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Pediatric cholecystectomy
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摘要
The description of the pediatric cholecystectomy covers all aspects of the surgical procedure used for the management of cholelithiasis in children.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection, clips and division, extraction.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection, clips and division, extraction.
Consequently, this operating technique is well standardized for the management of this condition.
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媒體類型
 刊物
2001-12
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普通的
最愛
 音訊
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數位出版
WeBSurg.com, Dec 2001;1(12).
URL: http://www.websurg.com/doi-ot02en221a.htm
URL: http://www.websurg.com/doi-ot02en221a.htm
Pediatric cholecystectomy
1. Introduction
Cholelithiasis is unusual in children, but the use of ultrasound examination has led to higher rates of diagnosis. A large ultrasound-screening program revealed a prevalence of 0.13% between the ages of 6 and 15 months (Davenport and Howard, in Atwell, 1998). Benefits such as reduced hospitalization and discomfort have led to the adoption of the laparoscopic approach to cholecystectomy. On average, hospitalization was reduced by about 70%, from 6.2 days to 1.7 days (Gollin et al., 1999). However, biliary duct injury was found to be higher in adults with laparoscopy (0-2%) than in open surgery (0-0.4%) (Deziel and Millikan, 1993; MacFayden et al., 1998). Calvete et al. (2000) found that the effect of the learning curve has been overestimated in laparoscopic cholecystectomy. 2. Anatomy
• Topographical anatomy
A cholecystectomy involves the hepatocystic triangle, the elements of which are located behind the peritoneum. The gallbladder is located in the right upper quadrant, and is embedded in the liver at the junction between segments IV and V. 1. Liver
2. Stomach
3. Lesser omentum
4. Gallbladder
5. Hepatic flexure
6. Greater omentum
• Local anatomy
The anatomy of the biliary tract vasculature and ductal structure is highly variable from one patient to another. A sound working knowledge of these variations and the principles of exposure and dissection facilitates identification of the important structures and prevents complications.1. Fundus
2. Body
3. Infundibulum
4. Cystic duct
5. Common hepatic duct
6. Common bile duct
• Vascular supply
1. Gallbladder2. Cystic artery
3. Node of Mascagni (cystic node)
4. Proper hepatic artery
5. Abdominal aorta
6. Portal vein
7. Gastroduodenal artery
3. Indications
The indications for laparoscopic cholecystectomy in children are dominated by the development of gallstones and related symptoms:- 6 to 12 months of unsuccessful medical therapy;
- hemolytic cholelithiasis;
- non-hemolytic cholelithiasis;
- gallbladder dyskinesia.
In the neonatal period, surgery is recommended only in the event of stone-related complications.
The simple removal of stones through a gallbladder incision without cholecystectomy is also carried out in hemolytic disorders associated with a splenectomy.
4. Preop period
Hospitalization prior to the procedure is not required, except for patients with complications such as acute cholecystitis, biliary pancreatitis or jaundice. Preoperative transfusions may be necessary in patients with underlying hemolytic conditions; these may be performed 1 to 2 weeks prior to hospitalization.
Cholangiography and ultrasonography can help identify anomalies of the biliary tree and vasculature, and detect mucosal tumors and concretions with or without calcifications.
For the operation:
- a short-term antibiotic prophylaxis is administered;
- the nasogastric tube is maintained throughout the procedure;
- micturition is obtained spontaneously or by Credé’s maneuver.
5. Operating room set-up
• Patient
The patient is placed in a supine position. The patient is under general anesthesia with mechanical ventilation through a tracheal tube.
Depending on the size of the patient, either the French or the American technique is used.
• Team
1. The surgeon stands on the left (American technique) or between the patient’s legs (French technique).2. The assistant stands on the patient’s right.
