(1)
Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
(2)
Department of Paediatric Surgery, King’s College Hospital NHS Foundation Trust, London, UK
Abstract
Cholelithiasis in the paediatric population is typically secondary to haemolytic disorders, structural biliary tract anomalies, or previous illness/medical interventions of infancy and early childhood. A proportion of cases are idiopathic. More recently, an increasing incidence of stone disease has been reported outside these traditional groups. This may reflect easier access to abdominal sonography and other diagnostic tools such as magnetic resonance cholangio-pancreatography (MRCP) as well as an increase in childhood obesity, particularly in adolescent girls [1]. There is no good evidence for the treatment of asymptomatic gallstones in otherwise well children as complication rates are low [2]. Surgery for a diagnosis of biliary dyskinesia is controversial and incidental cholecystectomy during another procedure is inappropriate in the paediatric population. Conversely, symptomatic patients with background conditions such as sickle cell disease and spherocytosis have a high risk of complications and should, in general, be offered laparoscopic cholecystectomy (LC), which has become the gold standard for intervention where the infrastructure and expertise are available.
Keywords
LaparoscopicCholecystectomyGall bladderBile duct24.1 General Information
Cholelithiasis in the paediatric population is typically secondary to haemolytic disorders, structural biliary tract anomalies, or previous illness/medical interventions of infancy and early childhood. A proportion of cases are idiopathic. More recently, an increasing incidence of stone disease has been reported outside these traditional groups. This may reflect easier access to abdominal sonography and other diagnostic tools such as magnetic resonance cholangio-pancreatography (MRCP) as well as an increase in childhood obesity, particularly in adolescent girls [1]. There is no good evidence for the treatment of asymptomatic gallstones in otherwise well children as complication rates are low [2]. Surgery for a diagnosis of biliary dyskinesia is controversial and incidental cholecystectomy during another procedure is inappropriate in the paediatric population. Conversely, symptomatic patients with background conditions such as sickle cell disease and spherocytosis have a high risk of complications and should, in general, be offered laparoscopic cholecystectomy (LC), which has become the gold standard for intervention where the infrastructure and expertise are available.
Paediatric LC is predominantly carried out in the elective setting following biochemical and radiological investigations to exclude bile duct stones. Cholecystitis, cholangitis, gall stone pancreatitis, and other acute presentations are generally managed conservatively with the aim of delayed surgery. This may be preceded by diagnostic/therapeutic endoscopic retrograde cholangio-pancreaticography (ERCP). LC has been described in the outpatient setting for children and, in expert hands, overall morbidity is low.
24.2 Working Instruments
10 mm Hasson port
5 mm ports × 3
30° 5-mm telescope
5 mm bowel graspers × 2
5 mm hook diathermy
5 mm Maryland forceps
5 mm Liga or polymer locking clips
5 mm scissors
10 mm retrieval bag
24.3 Positioning, Port Siting, and Ergonomic Considerations
The patient is positioned supine and secured to the operating table (Fig. 24.1). There are two widely used setups to perform this operation: the French (Dubois) and the American (Reddick Olsen) positions. In the French position, the patient lies in the lithotomy position, the operating surgeon stands between the patient’s legs, the assisting surgeon is on the patient’s left side, and the scrub nurse on the right. In the American position, the patient lies supine with arms in abduction, the operating surgeon stands on the patient’s left side with the scrub nurse to his left, and the surgical assistant is on the patient’s right. From an ergonomic perspective, there is little difference between the two approaches in a modern dedicated minimally invasive surgery suite [3]. The authors favour a modification of the American position: the patient is supine with arms down on either side with one surgical assistant to the left of the operating surgeon for the camera and another (or a robot arm) to the right of the patient for gallbladder retraction.
Port position depends on various factors including patient age and size, liver size, and gallbladder location and, importantly, surgeon preference (Fig. 24.2a, b). A trans- or infraumbilical port is placed using the open technique. In adolescents with a high body mass index, an optical trocar inserted in a suitable peri-umbilical position may facilitate safe access. Once the port is inserted and the camera introduced, the surgeon can judge where to place the working ports. The authors favour three port “subcostal” placement: two ports are positioned in the right subcostal position; the most lateral for gallbladder retraction over the liver to expose the operating field. Medial to that, the surgeon’s left-hand operating port and finally an epigastric port, to the left of the falciform ligament for the right operating hand.
Fig. 24.1
Operating room set-up
Fig. 24.2
(a) Illustration of port positions. (b) Digital image of port positions
24.4 Relevant Anatomy
The safety of laparoscopic cholecystectomy depends on the correct identification and interpretation of the relevant anatomy (Fig. 24.3a, b). The most important structures to identify are related to Calot’s triangle, also known as the hepatobiliary or cystohepatic triangle. This is an anatomic space bordered by the common hepatic duct medially, the cystic duct laterally, and the upper aspect of the cystic artery/inferior border of the liver superiorly. It is the key landmark to ensure safety during LC. Dissection of Calot’s enables the surgeon to identify the cystic artery as it crosses the triangle from medial to lateral sides. The blood supply of the common bile duct is usually derived from cystic and pancreatico-duodenal artery branches. It is therefore prudent to ligate the cystic artery at its gallbladder end rather than too close to the right hepatic artery.
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