/NWUNW_
The Technique of Laparoscopic in Children
Cholecystectomy
ANDREW M. DAVIDOFF, M.D.,* GENE D. BRANUM, M.D.,* ELIZABETH A. MURRAY, R.N.,* WUI K. CHONG, M.D.,t RUSSELL E. WARE, M.D.,4 THOMAS R. KINNEY, M.D.,4 THEODORE N. PAPPAS, M.D.,* and WILLIAM C. MEYERS, M.D.*
Twelve children underwent elective laparoscopic cholecystectomy for symptomatic cholelithiasis during a 10-month period in one institution. The operative technique that has been described for adults was modified because of the smaller dimensions of pediatric patients. These modifications are discussed in this report, as are new alternatives for evaluating the common duct. No operative complications or conversions to open cholecystectomy occurred, and no complications after surgery were seen during an average follow-up period of 4.5 months. The benefits of laparoscopic cholecystectomy include decreased pain and ileus after surgery, shortened hospitalization, and improved cosmesis. Laparoscopic cholecystectomy is safe and efficacious in children, and it compares favorably with traditional cholecystectomy in the pediatric age group. 'L
APAROSCOPIC CHOLECYSTECTOMY HAS rapidly become a popular alternative to open cholecystectomy in adult patients. The safety and efficacy of this approach are well documented in large series of adult patients treated by skilled surgeons. 1-4 Although the number of children and adolescents who require surgical removal of the gallbladder is relatively small, the benefits of the laparoscopic approach are particularly attractive for these younger age groups. The technique of laparoscopic cholecystectomy was used successfully in 12 pediatric patients, with minor modifications that are described in this report.
Patients and Methods Patients Twelve children underwent elective laparoscopic cholecystectomy at Duke University Medical Center during Address reprint requests to William C. Meyers, M.D., Box 3041, Duke
University Medical Center, Durham, NC 27710. Accepted for publication October 4, 1991.
186
From the Departments of Surgery,* Radiology,t and Pediatrics,f Duke University Medical Center, Durham, North Carolina
the 10-month period from October 1990 through July 1991. Seven patients were male and five female. The average age was 13 years, with a range of 8 to 19 years. In each case, the indication for operation was symptomatic cholelithiasis. Gallstones were documented before surgery by ultrasonography in each patient. In 11 children, cholelithiasis had developed as a complication of a hemolytic disorder, and 1 child had gallstones secondary to glycogen storage disease (Table 1). Patients with sickle hemoglobinopathies received red blood cell transfusions and intravenous hydration as part of a preoperative routine.5 Methods The patient is placed in the supine position on the operating table. After the induction of general anesthesia, a Foley catheter is placed in the urinary bladder and an orogastric tube passed into the stomach. The abdomen is prepared widely and draped in the usual sterile fashion. A 1.5-cm incision is made, either as a "smile" just inside the umbilicus or through the lower margin ofthe umbilical ring, and a Verres insufflation needle is inserted through the skin incision and into the peritoneal cavity, directed caudally toward the pelvis, as for diagnostic peritoneal lavage. For small children with relatively scaphoid abdomens, an alternative technique is the use of the Hassan trocar, which is placed through the fascia and into the peritoneal cavity under direct vision to avoid penetrating any abdominal viscera or the less mobile retroperitoneal vascular structures. Another reason for direct trocar insufflation in pediatric patients is the potential or suspected
LAPAROSCOPIC CHOLECYSTECTOMY IN CHILDREN
Vol. 215 * No. 2
TABLE 1. Patient Characteristics
Medical Condition
No. of Patients
Major sickle hemoglobinopathy Hereditary spherocytosis Glycogen storage disease Dyserythropoetic anemia
9 I I I
presence of an umbilical hernia that may contain bowel adhered to the peritoneal lining. This situation is not a frequent concern in adults. Once the tip of the Verres needle or Hassan trocar is within the peritoneal cavity, carbon dioxide (CO2) is insufflated to a pressure of 15 mm Hg, usually provided by a volume of -2 liters. A greater insufflation pressure is usually not necessary because of the elasticity of the abdominal wall of children. A 10-mm disposable trocar is inserted through the umbilical incision ifthe Hassan trocar is not being used, and the operating camera is introduced into the abdominal cavity. Three additional skin incisions are then made, one in the upper midline just below the xiphoid process and two others along the subcostal margin. These incisions are placed as far apart as possible to avoid overlap of the instruments during the dissection. Under direct laparoscopic visualization, a second 10-mm trocar is