Laparoscopic Cholecystectomy in Children: Initial Experience and Recommendations ByChristopher

R. Moir, John H. Donohue, and Jon A. van Heerden

Rochester, l Our initial

experience

with

laparoscopic

cholecystec-

tomy in children and the modification of techniques required for pediatric surgical patients is reported. Six children aged 6 to 17 years underwent laparoscopic cholecystectomy for symptomatic cholelithiasis. All patients had biliary colic and did not require concomitant intraabdominal surgical procedures. Average operative time was 69 minutes; none were converted to open cholecystectomy. One patient returned home the evening of surgery, two patients were discharged the following morning, and two patients were discharged 2 days following the procedure because of their distance from home. There were no complications. All patients have remained asymptomatic on follow-up of 1 to 5 months. Based on this initial experience, several changes in the technique as reported in adults are recommended. Due to the softness and laxity of the anterior abdominal wall, an infraumbilical incision for the lo-mm camera trocar is more cosmetically acceptable and just as efficient. There is a smaller intraabdominal space with which to work, tempting one to overinflate the abdomen for better visualization. Care should be taken to ensure that the intraabdominal pressure does not exceed 15 mm Hg despite the small volumes required to do so. Placement of the second epigastric incision is more inferior and lateral than the standard recommendation for adults. The cystic duct must be controlled as early as possible in the operative course to prevent egress of stones from the gallbladder into the common duct. In one patient, these migrating stones were milked back into the gallbladder and a second clip placed. It is imperative that the entire length of the cystic duct be well visualized and clearly defined before clips are placed. Smaller titanium clips may be used. Blunt dissection with electrocautery is a safe and expedient method of dissection. Laser dissection is not recommended for pediatric cholecystectomies. Based on our very encouraging early experience, when no other concomitant procedure is required, we strongly recommend laparoscopic cholecystectomy for any pediatric patient with symptomatic cholelithiasis. Copyright o 1992 by W.B. Saunders Company INDEX WORDS:

Laparoscopic cholecystectomy,

pediatric.

I

N JUST OVER 2 years, laparoscopic cholecystectomy has become a popular treatment for adults with symptomatic cholelithiasis.’ Due to the phenomenal interest in this procedure, pediatric surgeons will

Minnesota

be asked to consider it for their patients as well. We present a pilot series of laparoscopic cholecystectomies in children to evaluate the feasibility and adaptability of the technique to the management of childhood cholelithiasis. Special consideration was given to concerns of the child’s anatomic differences, including the possibility of congenital anomalies and risks of common bile duct injury. MATERIALS AND METHODS Six consecutive children with cholelithiasis referred to the Mayo Clinic between December 1990 and August 1991 were offered laparoscopic cholecystectomy. All children or their parents had heard of the procedure and readily accepted. There were four girls and two boys with an average age of 11 years (range, 6 to 17 years). Five children presented with biliary colic and fatty food intolerance of 4 months to 1 year. One 7-year-old girl had resolved gallstone pancreatitis. All children had cholelithiasis demonstrated on ultrasonography. There were no preoperative findings of congenital pancreaticobiliary anomalies or any hematologic disease. Total operative time ranged from 45 minutes to 2 hours (average time, 89 minutes). An operative cholangiogram was performed in one patient; another underwent umbilical hernia repair at the end of the procedure. During dissection of the infundibulum in one patient, several small stones were visualized in the cystic duct. These were milked back into the gallbladder prior to clip application. One further patient had a small accessory bile duct that was visualized laparoscopically from its origin in the liver bed to insertion in the gallbladder, allowing safe division. Pathology confirmed chronic cholecystitis in all patients. Stones were universally small and ranged in number from 1 to over 50 per gallbladder. All patients except one had mixed cholesterol stones; a B-year-old boy had pigment stones. There were no major complications or infection. Postoperative nausea was present in three patients; abdominal wall tenderness delayed discharge in two other patients who lived over 1,000 miles away. These two patients went home 2 days following the procedure, three others left the morning following surgery; the 6-yearold boy returned home the evening of surgery. Follow-up of 1 to 5 months was by patient visit or telephone call. All six were symptom-free. All had returned to normal activities within 4 days of surgery, including playing baseball, snow shoveling, and school.