3. The scrub nurse stands on the patient’s left.
4. The anesthesiologist stands at the patient’s left shoulder.
• Equipment
The monitor and laparoscopic unit are located near the patient’s right shoulder. The anesthetic unit is located near the head of the patient. The electrocautery unit is behind the scrub nurse.1. Laparoscopic unit
2. Anesthetic unit
3. Instrument table
6. Trocar placement
• Pneumoperitoneum
The pneumoperitoneum is generally performed with a Veress needle in the umbilical region with the insufflation of CO2 up to a pressure of 10 mm Hg to 12 mm Hg, with an initial inflow of 1L/min. With scoliosis, previous operations on the upper abdominal quadrants and in infants, an open procedure is suggested. We have no experience in cholecystectomy with patients younger than 1 year, for whom an open technique is always indicated because of the high risk of a blind puncture of the abdomen.If an open technique is required, the incision is performed under direct visualization of the fascia and peritoneum and a stay suture is positioned on the fascia to fix a 5 mm or 10 mm reusable trocar.
• Trocar placement
Four trocars are used. Apart from the optical trocar, the position of the other trocars is not constant because the size of the abdominal wall varies with the age of the patients. A: 5-10 mm (10 mm for patients older than one year), in the umbilical region
B: 5 mm, in the right side along the median axillary line or the midclavicular line below the navel
C: 5 mm, in the right subcostal region along the mammary or epigastric line
D: 5-10 mm, in the left subcostal region along the median clavicular line
7. Instrumentation
• Optical
Trocar A1. 30° laparoscope, 2. traumatic grasper
• Operating
Trocar B1. atraumatic grasper
Trocar D
2. scissors, 3. hook, 4. clip applier, 5. atraumatic dissector, 6. retrieval bag, 7. irrigation-suction device
• Retracting
Trocar C1. liver retractor
8. Major principles
The aims of this procedure are:1. perfect exposure of the right subhepatic region;
2. identification of anatomical structures;
3. dissection of the hepatocystic triangle;
4. dissection, clipping and division of the cystic artery and cystic duct;
5. cholecystectomy.
9. Exploration
As in adults, a quick exploration is mandatory to look for anatomical anomalies or injuries, and also to confirm the feasibility of the laparoscopic approach.10. Exposure
• Retraction of the gallbladder
Perfect exposure of the right subhepatic region is crucial, as it will facilitate correct identification and dissection. In the French technique, the fundus of the gallbladder is grasped and pulled cephalad to the right shoulder of the patient, then the infundibulum is grasped and pulled laterally and caudad, spreading the hepatocystic triangle. Between the French and the American techniques, we prefer the first because the gallbladder is retracted downward and the liver is pushed upward. This allows perfect visualization of the hepatocystic triangle without distortion of the main biliary tree. The upward retraction of the gallbladder characteristic of the American position, in our opinion, can cause kinking on the common bile duct and risks damaging it.
• Lysis of adhesions
In children, it is not usually necessary to divide adhesions between the bowel and the liver if there has been no previous surgery. There are no limitations if the child has been previously operated on to treat duodenal atresia.11. Dissection
• Identification of the cystic duct
The peritoneum is divided close to the cystic duct and the infundibulum. An atraumatic dissector may be used. Dissection is carried out gradually until the cystic duct is identified and bluntly isolated.1. Incised anterior peritoneal leaflet
2. Incised posterior peritoneal leaflet
3. Cystic duct
• Identification of the cystic artery
The cystic artery is identified and isolated in the same manner.1. Cystic artery
• Intraoperative cholangiography
An intraoperative cholangiogram is not needed if the preoperative evaluation is correctly performed and if the anatomy is checked. If bile duct migration is suspected, a retrograde endoscopic cholangiogram is preferred after surgery. • Danger
Dissection must prevent any injury to the biliary tree. This is performed following a perfect anatomical visualization of the elements. The absence of fat and inflamed tissue in children simplifies this task. However, bleeding may occur if the dissection is not performed cautiously and coagulation is not effective. Biliary stenosis and damages of the main biliary tree may also result from an incorrect dissection. In the event of complications, conversion to open surgery is recommended.12. Clips and division
• Clip application
The cystic artery, and then the cystic duct, are ligated between titanium or absorbable clips. For both structures, 2 clips are applied proximally and 1 clip is applied distally. Absorbable ligatures may be used in children. An ultrasound activated scalpel can be used because of the limited size of the cystic artery and duct.• Division of the cystic duct
The cystic duct is divided with scissors. There should be no bile leakage and a single duct with a single lumen must be seen after division.• Division of the cystic artery
The cystic artery is also divided. • Danger
Early complications can derive from a stenosis of the common bile duct if the surgeon inserts the clip without seeing its tip.Biliary leakage occurs if clips are not correctly inserted and if a bile duct is not detected. If leakage is suspected, a drainage of the region is left in place.