passed through the upper midline incision to the right of the falciform ligament, and 5-mm trocars are passed through the subcostal incisions (Fig. 1). The next consideration is providing adequate exposure of Calot's triangle at the neck of the gallbladder. This procedure is easily performed in adults by retracting the body of the gallbladder up and over the edge of the liver. However, the small dimensions of the right upper quadrant in children and the large liver in these patients, who frequently have various metabolic disturbances, may make it impossible for traction on the gallbladder fundus to provide adequate exposure. Therefore, the gallbladder must be grasped lower, toward Calot's triangle, and retracted in a caudal direction (Fig. 1). After exposure of Calot's triangle has been achieved and blunt dissection of pericholecystic adhesions has been performed, the next consideration is cholangiography. Because of the higher incidence of common duct abnormalities in patients with hemolytic disorders and the small portal anatomy in pediatric patients, cholangiography is usually desirable.6 Possible techniques include percutaneous puncture of the gallbladder under direct vision with an intravenous catheter (Fig. 2A), or direct cystic duct cannulation with a cholangiocatheter passed through an Olsen forceps (Fig. 2B), with Renografin (Squibb Diagnostics, New Brunswick, NJ) injection and common duct visualization with static films or fluoroscopy. The method should be chosen based on the size of the patient and cystic duct, the location ofthe stones, the amount of hilar
187
inflammation, the exposure, and the type of information sought. For example, a gallbladder cholangiogram is usually more appropriate with severe hilar inflammation or difficult exposure. Cystic duct cannulation is usually better when exposure is adequate and a large duct is present or proximal cystic duct stones are suspected. A new alternative for common duct visualization is intraductal ultrasonography, in which an ultrasound probe is passed down the cystic and common ducts, through the ampulla of Vater, and into the duodenum (Fig. 3). This has the benefit of imaging directly the ducts and avoiding ionizing radiation. As with adult patients, blunt dissection of the cystic duct is begun at the neck of the gallbladder and proceeds toward the common duct. The cystic duct is freed from surrounding areolar tissue, and the cystic duct-common duct junction is identified. Clips are applied to the cystic duct, which is then divided with operating scissors. The cystic artery is then dissected bluntly, clipped, and divided in a similar fashion (Fig. 4). The blunt dissector is then replaced with the hook cautery. The gallbladder peritoneum is then incised and the gallbladder removed from its bed. Because ofthe small dimensions in the right upper quadrant, the gallbladder may have to be grasped via the midline trocar and dissection performed with one of the lateral trocars to provide adequate traction for the exposure. Decompression of the gallbladder with a suction trocar may also be necessary for optimal visualization of the gallbladder fossa. The gallbladder is removed via either the umbilical or the subxiphoid trocar. The subxiphoid trocar is usually sufficient because of the small size of the gallbladder, making repositioning of the camera to the midline trocar unnecessary. The four abdominal wounds are irrigated and closed with absorbable sutures. Subhepatic drains may easily be placed laparoscopically through any of the trocar sites. Usually one or two heavy absorbable sutures are required for closure of the umbilical fascial defect. Before closure, it is important to check, either directly or via the laparoscope, for the presence of an umbilical hernia, which can then be repaired simultaneously with the closure. Results Details of the management during surgery and the course of nine of the patients with sickle hemoglobinopathies were previously described in detail.7 Briefly, each of the 12 patients in the current series underwent successful laparoscopic cholecystectomy. The mean operative time was 86 ± 15 minutes, and the mean time for general anesthesia was 135 ± 25 minutes. No operative complications occurred, and the estimated blood loss for each patient was minimal. A cholangiogram was performed during surgery on 6 patients, and intraductal ultrasound was performed on 1 patient. No common bile duct stones
188
DAVIDOFF AND OTHERS
Ann. Surg. * February 1992
10 mm trocar with insufflation of CO2
5
mm
trocar with clamp
5 mm trocar with clamp grasping neck of gallbladder
10
mm
trocar with video camera
FIG. 1. The positioning of the four transabdominal trocars for laparoscopic cholecystectomy. Note the limited room for instrument manipulation in the right upper quadrant due to smaller patient dimensions and enlarged liver frequently found in the pediatric population.