The Laparoscopic

Procedure

From the Section of Pediatric Surgery and the Department of Surgery, Mayo Foundation, Rochester, MN. Presented at the 43rd Annual Meeting of the Surgical Section of the American Academy of Pediatrics, New Orleans, Louisiana, October 26-27, 1991. Address reprint requests to Christopher R. Moir, MD, Mayo Clinic, 200 First St Srt: Rochester, MN 55905. Copyright o 1992 by WB. Saunders Company 0022-3468/92/2708-0026$03.00/0

Based on this initial experience, the following is a description of our standard procedure for pediatric laparoscopic cholecystectomy. Laparoscopic cholecystectomy is indicated in all children to whom open cholecystectomy would be offered. Relative contraindications include jaundice, ongoing pancreatitis, coagulopathy, cirrhosis, and the need to perform a concomitant procedure such as splenectomy. All children arc admitted to the hospital on the morning of the procedure. A broad-spectrum antibiotic is given once the intrave-

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JournalofPediatric Surgery, Vol27, No 8 (August),1992: pp 1066-1070

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nous line has been placed. Due to the softness and laxity of the anterior abdominal wall, an infraumbilical incision for the lo-mm camera trocar is more cosmetically acceptable and just as efficient as the more superiorly placed incisions in the adult. This more inferior placement (3 to 4 cm) of the camera trocar is acceptable in the smaller child in whom separation of instruments may be important. The larger or obese teenager may well need a more superiorly placed camera incision to avoid peering over a horizon of abdominal contents to view the gallbladder. The same may be true for congenital scoliosis, which may again obstruct the view from below. A vertical intraumbilical skin incision just below the center point of the umbilicus is cosmetically acceptable and almost invisible. If an umbilical hernia is present, we have found a standard umbilical hernia incision is entirely adequate for insertion of the trocar. A Veress needle? is inserted with the patient in the Trendelenberg position and with a Foley catheter and nasogastric tube in place. There is a smaller intraabdominal space with which to work, tempting one to overinflate the abdomen for better visualization. Care should be taken to ensure that the intraabdominal pressure does not exceed 15 mm Hg despite the small volumes required to do SO.~It is recommended that a pressure-regulated insufflator be used in children to prevent overdistention and high intraabdominal pressures. Children under age 8 may benefit from lower pressures of 12 to 13 mm Hg. Following umbilical trocar insertion, the patients are placed in the reverse Trendelenberg position and rotated to the left (toward the surgeon). Placement of the second epigastric lo-mm incision is more inferior and lateral than the standard recommendations. The smaller child’s liver is proportionally larger and extends more inferiorly than the older child. Too high a placement of this working trocar in our first patient made the subsequent angles difficult to work with. The two laterally placed trocar incisions should be within a line of possible open cholecystectomy and may be 5-mm trocars. A smaller camera may be placed through a 5-mm umbilical trocar rather than the IO-mm. A 30” oblique viewing camera is used in all cases. We have found a lo-mm camera to be manageable even in the youngest child. The cystic duct must be controlled as early as possible to prevent egress of stones from the gallbladder into the common duct. All children in this series had small gallstones that seemed particularly susceptible to unintentional expulsion into the common duct. It is imperative, particularly in the child who may have developed cholelithiasis on the basis of congenital anomalies, that the junctions of the cystic duct with the gallbladder and with the common duct are adequately visualized before the clips are placed. Similarly, accessory ducts can be easily visualized and ligated if care has been taken to do so. Operative cholangiography is used electively for patients with a history suggestive of common bile duct stones or in those patients where the anatomy cannot be easily and readily visualized. We have found smaller titanium clips to be very useful in the younger child. Careful dissection and monopolar or bipolar electrocautery is a safe and efficient method of dissection despite the thin structures and the close proximity of major vessels. Once the cystic duct and artery have been doubly clipped and ligated, the gallbladder is removed in a retrograde fashion using monopolar electrocautery. As with adults, before the gallbladder is detached from the liver, the operative field is inspected and hemostasis obtained. The gallbladder can be removed through either IO-mm trocar, but large gallbladders should be removed through the umbilicus after the trocar has been removed and the gallbladder aspirated. This will prevent spillage of stones and egress of bile. Once the gallbladder is removed, the pneumoperitoneum is evacuated under controlled circumstances to prevent incarceration of bowel or omentum in the

incisions. The puncture sites are closed in layers with absorbable suture material. In keeping with the outpatient concept, “bandaids” are generally used as dressings. The children are offered fluids and encouraged to ambulate as soon as tolerated. DISCUSSION

