Gall Stone Surgery
Professor David Lloyd has performed over 4000 laparoscopic cholecystectomies in addition to many laparoscopic explorations of the common bile duct. Most patients have their surgery done as a day case and return to normal activities within 7 – 10 days. The operation is performed using up to 4 small incisions (ports) but in selected patients the gall bladder can be removed through a single small incision near the navel (called a single port or ‘scarless’ surgery, although it is not truly scar-free (View Video).
It is recommended that anyone with symptoms relating to their gall bladder should consult a specialist about their symptoms and discuss whether they should undergo a cholecystectomy. The procedure has become routine in specialist hands but problems still occur so it is important to understand the procedure and ask your specialist about complications.
The Gall Bladder & Gall Stones
Gall Stones is a small muscular sac attached to the bile duct underneath the liver. It does not have a major function in the body and you can live a perfectly good and healthy life without it. Its function is to store and concentrate a small amount of bile - perhaps only an egg cup full - and release it into the intestines in response to eating a lot a fatty food. More than half a litre of bile is made in the liver every day and most of it flows down the bile duct straight to the duodenum (stomach) bypassing the Gall Bladder. Only a very small amount of bile trickles into the Gall Bladder which stores and concentrates it.
Gall Stones are hard crystals of bile (sediment) which form in the Gall Bladder. They form when bile hardens in the Gall Bladder. Almost all stones contain cholesterol and are usually yellowy in colour. Bilirubin or pigment stones are dark and almost black in colour. Some stones are a mixture of the two.
They can vary in size and consistency and can resemble grains of sand, dried peas or even avocado stones. They can be hard or soft depending on the varying amounts of cholesterol, bile pigment, calcium, phosphate and other minerals found in bile fluid. Gall Stones are very common and form in the bile usually stored in the gall bladder. About 20% of women and 10% of men will develop Gall Stones. The balance between cholesterol in the bile and bile salts is a delicate one and factors which increase cholesterol in bile increase the risk of gallstone formation. These factors include being female, the oral contraceptive pill, hormone replacement therapy, cholesterol lowering drugs, rapid weight loss and fasting, and diabetes. Obesity, probably the most common predisposing factor, tends to lower bile salts which allow cholesterol stones to form.
Low fibre diets, high cholesterol diets and starchy diets tend to increase the formation of Gall Stones. Pure pigment stones may result from excessive breakdown of red blood cells (haemolytic anaemia, hereditary spherocytosis etc.) and liver cirrhosis. Why some people develop Gall Stones and others do not is unclear, but they are extremely common and occur in men and some children as well as women.
Problems Caused by Gall StonesBiliary Colic and Acute Cholecystitis
Severe pain under the right rib margin can be one of the worst pains experienced by us and women say it can even be worse than labour pains. In addition to this severe colicky pain called biliary colic, nausea and bloating, Gall Stones can cause severe inflammation of the gall bladder (acute cholecystitis) which presents with continuing pain and fever. Patients can feel very unwell, tired and bloated with some vomiting. Acute cholecystitis must be treated with antibiotics and most cases resolve within five days. Severe inflammation requires intravenous antibiotics, fluids and hospital admission. Morphine-type drugs may have to be given.
Some patients have a low-grade inflammation of the gall bladder and present with a continuing dull ache under the right rib cage. In these patients, the gall bladder is probably scarred and shrunken and the condition is called chronic cholecystitis. Antibiotics are not effective and cholecystectomy is advised.
Jaundice and Acute Pancreatitis
Occasionally a stone moves out of the gall bladder into the main bile duct blocking the flow of bile from the liver. These patients can become jaundiced or develop inflammation of the pancreas (acute pancreatitis). In many patients the stone passes through the bile duct and into the duodenum to be excreted in the motions and the jaundice settles spontaneously. If the jaundice persists, the stone must be removed surgically. This can be done using a special endoscope passed through the stomach and into the duodenum (the procedure is known as an ERCP). If the stone aggrevates the pancreas and acute pancreatitis develops patients can become acutely unwell and should be treated in hospital. Stones in the bile duct are very serious and attempts to remove them should always be considered even if open surgery is required.
Cancer of the Gall Bladder
Very rarely, if the stones have been present for many years (perhaps more than 30 years) within the gall bladder, there is a risk of developing cancer of the gall bladder itself. Although most surgeons would not advise cholecytectomy because of this small risk it should be mentioned to the patient.
What are the Symptons of Gall Stones?More than 80% of people do not know they have gallstones and never have symptoms. Those who experience symptoms may have occasional but severe abdominal pain (known as biliary colic) or simply have a vague feeling of nausea or bloatedness. Other patients have vague nausea and/or dyspepsia or indigestion.
The commonest presentation is that of pain under the ribs on the right side or even upper abdominal pain, with some pain experienced in the back - near the right shoulder blade. This commonly, but not always, occurs after eating fatty food, and usually lasts several hours. Some people feel or are sick, and others complain of indigestion.
The pains can be so severe that occasionally hospital admission is required. Some patients can suffer pain only in the back and rarely patients experience pain on the left side.
How are Gall Stones Diagnosed?Many patients have classical symptoms of right-sided upper abdominal pain coming on an hour or so after eating fatty food thus raising the suspicion that Gall Stones may be present.
For confirmation an ultrasound scan is done which usually identifies the majority of stones. Tiny gravel-sized stones are sometimes hard to define particularly in obese patients and patients with scarred small gall bladders are often difficult to examine.
If an ultrasound examination does not confirm stones then it is unlikely they are present and another cause the symptoms must be sought. Other tests are available to diagnose Gall Stones but most have been superseded by ultrasound.
