- What is the gallbladder?
- How do gallstones form and how do they cause trouble?
- What happens when the gallstone stays wedged in the gallbladder or common bile duct outlet?
- What is ERCP?
- Do gallstones always need to be treated surgically?
- Is surgery the only treatment for gallstones?
- How are gallstones treated?
- What is laparoscopic cholecystectomy?
- Is anyone able to have laparoscopic cholecystectomy?
- What are the surgical risks of laparoscopic cholecystectomy?
- What is the effect of having the gallbladder removed?
- What sort of surgeon performs laparoscopic cholecystectomy?
- Andrew Bowker’s Experience with laparoscopic cholecystectomy
What is the gallbladder?
The gallbladder is a thin-walled sac of similar dimensions to an un-inflated balloon. It acts as a storage unit for bile, which is made by the liver. The bile is secreted into tubes that join together in the liver and eventually drain via a common main tube (the common bile duct) into the duodenum (intestine), much as the small branches of a tree lead down to the trunk.
The gallbladder is a side branch of the common bile duct. It siphons off some of the passing bile, stores it and concentrates it. This concentrated bile is called on by the gut when extra bile is required to digest a fatty meal.
How do gallstones form and how do they cause trouble?
Gallstones are also known as calculi. It is in the concentrated bile of the gallbladder that they precipitate out and grow. Most of the time they do not cause any problems, but if one becomes wedged in the narrow outlet of the gallbladder, the gallbladder is thrown into spasm as it tries to overcome the obstruction. This typically equates to very severe pain, “worse than labour pains”, to those in the know. In most cases, the pain is relieved when the stone moves away from the gallbladder outlet, back into the main body of the gallbladder, where it has the potential to cause trouble again.
Contrary to popular belief, the gallstone is not usually “passed”. However, this can happen, in which case the stone can then lodge in the outlet of the common bile duct, at the point where it enters the duodenum (intestine). In this situation the pain is the same, but if complete blockage occurs, the bile cannot drain down from the liver and obstructive jaundice develops. This is accompanied by dark urine and pale stools. The blood test measuring liver function also becomes markedly deranged.
Another digestive gland, the pancreas, drains into the bottom end of the common bile duct. If it becomes obstructed as well, the potentially life-threatening condition of pancreatitis can develop. The offending calculus often passes spontaneously into the gut and the problem is relieved, although it takes much longer for the liver function tests to return to normal. If pancreatitis developes, intensive medical support may be required to aid recovery. Occasionally, pancreatitis is fatal.
What happens when the gallstone stays wedged in the gallbladder or common bile duct outlet?
Sometimes the gallstone does not roll clear of the gallbladder outlet, in which case pain continues and the gallbladder becomes inflamed. This is called cholecystitis. It can eventually settle spontaneously, but there is potential for the patient to become very unwell and the gallbladder can lose its blood supply – become gangrenous. The likelihood of this occurring is greater in diabetics and the elderly. Early surgery to remove the gallbladder, or at least drain it, is the best option in this situation.
Alternatively, if a gallstone remains wedged in the outlet of the common bile duct, jaundice will persist. When infection supervenes, the condition is known as cholangitis. This is dangerous and requires urgent treatment with antibiotics and relief of the obstruction by endoscopic retrograde cholangiopancreatography (ERCP).
What is ERCP?
Endoscopic retrograde cholangiopancreatography (ERCP) involves the passage of a flexible endoscope (telescope) through the mouth down to where the common bile duct enters the duodenum. The duodenum is the segment of intestine immediately beyond the stomach. Through the endoscope the presence of a gallstone(s) in the common duct can be confirmed and then retrieved from the duct. This procedure is done under sedation, such that, while the patient is able to cooperate, there is usually little or no recollection of the procedure afterwards.
Do gallstones always need to be treated surgically?
