Gallbladders and Gallstone Surgery

How the gallbladder works

The gallbladder is a small thin-walled sac which stores bile produced by the liver. Bile drains from the liver and passes through the common bile duct into the intestine (duodenum). The gallbladder sits to one side of the common bile duct, as a side branch. It takes a portion of bile as it passes by, concentrates it and stores it, for use when the gut needs help to digest a fatty meal.

What causes gallstones and why are they a problem?

Gallstones, also known as calculi, are small stony masses that form in the concentrated bile of the gallbladder. They remain there without incident, until such time as one becomes stuck at the cystic duct (the outlet of the gallbladder), causing severe pain as the gallbladders spasms to try to clear the blockage. Some people equate the pain to being “worse than labour pains”. Usually the pain subsides when the stone drops back into the gall bladder – but the problem is likely to recur.

Adjusting the diet can help some people manage their symptoms, but most attacks are sudden and random; there is, however, a higher likelihood that pain occurs after the main meal of the day, later in the evening.

Although gallstones are not usually “passed”, as people often believe, this can sometimes happen. In this case the stone can then cause pain when it lodges in the common bile duct’s outlet, at the point where it enters the intestine (duodenum). If the outlet is completely blocked, it causes obstructive jaundice as the bile cannot drain down from the liver. Other signs are dark urine, pale stools and altered blood tests for liver function.

The pancreas also drains into the common bile duct near its outlet to the duodenum. If a gallstone obstructs this drainage, pancreatitis (a potentially life-threatening condition) can result. Intesive medical support is sometimes needed for this condition. Often the gallstone moves of its own accord into the gut, relieving the obstruction, although liver function takes longer to stabilise.

If the gallstone remains in the gallbladder or common bile duct outlet

In cases where a gallstone stays wedged in the gall bladder outlet, pain remains and the gall bladder becomes inflamed (cholecystitis). At this stage, the problem can still right itself, but there is potential for the gallbladder to lose its blood supply, making the patient very ill. The elderly and diabetics are more susceptible to this. If cholecystitis develops, early surgery is the best management.

Blockage of the common bile duct outlet can sometimes be complicated by infection. This is called ascending cholangitis and is potentially lethal. Urgent treatment with antibiotics and endoscopic drainage (ERCP) is required.

ERCP (Endoscopic Retrograde Cholangio Pancreotography) involves feeding a flexible endoscope through the mouth down to the point at which the common bile duct enters the duodenum, just past the stomach. The offending gallstone can be identified and removed using this technology. The procedure is done under sedation rather than a full anaesthetic.

Is surgery essential?

Not always. Sometimes gallstones are only discovered when an investigation is being being carried out for another complaint. If there are no symptoms, leaving them untreated is a reasonable option. The likelihood of asymptomatic gallstones causing considerable problems is between 25% and 50% for every 10 years they go untreated. Even those who have experienced attacks of pain sometimes choose to go without surgical treatment – but most would prefer not to risk the chance of a further episode.

What are the other treatment options?

Often the types of food people eat relate to episodes of pain; avoiding fatty foods can keep them pain-free. However, this is unreliable and only around 35% of people find they can manage the problem through dietry manipulation. Others try different methods, such as the “alternative” treatment of encouraging gallstones to pass by drinking large quantities of lemon juice and olive oil, but the logic behind this is flawed. Successful passage of gallstones from the gallbladder creates risk of potentially fatal complications such as cholangitis, jaundice, and pancreatitis (see above). Bouts of gallstone pain can occur up to years apart and these gaps are the likely explaination for any "success" of alternative treatment.

The definitive answer is to remove both the problem and the cause, i.e. the gallstones and the gall bladder that produced the stones. In the era of open gallbladder surgery, a large cut in the muscle was required, with significant associated misery. Other options were considered, particularly for elderly or unfit patients. Dissolving the stones with ursodeoxycholic acid had limited success in a small number of patients, but the medication was expensive and often caused diarrhoea. Using ultrasound energy to shatter the stones, although effective in treating kidney stones, only works for a small percentage of gallstones. This is due to the softer composition of a gallstone. Shattering also leaves behind hazardous small fragments. Both the above options leave the gallbladder intact, with the potential to produce more stones.

