Search Results (16)

Background: Symptomatic cholelithiasis is the leading indication for pediatric cholecystectomy. While historically linked to hemolytic disorders, non-hemolytic gallbladder disease in children has become increasingly common in recent decades. Objective: The objective of this study was to describe the distribution and temporal trends of indications for cholecystectomy among children (ages ≤ 19 years) undergoing surgery at a tertiary pediatric center in Israel and to compare clinical presentation between hemolysis-related and non-hemolysis-related cases. Methods: We conducted a retrospective observational cohort study of all pediatric patients who underwent cholecystectomy at Schneider Children’s Medical Center between 2011 and 2024. Patients with congenital biliary tract anomalies or biliary tract neoplasms were excluded. Results: A total of 199 cholecystectomies were performed (median age 13.4 years). Hemolysis-related cholelithiasis accounted for 34.2% of cases; five patients (2.5%) had gallbladder polyps or other benign lesions, while the remaining patients had non-hemolysis-related cholelithiasis. No cases of biliary dyskinesia were identified. The proportion of non-hemolysis-related cholecystectomies remained stable over time. Among symptomatic patients, the rate of choledocholithiasis was significantly higher in the hemolysis-related group compared to the non-hemolysis group (27% vs. 7.9%, p = 0.004). No statistically significant association was observed between obesity and increased disease severity or adverse outcomes. Conclusion: Unlike trends reported in some Western countries, the number of cholecystectomies performed for non-hemolysis-related cholelithiasis in our single-center cohort did not increase over time. Hemolysis-related disease remains a leading indication for pediatric cholecystectomy. Prophylactic surgery may help prevent biliary complications in this group while symptomatic patients have substantial complication rates. Full article

Introduction: Since its introduction in 1994, robot-assisted surgery has advanced significantly and has become a widely accepted tool in minimally invasive surgery. Over the past two decades, robotic technology has also been increasingly adopted in pediatric surgery. Currently, only two robotic systems are officially approved for pediatric use: the da Vinci surgical system and the Senhance system, both of which have certain limitations. To address these challenges, new robotic platforms such as the Versius system are being developed. Materials and Methods: Following approval from the institutional bioethics committee, a total of 14 pediatric patients underwent robotic-assisted surgery using the Versius robotic system between 10 June and 21 October 2024. Procedures included pyeloplasty, vascular hitch, and cholecystectomy. Results: Procedures with the Versius system were performed including children as young as six years of age and with body weight as low as 15 kg. All procedures were completed successfully without conversion to conventional laparoscopy or open surgery. No intraoperative complications were recorded. The overall postoperative complication rate was 21.4% (3/14 cases), including one anastomotic leak, one case of postoperative hematuria, and one case of postoperative ascites. Discussion: The Versius system represents a promising robotic platform for pediatric surgery, offering a different approach to robotic surgery through modularity, mobility, and compatibility with 5 mm instruments. However, several challenges remain, including prolonged setup and docking times, cable management issues, arm conflicts, and limited access to advanced instrumentation. Nevertheless, with ongoing technological development, robotic surgery is likely to play an increasingly important role in pediatric surgical care. Full article

Postoperative pain management in pediatric patients remains a significant challenge despite improvements in perioperative care. Regional anesthesia techniques applied as part of multimodal analgesia strategies offer the potential to reduce opioid use, accelerate recovery, and minimize side effects such as respiratory depression, nausea, and delayed mobilization. This review examines the clinical applications, advantages, and limitations of regional anesthesia blocks in the context of common pediatric surgical procedures—appendectomy, inguinal hernia repair, circumcision, cholecystectomy, and pyloromyotomy. We provide procedural comparisons in terms of analgesic efficacy, opioid-sparing effects and suitability for ambulatory surgery. In conclusion, regional anesthesia techniques have significant potential to improve postoperative outcomes in pediatric patients. However, block selection should be individualized, considering the type of surgical procedure, patient characteristics, and operator experience. Increasing applicability and routinely implementing ultrasound-guided procedures will encourage the safer and more effective use of these techniques in pediatric anesthesia. Full article