Laparoscopic techniques have been used and perfected since the early 1900~.~The remarkable growth of laparoscopy in recent years has been stimulated by the ever increasing array of therapeutic procedures. In 1990, DuBois et aI5 published a series of laparoscopic cholecystectomies that began in 1988. Reports from the United States soon followed. As the number of patient series burgeons, it is estimated that laparoscopic cholecystectomy will soon be the procedure of choice for symptomatic cholelithiasis.1,4,6.7 Intense public interest in laparoscopic cholecystectomy has hindered attempts at controlled trials of this new technique. 8,9This pilot project of six consecutive pediatric laparoscopic cholecystectomies has shown that the procedure can be done without complication and as quickly as open cholecystectomy. No patient required conversion to open cholecystectomy, but preoperative preparation and incision planning anticipated an earIy switch to standard cholecystectomy before trouble arose. Careful consideration of the child’s anatomic differences was essential for these excellent results. A relatively large liver that extends below the costal margin must be identified under anesthetic and positive-pressure ventilation prior to incision placement. Trocars placed too high may result in difficult operative angles and inadequate retraction that may predispose to ductal injury. Ductal anomalies or accessory bile ducts, as seen in one of the present patients, should be considered in this patient population, but do not represent a contraindication to surgery. With proper retraction and judicious dissection, the origin and insertion of the cystic duct and any accessory ducts can be atraumatitally visualized prior to division. Common bile duct injury has appeared as a more common complication of laparoscopic cholecystectomy than the standard approach.*T6J0Unfamiliarity with the technique, differences in retraction, and loss of depth of field visualization are inherent problems with this approach. When doubt exists, we recommend operative cholangiography and conversion to open cholecystectomy if the ductal anatomy cannot be clearly discerned. Children generally have small stones that can be easily pushed into the common duct. The cystic duct should therefore be controlled as quickly as possible while manipulation of the gallbladder is kept to a minimum. Small stones should be looked for and milked back into the gallbladder prior to division of

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the cystic duct. Cholangiography is particularly important in these cases. A previous episode of gallstone pancreatitis was not a contraindication to surgery in our patient provided the above steps were taken.” We have not used the laser for dissection or coagulation. l2 In all six patients the structures were quite thin, and close proximity to major vessels presented a potential hazard. Although the laser is a very precise tool, in our hands cautery has been a safe, effective, and expedient method of dissection. It is an inexpensive and familiar surgical method that may reduce the workload in this unfamiliar setting.

In this series, the shortened hospital stay, reduction of pain, and early return to school and usual activities have been met with great enthusiasm by the patients and their parents. The laparoscopic scars have been very acceptable. The improved pulmonary function may also reduce operative risks in children with cystic fibrosis.13J4 Based on our very encouraging early experience, when no other concomitant procedure is required, we strongly recommend laparoscopic cholecystectomy for any pediatric patient with symptomatic cholelithiasis.

REFERENCES 1. Meyers WC, Branum GD, Farouk M, et al: A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 324:1075-1078,199l 2. Veress J: Neues instrument zue ausfuhrung von brust oder bauchpunktionen. Dtsch Med Wopchenschr 41:1480-1481,193s 3. Wittgen CM, Andrus CH, Fitzgerald SD, et al: Analysis of the hemodynamic and ventilatory effects of Iaparoscopic cholecystectomy. Arch Surg 126:997-1001,199l 4. Graves HA Jr, Ballinger JF, Anderson WJ: Appraisal of laparoscopic cholecystectomy. Ann Surg 213:655-664,199l 5. Dubois F, Icard P, Berthelot G: Coelioscopic cholecystectomy: Preliminary report of 36 cases. Ann Surg 211:60-62,199O 6. Peters JH, Ellison EC, Innes JT, et al: Safety and efficacy of laparoscopic cholecystectomy: A prospective analysis of 100 initial patients. Ann Surg 213:3-12,199l 7. Schirmer BD, Edge SB, Dix J, et al: Laparoscopic cholecystectomy: Treatment of choice for symptomatic cholelithiasis. Ann Surg 213:665-677,199l

