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Laparoscopic cholecystectomy in the pediatric patient
Laparoscopic
Cholecystectomy
in the Pediatric
Patient
By George W. Holcomb III, Douglas 0. Olsen, and Kenneth W. Sharp
Nashville, Tennessee @Since June 1990, five girls and one boy have been evaluated for biliary colic. Gallstones were documented by sonography. Two girls, ages 8 and 14 years, had hereditary spherocytosis, and a O-year-old boy had sickle cell disease. The other three girls, ages 13, 13, and 15 years, developed cholelithiasis and biliary colic without a history of hematological disease. Three children weighed less than 90 lb, with the smallest weighing 45 lb. All patients underwent laparoscopic cholecystectomy without complications. Operative cholangiography was performed in five of the six children. The KTP-532 laser was used for dissection of the gallbladder from the liver bed in two patients, and electrocautery was used in the remaining four. The average operating time was 1 hour 45 minutes. This is a report of the use of laparoscopic cholecystectomy in pediatric patients. The advantages of its use include a shorter hospitalization, decreased postoperative discomfort, and a much shorter interval between the surgical procedure and return to normal activities such as school and play. At this time, it is recommended for those children without complications from their cholelithiasis such as common duct obstruction and gallstone pancreatitis. Copyright o 199 1 by W. B. Saunders Company INDEX WORDS:
Cholecystectomy,
laparoscopic,
pediatric.
L
APAROSCOPIC cholecystectomy is an innovative technique that has been applied almost exclusively to adult patients. Despite the exponentially increasing number of laparoscopic cholecystectomies on adults to date, there is a paucity of reports in the literature about this new technique.lm4 No reports of this procedure discuss its use in pediatric patients. Since June 1990, six consecutive pediatric patients have been treated for cholelithiasis and biliary colic using the technique of laparoscopic cholecystectomy without complication. MATERIALS AND METHODS Five girls and one boy with biliary colic have been evaluated since June 1990 (Table 1). All patients had cholelithiasis documented by ultrasound and one patient was noted to have acute cholecystitis with pericholecystic fluid at ultrasound. Three of the children had hematological disease. Two girls, ages 8 and 14 years, had hereditary spherocytosis, and a 9-year-old boy had sickle cell disease. The other three girls, ages 13, 13, and 15 years, developed cholelithiasis and biliaty colic without a history hematological
From the Departments of Pediatric Sutgety and General Surgery, Vanderbilt Universi~ Medical Center, Nashviiie, TN. Date received: March 15, 1991; date accepted: May 8, 1991. Address reprint requests to George W. Holcomb HI, MD, Department of Pediatric Surgery, Vanderbilt University Medical Center, 338 MedicalArts Bldg, 12112lst Ave S, Nashville, TN 37212. CoWright 6 1991 by WB. Saunders Company 0022-3468/91/2610-0011$03.00/0
1186
disease. Three children weighed less than 90 lb, with the smallest weighing 45 lb. The other three weighed between 100 and 130 lb. Five of the six children underwent elective laparoscopic cholecystectomy and were discharged the following morning. The 8-yearold girl with spherocytosis presented with acute cholecystitis and obstructive jaundice. Admission bilirubin was 13 mg/dL and common bile duct dilatation without a definite calculus was noted on ultrasound. Her jaundice and common bile duct dilation resolved on intravenous fluids and analgesics. She underwent laparoscopic cholecystectomy with intraoperative cholangiography 5 days after admission without complication, and was discharged on the second postoperative day. Intraoperative cholangiography was possible in five of the six patients and did not show common duct obstruction or dilatation (Fig 1). It was not successful in the oldest patient in this series because the cholangiocatheter could not be introduced into the cystic duct. Total operative time ranged from 90 to 140 minutes (mean, 105 minutes). The KTP-532 (Laserscope, San Jose, CA) laser was used for dissection of the gallbladder from the liver bed in the first two patients, but electrocautery was used in the last four children, primarily because of the expense of the laser. One of the patients had a previously established operative gastrostomy for nutritional supplementation while she recovered from encephalitis and underwent laparoscopic cholecystectomy for persistent epigastric pain and cholelithiasis without difficulty. All six gallbladders exhibited cholelithiasis and chronic cholecystitis on pathological examination. Additionally, one patient also had cholesterolosis and one exhibited acute cholecystitis in addition to cholelithiasis.
