Laparoscopic
Cholecystectomy
By Kurt D. Newman,
Louis M. Marmon,
Robert
in Pediatric Attorri,
and Stephen
Patients Evans
Washington, DC l Laparoscopic cholecystectomy has gained increasing application as an operative approach for adults with gallbladder disease. We assessed the safety and feasability of this technique in five pediatric patients with symptomatic cholelithiasis, two of whom had sickle cell disease. With several technical modifications, we found that laparoscopic cholecystectomy was safe and effective in children. This technique permitted early discharge with expedient return to full activity. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: Cholecystectomy,
laparoscopic,
pediatric.
I
N RECENT years, cholelithiasis has been recognized in increasing numbers of pediatric patients.’ The traditional surgical approach to the management of symptomatic cholelithiasis in children has been open cholecystectomy as for adults. Laparoscopic cholecystectomy has been introduced as an alternative to open cholecystectomy for adults.2’ Published series of laparoscopic cholecystectomies report decreased length of hospital stay, diminished costs, and lower morbidity for patients undergoing this procedure. Because children and adolescents might similarly benefit from laparoscopic cholecystectomy, we have begun a study of this technique to assess its safety and feasibility for pediatric patients with symptomatic cholelithiasis. MATERIALS
AND
METHODS
The children undergo general anesthesia and are placed in a supine Trendelenburg position. A nasogastric tube and a urinary catheter are placed. A Veress needle is introduced into the peritoneal cavity through a small incision just inferior to the umbilicus. An adequate pneumoperitoneum is obtained and for children is approximately 1 to 1.5 L, although in adults it is 2 to 4 L. When an adequate tympanitic pneumoperitoneum is achieved, a larger trocar is inserted followed by placement of the laparoscope with a camera attachment. Three additional trocars are inserted into the peritoneal cavity under direct vision, 4 to 5 fingerbreadths below the right costal margin. These are more caudad and lateral than the usual placement for adults (Fig 1).
From the Departments of Pediatric Surgery, Children’s National MedicaZ Center, George Washington University, and Georgetown University School of Medicine, Washington, DC. Date received: fanuary 31,199l; date accepted: April 23,1991. Address reprint requests to Kurt D. Newman, MD, Department of Surgery, Children’s National Medical Center, 11 I Michigan Ave m Washington, DC 20010. Copyright o 1991 by W. B. Saunders Company 0022-3468/91/2610-0010$03.00/0
1184
The gallbladder is identified, placed on traction, and dissected away from the duodenum. The cystic duct and artery are isolated and divided between clips. Cholangiography may be performed safely when indicated. A small cholangiocatheter is introduced through a specially designed instrument which passes through the trocar. This instrument places traction on the cystic duct, holds the catheter in place, and prevents extravasation of contrast. Cholangiography may be particularly important in children in order to demonstrate the ductal anatomy and congenital anomalies, thereby avoiding ductal or vascular injuries. Once the cystic duct and artery have been identified and divided, the gallbladder is dissected from the liver bed, using electrocautery or laser dissection. In this series, we used electrocautery because of the lower margin of safety of the laser in the smaller pediatric abdomen. The gallbladder is then removed through the umbilical incision under direct vision. The gallbladder bed is irrigated and the trocars are removed after release of the pneumoperitoneum. The incisions are closed with subcuticular sutures. RESULTS
Five children, ranging in age from 7 to 16 years, underwent laparoscopic cholecystectomy. The mean weight was 51 kg (range, 20 to 82 kg). All five patients had biliary colic and ultrasound evidence of cholelithiasis. There were no operative complications, and the mean time of surgery was 94 minutes (range, 77 to 115). Three patients were admitted on the morning of operation; the exceptions being the two children with sickle cell disease who required a preoperative exchange transfusion. Pathology examination showed cholelithiasis in all cases. The mean hospital stay was 28.5 hours (range, 20 to 34). All five returned to school and their presurgery activity within a week. DISCUSSION
Technical advances have led to the widespread application of laparoscopic cholecystectomy for adults with biliary colic and, increasingly, for those with acute cholecystitis. With a few technical modifications, we have applied the technique of laparoscopic cholecystectomy to smaller and younger patients. These modifications include lateral and caudad placement of the trocars to facilitate manipulation of the gallbladder and down-sizing the laparoscopic equipment. The advantages of Iaparoscopic cholecystectomy derive from the small incisions and avoidance of bowel manipulation and resultant ileus. Patients recover rapidly and lengthy hospital stays are avoided. The morbidity of prolonged bed rest is minimized. Hospitalization costs are markedly decreased. For
Journaloft’ediatric
Surgery, Vol26, No 10 (October), 1991: pp 1184-l 185
LAPAROSCOPIC
CHOLECYSTECTOMY
IN CHILDREN
1185
\
Fig 1. Placement of trocar incision sites for adult and pediatric laparorcopic cholecystectomy. A, adult sites; P, pediatric sites. Right anterior axillaty line and midclavicular line: A, and AZ, 2 to 3 cm below costal margin; P, and P2, 4 to 6 cm below costal margin. One centimeter to the right of the midline: A.,, % the distance from the xyphoid to the umbilicus; P,, % the distance from the typhoid to the umbilicus.
