LAPARASCOPIC CHOLECYSTECTOMY

Gallstones

 

The Gallbladder:

 

The gallbladder is about the size of a small pear and is situated under the liver, in the upper right side of the abdomen. It is a cul de sac coming off the bile duct which is a tube that carries the bile from the liver to the intestines. Bile allows you to absorb fat and important vitamins from your diet. The gallbladder siphons off bile from the bile duct, stores and concentrates it and when you eat, it squirts the stored bile into the bile duct and thus down to the intestine.

 

 

How do you get gallstones?

 

When the gallbladder does not empty properly, the bile gets too concentrated and the bile salts precipitate out, just as salt would eventually if you kept on adding it to a glass of water. The stones then grow. Sometimes they are single and get larger, sometimes they are multiple and can be very small. The number of gallstones you have makes very little difference – it only takes one small stones to cause trouble.

 

Gallstones are partly hereditary as they “run in families”. There is probably also a dietary cause (fat in the diet) and conversely, gallstones often develop after prolonged fasting such as in radical dieting and rapid weight loss. Gallstones are also associated with pregnancy and are twice as common in women anyway. Gallstones are more common in the overweight and occur with greater frequency with increasing age.

 

 

 

How are gallstones diagnosed?

 

An ultrasound scan will confirm whether you have gallstones. The scan is usually ordered by your family doctor. It is simple, painless and not expensive. It is very accurate and only rarely are stones missed by the scan. Other scans can pick up gallstones too but they are either less sensitive or much more expensive. Ultrasound scan results are available immediately after the scan.

 

 

 


Who needs surgery?

 

Gallstones are quite common and are sometimes discovered when a scan is done for some other reason eg pregnancy. An operation is only performed on those patients who have pain, however there might be special cases where surgery would be considered, such as where patients are going to reside in a place without adequate medical care, or where the scan has shown possible cancer or where the scan has shown growths that may become cancerous. Surgery may be recommended in diabetic patients too.

 

However over time, people with gallstones who initially have no pain, do have a risk of developing symptoms – the rate is about 2% per year, so over a period of twenty years, there’s approximately 40% chance that the gallstones will cause pain.

 

 

Is there treatment other than surgery?

 

Although the frequency of attacks can be reduced by eating less fat (and dairy food is one of the most common triggers of pain, especially cheese), it is not reliable. I have had patients who got pain after eating lettuce.

 

Other treatments have been tried, such as shattering the stones with acoustic shock waves. This works well for kidney stones but not for gallstones, mainly because either the stones are too big to shatter or because the body is unable to get rid of the stone fragments after shattering.

 

Dissolving gallstones has also been tried but the treatment is expensive (and not funded by the government) and it often caused side-effects such as diarrhoea. The treatment takes a couple of years, and works for only some stones.

 

Both of these treatments leave the gallbladder in place and there is a high risk of re-growing stones after a few years and having to go through the whole process again. Various diets such as drinking large quantities of olive oil have been tried but in my experience, they do not fix the problem. The only reliable treatment is surgery.

 

People often ask why the gallbladder has to be removed and not just the stones. Firstly, it is technically not straight-forward to empty the gallbladder completely and repair it safely, but the main reason is that the gallbladder is diseased and that is why the gallstones form in the first place – the gallbladder is not emptying itself fully and therefore the bile is being over-concentrated. In other words, the gallstones would form again, possibly within months.

 

 

Gallbladder pain

 

The typical pain from a gallbladder attack is called biliary colic. It is a severe pain usually in the top part of the abdomen or in the chest. It sometimes spreads to the back, between the shoulder blades and usually makes the patient restless, walk about or double up. It can last minutes, hours or even days. It tends to wake people up at night and is often accompanied by vomiting. More severe attacks are associated with fever. Other types of abdominal pains, either in different places or of a different nature can be due to gallstones but it’s sometimes hard to tell.

 

There is no test that will reliably determine whether someone’s pain is due to gallstones. The diagnosis is made by matching the symptoms with the usual picture and by what the blood tests and the ultrasound scan show.

 

Not in everyone with gallstones is their pain actually due to the gallstones and so sometimes their pain is not relieved by removing the gallbladder.

 

Gallbladder pain rarely occurs where there are no gallstones (called acalculous cholecystits) but this diagnosis needs to be made very carefully, after extensive tests to rule out other causes of pain.

 

 

What are the consequences of having gallstones?

