L a p a ro s c o p ic c h o le c y s te c to m y in c h ild re n a n d a d o le s c e n ts
Servifo de Cirurgia do Aparelho Digestivo do Hospital Nove de Julho - Siio Paulo, Brazil
D u rin g th e p e rio d b e tw e e n A u g u st 1 9 9 1 a n d N o ve m b e r 1 9 9 5 , se ve n p a tie n ts u n d e r a g e 1 7 w e re su b m itte d to vid e o la p a ro sco p ic ch o le cyste cto m y (L C ). T w o w e re m a le s a n d five fe m a le s w ith a g e s ra n g in g fro m 1 2 to 1 6 ye a rs (m e a n 1 3 .8 ye a rs). T h e d ia g n o sis o f ch ro n ic ch o le cystitis w ith g a llsto n e s w a s m a d e b y th e clin ica l h isto ry a n d p h ysica l a n d u ltra so n o g ra p h ic e xa m in a tio n s. T h e re w a s n o e vid e n ce o f a n a sso cia tio n w ith h e m o lytic d ise a se s, fa m ilia l h yp e rlip id e m ia o r G lu co se -6 -p h o sp h a te d e h yd ro g e n a se (G 6 P D ) d e fi-cie n cy. T h e su rg e ry w a s p e rfo rm e d u n d e r g e n e ra l a n e sth e sia a n d th e a b d o m e n a p p ro a ch e d b y fo u r p o rts: a 1 0 m m u m b ilica l in cisio n , a 5 m m cystic, a 5 m m o n e a t th e xip h o id a p p e n d ix a n d a 1 0 m m o n e a t th e le ft la te ra l m a rg in o f th e le ft re ctu s a b d o m in a l m u scle b e tw e e n th e u m b ilica l sca r a n d th e xip h o id a p p e n d ix. O p e ra tive tim e a ve ra g e d 1 2 0 m in u te s (1 0 5 -1 5 0 m in ). O n e ca se re q u ire d co n ve r-sio n to la p a ro to m ic a p p ro a ch b e ca u se o f M irizzi's S yn d ro m e , w h ich w a s d ia g n o se d b y in tra o p e ra tive ch o la n g io g ra p h y p e rfo rm e d in a ll ca se s. T h e re w e re n o d e a th s o r m a jo r p o sto p e ra tive co m p lica tio n s. H o sp ita l sta ys ra n g e d fro m 1 -3 d a ys in th e six p a tie n ts su b m itte d to L C . T h u s L C in ch ild re n ca n b e co n sid e re d a g o o d m e th o d , re q u irin g o n ly m o re ca re re g a rd in g th e u se o f p ro p e r e q u ip m e n t, co m p le te a n d ca re fu l d isse ctio n o f th e b ilia ry h ilu s, a n d in tra o p e ra tive ch o la n g io g ra p h y. T h e la tte r is in d isp e n sa b le , a s th e se ch ild re n ca n p re se n t a h ig h e r ra te o f a n a to m ic a n o m a lie s. T h e a d va n ta g e s o f th is te ch n iq u e in clu d e a le ss p a in fu l p o sto p e ra tive p e rio d w ith a fa ste r re co ve ry, a n d it is e sp e cia lly re co m m e n d e d in ch ild re n , w h o a re le ss to le ra n t to p h ysica l re strictio n a n d p a in th a n a d u lts.
U N IT E R M S : V id e o la p a ro sco p y, C h o le cyste cto m y a n d P e d ia tric su rg e ry.
