Laparoscopic Surgery

Inflammation of the gallbladder, or physical obstruction due to gall stone either within the gallbladder itself, or down the bile duct, affecting the liver or pancreas, are common clinical problems in our society.  They are more common in women than men, and while there may be some hormonal influences working in this, these are not fully understood.  Hereditary influences are clearly important, and it is common to see many members in one family who present with Cholecystitis (inflammation of the gallbladder or Cholus), or with Biliary Colic, due to gallstone obstruction.

• What does the gallbladder do?

The gallbladder in the human being is a small organ, about the size of a collapsed party balloon, which is attached on the side of the common bile duct, which drains bile, from in the liver, down the duct and into the intestine.  The gallbladder itself stores a little bit of bile, and in normal situations will contract and push that small amount of bile out and down the bile duct in response to the eating of fatty foods.  This is a small amount of bile only, and nothing like the amount of bile stored in large gallbladders in many other members of the animal kingdom.  Interestingly, when people have had to have their gallbladder removed because of clinical problems, ultrasounds record a slight dilation of the common bile duct occurring when the gallbladder is no longer present, which suggests an increased flow of bile from the liver down that duct, to compensate for gall bladder removal.

While all is not known about gallbladder function, we know enough to say confidently that if symptoms develop of Cholecystitis, or Biliary Colic, that removal of the gallbladder with its enclosed stones, if present, is the best solution, as symptoms will continue and perhaps even become worse with problems such as obstructive jaundice, pancreatitis, or obstruction of the gallbladder with potential perforation and peritonitis.

• If the gallbladder is removed does it lead to any digestive or dietary changes?

Removal of the gallbladder, we can confidently say, is not directly related to any change in bowel function or digestion at all.  When the gallbladder is causing clinical problems it is best to restrict fatty food intake, until the gallbladder and gallstones are removed.  Post-operatively there is no restriction on diet at all.

• What are the common symptoms of gallbladder disease?

Commonly people with an inflamed gallbladder and/or gallstone disease experience pain in the upper abdomen, and/or pain through to the tip of shoulder blade to the middle or to the right side of the back.  Sometimes pain in the back is the long term clinical presentation.  There is often nausea associated on a regular basis, and in acute situations vomiting can occur with severe pain.  Sometimes a gallstone will track down the bile duct and cause obstructive jaundice as the first presentation of gallbladder disease, or even pancreatitis.  Gallbladder inflammation can sometimes present acutely with high fevers and even peritonitis.  Symptoms will often have been present to minor degrees for many years, and when finally a person experiences significant enough symptoms to go to a doctor and have the diagnosis made, this can be many years after gallbladder inflammation (Cholecystitis) and gallstone development have begun.

• Are gallstones always present, and what do gallbladder polyps indicate?

Most people who develop gallbladder symptoms have gallstones within the gallbladder and ultrasounds remain the best investigation to detect these.  The stones may vary immensely from even hundreds of tiny gallstones within the gallbladder up to a single solitary large gall stone.  The development of stones is due to inflammation of the lining the gallbladder (Cholecystitis – Inflammation of the Cholus, or gallbladder).  In about 5% of people, presenting with gallbladder symptoms, there are, however, no gallstones present and this condition is Acalculous Cholecystitis.  This can often be difficult to diagnose and requires further scanning including nuclear scans such as a HIDA scan.

Sometimes ultrasounds will suggest the presence of gallbladder polyps, and the great majority of gallbladder polyps are reflective simply of inflammation (Cholecystitis) with development of an inflammatory polyp change in the lining of the gallbladder.  These are not a precancerous situation.  Gallbladder polyps reflect the fact that there is Cholecystitis present, and if symptoms are also present then consideration of gallbladder surgery needs to be undertaken. About 50% of these polyps are , in fact, adherent tiny gall stones/

• Do all patients with gallstones have to have the gallbladder removed?

Operation for gallbladder disease is only recommended when there are symptoms affecting the patient’s life.  Sometimes an ultrasound of the abdomen has revealed a person to have gallstones present in the gallbladder but if no symptoms exist at all then surgery is not usually recommended.  There are many who, for reasons difficult to explain, can have gallstones without symptoms of any note, throughout their life and never need surgery.  The indication for surgery is based upon the presence of symptoms of gallbladder disease as outlined above.

• What does surgery involve?

If the patient is advised that surgery is indicated for gallstone disease or for cholecystitis, this is usually undertaken with a laparoscopic (keyhole) cholecystectomy operation, and in most such operations an operative cholangiogram is done (an x-ray during the operation of the bile ducts to make sure stones have not moved out of the gallbladder down the bile duct).  Surgery involves four small incisions on the abdomen with a video camera relaying pictures to a television screen allowing the operator to see the internal aspects of the abdomen and work with three other instruments, and an assistant surgeon, for careful removal of the gallbladder with the gallstones contained.  In many cases a drain tube will be left overnight to indicate whether or not there may be leakage of bile – This only occurs in 2% of people having gallbladder surgery, but if detected early, with bile in the drain tube, then this can be acted upon with further procedures to seal the leakage before any secondary clinical issues occur due to undiagnosed bile leakage. In 98% of people any drain tube left in after operation will be removed the following day as there is no bile leakage and the patient will usually go home on that day.  While there is a small amount of pain associated with the wounds, this is usually controlled readily with simple analgesic medication such as Panadol, but in the first day or two some people will need slightly stronger medication and that is always provided.

Recovery from surgery is usually quite fast with most people recovering their appetite over the next week back to eating completely normally, and within two weeks being ready for all of their normal activities and returning to work.  The laparoscopic (keyhole) nature of the surgery means that return to physical activity is quite rapid, on the advice of the surgeon.

There is a small chance a laparoscopic operation has to turn into an open operation with a larger incision, if the vision through the laparoscope is not good enough to allow the careful dissection required for the completion of gallbladder surgery.  This occurs in about 3% of people.

The operation takes on average about 45 to 60 minutes.

• What complications can occur after surgery?

The main complication is that of bile leakage as discussed above.  In any operation significant blood loss can, rarely, occur, but this would be then dealt with according to needs.  Infection in wounds can occur in less than 5% of people (usually at the umbilical or main operative port site), and this would be evidenced by increasing redness and soreness a few days after operation, and is usually simply treated with antibiotics.  Occasionally drainage of that small wound has to occur.  Very rarely other organs in the region of the operation can be damaged and then would need appropriate treatment to repair those.  Gallbladder surgery is quite routine and will result in excellent resolution of symptoms present pre-operatively, and a great increase in quality of life for most people having that surgery.