The currently available scientific evidence suggests that the simultaneous performance of laparoscopic splenectomy and cholecystectomy is feasible and safe in paediatric patients with HS [3]. However, expert consensus determines the independent indications for splenectomy and cholecystectomy, so not every patient with HS will benefit from performing both techniques at the same time [2-4].

Splenectomy is indicated in patients with severe anaemia, preferably after 6 years of age given the high risk of post-splenectomy infections due to encapsulated microorganisms [5]. The severity of anaemia is determined by analytical parameters (Table 1) [2-4]. The size of the spleen is not per se an splenectomy indication, nor is there evidence that defends the limitation of physical activity in patients with splenomegaly [1]. Currently, only in cases of concomitant symptomatic cholelithiasis is simultaneous cholecystectomy indicated; while in asymptomatic cholelithiasis there is less evidence in this regard. Liu et al. published the first study concluding that asymptomatic cholelithiasis progresses or persists after splenectomy and therefore simultaneous cholecystectomy reduces long-term complications [6]. And Mack et al. suggest that concurrent cholecystectomy does not increase morbidity and can therefore be performed even in ASA 3 or 4 patients [7]. These publications seem to indicate the beginning of a change in trend towards the simultaneous performance of both procedures; however, more studies are necessary to help corroborate these theories and change clinical practice.

On the other hand, isolated cholecystectomy is indicated in patients with symptomatic cholelithiasis. The indications for simultaneous splenectomy should be the same as those for patients who do not require cholecystectomy [2-4].

Following the previously described indications, the need for concurrent splenectomy was ruled out in our patient given that he had moderate anaemia (haemoglobin 8-12 g/dL, reticulocyte count >10% and total bilirubin >2 mg/dL) without limitation of his usual activity nor transfusions dependency. Furthermore, it was considered that the laparoscopic approach could be hindered by the large size of the spleen, and that performing both techniques could involve a very long surgical time with the consequent increase in morbidity.

In relation to the usefulness of IOC, there is currently no consensus on the need to associate laparoscopic cholecystectomy with routine IOC vs. selective. Kovács et al. published a meta-analysis where they determined that the selective indication of IOC may be appropriate, combining it with measures that prevent CBD injury (critical safety vision, initial approach to the fundus, use of multiple ports, low conversion threshold, etc.) and performing preoperative tests (abdominal, laparoscopic or endoscopic ultrasound or cholangio-MRI) [8].

In paediatrics, risk criteria have been suggested for the diagnosis of choledocholithiasis (CBD dilation >6 mm, choledocholithiasis on ultrasound, or total bilirubin >1.8 mg/dL) [9]. This patient was considered a candidate for CBD exploration because he had persistent elevation of total bilirubin (4.05 mg/dL) at the expense of direct bilirubin (2.23 mg/dL). Given the small size of the cystic duct, it was not possible to proceed with endoscopic exploration of the CBD (only a 5 mm choledochoscope was available) [10]. The IOC ruled out the presence of CBD stones or other CBD anomalies. It is a technique with low risk of complications (bleeding, bile leak, conversion) that allows visualization of the anatomy of the CBD in real time and reduces the postoperative risk of persistent lithiasis, bile leak or iatrogenic CBD injuries [11].