IN T R O D U C T IO N
C
h r o n i cc o m m o nc h o l e c y s t i t i si n a d u l t s b u t i n f r e q u e n tw i t h g a I l s t o n e si n c h i l d r e n .i s r e l a t i v e l yF i r s t d e s c r i b e d b y G i b s o n o f L e i t h i n 1 7 2 1 , i t c a n b e g i n a t a n y a g e b u t u s u a l l y o c c u r s b e t w e e n 4 0 a n d 5 0 y e a r s a n d i s m o r e f r e q u e n t i n f e m a l e s ( 4 : I ) . W h e n o c c u r r i n g i n i n f a n c y , i t i s a s s o c i a t e d w i t h c o m p l i c a t i o n s o f p r e m a t u r i t y ; i n a d o l e s c e n c e i t c o m m o n l y a p p e a r s a s s o c i a t e d w i t h h e m o l y t i c d i s e a s e s .\W i t h t h e w i d e s p r e a d u s e o f u l t r a s o n o g r a p h y , i t s d i a g n o s i s h a s b e c o m e m o r e f r e q u e n t , a n d i t i s r e c o g n i z e d m o r e a n d m o r e i n y o u n g e r a g e g r o u p s . S t a r t i n g w i t h t h e
A d d r e s s fo r c o r r e s p o n d e n c e : B r u n o Z ilb e r s te in
S e r v i9 0 d e C ir u r g ia d o A p a r e lh o D ig e s tiv o d o H o s p ita l N o v e d e J u lh o
A v . B r a s il, 7 0 3 - J d . A m e r ic a
S a o P a u lo /S P - B r a s il- C E P 0 1 4 3 1 - 0 0 0
i n t r o d u c t i o n o f v i d e o e n d o s c o p i c s u r g e r y a t t h e b e g i n n i n g o f t h e n i n e t i e s , w i t h i t s i n h e r e n t a d v a n t a g e s , a n d a l l i e d w i t h u l t r a s o n o g r a p h y , c h o l e c y s t e c t o m y w a s a l s o i n d i c a t e d i n t h e y o u n g e r a g e g r o u p .
A m o n g s e r v i c e s w h i c h p e r f o r m L a p a r o s c o p i c C h o l e c y s t e c t o m i e s ( L C ) , t h e p r e v a l e n c e i n t h e y o u n g e r a g e g r o u p v a r i e s a n d n o s t a t i s t i c a l d a t a i s a v a i l a b l e . D i f f e r e n t a u t h o r s r e p o r t r a n d o m f i g u r e s ( T a b l e I ) . T h i s s t u d y a n a l y z e s t h e r e s u l t s f r o m 1 9 9 1 t o t h e p r e s e n t o f L C i n c h i l d r e n , e m p h a s i z i n g t h e t e c h n i c a l p r e c a u t i o n i n t h i 's p r o c e d u r e .
M A T E R IA L A N D M E T H O D S
A ) P A T IE N T S
D u r i n g t h e p e r i o d f r o m A u g u s t 1 9 9 1 t o N o v e m b e r 1 9 9 5 , 6 1 4 L C s w e r e p e r f o r m e d i n o u r s e r v i c e . A m o n g
Z IL B E R S T E IN , 8 .; E S H K E N A Z Y , R ; R IB E IR O Jr., M .A .F .; S A L L E T , J A & R A M O S , A C . -L a p a ro sco p ic ch o le cyste cto m y in ch ild re n a n d a d o le sce n ts
1 2 9 4
T a b le 1
H o s p ita l S ta y
2 4 h - 7 d a y s
4 8 h
2 4 h
4 8 h
2 4 h
2 4 h
2 4 h
2 4 - 4 8 h
5 5 h
2 4 h D e a th s
C o n v e rs io n s C o m p lic a tio n s
N o . o f p a tie n ts A u th o r/y e a r
V in o rg ra d /9 31 2 1 4 4 2 0
P in tu s /9 51 3 1 0 0 0
N e w m a n /9 11 4
5 0 0 0
D a v id o ff/9 21 5 1 2 0 0 0
C e rv a n te s /9 21 6 1 0 0 0
S ig m a n /9 11 7 2 0 0 0
H o lc o m b /9 48 2 7 1 0 0
M o ir/9 25 6 0 0 0 .