Background/Objectives: ERCP is an established method of treating cholelithiasis; however, data on its use in the pediatric population is limited. The aim of this study was to assess the prevalence of cholelithiasis among Polish children, the number of ERCP procedures performed on them, and the time between endoscopic and surgical procedures when both were necessary. Methods: We performed a retrospective data analysis on Polish children hospitalized due to biliary tract pathologies (ICD-10 K80–K83) in the period of 2010–2022. Results: In the years 2010–2022, 15,581 hospitalizations linked to the diagnosis of K80–K83 were reported. Of these, 40.71% involved patients undergoing a surgical procedure, and 4.28% involved patients undergoing ERCP (10.15% of unique patients underwent ERCP). Females accounted for 65.91% of hospitalizations, and patients in the age group of 14–17 represented 57.31% of hospitalizations. No significant yearly trends were observed in the number of hospitalizations and ERCP procedures performed. The median time between ERCP and surgical procedures was 32 days. Conclusions: Both the number of ERCP procedures performed in Poland and the demography of patients are consistent with data from the literature. Further research is needed to fully understand the treatment of cholelithiasis among Polish children. Full article

Background: Pediatric cholelithiasis has become increasingly diagnosed, partly due to enhanced imaging accessibility and rising obesity rates. Despite laparoscopic cholecystectomy being the standard treatment, the optimal timing for surgery remains debated, especially in complicated cases. The aim of our study is to analyze the demographic, clinical, and surgical characteristics of pediatric patients undergoing cholecystectomy and to identify the most favorable timing for surgery in terms of outcomes and complications. Material and methods: A retrospective study was conducted on 101 pediatric patients who underwent cholecystectomy between 2015 and 2024 at a tertiary children’s hospital. Patients were categorized based on surgical timing: elective, early (day 1–4), intermediate (day 5–14), and delayed (after day 14). Demographic data, clinical presentation, laboratory values, imaging, operative time, intraoperative findings, and postoperative complications were analyzed. Results: The median age was 15 years, with 64.35% female. Obesity was highly prevalent and significantly associated with choledocholithiasis and pancreatitis. Elective and delayed surgeries (after 14 days) had the shortest operative times (median: 2 h) and the lowest complication rates. Early surgeries (within 4 days) showed longer operative times and a higher incidence of intraoperative difficulties and complications. Histopathological findings did not influence clinical management, suggesting potential for selective examination. Conclusions: Elective or delayed cholecystectomy after a “cool-down” period of 5–14 days provides the most favorable outcomes in pediatric patients with complicated cholelithiasis. Conservative management remains appropriate for asymptomatic cases. A standardized approach to surgical timing may reduce complications and hospital costs Full article

Introduction: Near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) is now widely regarded as a valuable aid in decision-making for complex hepatobiliary procedures, with increasing support from recent studies. Methods: We performed a systematic review following PRISMA guidelines, utilizing PubMed, CINAHL, and EMBASE databases to locate studies on the perioperative use ICG in pediatric hepatobiliary surgeries. Two independent reviewers assessed all articles for eligibility based on predefined inclusion criteria. We collected data on study design, patient demographics, surgical indications, ICG dosing, timing of ICG injection, and perioperative outcomes. Results: Forty-three articles, including 930 pediatric patients, from 1989 to 2025 met the inclusion criteria for narrative synthesis in our systematic review, of which 22/43 (51.2%) were retrospective studies, 15/43 were case reports (34.9%), 3/43 (7.0%) were experimental studies, and the other three were prospective comparative studies (7.0%). The current clinical applications of ICG in hepatobiliary pediatric surgery include bile duct surgery (cholecystectomy, choledochal cyst, biliary atresia), reported in 17 articles (39.5%), liver tumor resection, reported in 15 articles (34.9%), liver transplantation, reported in 6 articles (14.6%), and liver function determination, reported in 5 articles (12.2%). Conclusions: ICG fluorescence navigation in pediatric hepatobiliary surgery is a highly promising and safe technology that allows for the intraoperative localization of anatomic biliary structures, aids in the identification and resection of liver tumors, and can accurately determine hepatic function. The lack of comparative and prospective studies, and the variability of the dose and timing of administration are the main limitations. Full article