Technique The patient is admitted on the day of surgery for elective laparoscopic cholecystectomy. Under general endotracheal anesthesia, a Foley catheter and orogastric tube are inserted and the abdomen is prepared and draped in the same fashion as used for a standard open cholecystectomy. A l-cm incision is made in the center of the umbilicus down to the fascia. A Veress needle is inserted obliquely in the fascia aiming just over the sacral promontory (Fig 2). The needle is filled with normal saline, the valve is opened, and the saline is allowed to flow into the abdominal cavity. If there is no resistance to flow and no return on aspiration, the needle is assumed to be in the general peritoneal cavity and CO, insufflation is begun at a low flow. After a small amount of CO, is insufflated, all four abdominal quadrants are assessed for tympany to indicate insufflation of the peritoneal cavity. Once a steady, low intraabdominal pressure is achieved, high flow is then initiated through the needle, maintaining intraabdominal pressure less than 15 mm Hg. After instillation of approximately 2.5 to 3.0 L of CO,, a lo-mm trocar is inserted through the umbilical incision and the laparoscope with an attached video camera is inserted. The operation is observed on two video monitors, one each on the side of the surgeon and first assistant. The operating surgeon stands on the patient’s left side to perform the operation, with the first assistant opposite. Initial inspection is in the area where the Veress needle was inserted to assess for possible intestinal or mesenteric injury. Abdominal and pelvic laparoscopy is then undertaken to assess any unsuspected abnormalities. Attention is directed toward the gallbladder, and 5-mm incisions are made in the midclavicular line just over the dome of the JournalofPediatric
Surgery, Vol26, No 10 (October), 1991: pp 1186-1190
PEDIATRIC LAPAROSCOPIC CHOLECYSTECTOMY
1187
Table 1. Pediatric Patients Undergoing Laparoscopic Cholecystectomy Case
nge
NO.
(vr)
sex
1
13
F
No
Yes
2
14
F
Spherocytosis
Yes
3
9
M
Sickle cell disease
Yes
4
13
F
No
Yes
5
15
F
Gastrostomy
6
8
F
Spherocytosis-acute
Associated
common
Disease
Cholangiogram
No cholecystitis,
Yes
bile duct obstruction
gallbladder and also in the anterior axillary line just above the anterior superior iliac crest (ASK). A 5-mm trocar is inserted through each of these incisions under direct visualization using the video camera. A l-cm incision is then made in the epigastric midline (Fig 3) or in the left upper quadrant (LUQ) for very small patients (weighing less than 80 lb). This subxiphoid or left epigastric port must be individualized according to the patient’s body habitus for optimal utilization of this trocar. Placement of the epigastric or LUQ trocar closer than 3 to 4 cm from the midclavicular trocar makes manipulation of the instruments difficult. A lo-mm trocar is then inserted through this incision and cholecystectomy is initiated. A grasping forcep is placed through the lateral S-mm port superior to the ASK and the gallbladder is rotated ventrally and superiorly over the liver. Another grasping forcep is inserted through the port in the midclavicular line and Hartmann’s pouch is then retracted to the patient’s right. With the camera connected through the umbilical port, a dissecting forcep is inserted through the subxiphoid port and the hilum of the gallbladder is skeletonized. Under video inspection, blunt dissection separates the cystic duct from the cystic artery and common bile duct (Fig 4). Having completely assessed the anatomy of the cystic duct and common
Fig 2. The Veress needle is inserted obliquely at the umbilicus aiming just over the sacral promontory.
duct triangle, a clip is placed on the cystic duct as close as possible to the gallbladder to prevent migration of stones into the cystic duct. In addition, clips are placed proximally and distally on the cystic artery, but the artery is not cut until cholangiography is performed. Cholangiography is then accomplished after making a lateral incision in the cystic duct. Either a Taut cholangiocatheter using the Olsen clamp or a 6F ureteral catheter is inserted into the cystic duct and the cholangiogram is obtained in a standard fashion (Fig 5). Once the cholangiogram is reviewed, and there is no evidence of injury to the cystic or common ducts and no evidence of obstruction to the common duct, the cholangiocatheter is removed. Two clips are placed proximally on the cystic duct away from the common duct so as not to injure the latter. The cystic duct is then
Fig 1. Cholanglograms were obtained in the (A) oldest patient and (B) youngest patient. The cholanglograms show filling of the common bile duct and hepatic radicals with free flow of dye into the duodenum. There is no evidence of common duct dilatation or obstruction.
