When possible, we prefer to perform cholecystec- tomy as an elective procedure after the inflammation has resolved. When pain or cholecystitis persists, however, cholecystectomy is performed without de- lay.

INTRODUCTION

Cholecystitis and cholelithiasis are increasing in fre- quency in infancy, childhood and adolescence, and the incidence is reported to be between 0.15% and 0.22%. Congenital anomalies of the gallbladder are rare. While total parenteral nutrition often results in cholestasis and stone formation in infants, haemato- logical disease such as sickle cell disease, hereditary spherocytosis and thalassaemia are more often seen in older children and adolescents. In the absence of an underlying haematological disorder, most gall- stones are associated with obesity, adolescent preg- nancy, a positive family history for cholelithiasis, the use of oral contraceptives, or as a complication of a choledochal cyst. Yet the origin of gallstones in ap- proximately 80% of pediatric patients remains un- known. While there is no sex predilection, females begin to predominate in incidence of gallstones among children who are heart transplant recipients, where the overall incidence is approximately 16%

post-transplant. Patients who have been on extracor- poreal membrane oxygenation (ECMO), also are at risk for gallstones, and should undergo cholecystec- tomy if stones develop.

Patients usually present with pain, jaundice or both. Less often than in adults, patients present with fever, right upper quadrant tenderness and leukocy- tosis, suggesting the presence of cholecystitis. These patients are placed on antibiotics and oral intake is withheld until it is clear that their acute inflamma- tion is resolving.

When possible, we prefer to perform cholecystec- tomy as an elective procedure after the inflammation has resolved. When pain or cholecystitis persists, however, cholecystectomy is performed without de- lay.

Today, laparascopy is recognized as the standard

procedure for cholecystectomy. The principles of the

open and laparoscopic procedures are essentially the

same (except for the incision). These procedures are

routinely performed under general anaesthesia with

endotracheal intubation. A nasogastric tube is placed

for gastric decompression and a bladder catheter or

Crede manoeuvre is used to empty the bladder.

Thom E. Lobe 388

Figure 35.1

The patient is placed supine on the operating table.

To facilitate access to the patient, we place the patient’s arms at the patient’s side rather than at right angles to the patient. The patients is placed on a table suitable for fluoroscopy under the assumption that an operative cholangiogram may be necessary. The

Figure 35.2

We begin the procedure with the insertion of an um- bilical cannula of 10 mm diameter. We believe that, while many are comfortable with the use of a Veress needle, the safest approach is an open, Hasson, ap- proach to cannula insertion. A 10-mm incision first is made in the umbilical ring, either cephalad or caudad to the umbilicus. We make this with a number 15 blade and carry the incision through the skin to the fascia.

Two haemostat clamps are then used to grasp the fascia so that it can be incised. This incision is carried down to the peritoneum, which is opened sufficient- ly so that the cannula can be inserted. A right-angled retractor can be used to elevate the abdominal wall to facilitate cannula insertion. The cannula is fixed to the abdominal wall by placing a suture through the skin to a small ring of rubber catheter that was cut and placed around the outside of the cannula for this purpose. Proper cannula position is checked using a 35

abdomen is prepped and draped as is customary so that the entire abdomen from xiphoid to pubis and from posterior axillary line to posterior axillary line is accessible. Four cannulas are used in general. Thier position depends somewhat on the patient’s size.

5-mm telescope. The abdomen then is insufflated with CO

gas to 15 torr.

Three other cannulas are inserted. Their position depends somewhat on the patient’s size. In general, one needs a cannula for the gallbladder and liver re- tractor, one for a grasper to hold and manipulate the neck of the gallbladder and another for dissection, duct and vessel ligation, and for the telescope when it is time for removal of the gallbladder. The gallblad- der liver retractor is placed in the mid to anterior ax- illary line between the level of the umbilicus and the level of the superior iliac crest (for smaller patients).

A cannula is inserted at about the mid-clavicular line

between the umbilicus and the costal margin (usual-

ly closer to the costal margin). The final cannula is

inserted at about the midline and the mid-clavicular

line (smaller patients). These cannulas can all be in-

serted directly under the watchful eye of the

surgeon’s telescope/camera.

