Indications for cholecystectomy in children include pigmented gallstones, symptomatic cholesterol stones, or biliary dyskinesia. Acalculous acute cholecystitis is also seen occasionally, especially in immunocompromised or critically ill patients. It is usually best to treat these children with percutaneous cholecystostomy tube placement, rather than a heroic attempt to remove the gallbladder. Children with incidental asymptomatic gallstones are usually recommended for cholecystectomy, though some are observed for months or years, and sometimes prescribed ursodiol, in the hope that the stones might resolve. They rarely, if ever, disappear.
The prevalence of biliary dyskinesia seems to be increasing. The diagnosis can be elusive but if the patient has: (1) intermittent RUQ or epigastric pain precipitated by meals, (2) associated nausea, and (3) a positive CCK-HIDA scan (gallbladder ejection fraction <35%), then cholecystectomy can be expected to relieve the pain in 85–90% of the cases. With only two of three of these findings, the likelihood of success is probably closer to 60 or 70%, and with only one, cholecystectomy should only be considered if the patient is truly debilitated, all other likely causes have been excluded, and the patient understands that there is a less-than-50% chance that the operation will be a success. Patients should also understand that removal of the gallbladder is not entirely without risk and that it can result in the unpleasant and often intractable problem of fecal urgency and loose bowel movements.
In general, intra-operative cholangiogram is rarely indicated and really only necessary in the rare case of anatomic confusion. Most children with one of the traditional indications for intra-operative cholangiogram (jaundice, pancreatitis, dilated CBD) and whose symptoms have resolved can safely undergo cholecystectomy without intra-operative cholangiogram. If the clinical impression is that they might actually have a stone in the CBD, they should undergo ERCP (or at least an MRCP) before undergoing cholecystectomy. Common duct exploration in children is technically difficult and potentially hazardous; it should almost never be necessary when the expertise to perform a therapeutic ERCP is available. Likewise, open cholecystectomy should rarely be necessary in children. The severe inflammation or fibrosis commonly seen in adults occurs rarely in children and the anatomy is rarely confusing.
Three-trocar cholecystectomy is certainly feasible but because it affords no significant advantage (it eliminates one 5-mm port) and the risks are almost certainly higher, it is difficult to justify its routine application. The single-port operation is being developed but whether it can be done with consistent safety remains to be seen. The operator should always control both the dissector and the assistant’s grasper (rather than the camera). This is how all other operations are performed and is certainly more natural. The dissection of the cystic duct should begin at the infundibulum of the gallbladder so that there is no question that it is the cystic duct that is being isolated and divided. The cautery hook should be used more like a spatula, dividing tissue that has been placed under tension by gentle traction, rather than using it as a hook every time. There is increasing evidence that, except in the case of true acute cholecystitis or cholangitis, laparoscopic cholecystectomy can be considered a “clean” case, making prophylactic antibiotics unnecessary.
As a complication of cholecystectomy in children, common bile duct injury appears to be exceedingly rare. Reconstruction is usually best accomplished with Roux-en-Y choledochojejunostomy, which can be prone to strictures due to the small caliber of the duct in most children. Bile leaks are also quite rare but are treated in the standard fashion (percutaneous drainage, ERCP, sphincterotomy, stent). Every attempt should be made to retrieve spilled stones, although retained intraperitoneal stones discovered incidentally months or years later are rarely cause for concern. In some cases, the cystic duct can be quite large and therefore not properly controlled with even the longest endoscopic hemoclip. In these situations, it is usually best to use an endoscopic linear stapling device to come across the duct, though this can be technically challenging.