Division of the common bile duct and hepatic ducts should be avoided.
13. Extraction
• Dissection of the gallbladder
The gallbladder is embedded in the liver, from which it has to be separated using a coagulating hook or scissors. A soft tissue layer from the fascia of the hepatic capsule is removed. Coagulation is monopolar because of the risk of bleeding, but the tip of the electrified instrument should be constantly visible. After complete release, the gallbladder is located on the dome of the liver. Hemostasis is checked.• Extraction of the gallbladder
The laparoscope is moved to trocar D.The gallbladder is extracted through the umbilical access, after removal of the port, under continuous visual monitoring. A 10 mm traumatic grasper is used to hold the gallbladder during extraction. A retrieval bag is used if the gallbladder is under tension or if leakage is suspected, and may be necessary to reduce the risk of parietal infection. If the gallbladder is full, a thin catheter is inserted through the infundibulum to extract the contents.
• Danger
Bowel injury may lead to peritonitis. As the duodenum and colon are not under direct vision during coagulation, extra care should be taken.14. End of the procedure
Hemostasis is checked.The peritoneum is checked for leakage and fluid collection.
CO2 is evacuated and the trocar site wounds are closed.
No drainage is left in place.
15. Postop management
Postoperative management should aim to detect complications resulting from hemorrhages, biliary stenosis and leakages, and infections. The risk of complications is reduced by sufficient preoperative assessment and meticulous dissection and clipping within the hepatocystic triangle.The patient is initially fed with water. If there are no problems, soon after bowel movements start normally (5-10 hours), the patient is fed with milk. The day after surgery, the patient is fully fed. If there is no fever, antibiotics are stopped on the evening of the operative day.
Generally, no nasogastric tube is left in place after surgery. In case of abdominal distention, gastric emptying and bowel enemas may be necessary. A bowel enema may only be needed the day after surgery if the patient does not spontaneously evacuate stool. If the patient is symptom-free, he is discharged on postoperative day 2.
16. Conclusion
We believe that the laparoscopic approach is the gold standard for pediatric cholecystectomy. If in doubt, or if biliary exploration is needed, a conversion to open surgery is recommended to less experienced laparoscopic surgeons.17. Reference
Calvete J, Sabater L, Camps B, Verdu A, Gomez-Portilla A, Martin J, et al. Bile duct injury duringlaparoscopic cholecystectomy: myth or reality of the learning curve? Surg Endosc 2000;14:608-11.
Davenport M, Howard ER. The gallbladder and pancreas. In: Atwell JD, editor.
Pediatric Surgery. New York: Oxford University Press; 1998. p. 422-34.
Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic
cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg
1993;165:9-14.
Gollin G, Raschbaum GR, Moorthy C, Santos L. Cholecystectomy for suspected biliary dyskinesia in
children with chronic abdominal pain. J Pediatr Surg 1999;34:854-7.
MacFadyen BV, Jr., Vecchio R, Ricardo AE, Mathis CR. Bile duct injury after laparoscopic
cholecystectomy. The United States experience. Surg Endosc 1998;12:315-21.