H a tle y /9 51 8 2 0 2 0 1
G u e rlu d /9 44 1 0 0 0
T o ta l 9 4 7 2 1
C o n v e rs io n F a c to rs a n d C o m p lic a tio n s : A g n e s ia o f th e g a llb la d d e r, b le e d in g , p re s u m e d le s io n o f th e b ile d u c t, p e rfo ra tio n o f th e g a llb la d d e r, c h o le d o c o lith ia s is a n d a c u te p a n c re a titis .
th e m , s e v e n ( 1 .1 4 p e r c e n t) w e r e o n p a tie n ts u n d e r 1 7 y e a r s
o f a g e . T w o p a tie n ts w e r e m a le s a n d f iv e f e m a le s , w ith
a g e s r a n g in g f r o m 1 2 to 1 6 ( m e a n 1 3 .8 y e a r s ) . T h e
d ia g n o s is w a s b a s e d in a ll c a s e s o n th e p a tie n t's c lin ic a l
h is to r y p h y s ic a l a n d u ltr a s o u n d e x a m in a tio n s ( T a b le 2 ) .
T h e c h ie f s y m p to m in a ll c a s e s w a s a b d o m in a l p a in
in th e r ig h t h y p o c h o n d r iu m , to g e th e r w ith o th e r c lin ic a l
s y m p to m s s u c h a s f e v e r a n d v o m itin g ( T a b le 2 ) . T h e
la b o r a to r y f in d in g s d id n o t d e m o n s tr a te a n a s s o c ia tio n w ith
h e m o ly tic d is e a s e s , f a m ilia l h y p e r lip id e m ia o r G 6 P D H
d e f ic ie n c y in a n y o f th e c h ild r e n . I n a ll c a s e s , s u r g ic a l
in d ic a tio n w a s d u e to r e c u r r e n t b o u ts o f a b d o m in a l p a in .
B) TECHNIQUE:
L C is p e r f o r m e d u n d e r g e n e r a l a n e s th e s ia w ith th e
p a tie n t in a s e m ig y n e c o lo g ic a l p o s itio n . T h e s u r g e o n s ta n d s
T a b le 2
N o . A g e S e x S y m p to n s
1 3 M R t. h y p o c h o n d ria l p a in , v o m itin g ,
n a u s e a
2 1 2 M R t. h y p o c h o n d ria l p a in , n a u s e a
3 1 6 F R t. h y p o c h o n d ria l p a in , M u rp h y +
4 1 5 F R t. h y p o c h o n d ria l p a in , v o m itin g
5 1 5 F R t. h y p o c h o n d ria l p a in , fe v e r
6 1 2 F R t. h y p o c h o n d ria l p a in , v o m itin g
7 1 4 F R t. h y p o c h o n d ria l p a in , v o m itin g
b e tw e e n th e p a tie n t's le g s , th e f ir s t a s s is ta n t a n d s c r u b
n u r s e a r e to th e s u r g e o n 's r ig h t, a n d th e s e c o n d a s s is ta n t
to th e le f t.
T h e V e r e s s n e e d le is in s e r te d th r o u g h a Ic m in c is io n
a t th e le v e l o f th e u m b ilic a l s c a r a n d p n e u m o p e r ito n e u m
is o b ta in e d , ( in tr a - a b d o m in a l p r e s s u r e 1 2 m m H g ) f o llo w e d
b y in tr o d u c tio n o f th e f ir s t 1 0 m m tr o c a r f o r in s e r tio n o f
th e c a m e r a . T h e o th e r tr o c a r s a r e in tr o d u c e d u n d e r d ir e c t
v is io n a n d a r e lo c a te d a t:
a ) a 5 m m tr o c a r a t th e le v e l o f th e r ig h t u p p e r
q u a d r a n t f o r in s e r tio n o f th e g r a s p in g in s tr u m e n ts a n d
e x p o s u r e o f th e f ie ld .
