A Treatment By Harvey

Laparoscopic Cholecystectomy: Option for Gallbladder Disease

H. Sigman,

Jean-Martin

Laberge,

L.T. Nguyen,

Daniel

Croitoru,

Andrew

in Children

Hong,

Karen Sigman,

and Frank M. Guttman

Montreal, Quebec 0 Laparoscopic cholecystectomy was performed safely in two children, ages 7 and 15 years. Special considerations were required in the younger child because of the discrepancy between the length of the instruments and the size of the peritoneal cavity. Both children remained in hospital less than 24 hours and were able to resume normal diet and activity quickly. Pediatric surgeons with special training in laparoscopic surgery may want to use this treatment modality for children with biliary tract disease. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: topic, children.

Laparoscopy;

cholecystectomy,

laparas-

L

APAROSCOPIC ChoIecystectomy (LC) is quickly replacing traditional cholecystectomy as a standard approach to treating chronic cholecystitis and cholelithiasis in adults. Encouraged by excellent results, low morbidity, and a high level of patient satisfaction, experienced laparoscopic surgeons in many institutions are expanding the criteria for suitability of patients for LC to include those with acute cholecystitis, morbid obesity, and previous upper abdominal surgery. The occurrence of gallbladder disease in the pediatric population is low, yet pediatric surgeons may wish to propose LC to their patients. Because almost all the courses and preceptor training are aimed at treating the adult patient, pediatric surgeons will need to adapt the principles and techniques from experiences in adults to the young population in order to perform the operation safely and efficaciously. The following two case reports describe LC in a children’s hospital. CASE

Case

REPORTS

1

A 7-year-old boy (weighing 20 kg) suffered from enuresis and dyspepsia. Abdominal ultrasound showed the presence of gall stones. It was felt that he should have a cholecystectomy, and LC was suggested to the parents as an optional approach. A surgeon with adult experience (H.H.S.) was invited to demonstrate the procedure to the attending and resident staff. The instruments used were those normally used for LC in adults. Experience gathered from surgery on 20-kg pigs and very small, thin adults indicated that the usual placement of the midclavicular port 2 cm below the costal margin and the right of midline port 4 cm below the xiphoid, as described by Reddick and Olsen,’ would leave the port sheaths too close to each other and to the gallbladder region, making dissection difficult. In addition, withdrawing the sheaths to provide distance from the gallbladder would encourage frequent dislodgement and the need for replacement of the sheaths. This in JoornalofPediafricSurgery, Vol26,NolO

(October), 1991: pp

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turn would cause loss of time, CO, gas leaks because of repeat punctures, and the possibility of developing subcutaneous emphysema due to tracking of gas through multiple tears in the peritoneum. Therefore, the locations of port placement were modified to distance the entry points from the gallbladder area (Fig IA). A nasogastric tube and urethral catheter were inserted after the patient was asleep in order to ensure an empty bladder and a decompressed stomach. With the patient in Trendelenburg position, a Veress needle was inserted through a small infraumbilical incision at a 45” angle toward the pelvis into the peritoneal cavity. The indrawing of a drop of saline, placed in the needle hub, into the peritoneal cavity by negative intracelomic pressure is confirmation of entry into free peritoneal cavity (saline drop test). Insufflation by an automatic high-flow insufflator (model ST-26012C; Storz, Tuttlingen, Germany), at the rate of 1 L/min CO, was performed at a pressure below 15 mm Hg, bearing in mind that the peritoneal cavity in a small child requires much less insufflation volume (0.5 to 1.1) than in adults. A 7-mm trocar to accomodate a 7-mm panendoscope was inserted through the infraumbilical site into the peritoneal cavity again directed toward the pelvis at a 45” angle to the horizontal. The trocar was inserted with a slow twisting motion and gentle pressure until a hiss from the open side valve of the trocar sheath indicated entry into the peritoneal cavity. A 0 scope was inserted and a camera (Supercam; Storz) was attached and connected to a monitor. The pelvic contents were inspected to ensure the absence of bowel or vascular injury. Two 5-mm trocars were then inserted under direct visualization on the monitor. The first was placed just medial and cephalad to the right anterior superior iliac spine directed toward the gallbladder area. The second entered in the right midclavicular line just cephalad of a line drawn between the anterior superior iliac spine and the umbilicus and also was directed toward the gallbladder. In adults, this trocar is often inserted about 3 cm below the costal margin. A fourth trocar (10 to 11 mm) was inserted in the left midclavicular line even with the plane of the third trocar. The fourth sheath was passed under the falciform ligament to rest in the right upper quadrant. The patient was then turned into reverse Trendelenburg position with rotation of the right side of the patient upward in order to allow the viscera to fall away from the gallbladder area. A ratcheted forceps was inserted through the right lateral portal, grasping the fundus of the gallbladder and pushing it and the liver cephalad to expose the triangle of Calot. An instrument was inserted through the right midclavicular portal to grasp the lower end of the gallbladder while the left lateral portal was used for all the other instruments required for dissecting and

