Transcript Laparoscopy for Splenic Conditions

Gallbladder Disease in Infants
and Children
George W. Holcomb III, MD, MBA
Children’s Mercy Hospital
Kansas City, Missouri
Biliary Disease
• Gallstones
• Hemolytic disease
• Non-hemolytic disease
• Biliary dyskinesia
• Acalculous disease
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 contraceptives
Hemolytic
Sickle cell disease
Spherocytosis
Thalassemia
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
Pilot Study
Pilot Study
Complicated Cholelithiasis
•
Acute cholecystitis
•
Jaundice
•
Pancreatitis
Timing of Cholecystectomy
• Non-complicated – 2 weeks
• Complicated
• Jaundice – following work-up
• Cholecystitis – 2-4 days
• Pancreatitis – once resolved
When to Suspect
Choledocholithiasis?
• Elevated bilirubin (jaundice)
• Elevated lipase, amylase (pancreatitis)
• Dilated CBD or stone(s) in CBD on
ultrasound
SUSPECTED
CHOLEDOCHOLITHIASIS
(Pre-operatively)
Management Options
Management Options
• Pre-op ERCP, sphincterotomy, stone
extraction
• Laparoscopic or open CBD
exploration at time of
cholecystectomy
• Post-op ERCP, sphincterotomy,
stone extraction
Factors
• Surgeon’s experience with
laparoscopic CBD exploration
• Availability of an endoscopist to
perform ERCP in children
Algorithm
Suspected Choledocholithiasis
Why?
• Surgeon knows at time of
laparoscopic cholecystectomy
whether CBD (laparoscopic or open)
exploration needed
• Potentially avoids a third anesthesia
and operation
Disadvantage
A number of ERCPs will be
performed in patients that do not
have CBD stones
IS ROUTINE
CHOLANGIOGRAPHY
NEEDED?
Cholangiography
• 1990-1995: Reasonable to perform
cholangiography to become facile
with technique
• 2006: Most surgeons have become
facile with this technique
Cholangiography
• To evaluate for CBD stones
• To define anatomy
One Surgeon’s Approach
• Reserve cholangiography for cases
where anatomy is unclear
• Use ultrasound pre-operatively to
define CBD involvement
Pre-operative Ultrasound
• Prior to laparoscopic cholecystectomy
• Confirm gallbladder stones, evaluate
for CBD dilation or stones
• Cost-effective strategy
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
Ultrasound study
(including radiologist
fee)
Charges ($)
Intraoperative
Cholangiography
Charges ($)
307.67 15-minutes OR time
1500.00
C-Arm with
radiologist fee
TOTAL
365.41
Sterile drape for CArm
20.00
Cholangiocatheter
83.50
Contrast for
cholangiogram
40.00
$307.67 TOTAL
$2008.91
Cholangiography
Cystic Duct
Cannulation
Kumar Clamp
Technique
Kumar Clamp Technique
Surg Endosc 8:927-930, 1994
Where do I place the
instruments/ports?