Background: The rising rates of gallstones and cholecystectomy in pediatric populations underscore the increasing concern regarding chronic cholecystitis. However, the morphopathogenesis of pediatric calculous cholecystitis is still not well understood. This study aimed to determine the expression and distribution of immunomodulatory factors interleukin-12 (IL-12), interleukin-13 (IL-13), interleukin-1β (IL-1β), sonic hedgehog protein (SHH), nuclear factor NF-kappa-B p65 subunit (NFkBp65), and heat shock protein 60 (HSP60) in the gallbladder walls of pediatric patients with chronic calculous cholecystitis. Methods: In total, 11 gallbladder samples were collected from pediatric patients with calculous cholecystitis during cholecystectomy, while 5 healthy gallbladder samples served as controls. IL-12, IL-13, IL-1β, SHH, NFkBp65, and HSP60 were detected by immunohistochemistry. The number of positive structures in gallbladder wall epithelium, vasculature, and inflammatory infiltrate was assessed semi-quantitatively by microscopy. A Mann–Whitney U test and Spearman’s rank-order correlation coefficient were calculated. Results: Statistically significant differences were observed between patient and control samples in the expression of IL-1β, SHH, and NFkBp65 in the epithelium, as well as in the expression of IL-12, SHH, and HSP60 in the blood vessels. The expression of IL-1β was stronger in the epithelium of controls, while other markers were more prominent in patient samples. Conclusions: An increased number of NFkBp65, IL-12, and HSP60 positive cells in patient gallbladder tissue suggests a significant role of these tissue factors in driving immune modulation and sustaining the inflammation in pediatric chronic calculous cholecystitis. The noticeable expression of SHH in patient gallbladder tissue indicates its part in tissue regeneration and repair processes, as well as in modulating inflammation and vascular responses in calculous cholecystitis. The significant positive correlations between the factors studied highlight the importance of their coordinated interaction and intricate crosstalk in the morphopathogenesis of calculous cholecystitis. Full article

Malignant lymphoma is an unusual form of gallbladder neoplasm. Almost all these tumors are diffuse large B-cell lymphomas or mucosa-associated lymphoid tissue-type lymphomas. Herein, we present a literature review of gallbladder Burkitt’s lymphoma (BL) cases that includes also an unpublished case in an HIV-infected child, observed by our center. The patient (a five-year-old black female child) attended the Federal Hospital of Lagoa, Rio de Janeiro, Brazil, underwent cholecystectomy, and the postoperative pathological analysis of the gallbladder revealed a diagnosis of BL (EBV-positive). Also, HIV serology was performed and returned positive. She was transferred to the Martagão Gesteira Institute of Pediatrics and Childcare for oncological treatment, dying from sepsis and disease progression about 18 months later. The patient did not undergo ART/cART. Previous cases of gallbladder BL were herein described and analyzed to characterize the clinicopathological features and possible similarities. BL can occur in the gallbladder both in the context of HIV infection and in the pediatric population. A biopsy is mandatory in cases with suggestive findings of lymphoma, and an early diagnosis can change the course of the disease. Furthermore, the case highlights the importance of an early initiation of ART/cART in people living with HIV (PLWH), especially in children. Full article

Background: Same-day discharge after a cholecystectomy is a common practice in the adult population and has been demonstrated as safe and viable for children as well. However, there is a lack of comprehensive teaching models for pediatric cholecystectomy. Drawing inspiration from standardized outpatient procedures, this study aimed to assess the clinical outcomes and feasibility of teaching programs and an Enhanced Recovery After Surgery (ERAS) protocol following ambulatory laparoscopic cholecystectomy in pediatric patients. Methods: In 2015, an ERAS pathway for laparoscopic cholecystectomy (LC) was implemented, focusing on admission procedures, surgery timing, anesthetic choices, analgesia, postoperative feeding, mobilization, and pain assessment. Day-case surgery was not applicable for acute cholecystitis, choledochal lithiasis, sickle cell disease, and hereditary spherocytosis cases. The protocol was employed for a group of attending surgeons and fellows, as well as a group of residents under the supervision of experienced surgeons. A retrospective analysis was conducted to evaluate the feasibility and effectiveness of ambulatory cholecystectomy in children and its utilization in training pediatric surgical trainees. Results: Between 2015 and 2020, a total of 33 patients were included from a cohort of 162 children who underwent LC, with 15 children operated on by senior surgeons and 18 by young surgeons. The primary diagnoses were symptomatic gallbladder lithiasis (n = 32) and biliary dyskinesia (n = 1). The median age at the time of surgery was 11.3 years (interquartile range (IQR) 4.9–18), and the median duration of surgery was 54 min (IQR 13–145). One intraoperative complication occurred, involving gallbladder rupture and the dissemination of lithiasis into the peritoneal cavity. Three patients (9%) required an overnight stay, while no postoperative complications or readmissions within 30 days were observed. ERAS was successfully implemented in 30 patients (91%). No significant differences in surgical outcomes were noted between senior and young surgeons. At an average follow-up of 55 months, no long-term sequelae were identified. Conclusions: These findings align with the current trend of increasing use of outpatient laparoscopic cholecystectomy and underscore its feasibility in the pediatric population. The application of a structured ERAS protocol appears viable and practical for training the next generation of pediatric surgeons. Level of Evidence: Level III. Full article

