspiration, and the second half of the procedure does not include reaspiration of the scolicidal agent (95% sterile alcohol) or catheter drainage [38]. 4. Summary Optimal treatment algorithms for hepatic echinococcal cystic disease are not fully deﬁned. Controversies revolve around the use of ERCP and open surgical, laparoscopic, or percutaneous procedures. Although the eﬃcacy of speciﬁc laparoscopic techniques remains a debated topic, it has been demonstrated at multiple centers around the world that the