Gallbladder removal is one of the most commonly performed surgical procedures in Australia. One in every 10 adults has gallstones and it is one of the most common diseases of the digestive system.
Today, gallbladder surgery is performed laparoscopically. The medical name for this procedure is Laparoscopic Cholecystectomy.
What is the Gallbladder?
The gallbladder is a small, pear-shaped organ that rests beneath the liver. Its main purpose is to collect and concentrate a digestive liquid (bile) produced by the liver.
Bile is released from the gallbladder after eating and travels through long narrow tubular channels (bile ducts) into the first part of the small bowel.
Release of bile from the gallbladder into the bowel is triggered by the intake of fat meals. Removal of the gallbladder is not associated with any impairment of digestion in most people.
What causes Gallbladder problems?
Gallbladder problems are usually caused by the presence of gallstones: small hard crystals primarily made of cholesterol and bile salts that form in the gallbladder or in the bile duct. It is uncertain why some people form gallstones and there is no known means to prevent gallstones.
Some predisposing factors that have been found to be associated with gallstones are female gender, obesity, rapid weight loss, increasing age, multiple pregnancy and a family history of gallstones.
These stones may block the flow of bile out of the gallbladder, causing it to swell and resulting in sharp abdominal pain (medically known as biliary colic), vomiting, indigestion and, occasionally infection (medically known as acute cholecystitis).
If the gallstone escapes the gallbladder and blocks the bile duct, jaundice (a yellowing of the skin) can occur. The block bile duct can lead to infections of the bile duct (medically known as cholangitis) and inflammation of the pancreas gland (medically known as pancreatitis).
Pancreatitis can range from a minor pain through to a severe life threatening illness.
The gallbladder is usually removed as soon as possible after a bout of pancreatitis.
Finally gallbladder cancer is a rare condition that can result from gallstones. However it is a very rare cancer and cholecystectomy is not usually indicated to prevent this type of cancer.
How are these problems found and treated?
Ultrasound is most commonly used to find gallstones. In a few more complex cases, other scans may be used to evaluate gallbladder disease. Gallstones do not go away on their own. Some can be temporarily managed with drugs or by making dietary adjustments, such as reducing fat intake. This treatment has a low, short-term success rate. Symptoms will eventually continue unless the gallbladder is removed.
Surgical removal of the gallbladder is the safest treatment of gallbladder disease. Removing gallstones alone is far more dangerous than removing the entire gallbladder. Other methods of dissolving or blasting stones also lead to far more serious complications.
One can function normally after gallbladder removal as it is largely redundant in the diseased state and the bile ducts can store all the bile necessary for digestion of food.
Who needs a cholecystectomy?
The indications for cholecystectomy include gallstone related pain (biliary colic), indigestion, infection or complications such as pancreatitis and cholangitis.
Generally patients who are found incidentally to have gallstones with no symptoms or prior complication do not require a cholecystectomy.
Rarely gallbladder polyps, which are growing require a cholecystectomy to prevent the possibility of gallbladder cancer.
What Preparation Is Required?
The following includes typical events that may occur prior to laparoscopic surgery; however, since each patient is unique, what will actually occur may be different:
Preoperative preparation includes blood tests, medical evaluation, chest x-ray and an ECG depending on your age, medical condition and anaesthetic recommendation
After Dr Noushi discusses the surgery including the potential risks and benefits of the operation, you will need to provide a written consent.
It is recommended that you shower the night before or morning of the operation.
You should have nothing to eat or drink for 6 hours prior to your procedure. Dr Noushi and the hospital will be more specific about the time to begin fasting depending on the time of day that your procedure is scheduled. However you are allowed to have medications that Dr Noushi or his anaesthetist has told you are permissible to take with a sip of water prior to surgery.
Medication may need to be adjusted or avoided. It is best to inform Dr Noushi and his anaesthetist of ALL your current medications as well as allergies to medications prior to the examination.
Most medications can be continued as usual. Medication use such as aspirin, non-steroidal anti-inflammatories (arthritis medication), blood thinners (eg. Warfarin, clopidegral etc), antidiabetic medication (insulin), Vitamin E, St John’s wart and any dietary drugs should be discussed with Dr Noushi and his anaesthetist prior to the procedure.
Blood thinners may need to be ceased for your procedure and this may require consultation with your other specialists.
It is also essential that you alert Dr Noushi and his anaesthetist if you require antibiotics prior to undergoing dental procedures, since you may also require antibiotics prior to this procedure (eg for patients with artificial heart valves).
Quit smoking and arrange for any help you may need at home.
How is the gallbladder removed?
Laparoscopic (keyhole) surgery is the most coomon method of removal of the gallbladder.