If the gallstones are an incidental finding (e.g. noted on ultrasound while investigating another complaint) and are not causing any symptoms whatsoever, it is perfectly reasonable to leave them alone. Even if they have caused attacks of pain, some people decide not to have anything done about them. However, usually the pain is very unpleasant and sufferers do not wish to repeat the experience. If gallstones are truly asymptomatic, the chance of them causing significant problems is between 25 and 50% for every 10 years they are left.
Is surgery the only treatment for gallstones?
Some people find that their attacks of pain are very much related to the types of food they eat. If they carefully avoid fatty items in their diet, they can keep out of trouble. Although fatty food causing attacks of pain is a classical association, it is only a minority (about 35%) who have the association. The remainder look to other means of controlling the situation. “Alternative” treatments may be sought, such as lemon juice and olive oil, but there is no good logic behind such treatments. Gallstone pain can be very intermittent, sometimes occurring even years apart, and any apparent success of alternative treatments is likely to relate to this.
How are gallstones treated?
Some people manage to control their symptoms by being careful with their diet. Unfortunately the majority experience attacks without pattern or warning, although there is a tendency for the pain to come on in the late evening, after the main meal of the day. The only reliable way to deal with the problem is to remove the gallstones, and the gallbladder that produced them i.e., take away the factory as well as the product. In the days of open gallbladder surgery, when the gallbladder was removed through a large muscle-cutting incision, this was quite a major undertaking. Non-surgical treatments were looked at, particularly in elderly or frail patients.
Attempts to dissolve the stones with ursodeoxycholic acid we are at best only partially successful in a small percentage of patients. The medication is also expensive and tends to cause diarrhoea. Shattering stones with ultrasound is successful for kidney stones, but gallstones are softer and do not absorb the ultrasonic energy in the same way. Again, the treatment works in only a small percentage of people and it still leaves the problem of having to get rid of the dangerous small fragments from within the gallbladder. Of course, with this approach the gallbladder remains as well, with the ability to produce more gallstones. Lay treatments, such as trying to get the gallstones to “pass” using large amounts of lemon juice and olive oil, are also tried. Even if they did work and the stones passed out of the gallbladder, they then have to negotiate the outlet of the common bile duct (see “how do gallstones form and how do they cause trouble?”), with the associated risk of causing obstructive jaundice, cholangitis and pancreatitis.
Since the early 1990’s it has been possible to remove the gallbladder laparoscopically, which has dramatically reduced the impact of surgery for the condition.
What is laparoscopic cholecystectomy?
Cholecystectomy is the medical term for removal of the gallbladder. Since the early 1990’s, it has been possible to do this with minimally invasive laparoscopic techniques. These involve the use of a 5 or10mm diameter rigid telescope (the laparoscope), which is inserted into the abdominal cavity at the level of the umbilicus and connected to a video monitor. The abdominal cavity is inflated with gas (CO2) under low pressure, usually 10mm Hg, so that a cave-like space is created. A video camera attached to the laparoscope projects the image onto the monitor so that the surgeon and assistant(s) can see what they are doing with their specially adapted long narrow instruments, which are passed into the abdomen through other access points.
In this way, cholecystectomy is performed through 5-10mm incisions, avoiding the major muscle-cutting incision of open surgery. On the inside, the operation is carried out much the same as with open surgery: the gallbladder anatomy is defined, the gallbladder drainage duct (cystic duct) and artery are sealed with titanium clips and divided and the gallbladder, with its contained stones, is removed. The big difference with the impact of the operation on the patient is due to avoidance of the large muscle-cutting incision.
More recently, technology has been developed that allows laparoscopic cholecystectomy to be performed via a single 1.5 – 2.0 cm incision in the umbilicus (see Single Incision Surgery). The main advantage of this is cosmetic. The operation itself and recovery is similar to standard 4 incision laparoscopic cholecystectomy.
The pain, misery and prolonged recovery of open surgery are avoided with the laparoscopic approach and the patient experiences a rapid and relatively discomfort-free return to normal activities. A general anaesthetic is required, but usually only simple analgesics (pain killers) such as paracetamol and antiinflammatories are all that are needed postoperatively. Most patients go home the morning after the operation, but there is a trend to perform laparoscopic cholecystectomy as a day-stay procedure.