Removing the gall bladder laparoscopically has been possible since the early 1990s, making surgery a much more attractive option.

What is laparoscopic cholecystectomy?

Removal of the gall bladder (cholecystectomy) is now accomplished using laparoscopic surgery, which avoids the major muscle cutting that is required with the open approach. A rigid telescope (the laparoscope), connected to a video monitor, is inserted into the abdominal cavity through a 10mm incision in the umbilicus. The cavity is expanded using low-pressure gas (CO2). On one end of the laparoscope is a video camera, which is in turn linked to a video screen. By watching the screen, the surgical team can then carry out the operation using instruments which are introduced through other operating ports. The gallbladder artery and drainage duct (the cystic duct) are divided between titanium clips. The gallbladder is separated from its liver attachments and removed via the umbilical operating port site.

Since no major muscle cutting is required, the patient can expect less pain and a shorter recovery period. The patient receives a general anaesthetic for the operation, and usually only simple painkillers such as paracetamol and anti-inflammatories are needed after the operation. Most patients stay overnight after the procedure.

Is Laparoscopic Cholecystectomy for everybody?

A general anaesthetic is needed, so the patient has to be reasonably healthy for this. Conditions such as an underlying major bleeding disorder can be problematic, but do not mean that surgery is out of the question. Laparoscopic surgery can be made more technically difficult by adhesions from previous abdominal surgery, or acute inflammation, but it should still be possible to complete the operation without resorting to the open surgical method.

The risks of laparoscopic cholecystectomy surgery

The risks involved in a general anaesthetic are very low, but are increased by medical conditions such as heart or lung disease, diabetes, smoking and obesity. Although not deemed a complication, conversion to open surgery should rarely be necessary. Some surgeons’ conversion rates are as high as 25%, but most surgeons experienced in this procedure have much lower levels. My conversion rate is 0.2%. The surgeon needs to gain consent for the possibility of conversion before the operation.

Accidental damage of the intestine during surgery is a possibility, as is dividing one of the main bile ducts that drains the liver. The latter is a bad complication which happened more frequently when laparoscopic cholecystectomy was new and surgeons were gaining experience in the technique. I am particularly vigilant when working close to the common bile duct, and have not encountered this complication.

How does the body function without the gallbladder?

The gallbladder stores concentrated bile in order to aid the digestion of fats in the diet. When this reservoir is removed through cholecystectomy, the liver continues to produce bile in quantities which are usually adequate for normal diets. After cholecystectomy, it is common for patients to experience a degree of fat intolerance through diarrhoea; if the fats in a meal are not properly absorbed, diarrhoea occurs. Typically this settles as the gut adapts to the loss of the gallbladder.

Approximately 4% of patients need to adjust to a long-term fat intolerance, where eating rich, fatty or greasy foods causes diarrhoea. In today’s world of excessive fat consumption, this may give incentive for improved eating habits.

Do all surgeons perform laparoscopic cholecystectomies?

All general surgeons have learned how to remove the gall bladder. Many, including myself, learnt before video-laparoscopic technology was developed. Today’s surgical trainees learn laparoscopic skills as a matter of course. Some take to the technique better than others, and a surgeon talented at open surgery may not be equally adept at laparoscopic procedures. During a laparoscopy, the surgeon watches the target area on a video monitor, which provides a 2-dimensional image. Working in this environment requires particular hand-eye coordination skills.

Most surgeons are capable of performing procedures laparoscopically, but some are more proficient at it than others. A surgeon’s temperament is also crucial; those who are more impatient are more likely to “bail out” and switch to open surgery, where persistence could have avoided conversion. It is possible to get an idea of an individual surgeon's laparoscopic skills by looking at his/ her conversion rates to open surgery. It is reasonable to discuss these matters with the surgeon as informed consent is an important issue when contemplating an operation.