Gallstones
What is the Gallbladder?
The gallbladder is an organ in the right upper corner of the abdomen. Its function is to store bile, which is produced in the liver. As well as a means to excrete toxins, bile is also passed into the intestine to mix with food and help with fat digestion.
Why do Gallstones form?
Stones that form in bile within the gallbladder are called gallstones. They result from excessive concentration of cholesterol or bile pigment within the bile.
Stones are more likely to form within a gallbladder that does not empty normally, causing bile to stagnate.
Can Gallstones Cause Harm?
Gallstones are clinically 'silent' in 80% of cases.
Of the other cases, gallstones within the gallbladder may cause pain alone. This condition is called 'biliary colic' and typically results in upper/right -sided abdominal pain that occurs soon after eating typically fatty foods.
Other complications of gallstones may occur as a result of obstruction and/or infection, which may lead to to sepsis.
When to Seek Urgent Medical Attention:
If you develop pain that is particularly severe, persistent or associated with jaundice (yellow eyes/skin) or fevers/shivers.
How are Gallstones Treated?
Unlike for kidney stones, external shockwave lithotripsy is not a safe or effective treatment for gallstones. Similarly, medications have not been found to be effective for dissolving gallstones.
Simple analgesics such as paracetamol and NSAIDs may be effective in controlling pain from biliary colic. Avoiding fatty foods may also reduce the frequency of symptoms.
Ultimately, the cornerstone of treatment for gallstones is keyhole surgery to remove the gallbladder, i.e. laparoscopic cholecystectomy.
How is the Surgery Performed?
This is a surgical procedure performed under general anaesthesia to remove the gallbladder. An incision is made next to the umbilicus to insert a fibre-optic camera called a laparoscope into the abdominal cavity.
The surgeon observes the laparoscope output on a monitor and insufflates carbon dioxide into the abdomen to create a working space.
Three additional incisions are made in the upper abdomen. and long, thin laparoscopic instruments are inserted through incisions 5-10mm long to perform the procedure.
Laparoscopic Cholecystectomy
The procedure typically takes 45 - 90 minutes. Occasionally the procedure may take 2-3 hours if there is significant scar tissue to divide which may be from previous abdominal surgery or a history of infection of the gallbladder. The chances of converting to open surgery is <2%.
The risks of laparoscopic cholecystectomy include wound infection, bleeding requiring blood transfusion, intra-abdominal collection, bile leak or bile duct injury (0.03%). Bile duct injury is a rare but serious complication and multiple manouvres are undertaken during the procedure to prevent this from occurring. This includes obtaining the Critical View of Safety.
Intraoperative Cholangiogram
Contrast material is injected into the bile duct system and an X-Ray machine is brought into theatre to take X-Ray images.
This is to confirm safe anatomy to complete the procedure safely as well as evaluate for stones that may have escaped the gallbladder
Transcystic Common Bile Duct Exploration
If the cholangiogram demonstrates a stone in the bile duct they can often be flushed simply by injecting saline under pressure while giving medication to relax the muscle at the bottom of the bile duct.
Stones that do not flush may be amenable to removal during laparoscopic cholecystectomy. This is a common bile duct exploration and requires specialist equipment to be brought in and connected and can be time-consuming.
ERCP
In a small proportion of cases, it is not possible to flush or retrieve a bile duct stone laparoscopically. In such cases the operation will be completed by removing the gallbladder but a second procedure will have to be scheduled.
The procedure is called ERCP (endoscopic retrograde cholangiopancreatography) which is an incisionless procedure performed through an endoscope inserted through the mouth into the small intestine where the bile duct opens into. The opening at the bottom of the bile duct is incised open and the stone is retrieved.
*Northern Surgical Care does not offer ERCP and a referral to a trusted colleague would be required if ERCP is indicated
How long is the recovery?
In Hospital
Laparoscopic Cholecystectomy typically requires an overnight stay in hospital prior to discharge to make sure post-operative pain is manageable with simple analgesics at home. Pain is typically around the umbilical wound, where the galbladder is extracted from, and the right shoulder tip.
At Home
Waterproof dressings are recommended to keep the wound dry for five days post-operatively. It is recommended that paracetamol is taken four times a day to control pain initially. As the days go by, this can be reduced to as-and-when required.
What Can I Eat?
You can go back to a full diet straight away. Fat is still digested by bile that is released from the liver.
Can I Exercise After Surgery?
It is recommended that you avoid heavy (>10kg) lifting for the first 4-6 weeks after surgery. This is to reduce the likelihood of a port-site hernia.
When Can I Go Back to Work and Drive?
Depending on your job you will likely need 1-2 weeks off work. You can go back to driving provided you are moving freely enough to do an emergency brake safely.
How will I be Followed-up?
A routine follow-up appointment will be made two weeks following surgery to make sure your recovery is on track.
When to seek help?
Wound Infection - If your wounds become red, warm, painful or discharge, you may have a wound infection and require a course of antibiotics
Jaundice - Yellow skin or eyes is a cause for concern following surgery and warrants urgent medical attention
Abdominal pain / Fevers - The discomfort from surgery should improve as the days go by. If you develop a new or worsening pain especially if accompanied with fever, you should seek urgent medical attention.