Is anyone able to have laparoscopic cholecystectomy?
Patients have to be fit enough to undergo general anaesthesia; it is not an operation which can be done under local anaesthetic. Other potential problems such as an underlying major bleeding disorder have to be identified and addressed, but are not contraindications to surgery. Previous abdominal surgery can create adhesions that make access to the gallbladder difficult, but they have not been an indication (in my experience) to convert to the open surgical approach, with its large muscle cutting incision. Similarly, acute inflammation can make the operation technically much more difficult, but, with patience, it should be possible to remove the gallbladder laparoscopically.
What are the surgical risks of laparoscopic cholecystectomy?
A general anaesthetic is required, with its attendant risks. These are very low, but are increased by certain medical conditions (heart and lung disease, smoking, diabetes, obesity, etc.).
Conversion to open surgery is not a complication, but should only very rarely be required. Some conversion rates are as high as 20%, but most surgeons performing this operation on a regular basis should be well below these levels. My own conversion rate is 0.16%. Consent for the possible need to convert should be obtained by the surgeon preoperatively.
It is possible to inadvertently damage the intestine while performing the procedure. This needs to be recognised early to avoid it becoming a serious issue. Damage to one of the main bile ducts draining the liver is the most feared complication, requiring early and expert intervention. When laparoscopic cholecystectomy was first being learned and performed by surgeons around the world in the early 1990’s, there was an increase in the rate of this particular complication. The rate has since decreased, as laparoscopic skills have accrued. I have not incurred this complication myself, but always take particular care when operating close to the common bile duct.
What is the effect of having the gallbladder removed?
The concentrated bile that is stored in the gallbladder is used in the digestion of fats in the diet. Cholecystectomy removes this reservoir of concentrated bile, but after the operation bile continues to flow down from the liver where it is made, and this is usually sufficient for normal dietary requirements. However, many people do experience some fat intolerance following cholecystectomy, and this is manifest as diarrhoea; if all the fats in a given meal are not absorbed, they cause diarrhoea. Fortunately this is usually a temporary phenomenon, as the gut rapidly adapts to the new situation.
A small percentage of patients (approximately 4%) have longstanding fat intolerance and know if they eat something rich/greasy/fatty they will be punished with diarrhoea, so they make their decisions accordingly. In this day and age of excessive fat consumption, a reduced fat intake is not a bad thing, but that is another story.
What sort of surgeon performs laparoscopic cholecystectomy?
All surgeons who have trained as General Surgeons have been taught how to remove the gallbladder. Many, myself included, learnt prior to advent of videolaparoscopic technology. Nowadays, trainees learn videolaparoscopic skills during their surgical training. However, there is no doubt that some find the technology more difficult to use than others, and the surgeon who is skilled at open surgery is not always the best at laparoscopic procedures. Laparoscopic procedures are performed by watching the surgical target on a video monitor, rather than the target itself. This requires particular hand-eye coordination skills. In addition, the image on the screen is in two dimensions, so adjustments need to be made to allow for the lack of depth of field.
Most surgeons become competent at performing laparoscopic procedures, but, as with all skill related activities, some are more laparoscopically adept than others. Surgical temperament is also important; the impatient surgeon is much more likely to “bail out” and convert to an open approach early on, when a little more perseverance may have allowed the procedure to be completed laparoscopically, with all the advantages of reduced pain and rapid recovery etc. These issues are reflected by the individual’s conversion rates to open surgery, taking note of complication rates at the same time. Patients should feel free to discuss these issues with their surgeon as part of the informed consent process.
Andrew Bowker’s Experience with laparoscopic cholecystectomy
- First laparoscopic cholecystectomy – 1992
- No. of cases (as of March 2017) – 2685
- No of single incision laparoscopic cholecystectomies (March 2017) 75
- No. conversions to open cholecystectomy – 4 (0.15%)
- Major bile duct injuries – 0