Vol. 215.- No. 2
LAPAROSCOPIC CHOLECYSTECTOMY IN CHILDREN
189
Cholangiogram via percutaneous needle in gallbladder
A
Cholangiogram catheter in cystic duct
B FIG. 2. Alternatives for cholangiography. (A) Percutaneous placement of an intravenous catheter under direct vision across the abdominal wall and into the gallbladder. (B) Direct cannulation of the cystic duct with a cholangiocatheter passed through an Olsen forceps. were detected by these techniques. The remaining patients were believed to have small common ducts that did not
scintigraphy showed no leak or obstruction of the extrahepatic biliary system, and the cause of his abdominal
require cholangiography. Two patients underwent coincidental repair of umbilical hernias. The postoperative course was generally uncomplicated. Most of the patients tolerated a regular diet the morning after surgery, and all but 2 ofthe patients were discharged within 2 days of the procedure. Two patients could not tolerate a regular diet until the third day after surgery and so were not discharged until that time. One patient with sickle cell disease had slightly more abdominal tenderness than was expected after surgery and underwent endoscopic retrograde pancreatocholangiography to exclude bile duct abnormality. The study findings were normal, and the patient's symptoms improved rapidly. Laparoscopic cholecystectomy did not relieve the intermittent diffuse abdominal pain in the child who had dyserythropoetic anemia. Ultrasound performed after surgery showed a small amount of fluid in the gallbladder fossa, but biliary
pain remains uncertain.
The children resumed their normal activities almost immediately after returning home. No long-term biliary complications were seen in these 12 patients during an average follow-up period of 4.5 months (range = 2-12 months). Discussion The benefits of laparoscopic cholecystectomy when compared with the traditional open approach are numerous. Decreased pain after surgery'" and improved pulmonary function8 have been well documented in several large adult series and were observed in this group of children. This finding is particularly important for the younger patients and those patients with sickle cell disease,
DAVIDOFF AND OTHERS
190
Ann. Surg. * February 1992
Common bile duct
Common hepatic duct1
_2
Cystic duct
I_
_
,
F]
_
Probe in common i
Probe in cystic duct
bile duct
I
A
B
FIG. 3. Intraluminal ultrasound of the common bile duct with a 20 MHz mechanically rotated transducer mounted on the end of a braided metal cable enclosed within a 6.6 Fr catheter. The black circle represents the transducer. (A) Cross-sectional image taken with the transducer in the cystic duct, showing the common hepatic duct. (B) Cross-section of the common duct showing the lumen and the wall.
in whom good postoperative pulmonary toilet is essential and in whom abdominal pain may be otherwise suggestive of sickle cell crisis. Decreased pain and duration of ileus
of Ligation 9
Cystic duict
and divided
FIG. 4. Clip ligation of the cystic artery after ligation and division of the cystic duct.
after surgery have resulted in a prompt return in appetite for these patients, enabling them to tolerate a regular diet sooner, usually the first morning after surgery and, consequently, permitting earlier discharge. When compared with 20 children reported previously who underwent open cholecystectomy (and inversion appendectomy),' the average length of hospitalization after surgery deceased by more than 70%, from 6.2 days to 1.7 days. The return to normal activity is dramatic; the most frequently expressed concern by parents whose child has undergone laparoscopic cholecystectomy has been whether the child is being too active too soon. Although the standard subcostal incision for open cholecystectomy heals with minimal scarring in children, the four small incisions made for the trocars used in the laparoscopic procedures are usually barely visible 4 months after surgery. Seven of the 12 patients in this series underwent intraoperative cholangiogram, and each study showed a widely patent common bile duct without evidence of common duct stones. Tiny cystic ducts were found in the other five patients who had large stones in the gallbladder, so cholangiograms were not performed. If choledocholithiasis is
Vol. 215 No. 2 -
LAPAROSCOPIC CHOLECYSTECTOMY IN CHILDREN
