Mini-laparoscopic cholecystectomy in children under 10 years of age with sickle cell disease

Laparoscopic cholecystectomy for cholelithiasis in children with sickle cell disease

Patients with sickle cell disease (SCD) suffer from an increased incidence of gallstone formation due to hemolysis of sickled red blood cells; this leads to an increased level of bilirubin in secreted bile that becomes a nidus for pigment stone formation. Laparoscopic cholecystectomy (LC) is considered a standard operative procedure for gallstone disease mainly due to lower postoperative wound complaints, faster recovery, better postoperative cosmetic results, shorter hospital stay, and earlier return to work. Although numerous studies have been published addressing both the advantages and complications of LC in acute calcular cholecystitis, there is still limited evidence concerning the safety and efficacy of LC for the management of cholelithiasis in pediatric patients with SCD, and controversies remain unresolved. In this review, we aim to comprehensively study the available literature and propose evidence-based practice recommendations for the optimal management of gallstones in pediatric SCD patients. The current practice differs greatly depending on the prevalence of SCD in a particular geographic area. We acknowledge the limited number of patients reported, the lack of randomized control trials addressing the practice of specific recommendations, and the need for further evidence-based studies.

Microlaparoscopic cholecystectomy with an unorthodox scope position

PURPOSE

We report our initial experiences with microlaparoscopic cholecystectomy (MLCE) in children using a 2.4-mm mini-scope placed to the right of the umbilicus. The umbilicus was used as the working trocar for large-diameter instruments.

METHODS

The mini-scope was inserted 2-3 cm to the right to the umbilicus and slightly above the umbilical line. A miniport for the 2-mm grasper was inserted laterally through the right abdominal wall, and a 5-mm working trocar was inserted infra-umbilically. The three-angle principle of laparoscopic instrumentation remained, as the trocar positions were merely shifted to the right side of the abdominal wall. With the patient in the supine position, the surgeon stood on the left side of the patient, facing the monitor.

RESULTS

MLCE was successfully performed in 12 children (average age: 15 years, average body weight: 46.4 kg). In two cases, the optic trocar was repositioned one cm laterally, because the initial trocar position was too close to the umbilicus and was colliding with the 5-mm instruments. The view at the cystohepatic triangle was sufficient. There were no specific complications due to the rearranged trocar positions or the use of a mini-scope. It was possible to displace the scope out of the umbilical area without compromising the superior cosmesis allowed by using only miniports.

CONCLUSION

Based on our early experiences, MLCE is safe and feasible. This technique helps reduce the access trauma and operative time while allowing for superior cosmesis.

Colelitíase no paciente pediátrico portador de doença falciforme

OBJETIVO: Considerando a alta freqüência da colelitíase no paciente pediátrico com doença falciforme e a controvérsia na literatura sobre a abordagem da condição, o presente texto objetiva revisar a literatura disponível. FONTE DE DADOS: Revisão dos estudos sobre colelitíase no paciente falciforme, publicados no período entre 1980 e 2007, em língua inglesa e portuguesa, envolvendo pacientes na faixa etária de zero a 18 anos e utilizando os bancos de dados Medline e Lilacs. SÍNTESE DOS DADOS: A colelitíase é a complicação digestiva mais comum no paciente falciforme e sua incidência aumenta com a faixa etária. Os mecanismos fisiopatológicos são conhecidos, assim como os métodos diagnósticos. A conduta terapêutica consensual na colelitíase sintomática é a colecistectomia, preferencialmente por via laparoscópica. Nos casos assintomáticos, a maioria dos autores recomenda a conduta cirúrgica, para evitar complicações, confusão no diagnóstico diferencial de dor abdominal futura e menor risco cirúrgico. Contudo, não existe consenso na literatura, havendo base para a adoção de conduta expectante. CONCLUSÕES: A doença falciforme tem grandes variações em sua apresentação clinica, história natural e gravidade da hemólise. Algumas populações podem apresentar menor freqüência de colelitíase e menor número de pacientes sintomáticos, possivelmente em razão de variações de haplótipos, fatores ambientais e diferentes manejos clínicos. Ainda não existem dados suficientes na literatura ou estudos randomizados e controlados que possibilitem definir o momento ideal para a colecistectomia no paciente falciforme com litíase assintomática. Dessa maneira, dependendo de características individuais e da população, podem ser aceitos o seguimento clínico ou a indicação precoce de colecistectomia.

Is there a safe advantage in performing outpatient laparoscopic cholecystectomy in children?