b ) a 1 0 m m tr o c a r a t th e le v e l o f th e le f t la te r a l m a r g in
o f th e le f t r e c tu s a b d o m in a l m u s c le , a t th e m id p o in t
b e tw e e n th e u m b ilic u s a n d th e x ip h o id a p p e n d ix . T h e
in s tr u m e n ts o f th e s u r g e o n 's r ig h t h a n d a r e in tr o d u c e d
th r o u g h th e s e p o r ts , a s w e ll a s th e d is s e c tin g f o r c e p s , h o o k ,
s c is s o r s , e le c tr o c a u te r y a n d th e c lip a p p lie r .
c ) a 5 m m tr o c a r , a t th e le v e l o f th e x ip h o id a p p e n d ix
f o r in s e r tio n o f a '''liv e r r e tr a c to r ," e m p lo y in g f o r th a t th e
s u c tio n /ir r ig a to r .
D is s e c tio n b e g in s b y o p e n in g C a lo t's tr ia n g le f o r
v is u a liz a tio n o f th e c y s tic d u c t a n d c y s tic a r te r y . R o u tin e ly ,
th e a u th o r b e g in s b y d is s e c tin g th e p e r ito n e u m f r o m th e
b ilia r y p e d ic le th r o u g h th e p o s te r io r s u r f a c e to a v o id in ju r y
to v ita l s tr u c tu r e s . I n itia l lig a tio n o f th e c y s tic a r te r y is
r e c o m m e n d e d to a v o id its r u p tu r e d u r in g m a n ip u la tio n o f
th e b ilia r y h ilu s . T h e n e x t s te p is th e p r o x im a l lig a tio n o f
th e c y s tic d u c t a s c lo s e ly a s p o s s ib le to th e in f u n d ib u lu m
o f th e g a llb la d d e r , a n d th e in tr o d u c tio n o f th e
c h o la n g io g r a p h y c a th e te r . T h is w a s p o s s ib le in a ll c a s e s .
s a o P a u lo M e d ic a l J o u rn a l/R P M 1 1 4 (6 ): 1 2 9 3 -1 2 9 7 , 1 9 9 6 Z IL B E R S T E IN , B .; E S H K E N A Z Y , R ; R IB E IR O J r., M .A .F .; S A L L E T , J .A .&
T a b le 3
N o . In tra o p e ra tiv e fin d in g s D u ra tio n P o s to p e ra tiv e H o s p i.
S y m p to n s D is c h a rg e
1 C h ro n ic g a lls to n e d is e a s e
+
c h o le s te ro s is 1 4 0 m in n o n e 1 s t p .o . d a y2 C h ro n ic g a lls to n e d is e a s e
+
c h o le s te ro s is 1 5 0 m in h e a d a c h e 2 n d p .o . d a y3 C h ro n ic g a lls to n e d is e a s e 1 0 5 m in n o n e 1 s t p .o . d a y
4 C h ro n ic g a lls to n e d is e a s e
+
c h o le s te ro s is 1 2 0 m in n o n e 1 s t p .o . d a y5 C h ro n ic g a lls to n e d is e a s e
+
ly m p h o id 1 5 0 m in v o m itin g 3 rd p .o . d a yh y p e rp la s ia in p e riv e s ic u la r ly m p h n o d e
6 C h ro n ic g a lls to n e d is e a s e 1 2 0 m in n o n e 1 s t p .o . d a y
7 C h ro n ic g a lls to n e d is e a s e
+
M iriz z i's S y n d ro m e 3 0 0 m in in c is io n a l p a in 1 s t p .o . d a yC o n c lu d in g th e c h o la n g io g r a p h y , th e c y s tic d u c t is lig a te d
d is ta lly w ith tw o c lip s , p r o x im a lly to th e o r if ic e o f th e
c a th e te r 's e n tr y .
U s in g e le c tr o c a u te r y , th e g a llb la d d e r is d is s e c te d
f r o m th e h e p a tic b e d a n d th e liv e r r e tr a c te d to p r o v id e
a d e q u a te e x p o s u r e o f th e d is s e c tio n s ite . A p la s tic b a g is
u s e d to r e m o v e th e g a llb la d d e r a n d is e x tr a c te d th r o u g h
th e u m b ilic a l p o r t. T h e c a m e r a is p la c e d in th e le f t 1 0 m m
p o r t to f a c ilita te th is m a n e u v e r . T h e h e p a tic b e d is th e n
in s p e c te d .
