Laparoscopic Cholecystectomy

Indications for Workup and Operation

The primary disease processes that lead to consideration for cholecystectomy include cholelithiasis, cholecystitis (acute, acalculous, and chronic), acute hydrops of the gallbladder, and biliary dyskinesia. Although the patient’s history may differ, usually the signs and symptoms are similar for all these conditions. Epigastric and right upper abdominal pain, with or without associated fever or jaundice, should immediately prompt the child’s healthcare provider to consider a gallbladder condition as the possible diagnosis.

Symptomatic cholelithiasis is often but not always the result of impaired gallbladder emptying related to gallstones. Gallstones are generally classified as being either nonhemolytic or hemolytic (secondary to sickle cell disease, spherocytosis, and thalassemia) in composition. Nonhemolytic gallstones are nearly always cholesterolic, whereas hemolytic gallstones are usually composed primarily of calcium bilirubinate. Regardless, the signs and symptoms are identical, related to biliary colic, and sometimes seen in association with excessive fat intake. An abdominal US will reveal the presence of gallstones in the gallbladder. Should cholecystitis occur, the patient may develop fever and possibly jaundice, and the US may show gallbladder wall thickening or pericholecystic fluid (or both). Leukocytosis and right upper abdominal pain frequently occur. Patients with symptomatic cholelithiasis should undergo elective laparoscopic cholecystectomy. Those with acute, severe cholecystitis are usually treated with intravenous antibiotics and urgent cholecystectomy. Rarely, in a patient with severe comorbidities or with a presentation of septic shock, a cholecystostomy tube may be required as a temporizing measure.

In the subset of patients with the presentation of gallstone pancreatitis, the standard algorithm for treatment is to allow the pancreatitis to slowly resolve by observing the patient’s symptoms and following the patient’s lipase and amylase levels. The cholecystectomy should be done in the same admission due to the risk for recurrence if the cholecystectomy is delayed.

The finding of biliary ductal dilation with US or the development of jaundice raises the possibility of choledocholithiasis. A number of options exist at this point. We prefer to proceed with preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone removal, if indicated, because the surgeon is then better able to plan the subsequent laparoscopic operation. ² ERCP has been shown to be a safe procedure in the pediatric population, although the availability of an experienced endoscopist depends on local expertise in one’s community. If the common duct stone is extracted at ERCP and sphincterotomy, the surgeon can proceed with routine laparoscopic cholecystectomy. However, if the stone cannot be removed, the surgeon will know that laparoscopic choledochal exploration and stone removal should be planned. If that is not successful, then open exploration may be needed under the same anesthesia.

When the symptoms of epigastric and right upper abdominal pain, with or without associated fever or jaundice, are associated with a severe illness, trauma, burn, or sepsis, acalculous cholecystitis should be considered. The etiology of acalculous cholecystitis is, as its name implies, not due to gallstones. It is believed that this development is related to the association of events surrounding the disease under treatment. This includes gallbladder quiescence, excessive red cell hemolysis, TPN use with the absence of food intake, dehydration, and an adynamic ileus. An abdominal US may reveal gallbladder distention, gallbladder wall thickening, and pericholecystic fluid. Occasionally, sludge or debris will be visualized in the gallbladder. Failure of medical management (nothing by mouth, parenteral antibiotics, and intravenous fluids) may result in the need for laparoscopic cholecystectomy.

Biliary dyskinesia is rarely seen in infants. However, this condition is being encountered more often in children and adolescents, and it is considered by many gastrointestinal providers to be a valid reason for cholecystectomy in this age group. These patients often present with nonspecific abdominal pain that may be located in the right upper abdomen or epigastrium. The pain may be associated with meals and may be related to an excessively fatty diet. An abdominal US is invariably not diagnostic. In this instance, a technetium-99m radionuclide scan is diagnostic. In healthy individuals, the gallbladder ejection fraction should be greater than 35%. If a patient has symptoms consistent with biliary colic and a radionuclide gallbladder-emptying scan documenting an ejection fraction of less than 35%, laparoscopic cholecystectomy should be considered. Unfortunately, not all symptoms in these patients will be relieved. An ejection fraction of less than 15% usually results in relief of symptoms. Similarly, there is a small subset of patients who suffer abdominal pain with biliary hyperkinesia. This is defined as a gallbladder ejection fraction greater than 65%. The number of pediatric patients with this specific pathology is small so there are still further studies to be done as to whether a cholecystectomy is the treatment of choice, but there is some preliminary evidence to suggest that cholecystectomy can provide symptom relief.

Operative Technique