The gallbladder is a small, pear–shaped organ that lies just beneath the liver in the upper right part of your abdomen. The gallbladder collects and stores bile, a digestive juice produced by the liver, and excretes it (through the common bile duct) into the intestines. The purpose of bile is to help digest large fatty meals.
Gallstones (Cholelithiasis)
Sometimes, stones (usually made of cholesterol, bile salts and lecithin) form in the gallbladder and block its outlet, causing pain (Biliary colic) or inflammation and infection (Cholecystitis). Sometimes the stones move out of the gallbladder but get stuck in the common bile duct, and can cause inflammation of the pancreas (Pancreatitis), fever, or jaundice (yellow color in the skin and eyes). Pain usually begins after a meal and may become severe and constant. There may be more symptoms after eating fatty foods. Other symptoms may include bloating, belching, vomiting, and indigestion. Some patients have no symptoms.
Diagnosis of Gallstones
Diagnosis is most often made by ultrasound, the same technique used to visualize fetuses in pregnant woman. With this technique, a detailed image of the gallbladder contents, including stones, can be produced.
Risk Factors of Gallstones
Men, women, and children can all get gallstones. They appear to be more common in obese women over the age of 40. Native Americans and Hispanics may also have higher rates. The overall incidence is 1 out of 1000 people. Women who exercise regularly may reduce their chance of getting gallstones.
Causes of Gallstones
The causes are still mostly unknown, although it is presumed that changes in the composition of the bile substance and failure of the gallbladder to empty properly are contributing causes.
Treatment for Gallstones
Medication and adjustments in the diet (low fat) can help alleviate some of the symptoms. However, if stones block the gallbladder outlet or are lodged in the bile duct, surgery is indicated. Patients who have symptoms, even minor ones, have a diseased gallbladder should strongly consider surgery. For patients with no symptoms, there is a significant risk that the first attack will be severe and require hospitalization, for this reason, such patients should also consider surgery. Furthermore, patients who are at increased risk for infection (such as diabetics or people undergoing chemotherapy) should consider removal of a diseased gallbladder. For these patients, a severe and acute attack may be very dangerous.
Gallbladder Surgery
There are two ways to perform gallbladder surgery: Open Cholecystectomy or Laparoscopic Cholecystectomy.
Open Cholecystectomy
An abdominal incision is made to expose the gallbladder, located under the right portion of the liver. The gallbladder with its stones is removed. Once the gallbladder has stones, it is diseased and cannot be left behind. Removal of gallstones alone is not standard accepted practice. Usually an X–ray test called the Intra–operative Cholangiogram is done during the surgery to see if gallstones are also in the common bile duct. If this test shows stones, then the common bile duct is explored and these stones are removed. Local anesthesia is given at the incision sites to help reduce pain, the incisions are all closed, and a dressing is applied.
General anesthesia is the preferred technique to make the patient comfortable and pain free. Postoperative pain may be managed with an epidural or by Patient Controlled Analgesia (PCA) where the patient activates a device to deliver a dose of intravenous painkiller. In addition, injections and oral painkillers are administered.
The most common side effects from the surgery and anesthesia are pain from the abdominal incision, nausea and vomiting, sore throat, muscle aches, tiredness and a general feeling of illness. Recovery usually takes several days to a week in the hospital. Patients are usually out of work 2–3 weeks and usually cannot resume significant physical activity for 6–8 weeks.
Laparoscopic Cholecystectomy
A telescopic instrument called a laparoscope is inserted into a small incision at the belly button (umbilicus). The laparoscope is connected to a tiny video camera which projects a magnified view of the operative site onto video monitors. These video monitors help your surgeon perform the surgery. Carbon dioxide is passed through the laparoscope to fill the abdominal cavity, providing your surgeon with a better view. Small abdominal incisions (one–fourth to one–half inch) are usually made near the primary one at the umbilicus to pass in special surgical instruments with which the operation is performed and the gallbladder removed. The common bile duct is usually examined with use of an Intra–Operative Cholangiogram (see above) to make sure that no stones have migrated into the duct.
If this occurs, stones within the bile duct can be removed laparoscopically by a surgeon with specific expertise using a sophisticated instrument called a Choledochoscope. During the surgery all contents of the abdominal cavity can be viewed and examined through the laparoscope, increasing the safety of the procedure and aiding in the diagnosis of other diseases. Local anesthetic is given at the incision sites to help prevent pain and the small incisions are all closed and covered with steri–strips or Band–Aids.
General anesthesia is the preferred technique to assure optimal operating conditions and a pain–free and comfortable state. Postoperative pain is usually managed with combinations of small doses of intravenous and oral painkillers. The most common side effects after surgery and anesthesia include nausea and vomiting, sedation, sore throat, generalized muscle aches, aches in the shoulder blades and back of neck from the gas (from nerve stimulation caused by the C02 gas used to inflate the abdomen), and mild pain from the incisions.
You will probably be able to go home after a few hours or early the next day once you can tolerate food and drink. If you are over age 65, have major health problems, have acute infection of the gallbladder (cholecystitis), or have prolonged surgery, you may need a longer time for recovery. Either way, you will probably be able to resume normal activities within the week after surgery although you may feel tired.
The Main Advantages of the Laparoscopic Technique are the following:
- Four small scars instead of one large abdominal scar.
- Reduced postoperative pain.
- Shorter hospital stay – able to leave the same day or early next day.
- Shorter recovery time – days instead of weeks – and a quicker return to normal daily activities and work.
It is important to follow your doctor’s instructions after the surgery. Feelings of queasiness, nausea and/or vomiting, muscle aches and gas pains, and pain from the incisions will dissipate over the next 3–4 days. Medication can be given to ease these side effects. Acetaminophen and ibuprofen help with the gas pains. Feelings of malaise and tiredness may last for 2–4 weeks. Although most people feel better within a few days, you may need to take it easy for two to four weeks.
Comparison between Laparoscopic Cholecystectomy & Open Cholecystectomy
If performed by surgeons who are expert in this area, laparoscopic cholecystectomy is safer than open cholecystectomy. Common bile duct injury may occur more often using laparoscopic technique than the open technique, depending on the skill and expertise of the surgeon. However, other complications such as infection, pneumonia, and phlebitis (clots in the legs) are less common than in the open technique. Your surgeon may need to convert it to an open procedure in cases of anatomic difficulties or uncertainties, though in experienced hands this chance is less than 1%.