From the Divisions of General Surgery, Sir Mortimer B. Davis, Jewish General Hospita!, Montreal Chiidren S Hospital, and McGill CJniversi@, Montreal, Quebec. Date received: January IO, 1991; date accepted: Febtuary 22, 1991. Address reprint requests to Harvey H. Sigman, MD, FRCSC, Department of Surgery, Sir Mortimer B. Davis, Jewish General Hospital, Montreal, Quebec H3T IE2, Canada. Copyright o I991 by W B. Saunders Company 0022-3468/9112610-0009$03.0010 1181

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Fig 1. Sites of trocar 15-year-old girl.

SIGMAN ET AL

entry in (A) a 7.year-old

boy, and

(B) a

removing the gallbladder. Clips were applied to the cystic duct and cystic artery after they had been dissected free from surrounding tissue using an endoclip applier. These structures were then divided with scissors and the gallbladder was dissected free from its bed by electrocautery. The subhepatic and suprahepatic areas were irrigated with saline and suctioned. The gallbladder was then extracted from the peritoneal cavity through the right-sided portal. It should be noted that we normally extract the gallbladder through a lo-mm umbilical port because the abdominal wall is thinnest at this point. This is done while observing, through an endoscope in another port, the intraperitoneal portion of the gallbladder exiting the peritoneal cavity. We used another route for these children because a 7-mm sheath had been placed in the umbilical region to accommodate the 7-mm endoscope, which precluded an exchange of instruments from one sheath to another. The child was able to get out of bed and drink 2 hours after surgery. An interesting anecdote should be reported at this point. As the patient sat up to get out of bed, he observed his neighbour in the opposite bed, who had undergone an appendectomy 2 days earlier, and said, “You are not feeling very well, are you?” He was discharged the next morning with no restriction on his diet or activity. He tobogganed on the third postoperative day and returned to school on the fourth.

Case 2 A 15-year-old girl with symptomatic gallbladder disease underwent LC uneventfully, using the standard approach as for an adult. The midclavicular trocar was inserted three fingerbreadths below the costal margin and the upper midline trocar was inserted one third the distance from the xiphoid to the umbilicus (Fig 1B). The gallbladder was again extracted through the upper port for the reasons described above. She was also discharged the next morning with no restriction on diet or activity. DISCUSSION

Calculous biliary tract disease is uncommon in children and the thrust in teaching LC has been toward performing the procedure in adults. It will be advisable for the pediatric surgeon to learn the principles of laparoscopy in small children from

the two operations described above. It is important that the principles of preceptorship as a means of learning LC be adhered to. Practice with training models and porcine experience will also allow the performance of LC with minimal risk to the patient. The number of LCs performed in most children’s hospitals will be small compared with the volume in comparable-sized adult institutions. Consideration should be given to whether the number of surgeons carrying out this procedure be limited in order to allow a few surgeons to develop expertise in this new technique. This may be particularly true when one considers that residents will also have to share in this small number of operations in order to become proficient. It is of value for two surgeons to work as a team while the procedure is learned so that consultation, support, and increased vigilance are readily available. The two critical periods during LC are at the time of insertion of the Veress needle and the initial trocar as blind procedures and at the time of isolation and division of the cystic artery and cystic duct. During the initial insertion, the surgeon must be alert to the dangers of injury to major blood vessels or bowel. These risks can be minimized by use of the saline drop test, and by aspiration from the Veress needle before insufflation to ensure that the needle is not in the intestine or in a major vessel. If the insufflation pressure increases above 15 mm Hg, one should be concerned that the needle is not in the free peritoneal cavity. If the pressure increases above 20 mm Hg, the needle should be extracted and reinserted. There should be no hesitation on the part of the surgeon to carry out open insertion of the umbilical sheath if there is a problem in insufflation or if there is a scar around the umbilicus due to previous surgery. The umbilical opening can be simply created by a small midline fascial incision, opening of the peritoneum, and insertion of a sheath followed by insufflation. A purse string suture tightened around the sheath will prevent gas leak and can be further secured with petrolatum gauze. A Hussan sheath can also be used to prevent gas leak during open insertion. Special vigilance is also required at the time that the stuctures forming the triangle of Calot are dissected, isolated, clipped, and divided. Injury to the common duct can probably occur more readily during