8. Neugebauer E, Troidle H, Spangenberger W, et al: Conventional versus laparoscopic cholecystectomy and the randomized controlled trial. Br J Surg 78:150-154,199l 9. Wolfe BM, Gardiner B, Frey CF: Laparoscopic cholecystectomy: A remarkable development. JAMA 265:1573-1574,199l 10. Hunter JG: Avoidance of bile duct injury during Iaparoscopic cholecystectomy. Am J Surg 162:71-76,199l 11. Sackier JM, Berci G, Phillips E, et al: The role of cholangiography in laparoscopic cholecystectomy. Arch Surg 126:1021-1026, 1991 12. Easter DW, Moossa AR: Laser and Iaparoscopic cholecystectomy: A hazardous union? Arch Surg 126:423,1991 13. Frazee RC, Roberts JW, Okeson GC, et al: Open versus laparoscopic cholecystectomy: A comparison of postoperative pulmonary function. Arm Surg 213:651-654,199l 14. Edelman DS: Laparoscopic cholecystectomy under continuous epidural anesthesia in patients with cystic fibrosis. Am J Dis Child 145:723-724,199l

Discussion Thorn Lobe (Memphis, TN): I enjoyed your timely presentation because there’s a keen interest and a great deal of skepticism among our pediatric surgical colleagues as to whether or not this is really something that we should get into and be doing as pediatric surgeons. You talked about the time of the procedure. I think that adult surgeons who are doing this procedure with great regularity are getting the procedure down to 20 to 45 minutes. We may never achieve this, doing as few cholecystectomies as we do as pediatric surgeons. However, clearly with experience, you decrease your time. I’d like to emphasize the point you made with the trocar site. In your manuscript you discussed making the trocar sites in line with what would be your subcostal incision. In particularly small infants, I actually make my trocar sites even lower, closer to the iliac crest, because in the very small abdomen you will

end up having dueling instruments if you get your trocar or your instruments too close together. You mentioned briefly in the manuscript the use of a 5-mm laparoscope. We use this size instrument routinely. We found that the optics are just as good, because as pediatric surgeons we are used to using small telescopes for bronchoscopy and cystoscopy. You do get a larger view and more light with a lo-mm laparoscope but the 5-mm instrument is more than adequate. There is another advantage to the smaller laparoscope. If you don’t have good visualization from the umbilicus, you can switch to another canulla without having to replace it with a larger one. You can approach the operative site from the side, for instance, to look at the posterior anatomy. You mentioned lasers, and said that you don’t use them and don’t see the need for them. That may be true, but we are seeing more complications from electrocautery by people who are essentially unfamil-

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iar with laparoscope technique. When you have smoke as plume, as you so well demonstrated in your film, the electrical current with monopolar electrocautery arcs as much as 2 to 3 mm, so we may see damage to adjacent loops of bowel and other viscera. We also see electrocautery current travel along vascular bundles. You may grab a vessel, say the cystic artery, and if your settings aren’t just perfect you may see that current travel down the hepatic artery close to the duct causing injury. So I think whatever technique you use, laser or electrocautery, you have to know how to use it correctly. We will see the development of many new instruments and techniques that are going to help us. I recently saw a laparoscopic ultrasonic dissector that will help us dissect the structures out safely without heat or electrical energy, and I have seen new bipolar instruments that are going to prevent this scatter and travel of electrical energy. You mentioned postoperative nausea as a complication. We minimize this in our patients by using Transderm Scope patches behind the ear. We put it on in the operating room so that they can take effect when they wake up. We also use Reglan in appropriate doses for the age and size. This seems to be helpful in minimizing postoperative nausea. In contrast to your patients, our procedures have mostly been in sickle-cell patients. We believe that this minimizes their hospital stay, and reduces their pulmonary complications. The Duke experience has verified this at the recent sickle cell meeting. I have several questions. You talk about cystic fibrosis (CF) patients. Have you performed this procedure on any CF patients? Do you think this really is going to make a difference in the pulmonary complications, or is their greatest risk being put to sleep and being intubated? Also, do you think there are any age and size limitations? Are there patients too small for this technique, or should we be doing this in everyone? Also, in light of the prospective, randomized series in adults in Montreal, yet to be published, that shows no difference between the open technique and the laparoscopic technique regarding hospitalization and postoperative complications, do you think that laparoscopy is better? And, should we, as pediatric surgeons be using this technique rather than the open procedure with which we are all familiar? Steven Rothenberg (Houston, TX): Just a quick comment and one question. I think it’s important that you mentioned bringing the upper trocars down, and I think that it’s a good point because the liver does get in the way. But, as Dr Lobe alluded to, if you don’t

