This was a prospective study of all children of cholelithiasis who presented for treatment at Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala, Haryana, India (April 2014 to April 2016). A total of 30 children aged between 1 and 18 years (mean age 12 years) were included in the study. An informed written consent was taken from the parents of the children included in the study. Sample size was calculated on the basis of number of children admitted with the gallstone disease in the surgery ward during the study period. Out of the total admissions of 45 children with cholelithiasis, 30 children were operated upon and hence included in the study.

The inclusion criteria of the study were all the children in the age-group of 1-18 years undergoing cholecystectomy (open or laparoscopic) during the study period. All the other children who did not undergo cholecystectomy were excluded from the study (those not giving consent for the study, not fit for anaesthesia and those with acute cholecystitis with conservative management). Approval from Institutional Ethics Committee was obtained for conducting the study.

All children were admitted to the hospital and their blood tests, liver function tests, coagulation parameters and renal function tests were done as per the protocol. A unit of blood was also arranged for all children whose haemoglobin was less than 10 gm%. A routine pre anaesthetic check-up and a paediatric evaluation were also done whenever required.

All patients were operated under general anaesthesia. An injectable antibiotic was given at the time of induction. Laparoscopic cholecystectomy was performed in 24 patients in a supine position with the standard four port technique. In six patients, open cholecystectomy was performed as the children were not fit to tolerate pneumoperitoneum (these children had history of bronchial asthma and had deranged pulmonary function tests, hence not suitable for laparoscopic cholecystectomy, even at low pressure). All the gall bladders removed at surgery were subjected to histopathological examination and the stones were analysed.

Postoperatively, all children were allowed to take oral fluids once bowel sounds appeared. Intravenous antibiotics (cefotaxime, ciprofloxacin) and parenteral analgesics (diclofenac) were given to keep the patients pain free.

The outcome measures assessed were postoperative pain, duration of hospital stay and time taken to resume normal daily activities. All children were followed up in Outpatient Department (OPD) regularly for upto three months. There were no early (postoperative nausea vomiting, fever) or late (jaundice, bile-leak) postoperative complications in the present study. The data was analysed using descriptive statistics.

Majority of the patients were in the age group of 13-18 years constituting (n=20, 66.7%) patients [Table/Fig-1]. In the present study, (n=12, 40%) patients were vegetarian and patients (n=18, 60%) were consuming mixed diet.

When the risk factors were analysed, the most common cause of cholelithiasis was found to be idiopathic, accounting for (n=14, 46.7%) cases [Table/Fig-2].

Acute right upper quadrant abdominal pain was the most common presentation in (n=18, 60%) patients. Dyspeptic symptoms were found in (n=6, 20%) cases and one child presented with jaundice (3.3%). In our study, (n=5, 16.6%) patients were asymptomatic and were admitted in paediatrics ward for fever and loss of appetite. They were later shifted to the surgical side when an ultrasound examination revealed gallstones.

Of the symptomatic patients, (n=22, 73.3%) patients had symptoms lasting from 3 to 6 months at time of presentation. Physical examination showed no abdominal signs in majority of patients (n=18, 60%); while, mild right hypochondrial tenderness was present in (n=7, 23.3%) patients. There were (n=5, 16.6%) patients who had a palpable lump in their right hypochondrium.

Laparoscopic surgery was performed in (n=24, 80%) patients who were deemed fit to undergo this procedure. Open cholecystectomy was performed in the remaining (n=6, 20%) patients [Table/Fig-3]. Operative findings recorded showed (n=23, 76.7%) patients had multiple stones, single stones were present in (n=5,16.6%) patients and biliary sludge in (n=2, 6.7%) patients. Stone analysis showed that more than half the patients had mixed stones i.e., (n=20, 66.6%) and (n=5, 16.7%) patients had pigment stones and cholesterol stones respectively. Histopathological examination of gall bladders revealed that (n=18, 60%) patients had normal mucosal pattern, (n=8, 26.7%) patients had chronic cholecystitis and (n=4, 13.3%) patients had acute cholecystitis.

There were no difficulties encountered during cholecystectomies. No drains were put in any patient and there were no complications. Postoperatively, all patients were assessed for intensity of pain according to the analgesic demand. Shoulder pain was the chief complaint in children who had laparoscopic cholecystectomy while pain in the main wound was the chief complaint in children who underwent open cholecystectomy. About (n=26, 86.7%) patients had mild pain which was relieved by injection paracetamol. About (n=4, 13.3%) patients needed additional support with voveran by way of pain relief. Patients operated laparoscopically were discharged on second postoperative day whereas those operated by open method were discharged on fifth postoperative day.