R E S U L T S
I n tr a o p e r a tiv e f in d in g s : n o a c u te c h o le c y s titis w a s
o b s e r v e d . C h o le s te r o lo s is w a s o b s e r v e d in th r e e c a s e s a n d
in o n e , ly m p h o id h y p e r p la s ia in a p e r i v e s ic u la r ly m p h
n o d e .
C h o la n g io g r a p h y w a s n o r m a l in s ix p a tie n ts . V a r io u s
in tr a h e p a tic s to n e s ( M ir iz z i's S y n d r o m e ? 3 w e r e o b s e r v e d
in th e s e v e n th c a s e . C o n v e r s io n to o p e n s u r g e r y w a s
r e s o r te d to in th is c a s e , a n d c h o le d o c o lith o to m y a n d a
b ilio d ig e s tiv e R o u x e n Y a n a s to m o s is p e r f o r m e d .
N o b le e d in g , in tr a o p e r a tiv e c o m p lic a tio n s , o r d e a th s
o c c u r r e d in a n y o f th e c a s e s . T h e a v e r a g e d u r a tio n o f th e
s u r g e r y w a s 1 2 0m in u te s ( 1 0 5 - 1 5 0 m in ) f r o m in itia tio n o f
a n e s th e s ia to c lo s u r e o f th e in c is io n s . O n e p a tie n t
c o m p la in e d o f h e a d a c h e in th e im m e d ia te p o s to p e r a tiv e
p e r io d ( p .o .) , w h ic h im p r o v e d w ith c o m m o n a n a lg e s ic s ;
tw o e p is o d e s o f v o m itin g o c c u r r e d in a n o th e r p a tie n t
d u r in g th e f ir s t 2 4 h o u r s , a n d th e p a tie n t s u b m itte d to
la p a r o to m y p r e s e n te d p a in in th e a b d o m in a l in c is io n ,
im p r o v e d w ith a n a lg e s ic s ( T a b le 3 ) . N o o th e r m o r e s e v e r e
c o m p lic a tio n s w e r e n o te d .
T h e s ix p a tie n ts w h o u n d e r w e n t la p a r o s c o p ic
c h o le c y s te c to m y w e r e f e d b e tw e e n 8 - 2 4 h o u r s p .o .
( a v e r a g e 1 2 h o u r s ) . T h e y w e r e d is c h a r g e d o n th e a v e r a g e
1 .5 d a y s p .o . (1 -3 d a y s ) a n d r e tu r n e d to th e ir n o r m a l
a c tiv itie s 2 - 3 d a y s la te r .
D IS C U S S IO N
C h r o n ic c h o le c y s titis w ith g a lls to n e s is a w e
ll-k n o w n c lin ic a l e n tity w h ic h is m o r e p r e v a le n t in f e m a le s .
I t is u n c o m m o n in c h ild r e n a n d a d o le s c e n ts I ( T a b le 2 ) .
T h e p a tie n ts in th is a g e g r o u p n o r m a lly p r e s e n t a b r o a d
a n a to m ic v a r ia tio n o f th e b ilia r y h ilu s , g e n e r a lly
d ia g n o s e d b y in tr a o p e r a tiv e c h o la n g io g r a p h y o r b y
p r e o p e r a tiv e r e tr o g r a d e e n d o s c o p ic c h o la n g io g r a p h y .4 .5
N o n e o f th e p a tie n ts in th is s e r ie s u n d e r w e n t th is e x a m
p r e o p e r a tiv e ly , h a v in g b e e n s u b m itte d o n ly to
in tr a o p e r a tiv e c h o la n g io g r a p h y , w h ic h is m a n d a to r y in
b ilia r y s u r g e r y , e s p e c ia lly in c h ild r e n .o-x T h e f a c t th a t
in ju r y to th e m a in b ile d u c t is th e m o s t f r e q u e n t
c o m p lic a tio n r e p o r te d in th e lite r a tu r elJ
-'1 c o n f ir m s th is .
