Orientation of the four ports used for laparoscopic cholecystectomy in children. The midepigastric port should be positioned according to the patient’s size; the smaller the child, the closer to the left midclavicular line. The right lateral port may also be placed more inferiorly in the right lower quadrant in smaller children. From Holcomb GW 3rd, et al. Laparoscopic cholecystectomy in infants and children: modifications and cost analysis. Journal of pediatric surgery. 1994;29(7):900–4. Reprinted with permission from Elsevier Limited.
The borders of the hepatocystic triangle, also known as Calot’s triangle , include the common hepaticduct medially, the cystic duct laterally/inferiorly, and the inferior border of the liver superiorly. Its contents include the cystic artery and the cystic lymph node. The right hepatic artery is located posterior to these structure but its proximity should be kept in mind  (Fig. 41.2). Accessory hepatic ducts and arteries may also be found in this space. Careful dissection in this triangle must be performed during laparoscopic cholecystectomy in order to obtain the critical view of safety, which consists of clearly visualizing the cystic duct entering the gallbladder, with an empty space between the gallbladder and liver except for the cystic artery which traverses the space to enter the gallbladder  (Fig. 41.3).
Calot’s triangle (shaded area). Bordered by the common hepaticduct medially, the cystic duct laterally/inferiorly, and the inferior border of the liver superiorly. Its contents include the cystic artery and the lymph node. The right hepatic artery is posterior to these structure but its proximity should be kept in mind during dissection. From Nagral S. Anatomy relevant to cholecystectomy. J Minim Access Surg. 2005;1(2):53–8. Copyright © Journal of Minimal Access Surgery (Open Access).
Critical view of safety. The cystic duct is visualized entering the gallbladder with an empty space between the gallbladder and liver except for the cystic artery which traverses the space to enter the gallbladder.
Depending on the size of the child, it may be helpful to have a foot board in place to prevent sliding when in reverse Trendelenburg position. Two monitors should be positioned at the 10 o’clock and 2 o’clock position in direct line of vision for both the surgeon and first assistant . After initial trocar placement, the bed should be positioned in reverse Trendelenburg with slight rotation to the child’s left. In performing a SILS cholecystectomy, the child should be in the split-legged (French) position with the surgeon between the legs and the assistant to the child’s left  (Fig. 41.4).
Positioning of patient and operative team during: (top) laparoscopic cholecystectomy and (bottom) SILS cholecystectomy.
A basic laparoscopic setup consisting of a high-quality videolaparoscope , two high-resolution monitors, and a high-flow carbon dioxide insufflator is needed . The laparoscope may be 3 mm or 5 mm in size and may be either a 0° or 30° lens. Depending on the desired mode of entry, a Veress needle or Hassan cannula can be used, with placement of four trocars (three 3 mm or 5 mm and one 10 mm). Commonly used instruments include: a fine-tipped dissector, two graspers, endoshears, a monopolar L-hook, a suction irrigator, a 5 mm clip applier, and an endobag. Additionally, a stone retrieval grasper is helpful when there is spillage of gallstones . In performing a SILS cholecystectomy, a right-angle light adapter is used in addition to the basic laparoscopic setup. Single-incision trocars include a SurgiQuest AnchorPort® trocar (SurgiQuest, Inc., Milford, Connecticut) and two 5 mm trocars versus a multiple access port such as a SILS™ Port (Medtronic, Minneapolis, Minnesota); instruments include a MiniLap alligator grasper (Stryker, Kalamazoo, Michigan), a reticulating gallbladder grasper, and another reticulating instrument .
An oral gastric tube may be placed to decompress the stomach. An open Hassan technique is recommended for initial trocar placement in small children, whereas either an open Hassan or a Veress needle may be used for bigger children. The abdomen is insufflated, and trocars are placed in the following positions: 10 mm umbilical, and 3 mm or 5 mm epigastric to the right of the falciform at the level of the inferior edge of the liver in bigger children (versus the left midclavicular line in small children), right subcostal midclavicular, and right subcostal lateral in bigger children (versus right lower quadrant in small children) . The fundus of the gallbladder is grasped from the right lateral/lower quadrant port and elevated to expose the porta hepatis. The infundibulum of the gallbladder is grasped through the right midclavicular trocar and retracted laterally and inferiorly to open the hepatocystic triangle. The visceral peritoneum overlying the area of the gallbladder/cystic duct junction is opened by grasping and gently pulling opposite of the infundibulum retraction on both the anterior and posterior sides until the cystic duct and artery and lymph node of Calot are identifiable. Gentle dissection around the cystic duct and artery is performed until the structures can be clearly traced onto the gallbladder. It is not necessary to dissect the cystic duct to its junction with the common duct, as this increases the risk of a common duct injury. However, it is necessary to dissect the triangle of Calot free of all tissue except for the cystic duct and artery in order to expose the base of the liver and obtain a critical view of safety. The cystic duct and artery are clipped and divided individually. The gallbladder is mobilized off the hepatic fossa using cautery or scissors; this dissection is helped by retracting the gallbladder away from the liver using the left hand and by flipping the gallbladder over the liver . The gallbladder can be removed from the peritoneal cavity with or without the use of an endobag depending on the integrity of the gallbladder wall. Any bile that was spilled is suctioned, and any gallstones that were spilled are retrieved. All trocars are removed under direct visualization, the abdomen is desufflated, and the fascia is closed using either figure-of-eight and/or interrupted stitchs. The skin incisions for all port sites are closed with subcuticular suture.
