PLAN THESE

PLAN
INTRODUCTION…………………………………………….………………………………….. 1
PREMIERE PARTIE …….…….…….…….…….…….…….…….…….…….…….…….……… 4
I. Historique de la cholécystectomie laparoscopique …….…….…….…….…….……. 5
II. Bases anatomiques : voies biliaires extra –hépatiques…….…….…….…….……….. 6
1. Voie biliaire principale …….…….…….…….…….…….…….…….…….…….……... 6
1-1.Anatomie descriptive…….…….…….…….…….…….…….…….…….…….….. 6
1-2.Rapports…….…….…….…….…….…….…….…….…….…….…….…….……… 13
1-3.Vascularisation et innervation de la voie biliaire principale…….…….….. 15
2. Voie biliaire accessoire…….…….…….…….…….…….…….…….…….…….…….. 17
2-1.La vésicule biliaire…….…….…….…….…….…….…….…….…….…….…….. 17
2-2.Le canal cystique…….…….…….…….…….…….…….…….…….…….………. 18
2-3.Rapports…….…….…….…….…….…….…….…….…….…….…….…….……... 18
2-4.Vascularisation et innervation…….…….…….…….…….…….…….………… 19
III. PHYSIOPATHOLOGIE DE LA LITHIASE BILIAIRE CHEZ L’ENFANT…….…….………… 21
1. En cas d’hémolyse chronique…….…….…….…….…….…….…….…….………… 21
1-1. Les pigments biliaires…….…….…….…….…….…….…….…….……………. 11
1-2.Lithogenèse…….…….…….…….…….…….…….…….…….…….…….……….. 21
1-3.Nature des calculs pigmentaires…….…….…….…….…….…….…….……... 22
2. En l’absence d’hémoglobinopathie…….…….…….…….…….…….…….…….…. 23
2-1.Composition de la bile normale…….…….…….…….…….…….…….……… 23
2-2.Formation de micelles…….…….…….…….…….…….…….…….…….……… 23
IV. CLINIQUE DE LA LITHIASE BILIAIRE CHEZ L’ENFANT…….…….…….…….……….. 24
1. Epidémiologie …….…….…….…….…….…….…….…….…….…….…….…….…… 24
2. Âge et sexe …….…….…….…….…….…….…….…….…….…….…….…….…… 24
3. Chez l’enfant drépanocytaire…….…….…….…….…….…….…….…….………… 24
4. Circonstances de découverte…….…….…….…….…….…….…….…….………… 25
5. Examen clinique…….…….…….…….…….…….…….…….…….…….…….………. 25
6. Examens paracliniques….…….…….…….…….…….…….…….…….…….…….… 26
6-1.La biologie….…….…….…….…….…….…….…….…….…….…….…….……. 26
6-2.L’échographie abdominale….…….…….…….…….…….…….…….…….…… 26
6-3. Les autres examens radiologiques….…….…….…….…….…….…….……. 26
7. Evolution-complications….…….…….…….…….…….…….…….…….…….…….. 27
7-1.La cholécystite aigue lithiasique….…….…….…….…….…….…….…….….. 27
7-2. Angiocholite lithiasique….…….…….…….…….…….…….…….……………. 28