T h is is s ig n if ic a n t d u e to th e g r a v ity o f th e c o m p lic a tio n ,
f o r a b e n ig n d is o r d e r is b e in g tr e a te d w h ic h n o r m a lly
h a s a g o o d s u r g ic a l o u tc o m e .2 .3
I n s p ite o f th e s m a ll s a m p le g r o u p , o u t o f th e s e v e n
p a tie n ts , M ir iz z i's S y n d r o m e w a s d ia g n o s e d in o n e ( 1 4 .3
p e r c e n t) , th u s c o n f ir m in g th e h ig h in c id e n c e o f a n a to m ic
a n o m a lie s . I t is w o r th e m p h a s iz in g th a t o n c e th is s y n d r o m e
w a s d ia g n o s e d , it w a s o p te d to c o n v e r t to o p e n s u r g e r y
b e c a u s e th e la p a r o s c o p ic m e th o d w a s n o t c o m p le te ly
s a f e .o.x C o n s e q u e n tly , th e c o m m itm e n t is to th e c o m p le te
m a n a g e m e n t o f th e d is e a s e , a n d n o t to th e th e r a p e u tic
m e th o d .
Z IL B E R S T E IN , B .; E S H K E N A Z V , R ; R IB E IR O J r., M A F .; S A L L E T , J .A .&
R A M O S , A .C . - L a p a ro s c o p ic c h o le c y s te c to m y in c h ild re n a n d a d o le s c e n ts
1296
L aparoscopy
has been
enthusiastically
recei ved
for the realization
of cholecystectom ies
because
it has
m ade the operation
less aggressive
and the p.o. period
easier.
N evertheless,
this m ethod
should
be carefully
applied
in children
because
they are physically
sm aller
than adults.
Furtherm ore,
anatom ic
alterations
of the
biliary
hilus are m ore com m on
in young
patients
w ith
chronic
gallbladder
disease.
N orm ally,
the
sam e
instrum ents
are
used
as in adults
and
they
are not
alw ays
suitable,
since
the
space
is sm aller
and the
abdom en
has less depth. Further
m ore, children's
Ii vers
are relatively
larger.
5T herefore,
the placem ent
of the
trocars
in the
abdom en
does
not obey
the
rules
of
positioning,
the distance
betw een
the trocars
m ay be
. changed,
and som etim es
to obtain
better
exposure
of
the biliary
hilus,
a fifth
trocar
m ay be inserted.
T he
latter is introduced
into the right flank,
slightly
below
the one placed
in the right
upper
quadrant.
T his port
serves
to grasp
the
fundus
of the
gallbladder
and
provides
traction
in the cranial
direction
to expose
the
biliary
hilus.
T hree
of our cases
required
the use of a
fi fth trocar.
O perative
tim e
w as
relatively
longer
than
that
m entioned
in the literature
(T able
3). T his
occurred
because
w e attem pted
to dissect
and
separate
the
anatom ic
structures
m ore carefully
to avoid injury to the
biliary hilus. T he outcom e,
how ever,
w as sim ilar
to L C
in adults, as the surgery
is less traum atic.
B ased on the analysis of this m aterial, surgery should
be accom plished
w ith the utm ost
care,
since
anatom ic
anom alies
m ay
be present
and
cholangiography
is
im perative
to assess the situation
of the m ain bile duct.
A s w e could observe, laparoscopic
cholecystectom y
in children
is a good procedure,
m erely
requiring
m ore
judicious care in the use of proper equipm ent
ancl com plete
and careful dissection,
w ithout om itting
the classical steps
of the operative technique
ancl intraoperative
findings.
Its
advantages, such as a less painful postoperative,
a speedier
recovery,
ancl a quicker
return
to norm al
activities
recom m end
it, particularly
in children
w ho
are m ore
intolerant to physical restriction
and pain than adults. E ven
so, it should never be placed above the com m itm ent
to the
com plete
treatm ent
of the disease
ancl the total safety of
the intervention.
