Gallstones & Cholecystectomy

Gallbladder Surgery

Laparoscopic cholecystectomy is the complete removal of the gall bladder without a major abdominal incision. Cholecystectomy is the surgical removal of the gallbladder and laparoscopic refers to the type of instrumentation and procedure used for this operation.

The procedure is performed in the operating room while the patient is under a general (complete) anaesthetic. Four small 5-10 mm incisions are used, one at the umbilicus (belly button), through which the laparoscope is inserted into the abdomen.  Three punctures along  under the ribs are used for placement of the instruments for removing the gallbladder and an additional tiny wound may be made for taking x-rays if necessary.The laparoscope is a long, narrow instrument consisting of a lighted tube with magnifying lenses – to serve as a surgical viewing scope.  It is attached to a small television camera in order for the surgeons and all assistants to view the gallbladder on an external video monitor during the procedure.

The gallbladder is a sack attached to the underside of the liver, which stores bile.  There are two major vessels attached to the gallbladder; the cystic artery which supplies blood to the gallbladder, and the cystic duct which transports bile to and from the bladder.

Either plastic or metallic surgical clips are placed on the duct and artery leading to the gallbladder, in order to secure the structures against leakage or bleeding.  Then an instrument heated by electric current is used to cut the attachment of the gallbladder from the liver bed.  The gallbladder is then removed from the abdominal cavity through the incision in the umbilicus.  This incision may be enlarged slightly if the gallstones are large. The time required to complete the procedure varies from 25 minutes  to 3 hours, depending on the state of the gallbladder, the amount of inflammation or swelling present and the local anatomy.

94-97 of every 100 patients will be cured of their pain after laparoscopic cholecystectomy.  The complications of gallstones will be prevented.

Any cholecystectomy is performed when your doctor concludes that the gallbladder is diseased, not functioning properly and/or contains gallstones.  The gallbladder is removed to avoid further complications such as bile duct obstruction, which can affect the liver. Indications for surgery include:

• Any patient with a complication of gallstone disease.

• Any patient with uncomplicated symptomatic gall stone disease who has had the natural history of symptomatic gallstones explained to them, and makes an informed choice to have surgery.

• Asymptomatic gallstone patients with a calcified gallbladder or a gall bladder polyp greater than one centimetre in diameter

• Selected asymptomatic diabetic patients with gallstones

The laparoscopic method of cholecystectomy is performed as a way to avoid, if possible, the major abdominal incision required for other methods of gallbladder removal, as well as to have minimal bleeding during the operation process.  The major abdominal incision in regular gallbladder removal procedures is the principle cause of the extended recovery period required.

In some cases, circumstances may arise during the procedure which may cause the surgeon to abandon the laparoscopic technique in favour of an “open” cholecystectomy procedure performed through a standard incision.  Some of the circumstances that may require conversion to open procedure include excessive bleeding, intense inflammation in the gallbladder or stones in the bile duct.  The same anaesthetic is used, but the surgeons must make another type of incision and alter their methods of gallbladder removal.

The advantages to the patient derived from removing the gall bladder by the laparoscopic method, in contrast to other removal procedures are:

• Reduced postoperative pain

• Shorter hospital stay

• Earlier return to full activity and work

• Less pain medication requirement

• Less visible abdominal scars

The major risks associated with this procedure are similar to those with open cholecystectomy.  These are infrequent or rare.  The most common risks include:

• Bleeding

• Infection

• Complications related to general anaesthetic (including the rare incidence of heart attack and death)

• Injury to the bile duct which could require major reconstructive procedures

• Blood clots forming in the legs

• Leakage of bile from the bile ducts into the abdomen

• Injury to abdominal organs from the laparoscopic insertion

Studies of laparoscopic procedures have found the following types of problems:

• Complications: 3-8 people in every 100

• Bile duct injuries: 1  in every 1000 people

• Conversion to Open Procedure:  2-4 people in every 100

• Deaths: 1 in every 1500-3000 people

Open operations may have a slightly lower rate of bile duct injuries and slightly higher rates of overall complications and deaths.

Other methods for treatment of  gall stones also exist.  These methods include removal, dissolving or breaking up of the gall stones without gall bladder removal using:

• Medications or chemicals to dissolve stones

• Shock waves passed through the skin to break up stones (lithotripsy)

Unfortunately these treatments are not applicable to the vast majority of patients and are rarely practiced in Australia as they seldom work.

If only the gallstones and not the gallbladder is  removed  there is a high probability that stones will reform in the gallbladder and symptoms will continue or recur. (It is rare for gallstones to form again in the bile duct after cholecystectomy).

For most patients there will be no long term side effects of having a diseased gallbladder removed. Once the wound pain has settled a very small number of patients may have more frequent bowel actions and some gastro-oesophageal reflux symptoms.

Asymptomatic gall stones (If your gallstones are not causing you pain):

• After gallstones are detected serious symptoms and complications will probably develop in 2 in every 100 people per year.  This gets less common after ten years.

• Biliary pain is the first symptom to develop in about 90% of people with previously asymptomatic gall stones.  After 20 years, two thirds of patients with asymptomatic gallstones will have had no biliary pain or complications.

• The lifetime risk of death with a wait and see approach is 0.8% to 2%.  The risk may increase the older you are when your gall stones are detected.

• Symptomatic gallstones (If your gallstones are causing you pain):

• About 30% of patients who have an episode of biliary pain will not have further episodes of pain during the next ten years.

• About 1-2 patients in every 100 develop complications of gallstones per year.  After 20 years about half the patients with symptomatic gallstones will not have had a biliary complication.

• The lifetime risk of death with a wait and see approach is 2% to 6%. The risk increases the older you are and when your gallstones are first detected.