1188
HOLCOMB, OLSEN, AND SHARP
skin incisions can be enlarged if necessary. At this point, great care is taken to inspect the peritoneal surface of the umbilical port to insure intact hemostasis and no evidence of spillage. Having removed the gallbladder, the abdomen is desumated and all ports are removed. The umbilical fascial opening is closed with an absorbable suture and all four skin incisions are approximated in a subcuticular fashion. The orogastric tube and Foley catheter are removed and the patient is transported to the recovery room. In patients who have had previous upper abdominal procedures, insufflation is initiated through the subcostal midclavicular port over the gallbladder because the right upper quadrant is usually free of adhesions. Video fluoroscopy is then initiated through this port using a 5-mm telescope placed through the smaller incision, and the umbilicus is visualized. If the umbilicus is free of adhesions, the lo-mm trocar is inserted through the umbilical incision under visual inspection and the procedure is performed as described. Antibiotics (Cefazolin) are administered preoperatively followed by one dose postoperatively. Children are usually discharged the following morning and allowed to resume regular activities within 3 days. They return for a postoperative examination 2 weeks following the procedure. DISCUSSION
Fig 3. The site of trocar insertions prior to laparoscopic cholecystectomy in a child. Site 1 is the umbilical port where the camera is inserted. Site 2 is the epigastric port that needs to be individualized according to the child’s body habitus. In patients weighing less than approximately 80 lb, this port often will need to be moved to the left epigastrium for optimal utilization of this site. Site 3 represents the port in the midclavicular line overlying the dome of the gallbladder, and site 4 represents the port just over the anterior superior iliac
Laparoscopic cholecystectomy is already becoming the standard of care for adults with symptomatic cholelithiasis. This technique has not been used in pediatric patients due to concern about the small size of the patient. However, from this experience, it is evident that the technique is equally applicable to children and can be performed without complication. In the adult literature, it is evident that there is a high learning curve for the procedure and that a physician should not be considered an expert until he or she has performed 15 to 20 procedures. Therefore, it is our recommendation that pediatric surgeons desiring to perform the procedure should serve as assistants for several of the procedures and perform the technique
crest.
divided distal to these two clips. In addition, the cystic artery is now divided and the gallbladder is removed in a retrograde fashion using electrocautery (Fig 6). During this part of the procedure, it is extremely important to maintain hemostasis in the liver bed as dissection proceeds superiorly. When the gallbladder is almost detached from the liver bed, the porta hepatis is reinspected for hemostasis and for proper placement of the surgical clips. The gallbladder is then completely detached and positioned temporarily over the liver. The area of dissection is irrigated with heparinized saline and the irrigant is inspected for blood or biliary contents. With a clear effluent, attention is turned to extraction of the gallbladder. The camera is removed from the umbilical port and placed in the lo-mm subxiphoid port. A grasping forcep is inserted through the umbilical port and the gallbladder is secured. Under direct visualization, the gallbladder is then extracted through the umbilical port (Fig 7). In children, the gallbladder often can be removed intact without the need for enlarging the umbilical fascial opening. If there is resistance at this point, the gallbladder can be aspirated and this usually is sufficient to allow its removal. The fasical and
Fig 4. Under visual inspection, blunt dissection separates the cystic duct from the cystic artery and common bile duct. Notice that clips have not been applied prior to complete identification of the structures in the triangle of Calot.