shown by cholangiogram, the common bile duct should be flushed vigorously with saline through the cystic duct cholangiocatheter in an attempt to force the stone into the duodenum. This approach usually has a high rate of success.56 However, if it fails, options include simply completing the laparoscopic procedure and following the patient postoperatively if the stones are small, referring the patient for endoscopic sphincterotomy after surgery, or converting the procedure to open laparotomy and performing a standard common duct exploration. Choledochoscopes that can be used during laparoscopic cholecystectomy in adult patients are available, but these instruments are too large to be useful in pediatric patients. The decision to perform laparoscopic cholecystectomy in children who are likely to have choledocholithiasis, i.e., patients with jaundice, pancreatitis, dilated ducts, or choledocholithiasis shown before surgery, may vary among different institutions, depending on the expertise at that hospital in pediatric endoscopy. The incidence of biliary injury during laparoscopic cholecystectomy in larger adult series has been very low, but the morbidity can be significant. No biliary complications were observed in this series, but the experience with laparoscopic cholecystectomy in adult patients has led to several recommendations.9 As with traditional open procedures, technical aspects of the surgery appear to be important. Adequate visualization of the portal structures is essential. The cystic duct and artery should be identified clearly before ligation and division of any structures in the porta hepatis. These structures can be quite small in younger patients, and great care must be taken when identifying and manipulating them. The laparoscope camera, because of its proximity to the operating field, may provide better visualization than is possible during an open procedure. Ideally, both the gallbladder-cystic duct and cystic duct-common duct junctions should be visualized. Acute inflammation and chronic scarring of the gallbladder bed can restrict adequate identification of the anatomy, and early consideration of conversion to open cholecystectomy is important when the anatomy remains uncertain. If unusual measures are necessary to control hemorrhage in the portal region, particularly when visualization is inadequate, burn or ischemic stricture of the common hepatic duct can occur. Finally, dissection away from the gallbladder neck toward the common duct, instead of in the other direction, may help prevent the common duct from being mistaken for the cystic duct and subsequently divided, the classic injury in adult patients.9 Biliary injury is rarely recognized during surgery; patients usually report persistent abdominal pain 1 to 2 weeks after surgery.9 One of the major benefits of the laparoscopic approach for cholecystectomy is the minimizing
191
of postoperative pain; therefore, significant abdominal pain after surgery, distinct from the pain of sickle cell crisis, should raise the suspicion ofbiliary injury and may warrant investigation with endoscopic retrograde pancreatocholangiography or biliary scintigraphy. The smallest patient in this series weighed 21 kg. It is not known whether there is a minimum patient weight below which the benefits of the laparoscopic approach may be diminished. The smaller portal structures may be difficult to identify, and the limited dimensions of the right upper quadrant may make the dexterous manipulation of the laparoscopic instruments impossible. The procedures in this series were all performed with adult instruments. As the utility of the laparoscopic approach for pediatric patients becomes apparent, smaller equipment may become available and permit this procedure to be performed on smaller patients. The performance of laparoscopic cholecystectomy by trained surgeons is clearly safe and efficacious for the pediatric population. Although there is a definite learning curve for the technique, its benefits, which are particularly attractive for pediatric patients, make it an important alternative to open laparotomy and cholecystectomy in children. Acknowledgments The authors thank Rob Gordon for providing the illustrations for this article.
References 1. Peters JH, Ellison EC, Innes JT, et al. Safety and efficacy of laparoscopic cholecystectomy: a prospective analysis of 100 initial patients. Ann Surg 1991; 213:3-12. 2. The Southern Surgeons Club. A prospective analysis of 1,518 laparoscopic cholecystectomies performed by Southern U.S. surgeons. N Engl J Med 1991; 324:1073-1078. 3. Graves HA, Ballinger JF, Anderson WJ. Appraisal of laparoscopic cholecystectomy. Ann Surg 1991; 213:655-664. 4. Schirmer BD, Edge SB, Dix J, et al. Laparoscopic cholecystectomy: treatment of choice for symptomatic cholelithiasis. Ann Surg 199 1; 213:665-677. 5. Ware RE, Filston HC, Schultz WH, Kinney TR. Elective cholecystectomy in children with sickle hemoglobinopathies: successful outcome using a preoperative transfusion regimen. Ann Surg
1988; 208:17-22. 6. Ware RE, Schultz WH, Filston HC, Kinney TR. Diagnosis and management of common bile duct stones in patients with sickle hemoglobinopathies. J Pediatr Surg (in press). 7. Ware RE, Kinney TR, Casey JR, et al. Cholecystectomy in children with sickle hemoglobinopathies: reduced morbidity using laparoscopy. J Pediatr (in press). 8. Frazee RC, Roberts JW, Okeson GC, et al. Open versus laparoscopic cholecystectomy: a comparison of postoperative pulmonary function. Ann Surg 1991; 213:651-654. 9. Davidoff AM, Pappas TN, Murray EA, et al. Mechanisms of biliary injury during laparoscopic cholecystectomy. Ann Surg (in press).