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also move the camera trocar down, you will have a great deal of difficulty with crossing of your instruments and getting a good picture. So you must bring down the infraumbilical trocar to maintain adequate distance between the upper and lower ports. The second thing is that adult general surgeons rely on endoscopic retrograde cholangiopancreatography (ERCP) a great deal as an adjunct to laparoscopy cholecystectomy. As a result, a lot of the absolute contraindications to laparoscopic cholecystectomy you mentioned are now no longer thought to be contraindications. We have had some experience with trying to use ERCP, and also if you recommend doing routine cholangiograms with laparoscopes as well so you know if you are going to need either ERCP or open exploration. George Holcomb III (Nashville, TN): Two comments: One is, I think that the subxiphoid port is better utilized to the left of the falciform ligament than to the right as shown in the movie. The second point is that in seven of our eight patients undergoing laparoscopic cholecystectomy we have performed cholangiography. I think it’s important to try to do a cholangiogram on every patient. Not only does it delineate the anatomy, but it’s important to gain experience in cholangiography. So I think it’s better to try to do it in all patients in order to gain that experience. If you do a cholangiogram, though, it’s best not to divide the cystic artery first, but rather divide the cystic artery after the cholangiogram. Christopher Moir (response): Dr Lobe, our average operative time is on par or slightly faster than the average time reported from the Southern Surgeons Club. Operative times will speed up with more experience, but I don’t expect the average time to be much under 1 hour due to constraints of cholangiography, acute inflammation, and teaching. Thank you for mentioning the 5-mm camera. I have asked for it to be available, but in every instance, including the 6-year-old boy, the lo-mm camera has been easily inserted through the umbilicus. The advantages of the larger scope are as you mention, a wider field and better optics. I am sure I will use a 5mm scope, but the opportunity has just not presented itself. In mentioning the use of the laser for laparoscopic procedures, you have continued the discussion which I believe has been nicely answered in the New England Journal of Medicine (Meyers et al, 324:10731078, 1991). Cautery or laser was used with equal efficacy. The point is not so much what we use for dissection, but how it is done. Personally, I found the

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cautery easier to use since I have been familiar with this instrument and it did not require any further learning in an already new situation. I agree entirely that nausea may be a limiting factor for early postoperative discharge. Transdermal scopolamine and preoperative metaclopramide are well worth evaluating. We have had no pulmonary complications, but have not performed laparoscopic cholecystectomy on any patients with severe pulmonary diseases such as cystic fibrosis. In these patients, one might consider laparoscopy done under spinal anesthesia as is performed in many centers in the US. At this time, I do not think we have a lower limit for age or size. On our 6-year-old boy, there was still plenty of room even using the lo-mm scope. There is no question though that the principles mentioned in this paper must be followed; that is, the instruments may have to be brought further down the abdominal wall, including the umbilical trocar. Again, this is because of the relatively larger size of the liver and the need to effectively separate the instruments thus preventing “dueling instruments,” as has been mentioned by Dr Holcomb. One would think that cholecystectomy in a patient under 2 years of age would be problematic by this approach. My personal preference has been to start with a laparoscopic approach and convert to an open cholecystectomy if it appears that difficulties may arise. Finally, open cholecystectomy is an extremely safe procedure and remains the gold standard for cholecystectomy. Although there were no major complications in this small group, there is no question that laparoscopic cholecystectomy has been associated with a higher incidence of common duct injury. If this procedure is to be confidently offered to our patients,

MOIR, DONOHUE, AND HEERDEN

it behooves us to be as safe and conservative as possible during this start-up phase, avoiding some of the difficulties that have been seen with the adult patients; this probably means a higher conversion rate to open cholecystectomy, which no doubt means a longer hospital stay, but certainly prevents the major complications. Dr Rothenberg, I absolutely agree that the decision to do laparoscopic cholecystectomy depends on your ability to get out of trouble. This includes the surgeon’s ability to deal with complications and the back up ability of our colleagues to perform ERCP or transhepatic procedures. I also believe that we should be attempting intraoperative cholangiogram more often than not, but still use the same indications as for an open procedure. This includes uncertainty of the ductal anatomy. The selective approach to operative cholangiogram is entirely patient- and proceduredependent. In this small series of patients, the procedures went extremely well. We could see exactly what was going on, and therefore, only thought cholangiogram necessary in one of the patients for possible common duct stones. Finally, in response to Dr Holcomb’s suggestion for placement of the epigastric trocar to the left of the falciform ligament. I believe this is a very good idea, especially in patients whose body habitus precludes separation of the instruments. An additional trocar placement has been reported to help in retraction of the left lobe of the liver when dissection of the gallbladder has been difficult. Again, I think this additional trocar could be avoided with more inferior and perhaps more lateral placement of the operating trocars.