The technique for a SILS cholecystectomy differs only slightly from the above described technique. An initial 15 mm horizontal infraumbilical skin incision is made. The abdomen is insufflated, three 3 mm or 5 mm trocars are placed in a horizontal fashion at the 10 o’clock, 5 o’clock, and 2 o’clock positions, and the laparoscope is inserted at the 5 o’clock position. In larger children, a multiport trocar may be placed via an open technique and rotated so that the trocars are in the above positions . A MiniLap alligator grasper is inserted along the trocars at the 7 o’clock position and used to retract the fundus of the gallbladder cephalad prior to being clamped down to the drapes . An alternative to using a MiniLap alligator grasper is to place a percutaneous stay suture in order to suspend the gallbladder cephalad. A reticulating grasper is used to retract the infundibulum of the gallbladder to the right and slightly cephalad before the handle is moved to the surgeon’s right, away from the other instruments . A dissector is placed through the 10 o’clock position and is used to proceed with the operation as usual. The three 5 mm fascial incisions are connected with electrocautery, the gallbladder is removed, and the incision is closed.
Two main techniques exist for IOC in children. In the first, a small lateral incision is made in the cystic duct, and a cholangiocatheter or small urethral catheter is inserted into the cystic duct and held/clipped in place while cholangiography is performed . An alternative to this approach is to insert a Kumar clamp through a 5 mm trocar and position it across the infundibulum of the gallbladder. A small (23G) needle is introduced through the side arm in the clamp, contrast is instilled into the proximal gallbladder, and cholangiography is performed . This technique avoids difficult cannulation of a small cystic duct, but cannot be performed in the setting of a cystic duct obstruction .
Fifteen to 20 % of people have variations in their biliary anatomy, the most relevant of which is a short cystic duct which can be associated with mistaking the common duct for the cystic duct . If there is unclear anatomy, conversion to an open procedure should be performed. An IOC may also be performed; however, this has not been shown to decrease injury to the common bile duct, only to lead to faster identification of an injury. Several techniques may be employed in the setting of significant inflammation to aid in safe dissection: gallbladder decompression with needle aspiration, lateral to medial approach for lysis of adhesions, and a dome-down approach to dissection. A 30 mm or similar size endoscopic stapling device can also be used to divide the infundibulum of the gallbladder for a partial cholecystectomy . In this situation, placement of a drain may be considered. Bleeding in the hepatocystic triangle is usually related to injury to the cystic artery or a branch of the right hepatic artery, and blind clipping in this area should be avoided; tamponade can often be achieved by applying gentle pressure with the gallbladder against the liver .
Laparoscopic cholecystectomy is associated with a decreased length of stay, analgesia use, and overall cost when compared to open cholecystectomy [16, 22, 23]. Same-day discharge has also been shown to be safe and may be better facilitated by the use of total IV anesthesia and a light diet for 72 h following surgery [24, 25]. SILS cholecystectomy follows the same course as laparoscopic cholecystectomy and offers no advantage over the latter except for with regard to cosmesis [19, 26]. Laparoscopic cholecystectomy with IOC has been shown to increase operative time without decreasing the rate of retained common bile duct stones or injury . However, selective use of IOC may be beneficial given that 10–15 % of patients with biliary pancreatitis will have common bile duct stones on ERCP. Laparoscopic cholecystectomy with ERCP is often the treatment of choice for patients with bile duct stones, though some groups have performed laparoscopic cholecystectomy with common bile duct exploration. Though technically difficult and associated with a risk for stricture in small children, in experienced hands, it has been shown to be associated with decreased length of stay and cost, with similar morbidity when compared to laparoscopic cholecystectomy and ERCP .