The Technique of Laparoscopic in Children
Cholecystectomy
ANDREW M. DAVIDOFF, M.D.,* GENE D. BRANUM, M.D.,* ELIZABETH A. MURRAY, R.N.,* WUI K. CHONG, M.D.,t RUSSELL E. WARE, M.D.,4 THOMAS R. KINNEY, M.D.,4 THEODORE N. PAPPAS, M.D.,* and WILLIAM C. MEYERS, M.D.*
Twelve children underwent elective laparoscopic cholecystectomy for symptomatic cholelithiasis during a 10-month period in one institution. The operative technique that has been described for adults was modified because of the smaller dimensions of pediatric patients. These modifications are discussed in this report, as are new alternatives for evaluating the common duct. No operative complications or conversions to open cholecystectomy occurred, and no complications after surgery were seen during an average follow-up period of 4.5 months. The benefits of laparoscopic cholecystectomy include decreased pain and ileus after surgery, shortened hospitalization, and improved cosmesis. Laparoscopic cholecystectomy is safe and efficacious in children, and it compares favorably with traditional cholecystectomy in the pediatric age group. 'L
APAROSCOPIC CHOLECYSTECTOMY HAS rapidly become a popular alternative to open cholecystectomy in adult patients. The safety and efficacy of this approach are well documented in large series of adult patients treated by skilled surgeons. 1-4 Although the number of children and adolescents who require surgical removal of the gallbladder is relatively small, the benefits of the laparoscopic approach are particularly attractive for these younger age groups. The technique of laparoscopic cholecystectomy was used successfully in 12 pediatric patients, with minor modifications that are described in this report.
Patients and Methods Patients Twelve children underwent elective laparoscopic cholecystectomy at Duke University Medical Center during Address reprint requests to William C. Meyers, M.D., Box 3041, Duke
University Medical Center, Durham, NC 27710. Accepted for publication October 4, 1991.
186
From the Departments of Surgery,* Radiology,t and Pediatrics,f Duke University Medical Center, Durham, North Carolina
the 10-month period from October 1990 through July 1991. Seven patients were male and five female. The average age was 13 years, with a range of 8 to 19 years. In each case, the indication for operation was symptomatic cholelithiasis. Gallstones were documented before surgery by ultrasonography in each patient. In 11 children, cholelithiasis had developed as a complication of a hemolytic disorder, and 1 child had gallstones secondary to glycogen storage disease (Table 1). Patients with sickle hemoglobinopathies received red blood cell transfusions and intravenous hydration as part of a preoperative routine.5 Methods The patient is placed in the supine position on the operating table. After the induction of general anesthesia, a Foley catheter is placed in the urinary bladder and an orogastric tube passed into the stomach. The abdomen is prepared widely and draped in the usual sterile fashion. A 1.5-cm incision is made, either as a "smile" just inside the umbilicus or through the lower margin ofthe umbilical ring, and a Verres insufflation needle is inserted through the skin incision and into the peritoneal cavity, directed caudally toward the pelvis, as for diagnostic peritoneal lavage. For small children with relatively scaphoid abdomens, an alternative technique is the use of the Hassan trocar, which is placed through the fascia and into the peritoneal cavity under direct vision to avoid penetrating any abdominal viscera or the less mobile retroperitoneal vascular structures. Another reason for direct trocar insufflation in pediatric patients is the potential or suspected
LAPAROSCOPIC CHOLECYSTECTOMY IN CHILDREN
Vol. 215 * No. 2
TABLE 1. Patient Characteristics
Medical Condition
No. of Patients
Major sickle hemoglobinopathy Hereditary spherocytosis Glycogen storage disease Dyserythropoetic anemia
9 I I I
presence of an umbilical hernia that may contain bowel adhered to the peritoneal lining. This situation is not a frequent concern in adults. Once the tip of the Verres needle or Hassan trocar is within the peritoneal cavity, carbon dioxide (CO2) is insufflated to a pressure of 15 mm Hg, usually provided by a volume of -2 liters. A greater insufflation pressure is usually not necessary because of the elasticity of the abdominal wall of children. A 10-mm disposable trocar is inserted through the umbilical incision ifthe Hassan trocar is not being used, and the operating camera is introduced into the abdominal cavity. Three additional skin incisions are then made, one in the upper midline just below the xiphoid process and two others along the subcostal margin. These incisions are placed as far apart as possible to avoid overlap of the instruments during the dissection. Under direct laparoscopic visualization, a second 10-mm trocar is passed