 

·               Once you experience gallbladder pain, it is virtually inevitable that you will go on and get further attacks. By eating less fatty food you could diminish your chances but this is not reliable. Sometimes the pain becomes more frequent and more severe. The stones that cause the pain are usually not passed by the body but fall from the gallbladder outlet where they are temporarily jammed, back into the gallbladder ready to later cause trouble again.

 

·               Sometimes the stones in the gallbladder get absolutely stuck in the outlet of the gallbladder and the gallbladder is completely blocked. The scenario is set for the gallbladder to then get severely inflamed or infected and this is called cholecystitis. This often requires emergency hospital admission, antibiotics and strong pain killers. Either the pain then settles gradually or an urgent operation is required. In severe cases the gallbladder can become gangrenous and the patient is very ill indeed.

 

·               The stones in the gallbladder can pass out of the gallbladder, fall into the bile duct and then jam at the bottom of the bile duct. This situation is far more serious and is more common when people have multiple small stones. This can result in jaundice, cholangitis or pancreatitis. Cholangitis is where there is infection in the bile duct and pancreatits is where the pancreas or sweetbread gland is inflamed. Both these conditions can be fatal. (see later “stones in the bile duct”)

 

·               Gallstones can work their way into the intestine and cause blockage requiring surgery. This is called gallstone ileus

 

·               Cancer of the gallbladder is rare but occurs only when there are gallstones in the gallbladder.

 

In summary, if you have gallstones, you will avoid further pain if you have surgery. However if you have stones in the bile duct, it is very important that you have them treated, in order to prevent the development of severe complications.

 

 

 

Stones in the bile duct.

 

Sometimes the ultrasound will pick up gallstones in the bile duct or at least show that the duct is wider than normal indicating it might be blocked. If the liver blood tests are abnormal, then that is often a pointer to duct stones. CT scan can detect bile duct stones and an MRI scan is accurate but it is expensive.

 

There are two ways to deal with bile duct stones. One is called ERCP (endoscopic retrograde cholangiopancreatography). The patient is heavily sedated with intravenous sedatives and then a camera within a flexible telescope is passed down through the stomach into the intestine and the bile duct is accessed from there by cutting open the outlet of the duct. The stones can then be retrieved using a basket or balloon. ERCP is very effective (over 90%) but it is an expensive procedure and more importantly, is associated with complications such as bleeding, intestinal perforation and pancreatitis. All of these can even be fatal and at the least require hospitalization. It is quite unfortunate if these complications develop when the ERCP was done to simply detect bile duct stones when in fact there were no stones in the bile duct after all.

 
Once the ERCP is done, the gallbladder usually still has to be removed as it will cause more trouble later on otherwise.

 

An alternative way is to confirm the presence of duct stones by performing a special X-ray of the bile duct during the operation to remove the gallbladder. This is called an intra-operative cholangiogram. This technique has also been shown to reduce the chances of severe complications of gallbladder surgery and is widely recommended by surgeons worldwide for this reason alone. It is cheap and adds only a few minutes to the operation.

 

If stones are found in the bile duct, the surgeon then can often remove them by using a special very narrow telescope passed into the duct. This is done during the operation to remove the gallbladder and is called laparoscopic common bile duct exploration. The advantage of this approach over ERCP is that no second procedure is required and the complications and cost of ERCP are avoided. In centres overseas, this approach is regarded as the gold standard and is routine.

 

I have used this technique with success over many years. Many surgeons do not use this technique as it is technically challenging and does take time and patience. They simply remove the gallbladder and either wait for symptoms to develop or refer straight to ERCP despite the disadvantages mentioned.

 

 

 

Laparoscopic cholecystectomy

 

Laparoscopic surgery (also called keyhole surgery) has revolutionised gallbladder surgery. It was first described about 25 years ago and is now the standard operation for gallbladder removal. Compared with the older method of making a large incision, this technique results in much less pain after the surgery and faster recovery. Plus there are fewer wound-related problems such as infection or wound breakdown and much smaller, less disfiguring scars. The operation is performed under general anaesthetic and takes just over an hour. Tubes called trocars are inserted into the abdomen. The largest tube is one centimetre in diameter and is near the navel; the other three trocars are placed under the rib cage. The abdomen is inflated with carbon dioxide gas to create a space to operate in. A telescope with a camera on the end is passed into this trocar and instruments are passed through the other three trocars to dissect the gallbladder free of its attachments and perform the intra-operative cholangiogram, an X-ray picture of the bile duct. Once the gallbladder is free, it is extracted from the abdomen via the largest incision, the one near the umbilicus. Sometimes the gallbladder is so large and thick-walled, this incision has to be enlarged a little.