Under general anesthesia, the surgeon enters the abdomen in the area of the belly-button and places a special cannula. A laparoscope (a tiny telescope connected to a special camera) is inserted through this cannula, giving a magnified view of the patient’s internal organs on a television screen. Then 3 smaller cannulas are inserted which allow the surgeon to delicately separate the gallbladder from its attachments and then remove it through one of the openings.
If there is concern about stones in the bile ducts then a special X-ray, called a cholangiogram will be performed. Special dye is injected down the bile ducts to outline any abnormality. Then the gallbladder duct (cystic duct) and associated artery (cystic artery) clipped with permanent titanium clips. These do not cause any long term problems.
After the gallbladder is removed the 4 small incisions are closed with a stitch or two and surgical tape.
The benefits of laparoscopic surgery include less post-operative pain, earlier discharge from hospital, shorter recovery period and smaller abdominal incisions.
Occassionally laparoscopic surgery cannot be completed and the surgeon may have to convert to the conventional open surgery.
This may be due to difficult operative conditions such as severe inflammation and scarring of the gallbladder, gangrenous gallbladder, abdominal adhesions, abnormal anatomy or difficulty with obtaining a good view.
The open procedure involves a larger incision in the upper abdomen to gain access to the gallbladder. Conversion to open surgery is not seen as a complication rather an essential safe progression of the operation to protect the patient from complication.
Conversion to open surgery occur in 2 out of every 100 patients. Postoperatively the patient will require a few extra days in hospital to recover.
What happens after gallbladder surgery?
Most patients make a full recovery in 4-6 weeks after surgery. Gallbladder removal is a major abdominal operation and a certain amount of postoperative pain occurs. Nausea and vomiting ia also common. Most patients who have a laparoscopic gallbladder removal go home from the hospital the day after surgery.
The sutures are dissolving and the dressings remain on for 7 days after which they can be removed and the wound left open.
Activity is dependent on how the patient feels. Walking is encouraged and patients will probably be able to return to normal activities within 2 week’s time which including driving, walking up stairs, light lifting and working. In general, recovery should be progressive, once the patient is at home.
Patients should not drive for 1 week after surgery and may return to work in 1-4 weeks depending on the nature of their job. Patients with administrative or desk jobs usually return in a 1-2 weeks while those involved in manual labor or heavy lifting may require 3-4 weeks. Patients undergoing an open cholecystectomy usually resume normal activities in four to six weeks.
The onset of fever, yellow skin or eyes, worsening abdominal pain, distention, persistent nausea or vomiting, or drainage from the incision are indications that a complication may have occurred.
You should contact Dr Noushi immediately if you have these symptoms.
Make an appointment with Dr Noushi within 2 weeks following your operation.
What are the possible complications from gallbladder surgery?
As with all surgical procedures gallbladder surgery does have some risk. Serious complications after gallbladder surgery are rare. It is not usual to outline every possible and rare complication from an operation, however it is important that you have enough information to weigh up the benefits, risks and limitations of surgery.
Complications from gallbladder surgery include (but not limited to) the following:
Wound infection, keloid/hypertrophic scar and wound pain.
Other general surgical and anaesthetic complications include nausea, bleeding, blood clots, chest infections, deep vein thrombosis, allergic reactions and heart troubles.
Specific complications to laparoscopic cholecystectomy include:
Unintended injury to adjacent structures such as the common bile duct or small bowel may occur and may require another surgical procedure to repair it.
Injury to the Bile duct injury: There is a small risk (1 in 400) of injuring a major bile duct draining out of the liver. It may be recognised at the time of the surgery or in the days that follow. Injury to a major bile duct frequently requires further procedures to diagnose and repair it.
Bile leak: Bile leak after the surgery can be from a major or minor bile duct within the liver. It occurs around 1 in 200 cases, and sometimes requires other procedures (ERCP) to dry it up. It rarely requires further surgery.
Retained stone. Sometimes an undiagnosed stone within the bile duct presents days or weeks following gallbladder surgery with pain and/or jaundice. This may also require another endoscopic day procedure (ERCP) to remove them.
When should I be concerned and call Dr Noushi after surgery?
Be sure to call Dr Noushi or the hospital if you develop any of the following:
- Persistent fever over 38 C
- Yellow skin or eyes
- Increasing abdominal or groin swelling
- Pain that is not relieved by your medications
- Persistent nausea or vomiting
- Inability to urinate
- Persistent cough or shortness of breath
- Purulent drainage (pus) from any incision
- Redness surrounding any of your incisions that is worsening or getting bigger
- You are unable to eat or drink liquids