Holcomb GW 3rd.
Children's Hospital, Vanderbilt University Medical Center, Nashville, TN 37212, USA.
Historically, cholelithiasis in children was thought to develop secondary to hemolytic disease. Within the past 20 years, however, its incidence in children without hemolysis is being diagnosed more frequently. Laparoscopic cholecystectomy has become the procedure of choice for gallbladder removal in children. Many of the principles for this technique in children are similar to those in the adult population. Because of the patient's smaller size and more pliable abdominal wall, however, several improvements in technique have been developed. In addition, special precautions are necessary in children because of other unique characteristics. At Children's Hospital, Vanderbilt University Medical Center, 80 infants and children have undergone laparoscopic cholecystectomy since June 1990 without intraoperative or postoperative complications. Modifications in the operative technique used in these patients are detailed.
Primary laparoscopic endorectal pull-through for Hirschsprungs disease in infants and children.
Wulkan ML. Georgeson KE.
Department of Surgery, University of Alabama School of Medicine and The Children's Hospital of Alabama, Birmingham, AL 35233, USA.
Colon pull-through for Hirschsprung's disease has classically been performed in multiple stages. Open primary pull-through procedures offer the advantages of shorter overall hospital stay, decreased morbidity, and earlier intestinal continuity, and colostomy is avoided. This article describes the techniques used and results obtained in 24 consecutive patients who had a laparoscopic primary endorectal pull-through for Hirschsprung's disease. The patients ranged in age from a few days to 6 years. Operative times ranged from 1-(1/2) hours to 3-(1/2) hours. Perioperative complications were relatively minor. None of the patients had clinical enterocolitis after primary laparoscopic pull-through, and there were no anastomotic strictures. Average postoperative length of stay was 3-(1/2) days. Primary laparoscopic endorectal pull-through is a safe and effective alternative to open primary or multistage pull-through procedures.
Laparoscopic appendectomy in children.
Blakely ML. Spurbeck WW. Laksman S. Hanna K. Schropp KP. Lobe TE.
Department of Surgery, University of Tennessee, Memphis, TN 38105, USA.
Laparoscopic appendectomy is a common surgery in most pediatric surgical centers. Many studies, mostly retrospective reviews in adults, show the advantages of the laparoscopic approach to be less wound infections, shortened postoperative recovery, and faster return to normal activities. In addition, less analgesic medication is required postoperatively. Potential disadvantages of laparoscopic appendectomy include an increased operative time, elevated costs when disposable instruments are used, and possibly more infectious complications when performed for complicated appendicitis. There are no prospective, randomized trials comparing laparoscopic versus open appendectomy in children. Until these studies are completed, questions will persist regarding the benefits of laparoscopic appendectomy in children.
Laparoscopic fundoplication and gastrostomy.
University of Alabama at Birmingham and The Children's Hospital of Alabama, Birmingham, AL 35233, USA.
Fundoplication and gastrostomy are among the more common operative procedures performed in infants and children. This article reviews the techniques, results, and complications of the surgical treatment of gastroesophageal reflux in 389 consecutive pediatric patients over the last 5 years. Chronic unremitting vomiting, failure to thrive, and an array of pulmonary symptoms were the leading indications for fundoplication in these children. Children who eat by mouth were primarily treated by a Toupet fundoplication, whereas gastrostomy-fed children generally received a Nissen fundoplication. The time to perform fundoplication and gastrostomy in our patients averaged about 3 hours for the first 10 patients but required a little over 1 hour for the last 50 patients. Most patients were discharged by the second or third postoperative day. Recurrent symptoms have developed in about 5% of our patients. Five of the 201 children who received a Toupet fundoplication (partial wrap) have been converted to a complete wrap fundoplication. Two of the patients having a Nissen fundoplication have required reoperation for their symptoms. The primary complications were seven cases of transient dysphagia, one case of esophageal perforation, and one case of gastric perforation. Laparoscopic fundoplication seems to achieve results equivalent to open fundoplication and is associated with considerably less postoperative pain and morbidity as well as a more rapid recovery.
Diagnostic laparoscopy for congenital inguinal hernia.
Holcomb GW 3rd.
Department of Pediatric Surgery, Children's Hospital, Nashville, TN 37212, USA.
Repair of indirect inguinal hernias is the most common general surgical procedure in infants and children. The question of whether or not to explore the contralateral side, however, has been the source of much debate among pediatric surgeons. With the advent of laparoscopy and the development of miniature telescopes, diagnostic laparoscopy has been advocated to decide in which child the contralateral side should be explored and a patent processus vaginalis ligated. This article describes the historical perspective in which this technique developed, the technique itself, and a report of the author's experience.
The clinical management and results of surgery for acute cholecystitis.
Hashizume M. Sugimachi K. MacFadyen BV.
Department of Surgery, Kyushu University, Fukuoka, TX, 812-8582, Japan.
The laparoscopic approach to acute cholecystitis is not only feasible, but it is also a cost-effective, safe, and beneficial treatment option in selected patients. Patients undergoing laparoscopic surgery for acute cholecystitis seem to enjoy the same benefits of diminished pain and shorter hospitalization as those patients undergoing an elective laparoscopic cholecystectomy. The complication rates are also comparable with those for an open cholecystectomy. An early laparoscopic cholecystectomy within 4 days of the onset of symptoms has been shown to reduce the number of major complications and conversion rate, thus resulting in a decreased hospital stay. A low threshold for conversion to laparotomy also seems to be an important factor in maintaining a low incidence of operative complications. The conversion to laparotomy is therefore considered to be a good surgical option for experienced surgeons. Patients who are in the high-risk category or who have severe disease are best managed initially by gallbladder drainage unless they have perforated disease, which thus requires an emergency laparotomy.