BACKGROUND

Laparoscopic cholecystectomy, the standard procedure for removing the sick gallbladder of children, is generally performed leaving the child overnight in the hospital.

PURPOSE

This study aimed to determine if there is a safe advantage in performing laparoscopic cholecystectomy as an outpatient procedure while setting the clinical parameters for those who will benefit from in-hospital stay.

METHODS

Thirty-five patients were selected for the study and were divided into group A, if the outpatient procedure was done, and group B, if the child was left overnight in the hospital. Retrospective review of medical charts was performed. Statistical significance was defined as P < .05.

RESULTS

Group A consisted of 13 patients and group B of 22 patients. All patients in group A left the hospital the same day of surgery. Distribution by age and sex in the groups was not statistically different. Preoperative symptoms of vomiting were statistically significantly higher in group B. Presence of an associated medical condition was higher in the in-hospital patients. Concomitant procedures, blood loss estimates, and duration of surgery showed no statistical difference. No child was readmitted after release from the hospital. Pre-, intra-, and postoperative pain management were the same in all patients. Mean postoperative stay and medical charges were statistically significant between the groups.

CONCLUSIONS

Laparoscopic cholecystectomy can safely be done as an outpatient procedure. Children with a complicated gallbladder disease process or associated medical condition benefit from an overnight stay. Perioperative pain management is crucial in all cases. Reduced hospital stay and medical charges are significant advantages in performing laparoscopic cholecystectomy as an outpatient procedure.

Asymptomatic cholelithiasis in children with sickle cell disease: early or delayed cholecystectomy?

SUMMARY BACKGROUND DATA

Our study aimed to evaluate the role of elective laparoscopic cholecystectomy (LC) in children with sickle cell disease (SCD) and asymptomatic cholelithiasis and, furthermore, to determine whether the outcome is related to the operation timing.

METHODS

The records of 30 children with SCD diagnosed with cholelithiasis from June 1995 to September 2005 were retraspectively reviewed. All 30 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them. The operation was accepted in the period of study by 16 children and refused by 14. During medical observation, 10 of the 14 children who refused surgery were admitted for severe biliary colics. Acute cholecystitis was diagnosed by abdominal ultrasound in 3 cases and in 1 case choledocholithiasis, ultrasonographically suspected, was confirmed by magnetic resonance cholangiopancreatography (MRCP) and treated during endoscopic retrograde cholangiopancreatography (ERCP). All children, emergency admitted, underwent LC after the onset of symptoms. The patients were divided up into 2 groups (A: asymptomatic; B: symptomatic) depending on clinical presentation and operation timing and the respective outcomes were compared.

RESULTS

Elective LC in asymptomatic children (group A) is safe with no major complications reported. During medical observation in children who refused elective surgery (group B), 6 biliary colics, 3 acute cholecystitis, and 1 choledocholithiasis were observed. Three sickle cell crises occurred in symptomatic children during biliary colics. The correlation between cholecystectomy performed in asymptomatic children (group A) and cholecystectomy performed in symptomatic children (group B) showed significant differences in the outcome. Morbidity rate and postoperative stay increased when children with SCD underwent emergency LC.

CONCLUSIONS

Elective LC should be the gold standard in children with SCD and asymptomatic cholelithiasis to prevent the potential complications of biliary colics, acute cholecystitis, and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

SIMPLE AND EFFECTIVE SUSPENSION TECHNIQUE FOR LAPAROSCOPIC CHOLECYSTECTOMY

Many surgeons elect to dispense with the lateral retraction port during laparoscopic cholecystectomy using the American four-port technique; however, this may not be easy and safe. To retain the superior ergonomical and observation advantages, suspension techniques that leave virtually no scars have been developed to substitute for the lateral retraction port. All published techniques for suspending the gall bladder fundus were reviewed and an attempt was made to evolve a technique that is expedient, safe and cost-effective. In our setting, the optimal technique is to pass a folded thread down a 14-G intravenous cannula that has punctured the abdominal wall to form a snare loop to entrap and hold the gall bladder fundus. The anchorage is maintained by a two-haemostat technique heretofore undescribed. In some of the cases where better exposure of the undersurface of the liver is needed, the cannula can be directed to puncture the thoracic cage at or below the seventh intercostal space to provide cephalad retraction and to rotate the liver superiorly. Postoperative chest radiographs did not show any pneumothorax. The simple suspension technique emulates the four-port technique's advantages in terms of favourable ergonomics and exposure (and hence safety). It is suitable for selected patients and due caution should be exercised.