Alpha Patient Education Series #2 – Gallstones

Laparoscopic Keyhole Surgery: Removal of Gallbladder

1. What are gallstones?

Gallstones are stones found within the gallbladder, a small bag-like organ which is attached to the lower surface of the liver.  The stones are composed of different materials (chemicals) such as cholesterol or bile pigments.  They vary in size from about 1 millimeter to a few centimeters.  Symptoms are not related to size of stones.  Rather, it is their location within the bile drainage system which is crucial.  In fact, small stones have the risk of dropping into the bile duct, thereby causing blockage of flow of bile from the liver to the duodenum.  The result is jaundice, a yellow discolouration of the skin and whites of the eyes – a potentially serious complication.

Before the modern era of surgery, many famous figures have suffered or died from gallstones.  Anthony Eden, a British prime minister during the Suez Crisis of 1956, was one such tragic victim.  Surgery was delayed as it was deemed to be too dangerous.  When it was eventually done, he remained very ill and required heavy medication which caused exhaustion and possibly impaired judgment.  It is often speculated whether the outcome of history might have been drastically different if only he could have had timely removal of the offending gallstone.

2. What are the symptoms?

Gallstones are usually asymptomatic (clinically silent) – the patient feels perfectly well.  They are detected during routine ultrasound scans of the abdomen, such as in pregnancy or during health check-ups. Common symptoms are gallstone colic (upper abdominal pain), abdominal discomfort and bloating, especially after heavy or oily meals. The pain will usually subside after about 3 to 4 hours. Occasionally, it may be so severe as to require injection medication.  Complications of gallstones are acute cholecystitis (inflammation of the gallbladder) which causes continuous, unremitting severe pain; bile duct obstruction resulting in jaundice; and pancreatitis (inflammation of the pancreas).  The latter two conditions may be fatal if treatment is delayed.

It should be noted that gallstone colic is often mistakenly attributed to gastric ulcer.

3. How are gallstones diagnosed?

Diagnosis is made from a good clinical history obtained by a trained specialist (surgeon or gastroenterologist).  Confirmation is via radiological scanning, either with ultrasound or computed tomography (CT, “CAT”) of the abdomen

4. What treatment is available?

Asymptomatic gallstones can be left alone.  Treatment is recommended only if there are symptoms or complications.  The risk of these events happening is about 1 to 2 % per year.  However, once symptoms develop, the patient will invariably suffer further attacks and treatment is strongly advised.  The gold standard of treatment is laparoscopic cholecystectomy, which is removal of the gallbladder via key-hole surgery. The main advantage of this method is that it is minimally invasive: the scar is small; post-operative pain is minimal; and hospital stay is consequently reduced.  In about 5 to 10 % of cases, the operation has to be converted to the open technique involving a surgical incision of 8 to 10 cm.  The usual reasons are either inflammation which renders it difficult to identify key anatomical structures, or complications such as bleeding.

The symptoms of gallstones will be relieved permanently after surgery.

5. More about laparoscopic cholecystectomy.

The patient is admitted to hospital for one or two days.  The operation is performed under general anaesthesia.  It takes about one hour.  Four small holes (5 to 12 mm in diameter) are made in the abdomen.  The surgeon places laparoscopy instruments into the abdominal cavity through these holes (ports) to perform the operation.  Titanium clips are placed on two vital structures (cystic duct and cystic artery) which have to be cut during the operation.  These clips are specifically designed for this operation and will remain in the body; they do not produce any side effects. The entire gallbladder, including the stones it contains, is removed (“delivered”) through one of the ports. The procedure is recorded and the patient can have a hard copy such as on DVD.

6. What are the complications of laparoscopic surgery?

The main complication is bile duct injury, which happens in about 1 to 2 % of operations. Treatment depends on the extent of injury and whether the injury is recognized immediately during the surgery or delayed post-operatively. Options range from stenting the bile duct (by placing a temporary plastic tube) for minor injuries, to major surgical reconstruction of the bile duct for complicated injuries, a difficult and hazardous process.

Obviously, such complications are best avoided.  The risk is related to previous scarring in the abdomen and the operative experience of the surgeon.

7. What are the long-term effects of laparoscopic cholecystectomy?

Patients will lead normal lives after the operation.  No more dietary restrictions!  Long-term follow-up is not required.