Figure 35.2

Thom E. Lobe 390

Figure 35.3

The gallbladder is grasped at the fundus and this is used to retract the gallbladder and liver superiorly and anteriorly. We use a self-retraining retractor to secure this cannula in place for most of the proce- dure. The right sub-costal cannula is used for the re-

tractor while we begin the dissection with a Mary- land dissector. It is helpful to position the patient in a reversed Trendelenburg position with the right side up.

35

Figure 35.4

Dissection is begun by stripping away the peritone-

um to expose the cystic duct and artery. Once the

duct and artery are exposed, we apply clips to these

structures and then divide them. We advise against

using electrocautery here so as to avoid any injury.

Figure 35.4

Thom E. Lobe 392

Figure 35.5

If there is any doubt as to the anatomy or if the duct is larger than it should be, or if the pre-operative studies suggest the possibility of stones, an operative cholangiogram is performed. We do this by clipping the cystic duct as is joins the gallbladder and making a small nick in its wall, large enough to insert the cannula for the study. We then use a 8-12 gauge plas- tic catheter as an “access port” for the cholangiogram catheter, and insert this directly through the abdom- inal wall. We prefer a balloon-tipped catheter, as this minimizes the risk for injury, and insert this directly into the duct through a nick in the duct midway between the gallbladder and the common bile duct.

Inflation of the balloon holds it in place. The cholan-

giogram can then be done under fluoroscopic control while the duct is observed to assure that there is no leak of contrast.

If the cholangiogram is negative for retained stones, another clip is applied after the catheter is re- moved. If the cholangiogram demonstrates stones to be present, there are three options. First, the patient can be opened for exploration. Second, the operation can be completed and the patient referred for post- operative endoscopic retrograde cholangiography.

Finally, a flexible endoscope can be used to examine and free the duct of stones (larger patients), or (in smaller patients) a pediatric cystoscope can be intro- duced into the duct for passage of a stone basket.

35

Figure 35.6

After the cystic artery and duct are divided, a right- angled hook electrocautery device or endoscopic shears connected to cautery are used to free the gall- bladder from its bed. After this is accomplished, the gallbladder bed is inspected for haemorrhage, which is controlled if found.

We then move the telescope from its umbilical site to the midline or left subcostal cannula to visualize removal of the gallbladder from the 10-mm umbilical cannula site. When there are stones present, we open the gallbladder (after it has been partially exterior- ised) and use a stone forceps to remove the stones

until the gallbladder can be extracted. The abdomen then is inspected for haemorrhage and lavaged if bile has been spilled during the procedure.

We then close the fascia for all wounds of 5 mm or

greater (small children), or close the umbilical

wound to prevent later herniation. All wounds are in-

filtrated with a long-acting local anaesthetic for post-

operative analgesia. Patients are awakened from an-

aesthesia and discharged from the hospital when

they can ambulate and tolerate liquids, usually on the

day of surgery or after overnight hydration in the

case of patients with sickle cell disease.

Figure 35.6

Thom E. Lobe 394

CONCLUSION

Patients with asymptomatic cholelithiasis are not scheduled for surgery unless they develop complica- tions. Laparoscopic cholecystectomy has replaced open cholecystectomy for the vast majority of cases.

Rarely, access cannot be achieved due to previous surgery, or the patient cannot tolerate the abdominal insufflation. In those cases a subcostal or midline ab- dominal incision is made, the intestines and liver are retracted out of the way and essentially the same pro- cedure is carried out.

More recently, some surgeons have elected to per- form the cholecystectomy from the fundus toward the porta hepatis. This may be helpful in cases of se- vere inflammation or marked oedema.

The most serious complication of this procedure is an unrecognized injury to the bile ducts. This can

occur when the anatomy is unclear; thus, the advice is to perform a cholangiogram when there is any doubt. Such injury can also occur from an electrical burn while using electrocautery near the portal area, thus the recommendation to avoid this practice.

When the gallbladder is opened accidentally dur- ing its dissection, bile and stones can spill into the peritoneal cavity. We make a modest effort to lavage and evacuate this spilled material, but rarely have we had post-operative problems from this.

Laparoscopic cholecystectomy is one of the more gratifying procedures we do. It is quick, simple and effective, and we see few problems afterwards.

35

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Hugh TB (2002) New strategies to prevent laparoscopic bile duct injury-surgeons can learn from pilots. Surgery 132 : 826–835

Lobe TE (2000) Cholelithiasis and cholecystitis in children.

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