Background: In children, laparoscopic cholecystectomy (LC) is now considered the gold standard for gallbladder (GB) removal. In the past, hemolytic disorders associated with cholelithiasis represented the most frequent conditions requiring LC; this is being overtaken by cholelithiasis and biliary conditions in overweight or ex-premature children. Aims: This study aims to describe current indications and timing for LC in pediatric patients. Methods: Retrospective study. Data on previous medical therapy, ultrasound, pre- and intraoperative aspects, and histology were collected for patients treated in 2020–2023. Results: In total, 45 patients were enrolled: 15 who underwent urgent surgery and 30 electives. Groups differed in terms of obesity rate, symptoms, ultrasound features, and intraoperative status. The most relevant risk factors for surgical complexity were age and pubertal stage, elevated cholestasis indexes, and gallbladder wall thickness > 3 mm at ultrasound. GB wall thickening ≥3 mm, US Murphy sign, fluid collections, and gallbladder distention on ultrasound correlated with high surgical scores. Conclusions: Indications for laparoscopic cholecystectomy in children seem to evolve caused by changing characteristics of the pediatric population. Patients with overweight/obesity may develop more complex GB diseases. Asymptomatic patients should be considered for surgery after observation, considering age and/or pubertal maturation when other risk factors are absent. Full article

The need for cholecystectomy during pediatric age has significantly increased in the last two decades. As biliary pathology increases, the probability of complicated cholecystectomies increases too. The aim of this article is to analyze our experience with difficult laparoscopic pediatric cholecystectomy, focusing on the importance of an accurate pre-operative imaging study. We retrospectively analyzed all patients affected by cholelithiasis who underwent laparoscopic cholecystectomy at the Pediatric Surgery Department of San Camillo Forlanini hospital of Rome and Santa Maria alle Scotte University Hospital of Siena from 2017 to 2022. Demographic data, body mass index (BMI), recovery data, laboratory tests, imaging exams, surgical findings, post operative management and outcome were taken into account. Overall, 34 pediatric patients, with a mean age of 14.1 years (6–18 years) were included, with a mean BMI of 29. All patients underwent abdominal ultrasonography and a liver MRI with cholangiography (cMRI). We identified five cases as “difficult cholecystectomies”. Two subtotal cholecystectomies were performed. Cholecystectomy in pediatric surgery can be difficult. The surgeon must be able to find alternative strategies to total cholecystectomy to avoid the risk of possible bile duct injury (BDI). Pre-operative imaging study trough ultrasound and especially cMRI is crucial to recognize possible difficulties and to plan the surgery. Full article

Ultrasound (US) is a non-invasive imaging technique frequently used to examine internal organs and superficial tissues, and invaluable in pediatric patients. In a surgical setting, intraoperative ultrasound allows to highlight anatomical structures in detail during traditional open and minimally invasive surgery, thanks to the use of specific probes. In fact, laparoscopic and robotic ultrasonography requires the development of specialized transducers that fit through laparoscopic trocars. In adults, laparoscopic ultrasound is used during cholecystectomy before dissection of the triangle of Calot, to guide liver biopsies and ablation procedures and for the staging of patients with pancreas adenocarcinoma. However, the applications in the pediatric field are still limited. This paper aims to share our preliminary experience with ultra-sound in minimally invasive laparoscopic and robotic pediatric surgery, describing two cases in which intra-operative ultrasound was applied, and to present a review of the literature on the state of the art of the actual uses in pediatric surgery. Full article