The difficult cholecystectomy: problems during dissection and extraction.
Department of Surgery, Carraway Methodist Medical Center, Birmingham, AL 35234, USA.
All surgeons will encounter difficult cholecystectomies. Many trying and untenable situations can be prevented or made easier by the cautious surgeon who has a carefully thought-out plan for each potential problem. Step-by-step, this article addresses the arduous challenges that may be faced beginning with diagnosis and continuing through the operative procedure including the decision to operate, the best intervention, abdominal entry, dealing with common duct stones, intraoperative cholangiography, exposure of the biliary anatomy, avoidance of bleeding or common duct injury, spilled stones, and postoperative bile collection. Each problem is addressed with emphasis on prevention and management.
Access problems in laparoscopic cholecystectomy: postoperative adhesions, obesity, and liver disorders.
Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
In the decade since the clinical arrival of laparoscopic cholecystectomy, there have been gratifying improvements in imaging technology and instrumentation, and innovative techniques have evolved. Laboratory-simulator devices are available for basic skills exercises and can at least reasonably mimic the appearance of the gallbladder and some other organs or anatomic regions. Unfortunately, there is no satisfactory method to practice dealing with certain structural abnormalities or disease processes. Because of that, some operations will be particularly difficult and the outcomes will be favorable only with careful planning and capable execution. The experiences and skill level of the surgeon can be enhanced by appropriate mental preparation. As a result, the surgeon will have the opportunity to accomplish the task, both laparoscopically and safely, under circumstances that initially were thought to be inappropriate or impossible for laparoscopy.
The difficult cholecystectomy: problems related to concomitant diseases.
Salky BA. Edye MB.
Division of Laparoscopic Surgery, Mount Sinai Medical Center, New York, NY, USA.
The difficult gallbladder is the most common "difficult" laparoscopic surgery performed by general surgeons. It is also "potentially" the one that places the patient at significant risk. This article reports on our first 1,900 laparoscopic cholecystectomies. With this report, it is the desire of the authors to share our experiences and lessons learned from more than 300 difficult gallbladder cases. We surgeons must strive for no bile duct injuries. If certain principles are followed, the surgeon will be able to improve his or her completion rate and decrease (if not eliminate) bile duct injuries. First and foremost is to know when to convert to open. Performance of fluorocholangiography to define anatomy is also very helpful in avoidance of bile duct injury. The laparoscopic surgeon should start with simple cases before "graduating" to more complex cases. Lastly, the ability to suture and knot tie is key in performing advanced procedures. This skill will allow completion of cases that otherwise would have to be converted to traditional surgery.
Alternative methods for management of the complicated gallbladder.
Johnson AB. Fink AS.
Veteran's Administration Medical Center, Atlanta, GA 30033, USA.
Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. However, in the presence of acute cholecystitis, 10% to 15% of patients face conversion to laparotomy. Alternatives to conventional therapy may therefore help to improve the clinical outcome of patients with complicated gallbladder disease. In selecting patients for alternative therapies, preoperative and intraoperative factors must be considered. Preoperative factors include the severity of biliary disease and preexisting medical risk factors; whereas intraoperative factors include conditions at the time of surgery that make dissection difficult or unsafe. Alternative therapies provide the least invasive management to safely temporize or definitively treat the acute condition. These alternatives include percutaneous cholecystostomy alone or followed by laparoscopic cholecystectomy, laparoscopic cholecystostomy followed by laparoscopic cholecystectomy, laparoscopic subtotal cholecystectomy, endoscopic retrograde cannulation of the gallbladder, and extracorporeal shockwave lithotripsy. By appropriate selection of the initial therapeutic approach, the surgeon may ultimately improve the clinical outcome in these complicated patients.
The management of gallbladder cancer: before, during, and after laparoscopic cholecystectomy.
Pearlstone DB. Curley SA. Feig BW.
University of Texas M.D. Anderson Cancer Center, Houston, TX 77401, USA.
Carcinoma of the gallbladder is a rare disease, but when encountered in the patient undergoing laparoscopic cholecystectomy, it can pose a number of dilemmas. Familiarity with the risk factors for malignant gallbladder disease can help identify patients in whom more extensive preoperative evaluation is warranted. When carcinoma is identified preoperatively, cholecystectomy should be performed as an open procedure. If malignancy is encountered unexpectedly during laparoscopic cholecystectomy, the procedure should be converted to an open resection to allow for appropriate evaluation of the stage of disease and appropriate surgical management. Most commonly, malignancy is identified postoperatively, only after pathological examination of the resected gallbladder. Except in rare circumstances, open reoperation is necessary to achieve an adequate curative resection. The current concerns about port site recurrence and carcinomatosis after laparoscopic resection of a gallbladder carcinoma are unwarranted based on current published data. The role of prophylactic excision or irradiation of port sites is uncertain based on current understanding of the biological behavior of the disease.
Laparoscopic cholecystectomy in pregnancy: a review of published experiences and clinical considerations.
Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
Symptomatic biliary disease during pregnancy may have serious consequences for both the mother and the fetus. Laparoscopic cholecystectomy was felt initially to be contraindicated in pregnancy, but clinical experience accumulated since 1991 has been extremely favorable. Specialists in the areas of anesthesiology, obstetrics and laparoscopic surgery should continue to carefully monitor and analyze practices and outcomes of laparoscopic cholecystectomy during pregnancy. At the present time, there is no consensus regarding several management issues, such as optimal pressure limits for insufflation. Nevertheless, the reported results are quite encouraging and may foretell an improvement in patient care for this special population as dramatic as that achieved by laparoscopic cholecystectomy in others.