younger patients, the ability to return to school and normal activities is of special importance. The minimization of scarring is an additional gain, especially when dealing with adolescents.
This technique may be of prime benefit to children and adolescents with sickle cell disease and other hemoglobinopathies. These children are at higher risk for the development of gallstones.5.6 Differentiation of pain due to gallstones from sickle cell crisis is difficult. The management of sickle cell patients with asymptomatic gallstones has been controversial. Because laparoscopic cholecystectomy is less debilitating than open cholecystectomy, a strategy using earlier surgical intervention for sickle cell patients may decrease the morbidity of gallbladder disease in these patients.’ Because gallbladder disease is increasingly recognized in smaller and younger children, technical refinements are necessary to extend laparoscopic cholecystectomy to the very small children.8-1’ Indications at present include only those children with cholelithiasis and biliary colic or those with a hemoglobinopathy and asymptomatic gallstones. Careful studies are required to document the utility and safety of laparoscopic cholecystectomy in pediatric patients with acute cholecystitis. Choledocholithiasis is currently a relative contraindication, although management strategies using endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy, combined with laparoscopic cholecystectomy, are being used in adults. Because ERCP may not be as technically feasible in children, new technology that permits common duct exploration, either directly or through the cystic duct, will find special application in children with common duct stones. Laparoscopic cholecystectomy is a safe and feasible alternative to open cholecystectomy for pediatric patients with symptomatic cholelithiasis.
REFERENCES 1. Holcombe GW Jr, Holcombe GW III: Cholelithiasis in infants, children and adolescents. Pediatr Rev 11:268-274,199O 2. Dubois F, Icard P, Berthelot G, et al: Coelioscopic cholecystectomy. Ann Surg 211:60-62, 1990 3. Reddick EJ, Olsen DO: Laparoscopic laser cholecystectomy. Surg Endosc 3:131,1989 4. Sackier JM, Berci G: Laparoscopic cholecystectomy. Contemp Surg 37:15-26,199O 5. Everson GT, Nemeth A, Kourourian S, et al: Gallbladder function is altered in sickle hemoglobinopathy. Gastroenterology 96:1307-1316, 1989 6. Ware R, Filston HC, Schultz WH, et al: Elective cholecystectomy in children with sickle hemoglobinopathies. Ann Surg 208:1722.1988
7. Malone BS, Werhn SL: Cholecystectomy and cholelithiasis in sickle cell anemia. Am J Dis Child 142:799-800, 1988 8. Robertson JF, Carachi R, Sweet EM, et al: Cholelithiasis in childhood: A follow-up study. J Pediatr Surg 23:246-249,198s 9. Pappis CH, Galanakis S, Moussatos G, et al: Experience of splenectomy and cholecystectomy in children with chronic hemolytic anemia. J Pediatr Surg 24:543-546, 1989 10. Schirmer WJ, Grisoni ER, Gauderer MW: The spectrum of cholelithiasis in the first year of life. J Pediatr Surg 24:1064-1067, 1989 11. Bailey PV, Connors RH, Tracy TF, et al: Changing spectrum of cholehthiasis and cholecystitis in infants and children. Am J Surg 158:585-588, 1989
Cholecystectomy
By Kurt D. Newman,
Louis M. Marmon,
Robert
in Pediatric Attorri,
and Stephen
Patients Evans
Washington, DC l Laparoscopic cholecystectomy has gained increasing application as an operative approach for adults with gallbladder disease. We assessed the safety and feasability of this technique in five pediatric patients with symptomatic cholelithiasis, two of whom had sickle cell disease. With several technical modifications, we found that laparoscopic cholecystectomy was safe and effective in children. This technique permitted early discharge with expedient return to full activity. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: Cholecystectomy,
laparoscopic,
pediatric.
