1. Gallbladder Disease in Infants and Children 2011 ISW Meeting George W. Holcomb III, MD, MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

2. Ann Surg 191:626-635, 1980

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

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

5. Biliary Dyskinesia Symptomatic biliary colic w/o stones Reduced GBEF and pain with CCK stimulation Has become the most common reason for cholecystectomy in many U.S. centers IU study – 37 pts – 71% resolution of symptoms  GBEF < 15% successful resolution of symptoms (O.R. – 8.00) Chronic cholecystitis seen on histological examination of many specimens

6. Symptoms Epigastric/RUQ pain Nausea/vomiting Fatty food intolerance Painless jaundice Pancreatitis

7. Imaging Studies Ultrasound Radionucleide gallbladder emptying study (with CCK) Hepatobiliary scan

8. Complicated Cholelithiasis Acute cholecystitis Jaundice Pancreatitis

9. Timing of Cholecystectomy Non-complicated disease – 0 – 14 days Complicated disease Jaundice – following work-up Cholecystitis – 2-4 days Pancreatitis – once resolved

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

11. MANAGEMENT OF SUSPECTED CHOLEDOCHOLITHIASIS

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

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

14. 14/131 suspected choledocholithiasis J Pediatr Surg 32:1116-1119, 1997

15. Algorithm Suspected Choledocholithiasis

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

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

18. IS ROUTINE CHOLANGIOGRAPHY NEEDED?

19. Cholangiography 1990-1995: Reasonable to perform cholangiography to become facile with technique 2011: Most surgeons have become facile with this technique

20. Cholangiography To evaluate for CBD stones To define anatomy

21. My Approach Reserve cholangiography for cases where anatomy is unclear Use ultrasound pre-operatively to define CBD involvement

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

23. Financial analysis of preoperative ultrasonography versus intraoperative cholangiography for detection of choledocholithiasis at Children's’ Mercy Hospital, Kansas City MO 2008 Immediate Pre-op Evaluation with US Charges ($)Intraoperative Cholangiography Charges ($) Ultrasound study (including radiologist fee) 307.6715-minutes OR time1500.00 C-Arm with radiologist fee 365.41 Sterile drape for C- Arm 20.00 Cholangiocatheter83.50 Contrast for cholangiogram 40.00 TOTAL$307.67TOTAL$2008.91

24. Cholangiography Cystic Duct Cannulation Kumar Clamp Technique

25. Surg Endosc 8:927-930, 1994

26. Where do I place the instruments/ports for a laparoscopic cholecystectomy?

27. Port Placement

28. Stab Incision Technique 2 cannulas 2 stab incisions

29. Key Steps in Operation 1.Begin dissection high on gallbladder to expose triangle of Calot 2.90 0 orientation cystic and common ducts

30. Critical View of Safety

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

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

33. CMH Experience 2000 - 2006 224 Pts (12.9 yrs, 58.3 kg) Indication Symptomatic gallstones166 Biliary dyskinesia 35 Gallstone pancreatitis 7 Gallstones/splenectomy 6 Calculous cholecystitis 5 Other 4 IPEG, 2007 J Laparoendosc Adv Surg Tech 18:127-130, 2008

34. CMH Experience 2000-2006 Mean operative time77 min Cholangiograms – Intraoperatively 38  Stones9  Cleared intraop5  Cleared postop4 Preoperatively (ERCP) 17  Stones found8 Ductal injuries0 IPEG, 2007 J Laparoendosc Adv Surg Tech 18:127-130, 2008

35. SSULS Cholecystectomy

36. More Difficult Operation

37. SSULS Cholecystectomy Please use this link if you experience problems viewing the video above.this link

38. SSULS Cholecystectomy Adults Can be performed safely but is more challenging Longer operating times (75 – 120 min) Difficulty with triangulation of instruments Additional ports/instruments - 10-30% cases Sutures thru infundibulum or fundus for retraction Slight incidence injury CBD (0.7% vs 0.2%) Selected patients  Relatively thin patient  Non-inflamed gallbladder  Intra-op cholangiogram can be difficult

39. SSULS Cholecystectomy Pediatrics CH-A: 25 cases Mean op time – 73 min (30-122) Additional instrument/port 22 pts (88%) Nougues CP et al. JLAST 20:493-496, 2009 CH-LA: 24 cases Mean op time – 97 min (65-145) Addt’l port – 2 pts (8%) Emami CN et al. Am Surg 76:1047-1049,2010

40. SSULS Cholecystectomy Pediatrics CMH: 24 cases Mean op time – 73 min Conversion to 4-port – 2 pts (8%) Garey CL et al J Pediatr Surg 46:904-907, 2011

41. SSULS Cholecystectomy Pediatrics Safe Effective Is it better than the 4-port technique?

42. CMH Prospective Randomized Trial Power analysis - 60 patients (59 to date) Primary outcome variable - operative time

43. Secondary Outcome Variables Complications Postoperative pain Cosmesis Infection rate Operative charges

44. www.cmhmis.com QUESTIONS