Laparoscopic cholecystectomy for gallbladder torsion in a 3-year-old child
A 3-year-old previously healthy boy was referred to an emergency medical center because of sudden abdominal pain and vomiting. Although he was diagnosed with acute gastroenteritis and prescribed medication, he continued to vomit several times, and his general condition worsened. Therefore, he was referred to our hospital the day after the onset of abdominal pain. Physical examination showed a flat and soft abdominal wall with mild rebound tenderness in the right hypochondrium and no palpable abdominal mass. Laboratory examinations showed a slightly elevated white blood cell (WBC) count of 16,500/μL, while C-reactive protein (0.25 mg/dL) and serum levels of liver enzymes were all within the normal ranges. Abdominal ultrasonography (AUS) revealed gallbladder wall thickness without gallstones. Additionally, a small amount of fluid was observed around the gallbladder and in the pelvic cavity. Because GT was not considered a differential diagnosis at the time of admission, he was admitted to the Department of Pediatrics, and treatment with antibiotics was started with a diagnosis of acute cholecystitis. Simultaneously, examinations for underlying disorders related to cholecystitis were planned; vasculitis, such as immunoglobulin A vasculitis or hemolytic anemia, were ruled out as a result. On day 1 of admission, the WBC count decreased to 12,500 /μl, and his abdominal pain slightly improved. Abdominal enhanced computed tomography (CT) showed swelling of the gallbladder with ascites, as did the AUS images from the day of admission (Fig. ). On day 2 of admission, due to the re-elevated WBC count of 16,000/μl, C-reactive protein level of 3.26 mg/dL, and persistent abdominal pain, a repeat AUS was carried out. An increase in the gallbladder wall thickness to 12 mm and a lack of intramural blood flow was noted (Fig. ), which led to a diagnosis of GT. The patient was referred to our department, and an emergency LC was carried out using the VISERA ELITE system (Olympus). A 12-mm trocar was inserted at the umbilical portion of a flexible laparoscope (LTF-S190-10; Olympus), followed by placement of three 5-mm ports, and the rest of the operation was carried out according to the standard procedure used in adult patients. The gallbladder was blackish, with severe edema, and surrounded by bloody ascites. After resection of the adhesion between the gallbladder and the greater omentum, the gallbladder was observed to be twisted 270° counterclockwise at the level of the cystic duct and mesentery (Fig. ). The gallbladder was easily untwisted clockwise to its natural position, which was classified as type I according to the Gross classification (Fig. ). After resecting a small amount of mesentery between the cystic duct and the liver bed, the cystic duct with the cystic artery was doubly ligated using Endoloop polydioxanone suture II and resected. The operation time was 104 min, and intraoperative blood loss was minimal. Microscopically, the resected specimen showed gangrenous cholecystitis without gallstones. Notably, the gallbladder bile culture was negative. The postoperative course was uneventful without any complications, and the patient was discharged on postoperative day 6.