Perioperative cholangiogram in pediatric cholecystectomy

Recently, the increased accuracy of ultrasound examinations has led to the more frequent identification of cholelithiasis. The minimally invasive approach has allowed a broader application of surgical therapy in children. We report on our experience with 43 laparoscopic cholecystectomies in children. Ultrasound examination has been used preoperatively to diagnose viscero-parietal adhesions, gallstone migration into the common bile duct, and to measure stone size and location. The etiology of gallbladder stones was of unknown origin (32% of cases), or due to hematological disorders or hyperbilirubinemia (36%), polyposis (5%), or anatomic anomalies of the cystic-choledochal junction (27%). Intraoperative cholangiography was never performed. Results were excellent, and complications were not experienced. During the follow-up, either residual concretions or stone migrations into both the choledocus and the extrahepatic biliary ducts were ruled out using ultrasound examination. The indication for cholangiography is a source of controversy in cholecystectomy. We believe that it is mandatory only when a bile tree dilation has been preoperatively detected by ultrasound examination or when stone migration is suspected. Skeletonizing the Calot's triangle elements is the method of choice to identify the anatomy of this region.