All children were followed up in OPD regularly for a period of three months. First visit was after a week and then follow up was done every 15 days thereafter. There were no early or late complications in either of the groups. Children went to school within one week (after laparoscopic cholecystectomy) and 1-3 weeks (after open cholecystectomy). All parents and children over six years were questioned regarding scar tenderness, dyspepsia, jaundice and loss of vigour by the child. No significant incapacitation was reported by the parents.

Gallstone disease has always been considered as a disease of the adults. It is relatively uncommon in childhood. A review of literature has suggested an increase in the frequency of cholelithiasis in children and resultant cholecystectomies [3,4,16]. An increased use of ultrasound for every case of pain in the abdomen also has helped in establishing a diagnosis of very small and single gallstones as well as biliary sludge.

Very little is known about the natural history and management of cholelithiasis in the childhood. Earlier, many non surgical techniques like ursodeoxycholic acid therapy and antibiotic usage were adopted to treat this disease [17]. As these techniques proved ineffective by way of having severe restriction in their applicability, cholecystectomy is presently considered as the gold standard for the treatment of gallstones in children.

In the present study, the mean age of children was 12 years and majority of them were in the age group of 13-18 years (n=20). Bogue CO et al., in their study of 382 cases, observed the mean age to be 9.4 years which was slightly younger than our mean age [5]. A study by Mehta S et al., with 404 patients found the mean age to be 13.1 years which is almost similar to present study [7].

Male children have been shown to have a higher incidence of gallstones unlike in adults where females show preponderance [17]. Review of literature has shown a strong positive family history with the mothers more affected than fathers [18]. A positive sibling history has not been documented. There was no family history of cholelithiasis in any of present patients.

Gökçe S et al., in their study on 124 children observed that 43.5% children had no identifiable risk factors and were considered idiopathic [19]. Obesity is a significant risk factor for hospital admission in children with cholelithiasis [20]. In the present study however, only one child (out of 30 children) was found to be obese [Table/Fig-2]. As most of present patients were from a rural background so obesity and its association with cholelithiasis could not be established [16]. Patients without any risk factors dominated the present study.

A review of literature showed that abdominal pain was the most common initial symptom that led to an ultrasound examination and detection of gallstones [21]. The other symptoms reported include fever, vomiting, diarrhoea and jaundice. Most children had these symptoms for about 6 to 12 months before presentation [21]. In the present study, most of the children presented late as they were on symptomatic treatment and herbal medicines were given to them before they were finally referred for an ultrasound to our hospital.

A laparoscopic cholecystectomy may need to be converted to open cholecystectomy due to adhesions, difficult Calot’s triangle anatomy and a small contracted gall bladder [22]. In the present study, 80% of patients underwent laparoscopic cholecystectomy and none of them had to be converted to open cholecystectomy for the above reasons. Multiple stones in the gall bladder are a very common finding in paediatric age group [21]. Similar findings were also observed in the present study. None of present patients had stones in common bile duct. A single patient who presented with jaundice had hepatitis with altered enzyme functions. No intraperitoneal drainage was used as was also reported by Hajong R et al., [23]. All surgeries were performed by senior laparoscopic surgeons and hence the time taken was also less in our study (45-60 minutes). The range of operating time reported in many studies is approximately 70-80 minutes [24].

In the present study, parenteral analgesia required in the laparoscopic group was only for a single day while for the open cholecystectomy patients, it was needed for three days. Similar analgesic requirement was also seen in other studies [25,26]. Although, the hospital operative charges for open and laparoscopic cholecystectomy are similar, most of the patients with laparoscopic cholecystectomy were discharged within 48 hours; however, those with open cholecystectomy were discharged on 7-8^th day after stitch removal. Open procedure thus was costlier as it included bed charges, drugs etc., for a longer period as compared to laparoscopic cholecystectomy. None of the children had neither early nor late complications. They resumed their normal daily activities by 4^th day in the laparoscopic group and by the 7^th day in the open cholecystectomy group. By three weeks, children from both groups were going to school.

A better correlation with the causes of cholelithiasis would have been obtained with a larger sample size in the present study.

An early ultrasound confirmation is recommended for all children who present to the OPD with a vague abdominal pain. Early cholecystectomy is the treatment of choice. Laparoscopic cholecystectomy is a safe, economic and efficacious procedure without any significant morbidity and no surgery related mortality. It has the benefits of no scar and minimal pain. Recovery is quick and this has a great impact on the psyche of both parents and patients. Cholelithiasis in children from a rural background does not reveal association with obesity as contrary to those from urban areas. These children also present late in the hospital due to lack of diagnostic facilities in rural areas. Hence, tertiary care facilities are warranted in rural areas for early diagnosis and management of such paediatric problems.