JOURNAL OF ADOLESCENTHEALTH 1992;13:693-695
TECHNOLOGIC
ADVANCES
s
i
SYLVAIN MARY
KLEINHAUS,
BETH GREGOR,
M.D., RPA-C,
RONALD
KALEYA,
M.D.,
AND SCOTT J. BOLEY,
The positive experience with laparoscopic cholecystectomy (LC) in the adult surgical community encouraged us to perform LC in out last nine adolescent patients requiring cholecystectomy. There were no operative or postoperative complications, and the average hospital stay was less than 3 days. All the teenagers resumed their normal activities 1 week after surgery and were pleased with the small operative scars. Once the technique has been mastered and adequate experience gained with the new instrumentation, laparoscopic cholecystectomy would seem to offer many advantages in the teenage patient. KEY WORDS:
Laparoscopy Cholecystectomy Cholecystitis Adolescent laparoscopy Laparoscopic cholecystectomy has resulted in one of the most rapid changes in the practice of general surgery in memory. Experience from thousands of laparoscopic cholecystectomies in adults has demonstrated decreased morbidity, shorter hospital stays, and earlier return to normal activities (1). Children and adolescents would appear to be excellent candidates for laparoscopic operations because of their concerns about body image (i.e., incisional scars) and the importance of early return
From fhe Departmentof Surgery,Monfejkre MedicalCenfer, Albert Einstein College ofMedicine, Bronx, New York. Address reprint requests to: Sylvain Kleinhaus,M.D., Department of Surgery, MonfefioreMedical Center, 222 East 210th Sfreef, Bronx, NY 10467. Presentedat theCanadianAssociationof PediatricSurgeonsMeeting in QuebecCity, Canada,September 19,199l. Manuscriptaccepfed Jury 21, 1992.
ROBERT
CANNING,
M.D.,
M.D.
to school and other physical activities, Our experience in laparoscopy in pediatric surgical patients (2) prompted US to utilize laparoscopic surgery in our last nine adolescents patients requiring cholecystectomy .
Description of Patients From December 1990 through August 1991 laparostopic cholecystectomy was performed in nine teenagers (ages 14-19 years). There were two males and seven females, four of whom were parous, including three with one child each and one with two children. Eight patients had symptoms of biliary tract disease including fatty food intolerance and intermittent attacks of right upper quadrant pain. One male patient had sickle cell disease with cholelithiasis and choledocholithiasis. This patient had repeated biliary symptomatology in the absence of any evidence of hepatic sickle cell crisis. During the episode prior to surgery, ultrasonography revealed stones in the gall bladder and dilatation of the common duct with an obstructing calculus. The common duct stone was removed by endoscopic retrograde cholangio pancreatography (ERCP) prior to laparoscopic cholecystectomy.
Results All procedures were carried out under general anesthesia and the standard four port technique was employed (one umbilical,’ one subxyphoid, one subcostal in the mid-clavicular line, and one subcostal in the anterior axillary line) (Fig. 1). We did not perform routine operative cholangiography, except in one patient who had a preoperative ERCP with a cholangiogram that was equivocal. One patient had acute and chronic cholecystitis; the others, chronic cholecystitis. There were no operative or postoper-
0 Society forAdolescentMedicine,1992 Publishedby EisevierScience Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
693 ooo-139x/92/$5.00
6%
KLEINHAUS fiT AL.
ative complications. Five patients were discharged on postoperative [PO) day 110.2, two on PO day no. 3 and two on PO day no. 4. The average operating time was 1 hr and 24 min (range, 180 tin in our first patient who had acute cholecystitis to 40 min in an obese M-year-old patient). The follow-up period has been from 6 to 14 months during which time the only complaints have been occasional transient pain at an incisional site, Three patients were back in schod 1 week following the operation, and all patients report satisfaction with the appearance of the scars and the outcome.
Laparoscopic chokcystectomy has become increasingly accepted in the adult surgical community as an alternative to open cholecystectomy. Although the first laparoscopic cholccystectomy was performed in 1987 by Mouret, and the first report in the English language was in 1989, between one-third and one-half of cholecystectomies performed in the United States are already being done by this method (3). The rapid growth of laparoscopic surgery has followed the development of new instrumentation, including the laparoscopic clip applier, which allows one to effectively control the cystic artery and cystic duct. Endoscopic cameras and t&vi&on monitors enable the entire dissection to be done under direct visicin with enhanced magnification prolrided by the
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 8
Hopkins Lenstelescopes (essentially identical, except for their length and diameter, to the bronchoscopes and cystoscopes used by many pediatric surgeons]. In addition, many varieties of dissectors, graspers, hooks, and spatulas facilitate the dissection during laparoscopic cholecystectomy. We observed the same benefits to our patients undergoing laparoscopic cholecystectomy, as have been described in adults. Patients are out of bed the same evening and resume a normal diet within 24 hr. The hospital stay is significantly shorter, an average of 2.75 days compared with over 5 days following open cholecystectomies. Postoperative pain is much less with the four small incisions, and postuperative respiratory complications are correspondingly decreased (4). Patients have rapidly resumed their normal activities (including school) sooner. This short recuperative period contrasts with the weeks of inactivity following open cholecystectomies. In teenagers, the issue of body image is an important one. The four scars, each 7-10 mm in length, are almost invisible within months, There is, however, a high incidence of common duct injuries reported among adult patients (approximately l%), which is 10 times that of open cholecystectomy (1). This high rate of the most dreaded complication of biliary surgery has been attributed to inexperience with the technique. Laparoscopic cholecystectomy requires a new set of skills (including adaptation to operating from a television screen) and familiarity with laparoscopy, The Z-day “handson” courses should only be used as an introduction to laparoscopic cholecystectomy. Other pediatric surgeons with extensive experience should be able to quickly adopt this new technique (5-7). Inadequate training and preparation of surgeons undertaking laparoscopic cholecystectomy has led to controversy as to credentialing requirements (8). Supporteed in part by the Theodore Jabara and Irving Shatz Laparoscopic Surgery Laboratory, Montefiore Medical Center/Albert Einstein College of Medicine.