7-3.Lithiase de la VBP non compliquée….…….…….…….…….…….…….…….. 28
7-4.Lithiase résiduelle….…….…….…….…….…….…….…….…….…….…….…. 28
7-5.Pancréatite aigue biliaire….…….…….…….…….…….…….…….…………… 29
7-6.Iléus biliaire….…….…….…….…….…….…….…….…….…….…….…….…… 29
IV. ETIOLOGIES DE LA LITHIASE BILIAIRE DE L’ENFANT….…….…….…….…….…….… 30
1. La drépanocytose….…….…….…….…….…….…….…….…….…….…….……. 30
2. La sphérocytose héréditaire….…….…….…….…….…….…….…….………….. 34
3. La thalassémie….…….…….…….…….…….…….…….…….…….…….…….….. 35
4. Le déficit en G6PD….…….…….…….…….…….…….…….…….…….…….……. 35
5. Autres causes….…….…….…….…….…….…….…….…….…….…….…….…… 36
V. TRAITEMENT DE LA LITHIASE BILIAIRE….…….…….…….…….…….…….…….…….. 37
1. BUTS….…….…….…….…….…….…….…….…….…….…….…….…….…….……. 37
2. MOYENS ET METHODES….…….…….…….…….…….…….…….…….…….……. 37
2-1. La chirurgie….…….…….…….…….…….…….…….…….…….…….…….….. 37
2-2. Le traitement médical….…….…….…….…….…….…….…….…….…….…. 42
3. INDICATIONS ….…….…….…….…….…….…….…….…….…….…….…….……… 43
3-1. Formes non compliquées….…….…….…….…….…….…….…….…….……. 43
3-2. Formes compliquées….…….…….…….…….…….…….…….…….…….……. 43
VI. LA CŒLIOCHIRURGIE CHEZ L’ENFANT….…….…….…….…….…….…….…….……… 44
1. Conséquences respiratoires….…….…….…….…….…….…….…….……………. 44
2. Conséquences cardio-vaculaires….…….…….…….…….…….…….…….……… 44
3. Modifications rénales….…….…….…….…….…….…….…….…….…….…….…. 45
4. Contres indications….…….…….…….…….…….…….…….…….…….…….……. 45
5. Cas particulier de l’enfant drépanocytaire….…….…….…….…….…….……… 45
6. L’anesthésie ….…….…….…….…….…….…….…….…….…….…….…….………. 48
VII. TECHNIQUE DE CHOLECYSTECTOMIE LAPAROSCOPIQUE CHEZ L’ENFANT….…… 49
1. L’installation ….…….…….…….…….…….…….…….…….…….…….…….………. 49
2. Le matériel nécessaire….…….…….…….…….…….…….…….…….…….…….… 51
3. Les temps opératoires….…….…….…….…….…….…….…….…….…….…….… 51
3-1. Le pneumopéritoine….…….…….…….…….…….…….…….…….…….……. 51
3-2. La mise en place des trocarts….…….…….…….…….…….…….…….…….. 52
3-3. Exposition de la vésicule et libération des adhérences….…….…….…… 54
3-4. Dissection du pédicule cystique….…….…….…….…….…….…….…….…. 54
3-5. La cholangiographie per-opératoire….…….…….…….…….…….…….…. 55
3-6. Le contrôle de l’artère cystique….…….…….…….…….…….…….…….….. 55

3-7. Dissection du lit vésiculaire….…….…….…….…….…….…….…….………. 56
3-8. Extraction vésiculaire….…….…….…….…….…….…….…….…….…….…… 56
3-9. Contrôle de l’hémostase….…….…….…….…….…….…….…….…….…….. 57
3-10. Exsufflation du pneumopéritoine….…….…….…….…….…….…….…… 57
4. La prise en charge post-opératoire….…….…….…….…….…….…….…….….. 57
5. Les complications biliaires spécifiques….…….…….…….…….…….…….……. 57
6. Variantes tecniques….…….…….…….…….…….…….…….…….…….…….……. 58
7. Notre technique….…….…….…….…….…….…….…….…….…….…….…….….. 60
DEUXIEME PARTIE : NOTRE TRAVAIL….…….…….…….…….…….…….…….…………. 68
CADRE D’ETUDE….…….…….…….…….…….…….…….…….…….…….…….…….……. 69
PATIENTS ET METHODE….…….…….…….…….…….…….…….…….…….…….…….… 74
I. METHODE….…….…….…….…….…….…….…….…….…….…….…….…….……… 75
1. Clinique….…….…….…….…….…….…….…….…….…….…….…….…………….. 75
2. Paraclinique ….…….…….…….…….…….…….…….…….…….…….…….……… 76
3. Protocole anesthésique….…….…….…….…….…….…….…….…….…….……… 76
4. Protocole thérapeutique….…….…….…….…….…….…….…….…….…….…….. 77
5. Variables étiudiées….…….…….…….…….…….…….…….…….…….…….……… 77
II. MALADES ….…….…….…….…….…….…….…….…….…….…….…….…………….. 79
1. La fréquence ….…….…….…….…….…….…….…….…….…….…….…….……… 79
2. L’âge….…….…….…….…….…….…….…….…….…….…….…….…….…….……. 80
3. Le sexe….…….…….…….…….…….…….…….…….…….…….…….…………….. 81
4. Origine géographique….…….…….…….…….…….…….…….…….…….…….… 82
5. Profil génotpique….…….…….…….…….…….…….…….…….…….…….…….… 83
6. Mode de révélation de la lithiase biliaire….…….…….…….…….…….…….… 84
7. Données radiologiques….…….…….…….…….…….…….…….…….…….……. 84
8. Données biologiques….…….…….…….…….…….…….…….…….…….…….….. 88
9. Indications opératoires….…….…….…….…….…….…….…….…….…….…….. 89
RESULTATS….…….…….…….…….…….…….…….…….…….…….…….…….…….……. 90
I. LES TYPES DE CHOLECYSTECTOMIES EFFECTUEES….…….…….…….………….. 91
II. LA DUREE D’INTERVENTION….…….…….…….…….…….…….…….……………… 91
III. LES INCIDENTS OPERATOIRES….…….…….…….…….…….…….…….…………… 91
IV. LA CONVERSION EN LAPAROTOMIE….…….…….…….…….…….…….…….……. 92
V. LA MORBIDITE ….…….…….…….…….…….…….…….…….…….…….…….……… 92
VI. LA MORTALITE….…….…….…….…….…….…….…….…….…….…….…….……… 94

