Laparoscopic Surgery for Gallstones

What is gallbladder?
Gallbladder is a pear-shaped organ attached to the undersurface of the liver. Its main function is to collect and store bile (a digestive liquid) produced by the liver. After eating, the gallbladder contracts and releases the bile. The bile is carried via a small tube called the cystic duct and then larger tubes called bile ducts into the small intestine where it helps in the digestion.

Digestive system and the gallbladder
Digestive system and the gallbladder

What are gallstones and how are they formed?
Gallstones are solid clumps of cholesterol or pigment material that form in the gallbladder. When the concentration of bile components like cholesterol or bile pigments increases, they precipitate to form solid crystals. These crystals then stick together and form gallstones. Why some people form gallstones is not clearly known, and therefore there is nothing one can do or avoid in the diet to prevent the gallstones from forming.

What symptoms do patients with gallstones experience?
Patients with gallstones often get severe abdominal pain in the right upper side - particularly after eating fatty food. If a gallstone blocks the common bile duct, jaundice (yellowing of the skin) can develop. Patients with gallstones may also suffer complications such as infection and inflammation of the gallbladder (cholecystitis) or of the pancreas (pancreatitis). Some people who have gallstones have no symptoms and these people are said to have so-called "silent" gallstones.

How are gallstones diagnosed?
Gallstones are usually diagnosed by a relatively simple test called ultrasonography. In this test a jelly is applied to the skin and a probe is moved over the abdominal wall to capture images of the internal organs.

Ultrasonography showing gallstones
Ultrasonography showing gallstones

How are gallstones treated?
Not all patients who have gallstones require surgery. In most instances those who do not have any symptoms (silent gallstones) may not require treatment. However, a decision not to operate should be taken only after consulting a specialist because when left alone gallstones are likely to cause complications. Once a patient develops symptoms because of gallstones they do not go away on their own. Some patients can be temporarily managed with medicines or by making dietary adjustments, such as cutting down on fat intake. However, this treatment is not a permanent solution to the problem. Surgical removal of the gallbladder (cholecystectomy) is the best treatment for patients in whom the gallstones cause symptoms.

What are the side effects of removing the gallbladder?
It is important to understand that a gallbladder that forms gallstones is a diseased organ and is not functioning normally. Therefore removal of such a diseased gallbladder is not associated with any side effects. Over a period of time, the function of storage of bile is taken over by the bile ducts and there is no impairment of the digestive process.

How is laparoscopic cholecystectomy performed?
Today removal of gallbladder is routinely performed by laparoscopic cholecystectomy. Instead of a fifteen to twenty cm incision of an open operation, the laparoscopic cholecystectomy is carried out through four small punctures each of which is 1/2 to 1 cm in length. As the incisions are small, the pain after the operation is minimal and therefore the recovery is much faster. The chances of infection in the incisions are almost negligible.

Laparoscopic view of the gallbladder
Laparoscopic view of the gallbladder

What if the operation cannot be performed by the laparoscopic method?
In a small proportion of patients (1% - 3%) during the operation the surgeon may decide to convert the laparoscopic operation to a traditional open one. This is required if the organs cannot be visualized safely or handled effectively. Conversion to an open operation is never considered a complication. In fact, it reflects a sound judgment on the part of the surgeon who is interested in safeguarding the patientís safety.

What happens after laparoscopic cholecystectomy?
The patient does experience some amount of pain for about 12 to 24 hours after laparoscopic cholecystectomy depending on individual tolerance. Also, some nausea and vomiting is not uncommon in the first 12 hours. Patients are always given medications to relieve the pain and take care of the nausea. Usually, the patient is allowed to drink fluids within 6 to 8 hours of surgery and is able to have meals from the day after surgery. Activity is dependent on how the patient feels, but all patients are encouraged to get up and walk as soon as they are comfortable. Most patients go home within a 48 hours after laparoscopic cholecystectomy as compared to five to seven day following the traditional open operation. Some patients, particularly the elderly and those with other medical problems like diabetes may have to stay in the hospital a little longer. In general, patients recover completely within 7 to 10 days.

How soon can I resume work?
In our society patients often prefer to take things easy for weeks after any operation because of a fear that they may harm themselves by being active. After laparoscopic cholecystectomy the recovery is quite rapid. Soon after returning home the patients are allowed all activities they feel comfortable with. Depending on the nature of their job, most patients are able to return to work within ten to fifteen days following a laparoscopic cholecystectomy. Patients with light, desk jobs usually return in a few days while those involved in heavy lifting may require a little more time.

What are the risks of laparoscopic cholecystectomy?
While there are risks associated with any kind of operation, the vast majority of patients undergoing laparoscopic cholecystectomy experience no complications. It is important to remember that before undergoing any type of surgery - whether laparoscopic or traditional- it is important to make sure that the surgeon performing the operation is well trained and experienced. In the hands of such surgeons the risks of laparoscopic cholecystectomy are negligible.

What about the cost of laparoscopic cholecystectomy?
In the minds of people there are certain misconceptions about laparoscopic surgery. One of them being that this surgery is affordable only to the rich. However, today laparoscopic surgery is offered at hospitals ranging from small charitable ones to large private corporate hospitals. Depending on the hospital and the type of room the patient chooses for admission, the cost of operation does vary but this is comparable to the cost of open cholecystectomy.

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Dr Bhandarkar edits journal issue on Single Incision Laparoscopic Surgery
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