Laparoscopic Cholecystectomy (Gallbladder Surgery)

LAPAROSCOPIC CHOLECYSTECTOMY FOR GALLSTONES

ANATOMY:
It is important to know the anatomy of gallbladder and the biliary system in order to understand the disease process of gallstones and their treatment.

The above picture illustrates the anatomy of the region. Bile is formed in the liver and comes out thru the right and left hepatic ducts which join together to form the common hepatic duct.The gallbladder is a balloon like structure beneath the liver in which bile is stored .The gallbladder joins the common hepatic duct to form the common bile duct( CBD ). The CBD opens into the small intestine and bile enters the small intestine mixing with the food and helps in the digestion and absorption of the fat component of the food.
The bile duct is joined by the pancreatic duct where it opens into the small intestine.This duct transports the pancreatic enzymes responsible for digestion of the protein component of the food.

Gallstones are formed in the gallbladder due to various reasons. eg

• Increased amount of cholesterol in the bile which can precipitate to form stones.
• During pregnancy in women : Hormonal changes result in the gallbladder not contracting normally which results in stagnation of bile resulting in sludge / stone formation.
• Infection in bile which forms a nidus around which stones form

Complications due to gallstones

Once gallstones form inside the gallbladder , the gallbladder does not function at its optimum level due to inflammation of its inner layer.
A stone may get stuck in the neck of the gallbladder (junction of the gallbladder and cystic duct).This causes raised pressure in the gallbladder when it tries to push the bile .This results in pain in upper central abdomen with bloatedness and sometimes radiation of pain to right upper back.This is known as biliary colic.If the stone falls back into the gallbladder the bile is pushed out and the episode subsides.Patient may suffer recurrent episodes of such biliary colic and some patients may actually notice that these episodes occur more when they eat fatty food.
If the stone remains stuck for a longer time in the neck of the gallbladder then it may cause inflammation of the whole gall bladder — a condition known as Acute Cholecystitis.In some cases the infected bile inside the gallbladder can result in formation of pus inside the gallbladder (Empyema Gallbladder).Rarely the wall of the gallbladder can turn gangrenous and perforate resulting in spillage of infected material inside the abdominal cavity.
If a stone slips into the common bile duct from the gallbladder and blocks it ; the bile is unable to move forward and due to back pressure in the liver , it enters the blood causing jaundice.In addition the bile which is stagnant in the CBD can get infected resulting in generalised septicaemia known as Cholangitis which can be life threatening.
If the stone slips further down , it can block the entry point of the CBD and the Pancreatic duct.The pancreatic enzymes are unable to come out into the small intestine and go back into the pancreas causing its inflammation (a condition known as Pancreatitis).Most cases (80%) are mild but 20% of cases are severe resulting in severe morbidity and 5 % of cases are life threatening.
The above illustrates the complications that can result form gallstones.
Treatment :

The definitive management of gallstone disease is surgery — removal of the gallbladder.This is done Laparoscopically ( i.e. by keyhole technique) and is known as Laparoscopic Cholecystectomy.(please refer to the section on Laparoscopy ).
In a small percentage of cases , the surgeon may decide to convert from a laparoscopic to the traditional open surgery if there is risk of injury to important structures like CBD , small bowel.

FAQ:

1. What will be the result of removal of gallbladder on me ?

Once the gallbladder is removed , certain adjustments will need to be made in the early post-operative period.You will be advised to have smaller meals more frequently for the initial 4-8 weeks.However after this normal eating habits can be restored.Sensible, healthy eating habits like avoiding very oily or very spicy foods are recommended.

2. Can the gallstones be removed by medicines ?
The dissolution of gallstones by medicines has been tried.It was found the medication (cholic acid , chenodeoxycholic acid ) helped dissolve very small stones (< 3 mm in diameter) and small in number (usually < 3 ).However the medication had to be taken for long periods ( upto 2 years) for it to be effective.The medication had lots of side effects like abdominal pain and vomiting.In addition , after stopping medicines the stones would reform.Medication as treatment has therefore not been found effective.
3. Why should I get my gallbladder removed if the gallstones are not causing any symptoms ?

Although the gallstones may not be causing any problems when first detected , they can in the future cause complications enumerated above.In addition , there is an association of gallstones over time with gallbladder cancer which can be a fatal disease.The increasing advances in technology and the establishment of standard operative techniques for this surgery has resulted in very low complication rate.Thus getting surgical removal of gallbladder is a better alternative to leaving the gallstones.