Laparoscopic Cholecystectomy in Children
Laparoscopic cholecystectomy is the procedure of choice for the treatment of adults with gallbladder stone disease. However, cholelithiasis is rare in children; for this reason, it is difficult to evaluate the validity of this procedure in a large case series of pediatric patients. The presence of gallbladder stones is generally idiopathic in children, and their discovery is sometimes incidental during a sonographic exam performed to search for other abdominal pathologies. However, there are well-known predisposing factors for developing gallbladder stones in children. Among infants affected by hemolytic disease hemolytic anemia, for instance, the incidence of gallbladder stones is much higher than the normal population. Its reported incidence ranges from 10 to 40 percent in various series. The management of children with cholelithiasis requires great caution; an accurate hematological study is always necessary to detect a possible underlying hematological disease. In cases of gallstones discovered incidentally, an accurate follow-up is suggested, since a spontaneous resolution of the pathology is possible. Generally, noncalcified gallbladder stones in children disappear within 3 to 6 months. By contrast, surgery is needed for calcified stones in both nonsymptomatic and symptomatic children. Laparoscopic cholecystectomy rather than open cholecystectomy is the procedure of choice in symptomatic infants. Laparoscopy in infants should be performed using very small instruments (3 or 5 mm in diameter). Technically, this approach is similar to the one employed for adults, although careful consideration of a child’ s anatomical difference is essential to avoid complications. It is important to keep in mind that in pediatric patients there may be biliary tree anomalies, such as gallbladder duplication, ductal abnormalities, accessory bile duct, or accessory cystic artery. These findings do not represent a contraindication to the laparoscopic procedure if the surgeon is able to perform a delicate and accurate dissection of the elements at the level of Calot’s triangle. Bile duct injuries, which are often reported in adults, are very rare in children may be due to more clear anatomy and less fat. The junction between the cystic duct and the common bile duct is much more visible in children, due to the scarcity of fatty tissue and adhesions at the level of Calot’s triangle at this age. This improved visualization makes the dissection of the cystic duct easier and less dangerous than in adult patients. The presence of common bile duct stones in children is an extremely rare event in the pediatric population. At any rate, the presence of jaundice, dilatation of the biliary tree at ultrasonography, alkaline phosphatase, and total bilirubin above the normal range by > 5 mg/dl, and/or a history of pancreatitis are indications for a cholangiography or an ERCP. In addition, we believe that intraoperative cholangiograms can also be performed in infants.
With respect to the ERCP, the sequential approach of endoscopic sphincterotomy and stone extraction followed by laparoscopic cholecystectomy is a safe and effective method in children as well as adults. One important advantage is that laparoscopic cholecystectomy in children can be associated, if necessary, with other technical procedures, such as the closure of a peritoneal vaginal duct in cases of inguinal hernia; thus, a second operation or another incision can be avoided. However, if another procedure is required, laparoscopic expertise on the part of the surgeon is fundamental to avoid additional morbidity. We performed a concomitant splenectomy in infants affected by spherocytosis and one with thalassemia. Based on our experience, laparoscopic cholecystectomy is a valid and effective procedure in pediatric patients as it is in adults. In children, it is important to perform a complete preoperative evaluation to search for the possible coexistence of hematological disease.