Saturday, February, 11, 2012

Gallstones and Gallbladder Disease - Surgery

Table of Contents

The Procedure. With laparoscopy, gallbladder removal is typically performed as follows:

  • Laparoscopic cholecystectomy requires general anesthesia, although it is now mostly done as outpatient surgery.
  • The surgeon inserts a needle through the navel and pumps carbon dioxide gas through it to create space in the abdomen. This step may raise blood pressure. Antihypertensive drugs may be helpful during surgery to protect patients who have high blood pressure or heart or kidney disease.
  • One or two 10 - 12 mm (about one-half inch) and three 5 mm (about one-fifth of an inch) incisions are made in the abdomen.
  • The surgeon inserts a laparoscope (a thin fiber optic scope), which contains a small surgical instrument and a tiny camera that relays an image to a video monitor.
  • The surgeon separates the gallbladder from the liver and other areas, and removes it through one of the incisions.
  • Evidence suggests that the use of cholangiography during the operation helps prevent injury in the bile ducts, a serious complication of cholecystectomy. With this procedure, dye is injected into the bile duct, and moving x-rays are used to view the duct.
  • Often patients will need to stay in the hospital overnight. However, some patients can go home the same day.

Robot-assisted surgery. Laparoscopic surgery may be performed using tiny keyhole incisions and 3 - 4 tiny robotic arms. A computerized program guides the arms during surgery. A systematic review comparing robot-assisted and human assisted removal of the gallbladder showed no difference in morbidity, conversion to open surgery, total operating time, or hospital stay. Robot-assisted surgery requires longer overall surgical time and is more costly.

Risk Factors for Conversion from Laparoscopy to an Open Procedure. In about 5 - 10% of laparoscopies, conversion to open cholecystectomy is required during the procedure. The rate of conversion to open surgery is higher in men than in women. This may be due to the higher rate of inflammation and fibrosis in men with symptomatic gallstones. Other reasons for conversion from laparoscopic to open surgery include:

  • Possible or known injury to major blood vessels
  • Internal structures are not clearly visible
  • Unexpected problems that cannot be corrected with laparoscopy
  • Common bile duct stones that cannot be removed with laparoscopy or subsequent ERCP
  • Previous endoscopic sphincterotomy
  • A thickened gallbladder wall

Complications and Side Effects of Surgery

  • Pain and fatigue are common side effects of any abdominal surgery. Patients should avoid light recreational activities for about 2 days and from work and more strenuous activities for about a week.
  • There is a relatively high incidence of nausea and vomiting after laparoscopic cholecystectomy, which can be treated with injections of metoclopramide. Patients may take anti-nausea medications such as granisteron before surgery to help prevent these effects. Local anesthesia at the incision sites (in addition to general anesthesia) before surgery may reduce pain and nausea afterwards.
  • Injury to the bile duct is the most serious complication of laparoscopy. It can include leakage, tears, and the development of narrowing (strictures) that can lead to liver damage. In order to minimize such injuries, some experts recommend that surgeons perform laparoscopy with cholangiography. Bile duct injury has been a more common problem in laparoscopy compared to the open procedure, but increasing surgical experience and the use of cholangiography is reducing this complication. Studies are reporting more comparable rates between the two procedures.
  • In about 6% of procedures, the surgeon misses some gallstones, or they spill and remain in the abdominal cavity. In a small percentage of these cases, the stones cause obstruction, abscesses, or fistulas (small channels) that require open surgery.
  • As with all surgeries, there is a risk for infection, but it is very low.

Patients should not be shy about inquiring into the number of laparoscopies the surgeon has performed (the minimum should be 40). Obese patients were originally thought to be poor candidates for laparoscopic cholecystectomy, but recent research indicates that this surgery is safe for them.

Open Cholecystectomy

Before the development of laparoscopy, the standard surgical treatment for gallstones was open cholecystectomy (surgical removal of the gallbladder through an abdominal incision), which requires a wide 6 - 8 inch incision and leaves a large surgical scar. In this procedure, the patient usually stays in the hospital for 5 - 7 days and may not return to work for a month. Complications include bleeding, infections, and injury to the common bile duct. The risks of this procedure increase with other factors, such as the age of the patient, or the need to explore the common bile duct for stones at the same time.

Review Date: 06/10/2010
Reviewed By: Reviewed by: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org)