小儿胆囊切除术（图文演示）

10. Exposure

[点击按纽展开更多->收起->回放]

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.

[点击按纽展开更多->收起->回放]

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

[点击按纽展开更多->收起->回放]

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

[点击按纽展开更多->收起->回放]

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

[点击按纽展开更多->收起->回放]

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.

[点击按纽展开更多->收起->回放]

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.

[点击按纽展开更多->收起->回放]

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

[点击按纽展开更多->收起->回放]

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.

[点击按纽展开更多->收起->回放]

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.

[点击按纽展开更多->收起->回放]

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 during
laparoscopic 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.