VII. LA DUREE D’HOSPITALISATION….…….…….…….…….…….…….…….………….. 96
VIII. LE COÛT DE L’INTERVENTION….…….…….…….…….…….…….…….…………… 96
TROISIEME PARTIE : DISCUSSION….…….…….…….…….…….…….…….……………… 97
I. DONNEES EPIDEMIOLOGIQUES….…….…….…….…….…….…….…….…………… 98
1. Fréquence….…….…….…….…….…….…….…….…….…….…….…….…………… 98
2. Profil génotypique….…….…….…….…….…….…….…….…….…….…….…….… 99
3. Âge….…….…….…….…….…….…….…….…….…….…….…….…….…….…….… 99
4. Sexe….…….…….…….…….…….…….…….…….…….…….…….…………………. 100
II. MODE DE REVELATION DE LA LITHIASE BILIAIRE….…….…….…….…………… 101
III. LES DONNEES PARACLINIQUES….…….…….…….…….…….…….…….………….. 101
1. Résultats échographiques….…….…….…….…….…….…….…….……………… 101
2. Résultats biologiques….…….…….…….…….…….…….…….…….…….…….… 102
3. Exploration de la VBP….…….…….…….…….…….…….…….…….…….…….… 103
IV. LES INDICATIONS OPERATOIRES….…….…….…….…….…….…….…….……….. 106
V. LES TYPES DE CHOLECYSTECTOMIE….…….…….…….…….…….…….…….…… 108
VI. LA DUREE DE L’INTERVENTION….…….…….…….…….…….…….…….…….…… 109
VII. LES INCIDENTS OPERATOIRES….…….…….…….…….…….…….…….…………… 110
VIII. LA CONVERSION EN LAPAROTOMIE….…….…….…….…….…….…….…….……. 112
IX. LA MORBIDITE ….…….…….…….…….…….…….…….…….…….…….…….……… 113
X. LA MORTALITE….…….…….…….…….…….…….…….…….…….…….…….……… 114
XI. LA DUREE D’HOSPITALISATION….…….…….…….…….…….…….…….…………. 115
XII. LE COÛT ….…….…….…….…….…….…….…….…….…….…….…….…….……… 116
XIII. LES SUCCES OPERATOIRES….…….…….…….…….…….…….…….……………….. 117
XIV. CONCLUSION ….…….…….…….…….…….…….…….…….…….…….…….…….. 118
XV. RESUMES ….…….…….…….…….…….…….…….…….…….…….…….…………… 123
XVI. BIBLIOGRAPHIE….…….…….…….…….…….…….…….…….…….…….…….…….. 127

LISTE DES ABREVIATIONS
% : pourcentage
ALAT : Alanine-Amino-Transférase
ASAT : Aspartate-Amino-transférase
°C : degrés Celsius
CCMH : concentration corpusculaire moyenne de l’hémoglobine
CHNEAR : centre hospitalier national d’enfants Albert ROYER
CPO : cholangiographie per-opératoire
EFR : exploration fonctionnelle respiratoire
F : fœtal
g/dl : gramme par décilitre
G/L : gramme par litre
G6PD : glucose-6-phosphate déshydrogénase
GDS : gaz du sang
h : heure
HALD : hôpital Aristide LE DANTEC
Hb : hémoglobine
HOGGY : hôpital générale de grand Yoff
L/m² : litre par mètre carré
LVBP : lithiase de la voie biliaire principale