1. Gallbladder Disease in Infants and Children
George W. Holcomb III, MD, MBA
Children’s Mercy Hospital
Kansas City, Missouri

4. Biliary Disease Gallstones Biliary dyskinesia Acalculous disease
Hemolytic disease
Non-hemolytic disease
Biliary dyskinesia
Acalculous disease

5. Risk Factors for Cholelithiasis in Infants and Children
Hemolytic
Sickle cell disease
Spherocytosis
Thalassemia
Nonhemolytic
Total parenteral nutrition
Gallbladder stasis
Lack of enteral feeding
Ileal resection
(necrotizing enterocolitis and Crohn’s disease)
Biliary tract anomalies
Adolescent pregnancy
Oral contraceptives

6. Biliary Dyskinesia Symptomatic biliary colic w/o stones
Reduced GBEF with CCK stimulation
IU study – 37 pts – 71% resolution of symptoms
GBEF < 15% successful resolution of symptoms (O.R. – 8.00)
Chronic cholecystitis seen in histological examination of many specimens

7. Pilot Study

8. Pilot Study

9. Complicated Cholelithiasis
Acute cholecystitis
Jaundice
Pancreatitis

10. Timing of Cholecystectomy
Non-complicated – 2 weeks
Complicated
Jaundice – following work-up
Cholecystitis – 2-4 days
Pancreatitis – once resolved

11. When to Suspect Choledocholithiasis?
Elevated bilirubin (jaundice)
Elevated lipase, amylase (pancreatitis)
Dilated CBD or stone(s) in CBD on ultrasound

12. SUSPECTED CHOLEDOCHOLITHIASIS (Pre-operatively)
Management Options

13. Management Options Pre-op ERCP, sphincterotomy, stone extraction
Laparoscopic or open CBD exploration at time of cholecystectomy
Post-op ERCP, sphincterotomy, stone extraction

14. Factors Surgeon’s experience with laparoscopic CBD exploration
Availability of an endoscopist to perform ERCP in children

16. Algorithm Suspected Choledocholithiasis

17. Why?
Surgeon knows at time of laparoscopic cholecystectomy whether CBD (laparoscopic or open) exploration needed
Potentially avoids a third anesthesia and operation

18. Disadvantage
A number of ERCPs will be performed in patients that do not have CBD stones

19. IS ROUTINE CHOLANGIOGRAPHY NEEDED?

20. Cholangiography
: Reasonable to perform cholangiography to become facile with technique
2006: Most surgeons have become facile with this technique

21. Cholangiography
To evaluate for CBD stones
To define anatomy

22. One Surgeon’s Approach
Reserve cholangiography for cases where anatomy is unclear
Use ultrasound pre-operatively to define CBD involvement

23. Pre-operative Ultrasound
Prior to laparoscopic cholecystectomy
Confirm gallbladder stones, evaluate for CBD dilation or stones
Cost-effective strategy

24. Immediate Pre-op Evaluation with US Intraoperative Cholangiography
Financial analysis of preoperative ultrasonography versus intraoperative cholangiography for detection of choledocholithiasis at Children's’ Mercy Hospital, Kansas City MO
Immediate Pre-op Evaluation with US
Charges ($)
Intraoperative Cholangiography
Ultrasound study (including radiologist fee)
307.67
15-minutes OR time
C-Arm with radiologist fee
365.41
Sterile drape for C-Arm
20.00
Cholangiocatheter
83.50
Contrast for cholangiogram
40.00
TOTAL
$307.67 $

25. Cholangiography
Cystic Duct Cannulation
Kumar Clamp Technique

26. Kumar Clamp Technique
Surg Endosc 8: , 1994

27. Where do I place the instruments/ports?

28. Port Placement

29. Stab Incision Technique
2 cannulas
2 stab incisions
J Pediatr Surg 38: , 2003

30. The Use of Stab Incisions
PAPS 2003
JPS 38: , 2003

31. Cost Savings from Stab Incisions
PAPS 2003
JPS 38: , 2003

32. Key Steps in Operation
Begin dissection high on gallbladder to expose triangle of Calot

33. Create 90 b/w cystic duct and CBD
Key Steps in Operation
Create 90 b/w cystic duct and CBD

34. What Do I Do If I Cut the Common Bile Duct?

35. Options Ligate duct Repair laparoscopically Repair open
wait for it to enlarge
transfer to experienced biliary surgeon
Repair laparoscopically
Repair open
interrupted sutures
T – tube
choledochojejunostomy at second operation