I
N RECENT years, cholelithiasis has been recognized in increasing numbers of pediatric patients.’ The traditional surgical approach to the management of symptomatic cholelithiasis in children has been open cholecystectomy as for adults. Laparoscopic cholecystectomy has been introduced as an alternative to open cholecystectomy for adults.2’ Published series of laparoscopic cholecystectomies report decreased length of hospital stay, diminished costs, and lower morbidity for patients undergoing this procedure. Because children and adolescents might similarly benefit from laparoscopic cholecystectomy, we have begun a study of this technique to assess its safety and feasibility for pediatric patients with symptomatic cholelithiasis. MATERIALS
AND
METHODS
The children undergo general anesthesia and are placed in a supine Trendelenburg position. A nasogastric tube and a urinary catheter are placed. A Veress needle is introduced into the peritoneal cavity through a small incision just inferior to the umbilicus. An adequate pneumoperitoneum is obtained and for children is approximately 1 to 1.5 L, although in adults it is 2 to 4 L. When an adequate tympanitic pneumoperitoneum is achieved, a larger trocar is inserted followed by placement of the laparoscope with a camera attachment. Three additional trocars are inserted into the peritoneal cavity under direct vision, 4 to 5 fingerbreadths below the right costal margin. These are more caudad and lateral than the usual placement for adults (Fig 1).
From the Departments of Pediatric Surgery, Children’s National MedicaZ Center, George Washington University, and Georgetown University School of Medicine, Washington, DC. Date received: fanuary 31,199l; date accepted: April 23,1991. Address reprint requests to Kurt D. Newman, MD, Department of Surgery, Children’s National Medical Center, 11 I Michigan Ave m Washington, DC 20010. Copyright o 1991 by W. B. Saunders Company 0022-3468/91/2610-0010$03.00/0
1184
The gallbladder is identified, placed on traction, and dissected away from the duodenum. The cystic duct and artery are isolated and divided between clips. Cholangiography may be performed safely when indicated. A small cholangiocatheter is introduced through a specially designed instrument which passes through the trocar. This instrument places traction on the cystic duct, holds the catheter in place, and prevents extravasation of contrast. Cholangiography may be particularly important in children in order to demonstrate the ductal anatomy and congenital anomalies, thereby avoiding ductal or vascular injuries. Once the cystic duct and artery have been identified and divided, the gallbladder is dissected from the liver bed, using electrocautery or laser dissection. In this series, we used electrocautery because of the lower margin of safety of the laser in the smaller pediatric abdomen. The gallbladder is then removed through the umbilical incision under direct vision. The gallbladder bed is irrigated and the trocars are removed after release of the pneumoperitoneum. The incisions are closed with subcuticular sutures. RESULTS
Five children, ranging in age from 7 to 16 years, underwent laparoscopic cholecystectomy. The mean weight was 51 kg (range, 20 to 82 kg). All five patients had biliary colic and ultrasound evidence of cholelithiasis. There were no operative complications, and the mean time of surgery was 94 minutes (range, 77 to 115). Three patients were admitted on the morning of operation; the exceptions being the two children with sickle cell disease who required a preoperative exchange transfusion. Pathology examination showed cholelithiasis in all cases. The mean hospital stay was 28.5 hours (range, 20 to 34). All five returned to school and their presurgery activity within a week. DISCUSSION
Technical advances have led to the widespread application of laparoscopic cholecystectomy for adults with biliary colic and, increasingly, for those with acute cholecystitis. With a few technical modifications, we have applied the technique of laparoscopic cholecystectomy to smaller and younger patients. These modifications include lateral and caudad placement of the trocars to facilitate manipulation of the gallbladder and down-sizing the laparoscopic equipment. The advantages of Iaparoscopic cholecystectomy derive from the small incisions and avoidance of bowel manipulation and resultant ileus. Patients recover rapidly and lengthy hospital stays are avoided. The morbidity of prolonged bed rest is minimized. Hospitalization costs are markedly decreased. For
Journaloft’ediatric
Surgery, Vol26, No 10 (October), 1991: pp 1184-l 185
LAPAROSCOPIC
CHOLECYSTECTOMY
IN CHILDREN
1185
\
Fig 1. Placement of trocar incision sites for adult and pediatric laparorcopic cholecystectomy. A, adult sites; P, pediatric sites. Right anterior axillaty line and midclavicular line: A, and AZ, 2 to 3 cm below costal margin; P, and P2, 4 to 6 cm below costal margin. One centimeter to the right of the midline: A.,, % the distance from the xyphoid to the umbilicus; P,, % the distance from the typhoid to the umbilicus.