Introduction: Different robotic systems have been used widely in human surgery since 2000, but pediatric patients require some features that are lacking in the most frequently used robotic systems. Hypothesis: The Senhance^® robotic system is a safe and an effective device for use in infants and children that has some advantages over other robotic systems. Methods: All patients between 0 and 18 years of age whose surgery was amenable to laparoscopy were offered enrollment in this IRB-approved study. We assessed the feasibility, ease and safety of using this robotic platform in pediatric patients including: set-up time, operative time, conversions, complications and outcomes. Results: Eight patients, ranging from 4 months to 17 years of age and weighing between 8 and 130 kg underwent a variety of procedures including: cholecystectomy (3), inguinal herniorrhaphy (3), orchidopexy for undescended testes (1) and exploration for a suspected enteric duplication cyst (1). All robotic procedures were successfully performed. The 4-month-old (mo), 8 kg patient underwent an uneventful robotic exploration in an attempt to locate a cyst that was hidden in the mesentery at the junction of the terminal ileum and cecum, but ultimately the patient required an anticipated laparotomy to palpate the cyst definitively and to excise it completely. There was no blood loss and no complications. Robotic manipulation with the reusable 3 mm instruments proved successful in all cases. Conclusions: Our initial experience with the Senhance^® robotic platform suggests that this is a safe and effective device for pediatric surgery that is easy to use, and which warrants continued evaluation. Most importantly, there appears to be no lower age or weight restrictions to its use. Full article

Background: In recent years, complicated biliary tract diseases are increasingly diagnosed in children. Laparoscopic exploration of the common bile duct (LCBDE) followed by laparoscopic cholecystectomy has gained popularity in children. The aim of this study was to investigate the outcomes of LCBDE in children and compare them with the treatment outcomes of previously used endoscopic retrograde cholangiopancreatography (ERCP). Methods: From January 2000 to January 2022, a total of 84 children (78.5% female) underwent laparoscopic cholecystectomy with a median follow-up of 11.4 (IQR 8, 14) years. Of these, 6 children underwent laparoscopic cholecystectomy (LC) + ERCP and 14 children underwent LCBDE for choledochiothiasis. The primary end point of the study was the success of treatment in terms of the incidence of complications, recurrence rate, and rate of reoperation. Secondary endpoints were stone characteristics, presenting symptoms, duration of surgery, and length of hospital stay. Results: The majority of patients were female in both groups (83.5% vs. 85.7%), mostly overweight with a median BMI of 27.9 kg/m² and 27.4 kg/m², respectively. Obstructive jaundice, colicky pain, acute pancreatitis, and obstruction of the papilla were the most common symptoms in both groups. The majority of patients (68%) had one stone, whereas two or more stones were found in 32% of patients. The median diameter of the common bile duct was 9 mm in both groups. The procedure was successfully completed in all patients in the ERCP group. In the group of patients treated with LCBDE, endoscopic extraction of the stone with a Dormia basket was successfully performed in ten patients (71.4%), while in the remaining four patients (28.6%) the stones were fragmented with a laser because extraction with the Dormia basket was not possible. The median operative time was 79 min in the LCBDE group (IQR 68, 98), while it was slightly longer in the ERCP group, 85 min (IQR 74, 105) (p = 0.125). The length of hospital stay was significantly shorter in the LCBDE group (2 vs. 4 days, p = 0.011). No complications occurred in the LCBDE group, while two (40%) complications occurred in the ERCP group: pancreatitis and cholangitis (p = 0.078). During the follow-up period, no conversions, papillotomies, or recurrences were recorded in either group. Conclusions: Exploration of the common bile duct and removal of stones by LCBDE is safe and feasible in pediatric patients for the treatment of choledocholithiasis. Through this procedure, choledocholithiasis and cholelithiasis can be treated in a single procedure without papillotomy or fluoroscopy. Compared with LC + ERCP, LCBDE is associated with a shorter hospital stay. The incidence of complications was rather low but not statistically significant. Full article

In the pediatric surgical environment, we can enrich our knowledge and improve our skills through interdisciplinary knowledge transfer in exchange with other surgical or even non-surgical disciplines. To demonstrate this, we present in this article three patient cases of method transfer enabling new techniques in minimally invasive pediatric surgery. 1. The somewhat modified application of the AeroStat rigid tip laparoscopic cholangiography catheter during the single-step laparoscopic cholecystectomy facilitates the safe intraoperative cholangiography with common bile duct flushing. 2. A magnetic rod is used during laparoscopic enterotomy to locate and retrieve ingested magnets. 3. Using a patient-specific MRI 3D model representing a syndromic high anorectal malformation improves surgical planning and parental education. Full article