PEDIATRIC LAPAROSCOPIC CHOLECYSTECTOMY
Fig 5. On the laft, a 6F ureteral catheter has been inserted into the cystic duct and cholangiography obtained. Notice the clip high on the gallbladder and away from the common bile duct giving adequate length on the cystic duct for performance of cholangiography. On the right. the cholangiocatheter has been removed and the cystic duct divided. Two clips are placed on the proximal cystic artery and the artery is being divided in this sketch. Note that the artery is not divided until the cholangiogram has been performed and the cystic duct has been divided.
with the assistance of expert general surgeons prior to embarking on the technique by themselves. This procedure is no different from other new procedures in that safety should be of paramount concern. Therefore, no structures in the triangle of Calot should be divided prior to cholangiography in order to accurately assess the anatomy of the area. In addition, operative time should not be a factor in the performance of the procedure and great care should be taken to all details in order to insure a safe procedure. If concern arises about bleeding or bile
duct injury during any part of the procedure, the operation should be converted to an open cholecystectomy. This possibility should be explained to parents prior to each operation. Absolute contraindications to laparoscopic cholecystectomy include an uncorrectable coagulopathy, generalized peritonitis, and abdominal wall sepsis at the site of the trocar insertion. Acute cholecystitis is not a contraindication to laparoscopic cholecystectomy. However, if edema or induration prevents the accurate identification of structures in the triangle of Calot in the gallbladder bed, then the procedure should be converted to an open cholecystectomy. As noted in patient 6 in this series, children with resolving acute cholecystitis and common duct obstruction can safely undergo laparoscopic cholecystectomy with
Fig 6. Following division of the cystic duct and artery, the gallbladder is dissected in a retrograde fashion from the liver bed using the electrocautery.
Fig 7. Following cholecystectomy, the gallbladder is extracted through the umbifkral port under direct viswfixatlon. In ddfdren, the gallbladder can usually be removed without the need for aspiration.
1190
HOLCOMB, OLSEN, AND SHARP
cholangiography. Although operative cholangiography is not always technically possible because the catheter will not always fit into or pass down the cystic duct, it should be attempted in every child to define the anatomy of the region and to gain experience in this part of the procedure so that it can be performed successfully in those patients in whom it is absolutely necessary. However, children with symptomatic cholelithiasis without ultrasonographic evidence or symptoms of common duct obstruction can undergo laparoscopic cholecystectomy even if cholangiography is not possible. These patients need to be followed closely to insure that common duct obstruction has not been overlooked. At this time, the management of common duct stones detected either preoperatively or intraoperatively is controversial. In adults, patients with stones detected preoperatively usually undergo endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy followed by laparoscopic eholecystectomy. For stones detected intraoperatively, common duct exploration can be performed in selected adult patients through the cystic duct or stones can be removed postoperatively at endoscopic sphincterot-
omy if less than 1 cm in diameter. At this time, for pediatric patients with common duct stones detected either preoperatively or intraoperatively, an open cholecystectomy with common duct exploration is recommended. In the future, endoscopic sphincterotomy may be used for common duct stones in older children as it is presently used in adults. Video laparoscopy is a new and safe approach for removal of the gallbladder. Advantages to the procedure in the pediatric patient include a 24-hour hospitalization for elective procedures, decreased postoperative discomfort, and a much shorter interval between the surgical procedure and return to normal activities such as school and play. The procedure requires skills that are not familiar to the majority of practicing pediatric surgeons and there is a long learning curve. However, once a surgeon has performed approximately 20 procedures, he or she will become much more comfortable with the operation and it may become the standard of care in the next few years. Moreover, laparoscopic cholecystectomy may herald increased use of laparoscopy in the pediatric patient for other procedures such as appendectomy.