younger patients, the ability to return to school and normal activities is of special importance. The minimization of scarring is an additional gain, especially when dealing with adolescents.
This technique may be of prime benefit to children and adolescents with sickle cell disease and other hemoglobinopathies. These children are at higher risk for the development of gallstones.5.6 Differentiation of pain due to gallstones from sickle cell crisis is difficult. The management of sickle cell patients with asymptomatic gallstones has been controversial. Because laparoscopic cholecystectomy is less debilitating than open cholecystectomy, a strategy using earlier surgical intervention for sickle cell patients may decrease the morbidity of gallbladder disease in these patients.’ Because gallbladder disease is increasingly recognized in smaller and younger children, technical refinements are necessary to extend laparoscopic cholecystectomy to the very small children.8-1’ Indications at present include only those children with cholelithiasis and biliary colic or those with a hemoglobinopathy and asymptomatic gallstones. Careful studies are required to document the utility and safety of laparoscopic cholecystectomy in pediatric patients with acute cholecystitis. Choledocholithiasis is currently a relative contraindication, although management strategies using endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy, combined with laparoscopic cholecystectomy, are being used in adults. Because ERCP may not be as technically feasible in children, new technology that permits common duct exploration, either directly or through the cystic duct, will find special application in children with common duct stones. Laparoscopic cholecystectomy is a safe and feasible alternative to open cholecystectomy for pediatric patients with symptomatic cholelithiasis.
REFERENCES 1. Holcombe GW Jr, Holcombe GW III: Cholelithiasis in infants, children and adolescents. Pediatr Rev 11:268-274,199O 2. Dubois F, Icard P, Berthelot G, et al: Coelioscopic cholecystectomy. Ann Surg 211:60-62, 1990 3. Reddick EJ, Olsen DO: Laparoscopic laser cholecystectomy. Surg Endosc 3:131,1989 4. Sackier JM, Berci G: Laparoscopic cholecystectomy. Contemp Surg 37:15-26,199O 5. Everson GT, Nemeth A, Kourourian S, et al: Gallbladder function is altered in sickle hemoglobinopathy. Gastroenterology 96:1307-1316, 1989 6. Ware R, Filston HC, Schultz WH, et al: Elective cholecystectomy in children with sickle hemoglobinopathies. Ann Surg 208:1722.1988
7. Malone BS, Werhn SL: Cholecystectomy and cholelithiasis in sickle cell anemia. Am J Dis Child 142:799-800, 1988 8. Robertson JF, Carachi R, Sweet EM, et al: Cholelithiasis in childhood: A follow-up study. J Pediatr Surg 23:246-249,198s 9. Pappis CH, Galanakis S, Moussatos G, et al: Experience of splenectomy and cholecystectomy in children with chronic hemolytic anemia. J Pediatr Surg 24:543-546, 1989 10. Schirmer WJ, Grisoni ER, Gauderer MW: The spectrum of cholelithiasis in the first year of life. J Pediatr Surg 24:1064-1067, 1989 11. Bailey PV, Connors RH, Tracy TF, et al: Changing spectrum of cholehthiasis and cholecystitis in infants and children. Am J Surg 158:585-588, 1989