A CT scan is useful only for large stones and stones which contain a lot of calcium can be seen on a plain X-ray of the abdomen. MRI scans are becoming more sensitive for Gall Stones but the main indication for requesting an MRI scan is to look for stones within the biliary tree (bile ducts). This specific MRI scan is called an MRCP. Rarely patients have an endoscopic examination (ERCP) to diagnose stones within the biliary tree.
Treatment for Gall Stones - CholecystectomyGall Stones are removed along with the gall bladder in an operation known as a cholecystectomy. Most gall bladders should be removed using keyhole surgery techniques as this is now considered to be the gold standard of treatment. This procedure is known as a laparoscopic cholecystectomy. The operation is done under a full general anaesthetic and usually takes 30 - 60 minutes. A small telescope (or laparoscope) is passed through a 1 cm incision just below the umbilicus and carbon dioxide put in to insufflate the abdomen and create a large space to visualise the gall bladder.
Three other tiny incisions are made beneath the right rib cage to allow the passage of the specialised laparoscopic instruments. The operation is monitored on a large television screen and the gall bladder (with the stones inside) is detached from the bile duct and the liver bed and removed through the umbilicus.
The tiny wounds are closed with dissolvable stitches beneath the skin so they do not show and do not need to be removed. In the UK most centres promote day-case surgery with the patients being discharged home the same day. 10% of patients stay overnight in hospital because of other medical conditions or the inability to get transport home. Complications are rare but do occur (View More) so it is important to have a very good relationship with your surgeon.
Removal of the Gall BladderGall Stones are removed along with the gall bladder in an operation known as a cholecystectomy. Most gall bladders should be removed using keyhole surgery techniques as this is now considered to be the gold standard of treatment.
This procedure is known as a laparoscopic cholecystectomy. This is done under a full general anaesthetic and usually takes 30 - 60 minutes. A small telescope (or laparoscope) is passed through a 1 cm incision just below the umbilicus and carbon dioxide put in to insufflate the abdomen and create a large space to visualise the gall bladder.
Three other tiny incisions are made beneath the right rib cage to allow the passage of the specialised laparoscopic instruments. The operation is monitored on a large television screen. The gall bladder (with the stones inside) is detached from the bile duct and the liver bed and removed through the umbilicus.
The tiny wounds are closed with dissolvable stitches beneath the skin so they do not show and do not need to be removed. In the UK most patients stay in overnight and are discharged from hospital the following morning. Increasingly, patients are done as day cases particularly in centres specialising in day-case keyhole surgery.
Complications of Gall Stone SurgeryAll surgical procedures are associated with complications. A laparoscopic cholecystectomy requires a general anaesthetic which can be complicated by deep vein thrombosis, aspiration pneumonia and post-operative tiredness and sleep disturbances. Thankfully, these are extremely rare. All patients are usually given an injection of heparin or tinzeparin to thin the blood and have pneumatic compression stockings during the operation to help the blood circulate in the legs. These measures help to reduce the incidence of deep vein thrombosis. Prolonged immobility or re-operation increases the risk of deep vein thrombosis and pulmonary embolism and early mobilisation is therefore recommended.
Complications of a laparoscopic cholecystectomy include bile leakage, fluid collections in the abdomen, bleeding and bile duct injury. Bile leakage can occur because of leakage from the cystic duct or an accessory duct draining from the liver bed straight into the gall bladder. This may occur in up to 1 - 3% of cases and is not specific to keyhole surgery alone. Moreover, they occur because removing the gall bladder can leave a raw surface of liver which contains tiny bile ducts. They are usually not serious but may require another procedure (an ERCP) or a second laparoscopy to wash the bile from the abdomen. Rarely an open operation is performed.
Infection of one of the port sites may occur - particularly if the gall bladder is infected or contains pus. Probably 1% of patients will develop an umbilical infection which may require hospital re-admission and treatment with antibiotics. Rarely, the pus has to be released from an infected area by further surgery.
Bile duct injury is the most devastating of all complications and has been reported in up to 1.5% of cases in published series from around the world. The bile duct itself is cut across, usually as a result of a failure to identify the anatomy exactly. Transection of the bile duct can occur in the most experienced of hands. Immediate reconstruction using a loop of small intestine is recommended and this should be done by a specialist liver surgeon (hepatobiliary surgeon). Long term follow-up is advised. This complication should be discussed with your surgeon prior to surgery.
Conversion to open surgery is employed when the operation cannot be finished using keyhole surgery, usually because the exact anatomy cannot be identified as a result of difficult inflammation and scar tissue around the gall bladder. 'Conversion' to open surgery using an incision beneath the rib-cage is not regarded as a failure, it simply reflects the fact that some gall bladders are extremely difficult to remove. Most surgeons will have a conversion rate between 1% and 5%.
Diarrhoea can occur in up to 1% of patients and usually settles within a few months or at least a year. Very few patients require treatment with oral bile salts which may have to be taken for many months.
Pain following a laparoscopic cholecystectomy is usually confined to a few days. Many patients experience shoulder pain due to the carbon dioxide used which irritates the diaphragm and causes referred pain to the shoulder. The incidence of this pain has dramatically been reduced by spraying the diaphragm with local anaesthetic at the end of the procedure. Abdominal pain is variable and may require in-patient treatment for 1 - 3 days. Most patients are up and around doing domestic activity within 5 days. It is recommended, however, that patients take at least two weeks off work to allow full recovery, and those with strenuous jobs may benefit from having 4 weeks rest.
Bleeding from the site of surgery is very rare but of course may happen. Mild bleeding may simply require observation for 24 - 48 hours but more severe bleeding may require a further laparoscopy to secure the site of bleeding.