through the upper midline incision to the right of the falciform ligament, and 5-mm trocars are passed through the subcostal incisions (Fig. 1). The next consideration is providing adequate exposure of Calot's triangle at the neck of the gallbladder. This procedure is easily performed in adults by retracting the body of the gallbladder up and over the edge of the liver. However, the small dimensions of the right upper quadrant in children and the large liver in these patients, who frequently have various metabolic disturbances, may make it impossible for traction on the gallbladder fundus to provide adequate exposure. Therefore, the gallbladder must be grasped lower, toward Calot's triangle, and retracted in a caudal direction (Fig. 1). After exposure of Calot's triangle has been achieved and blunt dissection of pericholecystic adhesions has been performed, the next consideration is cholangiography. Because of the higher incidence of common duct abnormalities in patients with hemolytic disorders and the small portal anatomy in pediatric patients, cholangiography is usually desirable.6 Possible techniques include percutaneous puncture of the gallbladder under direct vision with an intravenous catheter (Fig. 2A), or direct cystic duct cannulation with a cholangiocatheter passed through an Olsen forceps (Fig. 2B), with Renografin (Squibb Diagnostics, New Brunswick, NJ) injection and common duct visualization with static films or fluoroscopy. The method should be chosen based on the size of the patient and cystic duct, the location ofthe stones, the amount of hilar
187
inflammation, the exposure, and the type of information sought. For example, a gallbladder cholangiogram is usually more appropriate with severe hilar inflammation or difficult exposure. Cystic duct cannulation is usually better when exposure is adequate and a large duct is present or proximal cystic duct stones are suspected. A new alternative for common duct visualization is intraductal ultrasonography, in which an ultrasound probe is passed down the cystic and common ducts, through the ampulla of Vater, and into the duodenum (Fig. 3). This has the benefit of imaging directly the ducts and avoiding ionizing radiation. As with adult patients, blunt dissection of the cystic duct is begun at the neck of the gallbladder and proceeds toward the common duct. The cystic duct is freed from surrounding areolar tissue, and the cystic duct-common duct junction is identified. Clips are applied to the cystic duct, which is then divided with operating scissors. The cystic artery is then dissected bluntly, clipped, and divided in a similar fashion (Fig. 4). The blunt dissector is then replaced with the hook cautery. The gallbladder peritoneum is then incised and the gallbladder removed from its bed. Because ofthe small dimensions in the right upper quadrant, the gallbladder may have to be grasped via the midline trocar and dissection performed with one of the lateral trocars to provide adequate traction for the exposure. Decompression of the gallbladder with a suction trocar may also be necessary for optimal visualization of the gallbladder fossa. The gallbladder is removed via either the umbilical or the subxiphoid trocar. The subxiphoid trocar is usually sufficient because of the small size of the gallbladder, making repositioning of the camera to the midline trocar unnecessary. The four abdominal wounds are irrigated and closed with absorbable sutures. Subhepatic drains may easily be placed laparoscopically through any of the trocar sites. Usually one or two heavy absorbable sutures are required for closure of the umbilical fascial defect. Before closure, it is important to check, either directly or via the laparoscope, for the presence of an umbilical hernia, which can then be repaired simultaneously with the closure. Results Details of the management during surgery and the course of nine of the patients with sickle hemoglobinopathies were previously described in detail.7 Briefly, each of the 12 patients in the current series underwent successful laparoscopic cholecystectomy. The mean operative time was 86 ± 15 minutes, and the mean time for general anesthesia was 135 ± 25 minutes. No operative complications occurred, and the estimated blood loss for each patient was minimal. A cholangiogram was performed during surgery on 6 patients, and intraductal ultrasound was performed on 1 patient. No common bile duct stones
188
DAVIDOFF AND OTHERS
Ann. Surg. * February 1992
10 mm trocar with insufflation of CO2
5
mm
trocar with clamp
5 mm trocar with clamp grasping neck of gallbladder
10
mm
trocar with video camera
FIG. 1. The positioning of the four transabdominal trocars for laparoscopic cholecystectomy. Note the limited room for instrument manipulation in the right upper quadrant due to smaller patient dimensions and enlarged liver frequently found in the pediatric population.