36. CMH Experience 2000 - 2006 224 Pts (65% female) Indication
(12.9 yrs, 58.3 kg)
Indication
Symptomatic gallstones 166
Biliary dyskinesia 35
Gallstone pancreatitis 7
Gallstones/splenectomy 6
Calculous cholecystitis 5
Other 4
IPEG, 2007

37. CMH Experience 2000-2006 Mean operative time 77 min Cholangiogram –
Preoperatively (ERCP) 17
Stones 8
Intraoperatively 38
Stones 9
Cleared intraop 5
Cleared postop 4
Postoperatively (ERCP) 2
Stones 0
Ductal injuries 0
IPEG, 2007

38. Laparoscopy for Splenic Conditions
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas City, MO

39. Splenic Conditions ITP Spherocytosis Splenic cysts Wandering spleen
J Pediatr Surg 28: , 1993

40. Pre-Operative Preparation
Ultrasound
Often done by pediatrician, hematologist
Rarely needed for splenectomy, except may be useful for extremely large spleen
CT Scan – Useful in planning splenic cystectomy
WinRho
Bone marrow stimulant
Usually used to platelet count
Useful pre-operatively to platelet count in ITP pt.
Immunizations –Pneumococcus (Prevnar, Pneumovax)

41. Patient Positioning

42. Patient Positioning

43. Personnel Positions

44. Laparoscopic Splenectomy
ITP, spherocytosis
Port placement
(2) cannulas (5, 12)
(2) stab (3 mm) incisions
Instruments
Harmonic scalpel (5 mm)
Articulating stapler (12 mm)

45. Laparoscopic Splenectomy
Operative Steps
Divide spleno-colic ligament, then short gastrics
Clip artery
Autotransfuse pt
Protects stapler malfxn

46. Laparoscopic Splenectomy
Operative Steps
Divide spleno-renal lig.
Articulating stapler across hilum
Bag specimen, morcellate extracorporally

47. Laparoscopic Splenectomy

48. Issues How large is too large?
28 cm. – Splenic artery ligation helpful
Can divide spleen (spherocytosis) with harmonic, if necessary

49. Issues Postoperative platelet ct. > 500,000
Reports of splenic vein/portal vein thrombosis following splenectomy (open and laparoscopic)
Baby aspirin ( 81 mg) QD for 6 mos
Re-check at 3 months & 6 months

50. Splenic Cysts Primary Pseudocysts (secondary) epithelial lining
no epithelial lining
often develop after trauma

51. Laparoscopic Splenic Cystectomy
First step is decompression of cyst

52. Laparoscopic Splenic Cystectomy
Excise cyst as close as possible to splenic parenchyma with harmonic scalpel
Coagulate lining with Argon beam coagulator
? Place omentum adjacent to exposed cyst lining

53. European Experience 3 European centers (Mainz, Mannheim, Hannover)
14 pts (median 8.5 yr)
10 recurrences (71%)
APSA 2006

54. Wandering Spleen

55. Wandering Spleen

56. Laparoscopic Splenopexy
J Pediatr Surg 42:E23-27, 2007

57. I.U. Experience 1995 - 2006 231 patients Mean age 7.7 yrs
Lap splenectomy – 223
211 - total
12 - partial
Lap splenic cystectomy – 6
Lap splenopexy - 2
Ann Surg, in Press

58. I.U. Experience 1995 – 2006 Complications
Ileus - 5
Bleeding - 4
Acute chest syndrome- 5
Pneumonia - 2
Portal vein thrombosis - 1
HUS - 1
Diaphragm perforation 2
Colon injury - 1
Port site hernia - 1
Total splenectomy after partial - 1
Recurrent cyst - 1
11% overall, 22% in SCD
Ann Surg, in Press