RESUMO
D u ra n te 0 p e rio d o d e a g o s to d e 1 9 9 1 a n o v e m b ro d e 1 9 9 5 , fo ra m s u b m e tid o s a c o le c is te c to m ia s p o r v id e o la p a ro s c o p ia 7 p a c ie n te s c o m id a d e in fe rio r a 1 7 a n o s , s e n d o d o is d o s e x o m a s c u lin o e c in c o d o fe m in in o . A id a d e v a rio u d e 1 2 a 1 6 a n o s (m e d ia d e 1 3 ,8 a ).0 d ia g n 6 s tic o d e c o le c is to p a tia c ro n ic a c a lc u lo s a fo i fe ito p e la h is t6 ria c lin ic a , e x a m e fis ic o e e s tu d o u ltra -s o n o g ra fic o . E m n e n h u m c a -s o fo i e v id e n c ia d a a a -s -s o c ia y a o c o m d o e n y a -s h e m o litic a -s , h ip e rlip id e m ia fa m ilia l o u d e fic ie n c ia d e G lic o s e -6 -fo s fa to d e s id ro g e n a s e . A a n e s te s ia e ra s e m p re g e ra l e 0 a b d o m e e ra a b o rd a d o p o r 4 p o rta is : u m b ilic a l (1 0 m m ), p o n to c is tic o (5 m m ), a p e n d ic e x if6 id e (5 m m ) e b o rd a la te ra l e s q u e rd a d o m u s c u lo re to a b d o m in a l e s q u e rd o e n tre a c ic a triz u m b ilic a l e0 a p e n d ic e x if6 id e (1 0 m m ).0 te m p o m e d io d o p ro c e d im e n to fo i d e d u a s h o ra s (1 :4 5 2 :3 0 ), e e m u m c a s o o p to u -s e p e la c o n v e r-s a o d a c iru rg ia p o r -s e tra ta r d e S fn d ro m e d e M iriz z i, a q u a l fo i d ia g n o -s tic a d a p e la c o la n g io g ra fia in tra -o p e ra t6 ria , p ro c e d im e n to e s te re a liz a d o e m to d o s o s c a s o s . N a o o c o rre ra m 6 b ito s n e m c o m p lic a y o e s n o p 6 s -o p e ra t6 rio . 0 te m p o d e in te rn a y a o v a rio u d e 1 a 3 d ia s n o s 6 p a c ie n te s s u b m e tid o s
a
c o le c is te c to m ia la p a ro s c 6 p ic a . D e s s a fo rm a , a c o le c is te c to m ia la p a ro s c 6 p ic a e m c ria n c ;a s p o d e s e r c o n s id e ra d a u m b o m m e to d o , re q u e re n d o a p e n a s m a is c u id a d o s q u a n to a o e m p re g o d e in s tru m e n ta l a d e q u a d o , d is s e c y a o c o m p le ta e c u id a d o s a d o h ilo b ilia r e re a liz a c ;a o d e c o la n g io g ra fia in tra -o p e ra ta ria , q u e e in d is p e n s a v e l, p o is e s s a s c ria n c ;a s p o d e m a p re s e n ta r m a io r in c id e n c ia d e a n o m a lia s a n a to m ic a s . S u a s v a n ta g e n s c o m o p a s -o p e ra t6 ri-o m e n o s d o lo ro s o e re c u p e ra c ;a o m a is ra p id a re c o m e n d a m -n a p rin c ip a lm e n te n a c ria n c ;a q u e to le ra m e n o s q u e 0 a d u lto a re s tric ;a o ffs ic a e a d o r.REFERENCES
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ZILBERSTEIN, B.; ESHKENAZY, R; RIBEIRO Jr., M.A.F.; SALLET, JA &
RAMOS, A.C. - Laparoscopic cholecystectomy in children and adolescents