Vol. 215.- No. 2
LAPAROSCOPIC CHOLECYSTECTOMY IN CHILDREN
189
Cholangiogram via percutaneous needle in gallbladder
A
Cholangiogram catheter in cystic duct
B FIG. 2. Alternatives for cholangiography. (A) Percutaneous placement of an intravenous catheter under direct vision across the abdominal wall and into the gallbladder. (B) Direct cannulation of the cystic duct with a cholangiocatheter passed through an Olsen forceps. were detected by these techniques. The remaining patients were believed to have small common ducts that did not
scintigraphy showed no leak or obstruction of the extrahepatic biliary system, and the cause of his abdominal
require cholangiography. Two patients underwent coincidental repair of umbilical hernias. The postoperative course was generally uncomplicated. Most of the patients tolerated a regular diet the morning after surgery, and all but 2 ofthe patients were discharged within 2 days of the procedure. Two patients could not tolerate a regular diet until the third day after surgery and so were not discharged until that time. One patient with sickle cell disease had slightly more abdominal tenderness than was expected after surgery and underwent endoscopic retrograde pancreatocholangiography to exclude bile duct abnormality. The study findings were normal, and the patient's symptoms improved rapidly. Laparoscopic cholecystectomy did not relieve the intermittent diffuse abdominal pain in the child who had dyserythropoetic anemia. Ultrasound performed after surgery showed a small amount of fluid in the gallbladder fossa, but biliary
pain remains uncertain.
The children resumed their normal activities almost immediately after returning home. No long-term biliary complications were seen in these 12 patients during an average follow-up period of 4.5 months (range = 2-12 months). Discussion The benefits of laparoscopic cholecystectomy when compared with the traditional open approach are numerous. Decreased pain after surgery'" and improved pulmonary function8 have been well documented in several large adult series and were observed in this group of children. This finding is particularly important for the younger patients and those patients with sickle cell disease,
DAVIDOFF AND OTHERS
190
Ann. Surg. * February 1992
Common bile duct
Common hepatic duct1
_2
Cystic duct
I_
_
,
F]
_
Probe in common i
Probe in cystic duct
bile duct
I
A
B
FIG. 3. Intraluminal ultrasound of the common bile duct with a 20 MHz mechanically rotated transducer mounted on the end of a braided metal cable enclosed within a 6.6 Fr catheter. The black circle represents the transducer. (A) Cross-sectional image taken with the transducer in the cystic duct, showing the common hepatic duct. (B) Cross-section of the common duct showing the lumen and the wall.
in whom good postoperative pulmonary toilet is essential and in whom abdominal pain may be otherwise suggestive of sickle cell crisis. Decreased pain and duration of ileus
of Ligation 9
Cystic duict
and divided
FIG. 4. Clip ligation of the cystic artery after ligation and division of the cystic duct.