References 1. Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991. 2. Kleinhaus S, Hein K. Sheran MB, B&y 5;. Laparoscopy for diagnosis and treatment of abdominal pain in adolescent girls. Arch Surg 1477;10:117&. 3. Reddick EJ, Olsen DO. Laparoscopic laser
cholccystcctomy; il
LAI’AKOSCOPIC
December 1992
comparison
with
mini-lap
cholecystectomy.
Sutg Endow
1989;3131-3. 4. Frazee RC, RoobertsJW, Okeson CC, et al. Open versus laparoscopic cholecystecomy. A comparison of postoperative puhnonary function. Ann Surg 199?;213:651-4. 5. Hnlcumb GW III, Otsen DO. $hharp KW. Laparoscopic
chole-
cystectomy in the pediatric patient. J Pediatr Surg 1991; 26:1186-90.
CHOLECYSTECTOh4Y
IN TEENAGERS
695
6. Newman KD, Mannon LM, Atlorri R, Evans 5. Lapro~~pic chokcystectomy in pediaMc patients. J Pediatr Surg 1991;26:21%5. 7. S&man EIH, Laberge JM, Groitoru D, et al. Laparoxopic the Iccystectomy: A treatment option for @Madder disease in
children. 3 Pediak Surg 199l;2&118t-3. 8. Talamini MA, GadTR T~ditian~versuslaparoscopic lecysteclomy Probl Gen Surg 1991;8:279-83.
the
TECHNOLOGIC
ADVANCES
s
i
SYLVAIN MARY
KLEINHAUS,
BETH GREGOR,
M.D., RPA-C,
RONALD
KALEYA,
M.D.,
AND SCOTT J. BOLEY,
The positive experience with laparoscopic cholecystectomy (LC) in the adult surgical community encouraged us to perform LC in out last nine adolescent patients requiring cholecystectomy. There were no operative or postoperative complications, and the average hospital stay was less than 3 days. All the teenagers resumed their normal activities 1 week after surgery and were pleased with the small operative scars. Once the technique has been mastered and adequate experience gained with the new instrumentation, laparoscopic cholecystectomy would seem to offer many advantages in the teenage patient. KEY WORDS:
Laparoscopy Cholecystectomy Cholecystitis Adolescent laparoscopy Laparoscopic cholecystectomy has resulted in one of the most rapid changes in the practice of general surgery in memory. Experience from thousands of laparoscopic cholecystectomies in adults has demonstrated decreased morbidity, shorter hospital stays, and earlier return to normal activities (1). Children and adolescents would appear to be excellent candidates for laparoscopic operations because of their concerns about body image (i.e., incisional scars) and the importance of early return
From fhe Departmentof Surgery,Monfejkre MedicalCenfer, Albert Einstein College ofMedicine, Bronx, New York. Address reprint requests to: Sylvain Kleinhaus,M.D., Department of Surgery, MonfefioreMedical Center, 222 East 210th Sfreef, Bronx, NY 10467. Presentedat theCanadianAssociationof PediatricSurgeonsMeeting in QuebecCity, Canada,September 19,199l. Manuscriptaccepfed Jury 21, 1992.
ROBERT
CANNING,
M.D.,
M.D.
to school and other physical activities, Our experience in laparoscopy in pediatric surgical patients (2) prompted US to utilize laparoscopic surgery in our last nine adolescents patients requiring cholecystectomy .
Description of Patients From December 1990 through August 1991 laparostopic cholecystectomy was performed in nine teenagers (ages 14-19 years). There were two males and seven females, four of whom were parous, including three with one child each and one with two children. Eight patients had symptoms of biliary tract disease including fatty food intolerance and intermittent attacks of right upper quadrant pain. One male patient had sickle cell disease with cholelithiasis and choledocholithiasis. This patient had repeated biliary symptomatology in the absence of any evidence of hepatic sickle cell crisis. During the episode prior to surgery, ultrasonography revealed stones in the gall bladder and dilatation of the common duct with an obstructing calculus. The common duct stone was removed by endoscopic retrograde cholangio pancreatography (ERCP) prior to laparoscopic cholecystectomy.