Port Placement
Stab Incision Technique
• 2 cannulas
• 2 stab incisions
J Pediatr Surg 38:1837-1840, 2003
The Use of Stab Incisions
Procedure (n)
Nissen (209)
Nissen (14)
Heller Myotomy (7)
Appendectomy (102)
Meckel’s Diverticulum (2)
Pyloromyotomy (77)
Cholecystectomy (31)
Pullthrough (20)
Splenectomy (21)
Adrenalectomy (6)
UDT (15)
Varicocele (5)
Ovarian (2)
Totals (511)
Used/case
1
2
2
2
2
1
2
2
2
2
1
1
1
714
Saved/case
4
3
3
1
1
2
2
1
2
2
2
2
2
1337
PAPS 2003
JPS 38:1837-1840, 2003
Cost Savings from Stab Incisions
Procedure (n)
Nissen (209)
Nissen (14)
Heller (7)
Appy (102)
Meckel’s (2)
Pyloric (77)
Chole (31)
Pullthrough (20)
Spleens (21)
Adrenal (6)
UDT (15)
Varicocele (5)
Ovarian (2)
Total = 511
Step Pt./Instit. Savings ($)
117,040 / 51,832
5,880 / 2,604
2,940 / 1,302
14,280 / 6,324
280/ 124
21,560 / 9,548
8,680 / 3,844
2,800 / 1,240
5,880 / 2,604
1,680 / 744
4,200 / 1,860
1,400 / 620
560 / 248
$187,180/$82,894
Ethicon Pt./Instit. Savings ($)
76,912 / 4,276
3,864 / 1,722
1,932 / 861
9,384 / 4,182
184 / 82
14,168 / 6,314
5,704 / 2,542
1,840 / 820
3,864 / 1,722
1,104 / 492
2,760 / 1,230
920 / 410
368 / 164
$123,004/$54,817
PAPS 2003
JPS 38:1837-1840, 2003
Key Steps in Operation
1. Begin dissection high on gallbladder to
expose triangle of Calot
Key Steps in Operation
2. Create 90 b/w cystic duct and CBD
What Do I Do If I Cut
the Common Bile Duct?
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
CMH Experience
2000 - 2006
• 224 Pts (65% female)
(12.9 yrs, 58.3 kg)
• Indication
•
•
•
•
•
•
Symptomatic gallstones
Biliary dyskinesia
Gallstone pancreatitis
Gallstones/splenectomy
Calculous cholecystitis
Other
166
35
7
6
5
4
IPEG, 2007
CMH Experience
2000-2006
• Mean operative time
• Cholangiogram –
77 min
• Preoperatively (ERCP)
• Stones
17
• Intraoperatively
• Stones
• Cleared intraop
• Cleared postop
38
• Postoperatively (ERCP)
• Stones
• Ductal injuries
8
9
5
4
2
0
0
IPEG, 2007
Laparoscopy for Splenic
Conditions
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas City, MO
Splenic Conditions
• ITP
• Spherocytosis
• Splenic cysts
• Wandering spleen
J Pediatr Surg 28:689-692, 1993
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)
Patient Positioning
Patient Positioning
Personnel Positions
Laparoscopic Splenectomy
• ITP, spherocytosis
• Port placement
• (2) cannulas (5, 12)
• (2) stab (3 mm) incisions
• Instruments
• Harmonic scalpel (5 mm)
• Articulating stapler (12 mm)
Laparoscopic Splenectomy
Operative Steps
• Divide spleno-colic
ligament, then short
gastrics
• Clip artery
• Autotransfuse pt
• Protects stapler malfxn
Laparoscopic Splenectomy
Operative Steps
• Divide spleno-renal lig.
• Articulating stapler
across hilum
• Bag specimen,
morcellate
extracorporally
Laparoscopic Splenectomy
Issues
• How large is too large?
• 28 cm. – Splenic artery
ligation helpful
• Can divide spleen
(spherocytosis) with
harmonic, if necessary
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
Splenic Cysts
• Primary
• epithelial lining
• Pseudocysts
(secondary)
• no epithelial lining
• often develop after
trauma
Laparoscopic Splenic Cystectomy
• First step is
decompression of
cyst
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
European Experience
• 3 European centers
(Mainz, Mannheim, Hannover)
• 1995 - 2005
• 14 pts (median 8.5 yr)
• 10 recurrences (71%)
APSA 2006
Wandering Spleen
Wandering Spleen
Laparoscopic Splenopexy
J Pediatr Surg 42:E23-27, 2007
I.U. Experience
1995 - 2006
231 patients
• Mean age 7.7 yrs
• Lap splenectomy –
• 211 • 12 -
223
total
partial
• Lap splenic cystectomy – 6
• Lap splenopexy
-2
Ann Surg, in Press
I.U. Experience
1995 – 2006
Complications
• Ileus 5
• Bleeding 4
• Acute chest syndrome- 5
• Pneumonia • Portal vein
thrombosis • HUS -
2
1
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
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