REFERENCES 1. Reddick EJ, Olsen DO: Laparoscopic laser cholecystectomy. Surg Endow 3:131-133,1989 2. Dubois F, Icard P, Berthelot G, et al: Coelioscopic cholecystectomy: A preliminary report of 36 cases. Ann Surg 211:60-62,199O 3. Phillips EH, Berci G, Carroll B, et al: The importance of
intraoperative cholangiography during laparoscopic cholecystectomy. Am Surg 12:792-795,199O 4. Peters JH, Ellison EC, Innes JT, et al: Safety and efficacy of laparoscopic cholecystectomy: A prospective analysis of 100 initial patients. Ann Surg 13:3-12,199l
Cholecystectomy
in the Pediatric
Patient
By George W. Holcomb III, Douglas 0. Olsen, and Kenneth W. Sharp
Nashville, Tennessee @Since June 1990, five girls and one boy have been evaluated for biliary colic. Gallstones were documented by sonography. Two girls, ages 8 and 14 years, had hereditary spherocytosis, and a O-year-old boy had sickle cell disease. The other three girls, ages 13, 13, and 15 years, developed cholelithiasis and biliary colic without a history of hematological disease. Three children weighed less than 90 lb, with the smallest weighing 45 lb. All patients underwent laparoscopic cholecystectomy without complications. Operative cholangiography was performed in five of the six children. The KTP-532 laser was used for dissection of the gallbladder from the liver bed in two patients, and electrocautery was used in the remaining four. The average operating time was 1 hour 45 minutes. This is a report of the use of laparoscopic cholecystectomy in pediatric patients. The advantages of its use include a shorter hospitalization, decreased postoperative discomfort, and a much shorter interval between the surgical procedure and return to normal activities such as school and play. At this time, it is recommended for those children without complications from their cholelithiasis such as common duct obstruction and gallstone pancreatitis. Copyright o 199 1 by W. B. Saunders Company INDEX WORDS:
Cholecystectomy,
laparoscopic,
pediatric.
L
APAROSCOPIC cholecystectomy is an innovative technique that has been applied almost exclusively to adult patients. Despite the exponentially increasing number of laparoscopic cholecystectomies on adults to date, there is a paucity of reports in the literature about this new technique.lm4 No reports of this procedure discuss its use in pediatric patients. Since June 1990, six consecutive pediatric patients have been treated for cholelithiasis and biliary colic using the technique of laparoscopic cholecystectomy without complication. MATERIALS AND METHODS Five girls and one boy with biliary colic have been evaluated since June 1990 (Table 1). All patients had cholelithiasis documented by ultrasound and one patient was noted to have acute cholecystitis with pericholecystic fluid at ultrasound. Three of the children had hematological disease. Two girls, ages 8 and 14 years, had hereditary spherocytosis, and a 9-year-old boy had sickle cell disease. The other three girls, ages 13, 13, and 15 years, developed cholelithiasis and biliaty colic without a history hematological
From the Departments of Pediatric Sutgety and General Surgery, Vanderbilt Universi~ Medical Center, Nashviiie, TN. Date received: March 15, 1991; date accepted: May 8, 1991. Address reprint requests to George W. Holcomb HI, MD, Department of Pediatric Surgery, Vanderbilt University Medical Center, 338 MedicalArts Bldg, 12112lst Ave S, Nashville, TN 37212. CoWright 6 1991 by WB. Saunders Company 0022-3468/91/2610-0011$03.00/0
1186
disease. Three children weighed less than 90 lb, with the smallest weighing 45 lb. The other three weighed between 100 and 130 lb. Five of the six children underwent elective laparoscopic cholecystectomy and were discharged the following morning. The 8-yearold girl with spherocytosis presented with acute cholecystitis and obstructive jaundice. Admission bilirubin was 13 mg/dL and common bile duct dilatation without a definite calculus was noted on ultrasound. Her jaundice and common bile duct dilation resolved on intravenous fluids and analgesics. She underwent laparoscopic cholecystectomy with intraoperative cholangiography 5 days after admission without complication, and was discharged on the second postoperative day. Intraoperative cholangiography was possible in five of the six patients and did not show common duct obstruction or dilatation (Fig 1). It was not successful in the oldest patient in this series because the cholangiocatheter could not be introduced into the cystic duct. Total operative time ranged from 90 to 140 minutes (mean, 105 minutes). The KTP-532 (Laserscope, San Jose, CA) laser was used for dissection of the gallbladder from the liver bed in the first two patients, but electrocautery was used in the last four children, primarily because of the expense of the laser. One of the patients had a previously established operative gastrostomy for nutritional supplementation while she recovered from encephalitis and underwent laparoscopic cholecystectomy for persistent epigastric pain and cholelithiasis without difficulty. All six gallbladders exhibited cholelithiasis and chronic cholecystitis on pathological examination. Additionally, one patient also had cholesterolosis and one exhibited acute cholecystitis in addition to cholelithiasis.