Results All procedures were carried out under general anesthesia and the standard four port technique was employed (one umbilical,’ one subxyphoid, one subcostal in the mid-clavicular line, and one subcostal in the anterior axillary line) (Fig. 1). We did not perform routine operative cholangiography, except in one patient who had a preoperative ERCP with a cholangiogram that was equivocal. One patient had acute and chronic cholecystitis; the others, chronic cholecystitis. There were no operative or postoper-
0 Society forAdolescentMedicine,1992 Publishedby EisevierScience Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
693 ooo-139x/92/$5.00
6%
KLEINHAUS fiT AL.
ative complications. Five patients were discharged on postoperative [PO) day 110.2, two on PO day no. 3 and two on PO day no. 4. The average operating time was 1 hr and 24 min (range, 180 tin in our first patient who had acute cholecystitis to 40 min in an obese M-year-old patient). The follow-up period has been from 6 to 14 months during which time the only complaints have been occasional transient pain at an incisional site, Three patients were back in schod 1 week following the operation, and all patients report satisfaction with the appearance of the scars and the outcome.
Laparoscopic chokcystectomy has become increasingly accepted in the adult surgical community as an alternative to open cholecystectomy. Although the first laparoscopic cholccystectomy was performed in 1987 by Mouret, and the first report in the English language was in 1989, between one-third and one-half of cholecystectomies performed in the United States are already being done by this method (3). The rapid growth of laparoscopic surgery has followed the development of new instrumentation, including the laparoscopic clip applier, which allows one to effectively control the cystic artery and cystic duct. Endoscopic cameras and t&vi&on monitors enable the entire dissection to be done under direct visicin with enhanced magnification prolrided by the
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 8
Hopkins Lenstelescopes (essentially identical, except for their length and diameter, to the bronchoscopes and cystoscopes used by many pediatric surgeons]. In addition, many varieties of dissectors, graspers, hooks, and spatulas facilitate the dissection during laparoscopic cholecystectomy. We observed the same benefits to our patients undergoing laparoscopic cholecystectomy, as have been described in adults. Patients are out of bed the same evening and resume a normal diet within 24 hr. The hospital stay is significantly shorter, an average of 2.75 days compared with over 5 days following open cholecystectomies. Postoperative pain is much less with the four small incisions, and postuperative respiratory complications are correspondingly decreased (4). Patients have rapidly resumed their normal activities (including school) sooner. This short recuperative period contrasts with the weeks of inactivity following open cholecystectomies. In teenagers, the issue of body image is an important one. The four scars, each 7-10 mm in length, are almost invisible within months, There is, however, a high incidence of common duct injuries reported among adult patients (approximately l%), which is 10 times that of open cholecystectomy (1). This high rate of the most dreaded complication of biliary surgery has been attributed to inexperience with the technique. Laparoscopic cholecystectomy requires a new set of skills (including adaptation to operating from a television screen) and familiarity with laparoscopy, The Z-day “handson” courses should only be used as an introduction to laparoscopic cholecystectomy. Other pediatric surgeons with extensive experience should be able to quickly adopt this new technique (5-7). Inadequate training and preparation of surgeons undertaking laparoscopic cholecystectomy has led to controversy as to credentialing requirements (8). Supporteed in part by the Theodore Jabara and Irving Shatz Laparoscopic Surgery Laboratory, Montefiore Medical Center/Albert Einstein College of Medicine.
References 1. Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991. 2. Kleinhaus S, Hein K. Sheran MB, B&y 5;. Laparoscopy for diagnosis and treatment of abdominal pain in adolescent girls. Arch Surg 1477;10:117&. 3. Reddick EJ, Olsen DO. Laparoscopic laser
cholccystcctomy; il
LAI’AKOSCOPIC
December 1992
comparison
with
mini-lap
cholecystectomy.
Sutg Endow
1989;3131-3. 4. Frazee RC, RoobertsJW, Okeson CC, et al. Open versus laparoscopic cholecystecomy. A comparison of postoperative puhnonary function. Ann Surg 199?;213:651-4. 5. Hnlcumb GW III, Otsen DO. $hharp KW. Laparoscopic
chole-
cystectomy in the pediatric patient. J Pediatr Surg 1991; 26:1186-90.
CHOLECYSTECTOh4Y
IN TEENAGERS
695
6. Newman KD, Mannon LM, Atlorri R, Evans 5. Lapro~~pic chokcystectomy in pediaMc patients. J Pediatr Surg 1991;26:21%5. 7. S&man EIH, Laberge JM, Groitoru D, et al. Laparoxopic the Iccystectomy: A treatment option for @Madder disease in
children. 3 Pediak Surg 199l;2&118t-3. 8. Talamini MA, GadTR T~ditian~versuslaparoscopic lecysteclomy Probl Gen Surg 1991;8:279-83.
the
