**Background:** Echinococcosis (hydatid disease) is a zoonosis caused by Echinococcus granulosus, a parasite transmitted via the fecal-oral route through contact with infected animals (primarily dogs, wolves, and coyotes) or contaminated food. The disease has wide geographical distribution with endemic areas in Central America, South America, and Mediterranean regions. The liver is the most commonly involved organ (70–75% of cases), followed by the lungs (15–25%). Cysts grow slowly at approximately 1 cm during the first 6 months, and the disease is often asymptomatic until advanced stages. Diagnosis is frequently incidental on imaging, with ultrasound having 95% sensitivity. Management involves anthelmintic therapy (Albendazole) combined with surgical resection, though the approach must be individualized based on cyst number, size, and location. The inherent risk of complications includes septic shock secondary to intraperitoneal rupture, which increases mortality risk.
**Methods:** This is a case report of a 32-year-old man from Caruru, Vaupés, Colombia, presenting with a 2-month history of mass-like sensation in the right rib cage, febrile peaks, and right upper quadrant abdominal pain. Thoracoabdominal CT revealed a hypodense multiseptate mass in the right lower lobe (71×68 mm) and a left hepatic lobe lesion with transverse diameter of 152 mm with subphrenic extension. Abdominal MRI confirmed a multiloculated cystic mass (50×106×171 mm) involving hepatic segments I, II, and IV, subphrenic space, and right hemidiaphragm, with additional right hemithorax lesion (48×76×71 mm) and an 8 mm cyst in hepatic segment II, consistent with WHO cystic echinococcosis stages CE2–3A. The patient was started on Albendazole 400 mg orally twice daily and targeted antibiotics for superinfection. Brain MRI showed no dissemination. A multidisciplinary surgical board between hepatobiliary and thoracic surgery planned a staged approach.
**Key Results:** The first surgical procedure involved right posterolateral thoracotomy at the sixth intercostal arch, identifying a 7×7 cm hydatid cyst adhered to the right lower pulmonary lobe and ipsilateral hemidiaphragm with abundant purulent collection involving costal cartilage of the 6th, 7th, and 8th right costal arch. Non-anatomic right lower lobe resection was performed including the cystic lesion, along with resection of compromised costal cartilage, partial diaphragm resection, and joint extraction of the pulmonary segment. Hepatic release was attempted but the patient developed distributive-vasogenic shock, requiring procedure termination with ViaFlex bag placement separating thoracic and abdominal cavities. Surgical time was approximately 7 hours with total blood loss of 600 cc. Post-operatively, the patient required ICU admission with invasive mechanical ventilation, multiple vasopressors, blood transfusion, and renal replacement therapy for 24 hours due to refractory metabolic acidosis. Eight days later, after achieving hemodynamic stability, the second surgery was performed under extracorporeal circulation via right femoral artery and vein cannulation with superior vena cava positioning. Partial pericardiectomy plus cyst resection was performed with pericardial reconstruction using a synthetic patch anchored with 5-0 Prolene. Through the previous thoraco-phreno-laparotomy incision, release of the hepatic cyst from the retrohepatic vena cava was achieved and left hepatectomy was performed using bipolar energy. The diaphragm was repaired with a 30×45 mm Parietene mesh fixed with polypropylene. Total cardiopulmonary bypass time was 80 minutes, surgical time was 6 hours, and total blood loss was 350 cc. The Cell Saver blood was not returned due to risk of parasitic dissemination. Hypertonic saline solution was used for continuous cavity irrigation. Tissue biopsy confirmed Echinococcus granulosus infection. The patient was discharged on Albendazole 400 mg orally twice daily for 90 days, with no relapse or complications at 30, 60, and 90 days follow-up.
**Clinical Implications:** This case demonstrates that extracorporeal circulation assistance can enable radical surgical resection of giant hydatid cysts with multivisceral involvement including the retrohepatic vena cava and pericardium, where conventional surgery poses prohibitive risks of hemodynamic instability and hemorrhage. The staged surgical approach allowed the patient to recover from the initial inflammatory response before definitive resection. The authors note that while extracorporeal circulation has been described for primary cardiac hydatid cysts, this is the first reported case of its use for combined large hepatic-diaphragmatic and pericardial cyst resection. The case also highlights the importance of multidisciplinary surgical planning, the role of hypertonic saline irrigation to prevent parasitic dissemination, and the debated risk-benefit of Cell Saver blood recirculation given the potential for bloodstream dissemination of the parasite. The successful outcome supports an individualized, mixed surgical and medical approach for complex hydatid disease with multiorgan involvement.