Technique The patient is admitted on the day of surgery for elective laparoscopic cholecystectomy. Under general endotracheal anesthesia, a Foley catheter and orogastric tube are inserted and the abdomen is prepared and draped in the same fashion as used for a standard open cholecystectomy. A l-cm incision is made in the center of the umbilicus down to the fascia. A Veress needle is inserted obliquely in the fascia aiming just over the sacral promontory (Fig 2). The needle is filled with normal saline, the valve is opened, and the saline is allowed to flow into the abdominal cavity. If there is no resistance to flow and no return on aspiration, the needle is assumed to be in the general peritoneal cavity and CO, insufflation is begun at a low flow. After a small amount of CO, is insufflated, all four abdominal quadrants are assessed for tympany to indicate insufflation of the peritoneal cavity. Once a steady, low intraabdominal pressure is achieved, high flow is then initiated through the needle, maintaining intraabdominal pressure less than 15 mm Hg. After instillation of approximately 2.5 to 3.0 L of CO,, a lo-mm trocar is inserted through the umbilical incision and the laparoscope with an attached video camera is inserted. The operation is observed on two video monitors, one each on the side of the surgeon and first assistant. The operating surgeon stands on the patient’s left side to perform the operation, with the first assistant opposite. Initial inspection is in the area where the Veress needle was inserted to assess for possible intestinal or mesenteric injury. Abdominal and pelvic laparoscopy is then undertaken to assess any unsuspected abnormalities. Attention is directed toward the gallbladder, and 5-mm incisions are made in the midclavicular line just over the dome of the JournalofPediatric
Surgery, Vol26, No 10 (October), 1991: pp 1186-1190
PEDIATRIC LAPAROSCOPIC CHOLECYSTECTOMY
1187
Table 1. Pediatric Patients Undergoing Laparoscopic Cholecystectomy Case
nge
NO.
(vr)
sex
1
13
F
No
Yes
2
14
F
Spherocytosis
Yes
3
9
M
Sickle cell disease
Yes
4
13
F
No
Yes
5
15
F
Gastrostomy
6
8
F
Spherocytosis-acute
Associated
common
Disease
Cholangiogram
No cholecystitis,
Yes
bile duct obstruction
gallbladder and also in the anterior axillary line just above the anterior superior iliac crest (ASK). A 5-mm trocar is inserted through each of these incisions under direct visualization using the video camera. A l-cm incision is then made in the epigastric midline (Fig 3) or in the left upper quadrant (LUQ) for very small patients (weighing less than 80 lb). This subxiphoid or left epigastric port must be individualized according to the patient’s body habitus for optimal utilization of this trocar. Placement of the epigastric or LUQ trocar closer than 3 to 4 cm from the midclavicular trocar makes manipulation of the instruments difficult. A lo-mm trocar is then inserted through this incision and cholecystectomy is initiated. A grasping forcep is placed through the lateral S-mm port superior to the ASK and the gallbladder is rotated ventrally and superiorly over the liver. Another grasping forcep is inserted through the port in the midclavicular line and Hartmann’s pouch is then retracted to the patient’s right. With the camera connected through the umbilical port, a dissecting forcep is inserted through the subxiphoid port and the hilum of the gallbladder is skeletonized. Under video inspection, blunt dissection separates the cystic duct from the cystic artery and common bile duct (Fig 4). Having completely assessed the anatomy of the cystic duct and common
Fig 2. The Veress needle is inserted obliquely at the umbilicus aiming just over the sacral promontory.
duct triangle, a clip is placed on the cystic duct as close as possible to the gallbladder to prevent migration of stones into the cystic duct. In addition, clips are placed proximally and distally on the cystic artery, but the artery is not cut until cholangiography is performed. Cholangiography is then accomplished after making a lateral incision in the cystic duct. Either a Taut cholangiocatheter using the Olsen clamp or a 6F ureteral catheter is inserted into the cystic duct and the cholangiogram is obtained in a standard fashion (Fig 5). Once the cholangiogram is reviewed, and there is no evidence of injury to the cystic or common ducts and no evidence of obstruction to the common duct, the cholangiocatheter is removed. Two clips are placed proximally on the cystic duct away from the common duct so as not to injure the latter. The cystic duct is then
Fig 1. Cholanglograms were obtained in the (A) oldest patient and (B) youngest patient. The cholanglograms show filling of the common bile duct and hepatic radicals with free flow of dye into the duodenum. There is no evidence of common duct dilatation or obstruction.
