小儿胆囊切除术（图文演示）

中文版：小儿胆囊切除术（中文图文演示）

PEDIATRIC   CHOLECYSTECTOMY
Authors
G Mattioli, V Jasonni
Abstract
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.

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

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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

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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

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1. Gallbladder
2. 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

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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.

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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.

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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.

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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

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Trocar A
1. 30° laparoscope, 2. traumatic grasper

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Trocar B
1. atraumatic grasper

Trocar D
2. scissors, 3. hook, 4. clip applier, 5. atraumatic dissector, 6. retrieval bag, 7. irrigation-suction device

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Trocar C
1. 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.