after surgery have resulted in a prompt return in appetite for these patients, enabling them to tolerate a regular diet sooner, usually the first morning after surgery and, consequently, permitting earlier discharge. When compared with 20 children reported previously who underwent open cholecystectomy (and inversion appendectomy),' the average length of hospitalization after surgery deceased by more than 70%, from 6.2 days to 1.7 days. The return to normal activity is dramatic; the most frequently expressed concern by parents whose child has undergone laparoscopic cholecystectomy has been whether the child is being too active too soon. Although the standard subcostal incision for open cholecystectomy heals with minimal scarring in children, the four small incisions made for the trocars used in the laparoscopic procedures are usually barely visible 4 months after surgery. Seven of the 12 patients in this series underwent intraoperative cholangiogram, and each study showed a widely patent common bile duct without evidence of common duct stones. Tiny cystic ducts were found in the other five patients who had large stones in the gallbladder, so cholangiograms were not performed. If choledocholithiasis is
Vol. 215 No. 2 -
LAPAROSCOPIC CHOLECYSTECTOMY IN CHILDREN
shown by cholangiogram, the common bile duct should be flushed vigorously with saline through the cystic duct cholangiocatheter in an attempt to force the stone into the duodenum. This approach usually has a high rate of success.56 However, if it fails, options include simply completing the laparoscopic procedure and following the patient postoperatively if the stones are small, referring the patient for endoscopic sphincterotomy after surgery, or converting the procedure to open laparotomy and performing a standard common duct exploration. Choledochoscopes that can be used during laparoscopic cholecystectomy in adult patients are available, but these instruments are too large to be useful in pediatric patients. The decision to perform laparoscopic cholecystectomy in children who are likely to have choledocholithiasis, i.e., patients with jaundice, pancreatitis, dilated ducts, or choledocholithiasis shown before surgery, may vary among different institutions, depending on the expertise at that hospital in pediatric endoscopy. The incidence of biliary injury during laparoscopic cholecystectomy in larger adult series has been very low, but the morbidity can be significant. No biliary complications were observed in this series, but the experience with laparoscopic cholecystectomy in adult patients has led to several recommendations.9 As with traditional open procedures, technical aspects of the surgery appear to be important. Adequate visualization of the portal structures is essential. The cystic duct and artery should be identified clearly before ligation and division of any structures in the porta hepatis. These structures can be quite small in younger patients, and great care must be taken when identifying and manipulating them. The laparoscope camera, because of its proximity to the operating field, may provide better visualization than is possible during an open procedure. Ideally, both the gallbladder-cystic duct and cystic duct-common duct junctions should be visualized. Acute inflammation and chronic scarring of the gallbladder bed can restrict adequate identification of the anatomy, and early consideration of conversion to open cholecystectomy is important when the anatomy remains uncertain. If unusual measures are necessary to control hemorrhage in the portal region, particularly when visualization is inadequate, burn or ischemic stricture of the common hepatic duct can occur. Finally, dissection away from the gallbladder neck toward the common duct, instead of in the other direction, may help prevent the common duct from being mistaken for the cystic duct and subsequently divided, the classic injury in adult patients.9 Biliary injury is rarely recognized during surgery; patients usually report persistent abdominal pain 1 to 2 weeks after surgery.9 One of the major benefits of the laparoscopic approach for cholecystectomy is the minimizing
191
of postoperative pain; therefore, significant abdominal pain after surgery, distinct from the pain of sickle cell crisis, should raise the suspicion ofbiliary injury and may warrant investigation with endoscopic retrograde pancreatocholangiography or biliary scintigraphy. The smallest patient in this series weighed 21 kg. It is not known whether there is a minimum patient weight below which the benefits of the laparoscopic approach may be diminished. The smaller portal structures may be difficult to identify, and the limited dimensions of the right upper quadrant may make the dexterous manipulation of the laparoscopic instruments impossible. The procedures in this series were all performed with adult instruments. As the utility of the laparoscopic approach for pediatric patients becomes apparent, smaller equipment may become available and permit this procedure to be performed on smaller patients. The performance of laparoscopic cholecystectomy by trained surgeons is clearly safe and efficacious for the pediatric population. Although there is a definite learning curve for the technique, its benefits, which are particularly attractive for pediatric patients, make it an important alternative to open laparotomy and cholecystectomy in children. Acknowledgments The authors thank Rob Gordon for providing the illustrations for this article.
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1988; 208:17-22. 6. Ware RE, Schultz WH, Filston HC, Kinney TR. Diagnosis and management of common bile duct stones in patients with sickle hemoglobinopathies. J Pediatr Surg (in press). 7. Ware RE, Kinney TR, Casey JR, et al. Cholecystectomy in children with sickle hemoglobinopathies: reduced morbidity using laparoscopy. J Pediatr (in press). 8. Frazee RC, Roberts JW, Okeson GC, et al. Open versus laparoscopic cholecystectomy: a comparison of postoperative pulmonary function. Ann Surg 1991; 213:651-654. 9. Davidoff AM, Pappas TN, Murray EA, et al. Mechanisms of biliary injury during laparoscopic cholecystectomy. Ann Surg (in press).
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