1188
HOLCOMB, OLSEN, AND SHARP
skin incisions can be enlarged if necessary. At this point, great care is taken to inspect the peritoneal surface of the umbilical port to insure intact hemostasis and no evidence of spillage. Having removed the gallbladder, the abdomen is desumated and all ports are removed. The umbilical fascial opening is closed with an absorbable suture and all four skin incisions are approximated in a subcuticular fashion. The orogastric tube and Foley catheter are removed and the patient is transported to the recovery room. In patients who have had previous upper abdominal procedures, insufflation is initiated through the subcostal midclavicular port over the gallbladder because the right upper quadrant is usually free of adhesions. Video fluoroscopy is then initiated through this port using a 5-mm telescope placed through the smaller incision, and the umbilicus is visualized. If the umbilicus is free of adhesions, the lo-mm trocar is inserted through the umbilical incision under visual inspection and the procedure is performed as described. Antibiotics (Cefazolin) are administered preoperatively followed by one dose postoperatively. Children are usually discharged the following morning and allowed to resume regular activities within 3 days. They return for a postoperative examination 2 weeks following the procedure. DISCUSSION
Fig 3. The site of trocar insertions prior to laparoscopic cholecystectomy in a child. Site 1 is the umbilical port where the camera is inserted. Site 2 is the epigastric port that needs to be individualized according to the child’s body habitus. In patients weighing less than approximately 80 lb, this port often will need to be moved to the left epigastrium for optimal utilization of this site. Site 3 represents the port in the midclavicular line overlying the dome of the gallbladder, and site 4 represents the port just over the anterior superior iliac
Laparoscopic cholecystectomy is already becoming the standard of care for adults with symptomatic cholelithiasis. This technique has not been used in pediatric patients due to concern about the small size of the patient. However, from this experience, it is evident that the technique is equally applicable to children and can be performed without complication. In the adult literature, it is evident that there is a high learning curve for the procedure and that a physician should not be considered an expert until he or she has performed 15 to 20 procedures. Therefore, it is our recommendation that pediatric surgeons desiring to perform the procedure should serve as assistants for several of the procedures and perform the technique
crest.
divided distal to these two clips. In addition, the cystic artery is now divided and the gallbladder is removed in a retrograde fashion using electrocautery (Fig 6). During this part of the procedure, it is extremely important to maintain hemostasis in the liver bed as dissection proceeds superiorly. When the gallbladder is almost detached from the liver bed, the porta hepatis is reinspected for hemostasis and for proper placement of the surgical clips. The gallbladder is then completely detached and positioned temporarily over the liver. The area of dissection is irrigated with heparinized saline and the irrigant is inspected for blood or biliary contents. With a clear effluent, attention is turned to extraction of the gallbladder. The camera is removed from the umbilical port and placed in the lo-mm subxiphoid port. A grasping forcep is inserted through the umbilical port and the gallbladder is secured. Under direct visualization, the gallbladder is then extracted through the umbilical port (Fig 7). In children, the gallbladder often can be removed intact without the need for enlarging the umbilical fascial opening. If there is resistance at this point, the gallbladder can be aspirated and this usually is sufficient to allow its removal. The fasical and
Fig 4. Under visual inspection, blunt dissection separates the cystic duct from the cystic artery and common bile duct. Notice that clips have not been applied prior to complete identification of the structures in the triangle of Calot.
