Laparoscopic gallbladder removal, or cholecystectomy, is the mainstay of surgical treatment of gallbladder disease. This minimally invasive approach is safer than open abdominal surgery. Still, even less invasive options—including those without any incisions at all—are being studied and used in some teaching medical centers.
“About 90 percent of gallbladder removals are performed laparoscopically in the United States,” says Lawrence R. Schiller, M.D., the director of gastroenterology at Baylor University Medical Center in Dallas. “Even so, the demand for less invasive treatment options for patients who are too ill or whose health is too poor overall to undergo even minimally invasive surgery safely has driven innovation.”
The gallbladder stores bile, a substance produced by the liver to aid in fat digestion. Bile is secreted into the duodenum (the portion of the small intestine joined to the stomach) during digestion. Gallstone formation, or cholelithiasis, is a common gallbladder disorder.
Sometimes, gallstones block the duct leading from the gallbladder to the main bile duct. This causes potentially dangerous inflammation of the gallbladder, or cholecystitis, that can result in severe infection or sepsis. Some patients with cholelithiasis never develop acute cholecystitis but may have other complications, such as jaundice or pancreatitis. Others develop chronic indigestion (abdominal pain or distress and nausea) that’s attributed to chronic cholecystitis. Most symptomatic gallbladder disorders require organ removal.
Removal and drainage
Researchers from the University of North Carolina School of Medicine reviewed the following surgical interventions for acute gallbladder disease in The New England Journal of Medicine last July. The approaches involve either removing the gallbladder or draining its contents.
Choice of technique depends on the disease’s severity, your overall health and the expertise of the surgeon and the hospital where the procedure will be performed.
• Laparoscopic cholecystectomy is the standard surgical treatment for symptomatic gallstones or gallbladder inflammation. Surgeons remove the gallbladder through one of up to four small abdominal incisions. The incisions result in less pain, little or no visible scar, a shorter hospital stay, and a quicker recovery compared with traditional open cholecystectomy, making laparoscopic cholecystectomy the preferred approach. Severe inflammation may make laparoscopic removal difficult and force the surgeon to do an open cholecystectomy. Potential complications with either technique include bile-duct or bowel injury.
• Natural orifice transluminal endoscopic surgery (NOTES) is performed by inserting an endoscope—a thin, lighted viewing tube—through a natural opening in the body, such as the vagina or the mouth. The gallbladder is removed through an internal incision that allows access to the abdominal cavity. NOTES is associated with less pain, shorter recovery, reduced complication risk, and little visible scarring when compared with other procedures. However, it’s technically difficult, takes more time and has been performed much less often. NOTES requires highly specialized equipment and expertise and is available at only a few medical centers.
• Percutaneous cholecystostomy is a drainage procedure used to stabilize critically ill patients unable to undergo gallbladder removal. Bile is drained from the gallbladder via a catheter inserted through a skin puncture. In most cases, the tube must remain in place for up to six weeks before surgery is done to remove the gallbladder. The approach is widely available, easily performed and highly effective. In some cases, surgeons may be able to remove gallstones at the same time, and subsequent surgery may not be needed. Potential complications include infections and catheter dislodgement.
• Transpapillary drainage and transmural drainage are alternative methods to drain the gallbladder. The transpapillary approach is effective and potentially has fewer complications, but the procedure is very difficult to perform. The transmural approach is effective for fragile patients. Neither procedure is widely available.
Making a treatment decision
Once acute cholecystitis is recognized, the gallbladder should be removed promptly when possible. Surgery has better outcomes when it’s performed within several days of symptom onset.
“Ultimately, whether removal or drainage is right for you will depend on the severity of your illness and your overall health,” Schiller says. “If your surgeon is considering a newer or more advanced procedure, ask how frequently he or she performs the procedure as well as what you should expect during recovery and what complications to watch for.”
For patients with acute cholecystitis unable to undergo surgery safely, antibiotics and bowel rest—which involves administering liquids and nutrients intravenously—may be prescribed while the patient is readied for a drainage procedure. Drainage lets the antibiotics work more effectively.
For patients with symptomatic cholelithiasis (but not blockage of the duct leading out of the gallbladder), cholecystectomy or other nonsurgical therapies to dissolve gallstones may be tried, including bile acid pills or injection of a solvent directly into the gallbladder via a catheter. Soundwave therapy to shatter gallstones (lithotripsy) also may be tried.
If those therapies fail to improve symptoms, cholecystectomy is likely the next step.