 

Sometimes the gallbladder is so densely inflamed, (this is only found out at the time of surgery) that the operation cannot be completed laparoscopically. A large incision on the right side of the abdomen is then required. This is rare (about 1%); an experienced laparoscopic surgeon will usually be able to successfully complete the operation laparoscopically. Very occasionally bleeding is encountered and this requires conversion from laparoscopic surgery to an open operation. Another reason why open surgery might be required is if the patient has had abdominal surgery before and there is a great deal of scarring in the abdomen preventing a good view of the gallbladder with the camera. Usually however the operative technique can be modified to avoid the previous surgery scarring and I rarely decline a patient the opportunity to have a keyhole operation just because of previous abdominal surgery.

 

The laparoscopic technique is thus suitable for almost anyone that can tolerate a general anaesthetic.

 

Other procedures can be performed at the same operation, for example hernia repair.

 

 

The risks of laparoscopic cholecystectomy

 

Complication rates are low for this procedure but as in any operation, complications such as infection, bleeding, damage to other organs and deep venous thrombosis (or DVT - clots in leg veins) can occur. The risks are minimized by administering antibiotics at the time of surgery, together with a small injection that very slightly thins the blood and reduces the chances of DVT. The most serious complication is damage to the bile duct and this is minimized by performing an intra-operative cholangiogram. (see above: “stone in the bile duct”). If the bile duct is damaged, another operation is required to repair it. Bile leaking from the liver is a rare complication that is apparent after discharge from hospital and usually requires repeat surgery, most often repeat laparoscopy.

 

 

After the operation

 

After the surgery, you are taken to the recovery room for about an hour and then to the ward. You can then go home whenever you are comfortable and eating and the nurses are content that your vital signs are normal. Most people stay in hospital overnight. Some patients go home the same day. Occasionally the stay is two nights. A drain tube is sometimes inserted into the abdomen at operation and usually this is removed the next morning. Sometimes a course of antibiotics is prescribed.

 

The wounds are all closed with absorbable sutures so none need to be cut out. There is no special restriction on either diet (however it is best to avoid a fatty meal at first) or physical activity – you do whatever you can manage easily; that is if it hurts, don’t do it.

                                                                                     

You can go back to work whenever you are comfortable. People often feel tired after operations and sometimes the gas used to allow visibility at operation gets trapped under the diaphragm and may cause shoulder pain for a day or so. The wounds usually are not very sore and pain-killers like paracetamol and or anti-inflammatory drugs like ibuprofen are given. The average time off work is one week.

 

If a large incision has to be made then a longer stay in hospital is required and longer period off work.

 

Should you have vomiting or fever or increasing pain after discharge, please contact your doctor or me directly without delay. However these symptoms are rare.

 

Most people notice no difference to their digestion after surgery. Remember, the gallbladder was not functioning properly before the surgery anyway and that’s why gallstones formed. Before the operation you were in effect digesting without a gallbladder. There is so much reserve capacity in the digestive system that the extra squirt of bile from the gallbladder is not needed for digestion. Some people notice their bowel motions are slightly looser but this is not common.

 

I like to see patients about three weeks after the surgery. The gallbladder is always sent off to the laboratory for analysis and I will have the result by this time.

 

 

Who performs laparoscopic cholecystectomy?

 

Most abdominal surgeons do this operation however not all are trained in laparoscopic bile duct exploration or are familiar with other advanced laparoscopic techniques. Therefore not all surgeons can remove bile duct stones at laparoscopic operation and instead refer patients for ERCP. Surgeons who do not perform advanced laparoscopic surgery may be less inclined to persist with the laparoscopic approach and may convert to open operation early.

 

My experience

 

I was one of the first surgeons to perform laparoscopic general surgical operations in Wellington, in 1991. After overseas training, I introduced many of these surgeries into Wellington, including

  • laparoscopic bowel surgery,
  • laparoscopic hernia surgery,
  • laparoscopic reflux operations,
  • laparoscopic bile duct explorations and
  • laparoscopic appendicectomy.

 

I have performed thousands of these operations, particularly cholecystectomies and my complication rate is less than most published figures from overseas institutions.

 

P: 04 9102 178 E: gary.stone@wgtnspecialist.co.nz F: 04 3895230