PEDIATRIC LAPAROSCOPIC CHOLECYSTECTOMY
Fig 5. On the laft, a 6F ureteral catheter has been inserted into the cystic duct and cholangiography obtained. Notice the clip high on the gallbladder and away from the common bile duct giving adequate length on the cystic duct for performance of cholangiography. On the right. the cholangiocatheter has been removed and the cystic duct divided. Two clips are placed on the proximal cystic artery and the artery is being divided in this sketch. Note that the artery is not divided until the cholangiogram has been performed and the cystic duct has been divided.
with the assistance of expert general surgeons prior to embarking on the technique by themselves. This procedure is no different from other new procedures in that safety should be of paramount concern. Therefore, no structures in the triangle of Calot should be divided prior to cholangiography in order to accurately assess the anatomy of the area. In addition, operative time should not be a factor in the performance of the procedure and great care should be taken to all details in order to insure a safe procedure. If concern arises about bleeding or bile
duct injury during any part of the procedure, the operation should be converted to an open cholecystectomy. This possibility should be explained to parents prior to each operation. Absolute contraindications to laparoscopic cholecystectomy include an uncorrectable coagulopathy, generalized peritonitis, and abdominal wall sepsis at the site of the trocar insertion. Acute cholecystitis is not a contraindication to laparoscopic cholecystectomy. However, if edema or induration prevents the accurate identification of structures in the triangle of Calot in the gallbladder bed, then the procedure should be converted to an open cholecystectomy. As noted in patient 6 in this series, children with resolving acute cholecystitis and common duct obstruction can safely undergo laparoscopic cholecystectomy with
Fig 6. Following division of the cystic duct and artery, the gallbladder is dissected in a retrograde fashion from the liver bed using the electrocautery.
Fig 7. Following cholecystectomy, the gallbladder is extracted through the umbifkral port under direct viswfixatlon. In ddfdren, the gallbladder can usually be removed without the need for aspiration.
1190
HOLCOMB, OLSEN, AND SHARP
cholangiography. Although operative cholangiography is not always technically possible because the catheter will not always fit into or pass down the cystic duct, it should be attempted in every child to define the anatomy of the region and to gain experience in this part of the procedure so that it can be performed successfully in those patients in whom it is absolutely necessary. However, children with symptomatic cholelithiasis without ultrasonographic evidence or symptoms of common duct obstruction can undergo laparoscopic cholecystectomy even if cholangiography is not possible. These patients need to be followed closely to insure that common duct obstruction has not been overlooked. At this time, the management of common duct stones detected either preoperatively or intraoperatively is controversial. In adults, patients with stones detected preoperatively usually undergo endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy followed by laparoscopic eholecystectomy. For stones detected intraoperatively, common duct exploration can be performed in selected adult patients through the cystic duct or stones can be removed postoperatively at endoscopic sphincterot-
omy if less than 1 cm in diameter. At this time, for pediatric patients with common duct stones detected either preoperatively or intraoperatively, an open cholecystectomy with common duct exploration is recommended. In the future, endoscopic sphincterotomy may be used for common duct stones in older children as it is presently used in adults. Video laparoscopy is a new and safe approach for removal of the gallbladder. Advantages to the procedure in the pediatric patient include a 24-hour hospitalization for elective procedures, decreased postoperative discomfort, and a much shorter interval between the surgical procedure and return to normal activities such as school and play. The procedure requires skills that are not familiar to the majority of practicing pediatric surgeons and there is a long learning curve. However, once a surgeon has performed approximately 20 procedures, he or she will become much more comfortable with the operation and it may become the standard of care in the next few years. Moreover, laparoscopic cholecystectomy may herald increased use of laparoscopy in the pediatric patient for other procedures such as appendectomy.
REFERENCES 1. Reddick EJ, Olsen DO: Laparoscopic laser cholecystectomy. Surg Endow 3:131-133,1989 2. Dubois F, Icard P, Berthelot G, et al: Coelioscopic cholecystectomy: A preliminary report of 36 cases. Ann Surg 211:60-62,199O 3. Phillips EH, Berci G, Carroll B, et al: The importance of
intraoperative cholangiography during laparoscopic cholecystectomy. Am Surg 12:792-795,199O 4. Peters JH, Ellison EC, Innes JT, et al: Safety and efficacy of laparoscopic cholecystectomy: A prospective analysis of 100 initial patients. Ann Surg 13:3-12,199l