Twenty-Five Year Experience with Laparoscopic Cholecystectomy in the Pediatric Population-From 10 mm Clips to Indocyanine Green Fluorescence Technology: Long-Term Results and Technical Considerations

Background: This study aimed to review our 25-year experience with pediatric laparoscopic cholecystectomy (LC) to assess its long-term outcome. Materials and Methods: The records of 215 children (127 girls and 88 boys) who underwent LC for the past 25 years (1993-2018) were retrospectively reviewed. All patients had a symptomatic cholelithiasis. The cholelithiasis was idiopathic in 185 patients (86%) and secondary in 30 patients (14%). A four-trocar technique was always adopted and cystic duct and cystic artery were clipped using 10-mm clips in the first 35 cases (16.3%) and 5-mm clips in the following 180 patients (83.7%). In the last 15 cases, indocyanine green (ICG)-enhanced fluorescence was adopted intraoperatively for a better identification of the anatomy of gallbladder and biliary tree. Results: The average operative time was 69 minutes and fell down to 52 minutes after introduction of ICG fluorescence (P = .001). Fifteen anatomic anomalies (6.9%), involving bile duct in 5 cases and cystic artery in 10 cases, were recorded. Technical problems were reported intraoperatively in 6 cases (2.8%). We recorded 4 postoperative Clavien IIIb complications (1.9%): 1 bleeding from the cystic artery, 1 dislocation of the clips on the cystic duct, and 2 iatrogenic injuries to the main bile duct managed with choledojejunostomy in 1 case and suture of the choleducus over a stent in the second case. We also recorded 3 umbilical granulomas (1.4%) (Clavien II). Conclusions: LC is a standardized and effective procedure to perform in children. Our 25-year experience showed that major complications (Clavien IIIb) can occur even in experienced surgeons' hands. Age, weight, and preoperative cholecystitis were significantly associated with the risk of bile duct injury in our series. Considering its versatility and safety, we believe that ICG fluorescence technology may be adopted in every LC to ease the dissection and reduce the likelihood of complications.