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LC than during open cholecystectomy because traction on the gallbladder and Hartmann’s pouch during LC may cause tenting of the common bile duct, placing it at risk. Some have suggested that routine cholangiography should be performed during LC in order to visualize the anatomy of the bile duct system and at the same time to determine the presence of common bile duct stones.2*3Only one patient, in the first series’ of 69 patients without cholangiography, was found to have bile duct stones in follow-up. The second series3 describes successful routine cholangiography during LC on 90% of 415 cases without reporting on the number of true-positive or falsepositive results. Voyles et al4 advised selective intraoperative cholangiography and reported no evidence of retained stones in 223 patients having LC without cholangiography when there were no risk factors for choledocholithiasis such as pancreatitis, jaundice, abnormal liver function tests, or a dilated common duct. We feel that patients with jaundice or dilated common bile duct should have endoscopic retrograde cholangiopancreatography prior to operation to rule out malignant obstruction and to carry out sphincterotomy if stones are present. It is important to develop the skill of performing cholangiography, but we believe it can be done on a selective basis. Cholangiography will not replace cautious and unhurried dissection, clear visualization of triangle of Calot structures, and good judgment in protecting the common bile duct. This institution has had no common duct

injuries and no retained stones after 150 LC in adults without cholangiography (unpublished data). One may question whether the advantages of LC in adults (eg, shorter hospitalization, less atelectasis, less ileus, quicker return to normal activity) are as important in the pediatric population. The advantages for the child may be even greater, in that the reduced pain, the avoidance of an upper abdominal incision, and the ability to have surgery on a nonhospitalized ambulatory basis with quick return to home and school will be of considerable importance from both a psychological point of view for child and parent as well as for the child’s physical well-being. The potential disadvantages of the operation in adults, which mainly relate to those of “key-hole surgery” such as missing other intraabdominal lesions because of inability to palpate manually, or technical difficulties because of adhesions due to previous surgery, or recurrent inflammation, should be less of a problem in children. Laparoscopic surgery in children, as in adults, will likely be used for an increasing variety of procedures.5 It will be important to develop specialized laparoscopic instruments for children to facilitate the surgery and make it safe. ACKNOWLEDGMENT The authors thank Netti Epstein for secretarial assistance; Christine Lalonde for creating the illustration; and Laborie Surgical, Montreal, Quebec, for providing the instruments.

REFERENCES 1. Reddick EJ, Olsen DO: Outpatient laparoscopic laser cholecystectomy. Am J Surg 160:485-489,199O 2. Zucker KA, Bailey RW, Gadacz TR, et al: Laparoscopic guided cholecystectomy. Am J Surg 161:36&I, 1991 3. Berci G, Sackier JM, Paz-Partlow M: Routine or selected intraoperative cholangiography during laparoscopic cholecystectomy? Am J Surg 161:355-360,199l

4. Voyles CR, Petro AB, Meena AL, et al: A practical approach to laparoscopic cholecystectomy. Am J Surg 161:365-370, 1991 5. Andze GO, Homsy Y, Laberge JG, et al: La place de la laparoscopie therapeutique dans le traitement chirurgical des testicules intra-abdominaux chez l’enfant. Chir Pediatr 31:299-302, 1990

Laparoscopic cholecystectomy: a treatment option for gallbladder disease in children.

Laparoscopic cholecystectomy was performed safely in two children ages 7 and 15 years. Special considerations were required in the younger child becau...
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