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Cholecystectomy
For gall bladder removal

Cholecystectomy is the operation for removal of the gall bladder. Traditionally the surgery is carried out through an incision in the right side of the upper abdomen. More recently the surgery has been carried out through a laparoscope employing 3 or 4 small incisions.

Anatomy and Physiology

The gall bladder is a small pear shaped organ located beneath the liver in the right side of the upper abdomen.

The cystic duct carries bile from the gallbladder and joins the common hepatic duct to form the common bile duct. The common bile duct then empties into the beginning of the small intestine. The main purpose of the gallbladder is to concentrate and store bile. It releases bile by ejecting it through the common bile duct into the small intestine when fatty foods are eaten. The bile aids in the digestion of fatty foods. However, one can live without the gallbladder without suffering symptoms.

Gallbladder and liver as seen through the laparoscope. Courtesy S. Dorfman, M.D.

Pathology

Stones may form in the gall bladder, which block the flow of bile resulting in pain in the right upper abdomen. Gallstones can lodge in the terminal part of the common bile duct that opens into the small intestine. Here the stones can also block the flow of pancreatic juice from the pancreatic duct that joins the common bile duct. This may result in a severe inflammation of the pancreas called pancreatitis. The exact cause of gall bladder disease is unknown. Some studies suggest that gallstones may be related to how the body handles cholesterol and bile acids that are synthesized in the liver and stored in the gall bladder. While some people may have no symptoms even in the presence of gallstones, others may have gallbladder problems even in the absence of stones.

Making the Diagnosis

Those individuals most likely to have gallbladder attacks are:

  • Women, especially in their 40s
  • Women who have been pregnant . The risk of gallstones may increases with each pregnancy
  • Overweight men and women
  • People who eat large quantities of dairy products, animal fats and fried foods
  • Family history of gallbladder disease

Gallbladder disease with stones may be associated with bloating, nausea or vomiting and in severe cases fever and other signs of infection. There may be intolerance to fatty foods. The symptoms of gallstones may occur after eating fried or oily foods, or a heavy meal. The symptoms may recur frequently and may be disabiling.

The diagnosis of gallstones is helped by the use of special tests:

  • Blood tests may be taken to detect jaundice or elevation of enzymes that occur as a result of blockage to the flow of bile
  • Ultrasound of the abdomen. This test employs sound waves to scan the abdomen for gallstones. The echoes from the sound waves are recorded and imaged on a screen. The presence, size and position of the gallstones can be determined as well as gallbladder wall thickness and the size of the common bile duct
  • HIDA scan. This scan employs a radioactive isotope to evaluate the function of the gallbladder

The Procedure

  • Removal of the gallbladder is classically carried out through an incision in the right upper abdomen
  • The gallbladder is directly exposed and dissected off the liver and surrounding structures and removed
  • If indicated, a dye study of the common bile duct can be performed to determine the presence of stones in the common bile duct. When present, open exploration of the common bile duct can be performed
  • This operation is now employed in cases where it may be dangerous or difficult to perform a laparoscopic cholecystectomy such as technical difficulties due to dense abdominal adhesions from previous surgery, highly inflamed and adherent gallbladder or when the anatomy of the gallbladder is not clearly visible through a laparoscope
  • The recovery period and hospital stay is usually 4-5 days

In some cases, it may not be possible to remove the gallbladder through a laparoscope. In these cases, this operation is usually transformed into an open cholecystectomy. In some cases, gallstones that are lodged in the common bile duct causing obstruction may be removed by exploration of the common bile duct at open surgery.

Laparoscopic Cholecystectomy

  • Today, the standard of care is usually a laparoscopic cholecystectomy
  • The laparoscope is a long tube with lenses at one end that are connected by fiber optics to a small television camera at the other. The fiber optics also carries light into the abdomen from a special light source. This system allows the surgeon to see and operate within the abdomen
  • The procedure is usually performed under general anesthesia
  • Antibiotics are given intravenously prior to the surgery to reduce the rate of infection
  • After anesthesia is begun, the skin is prepared with antiseptic solution and 3-4 small incisions (called port sites) are made on the abdominal wall
  • A special needle (Veress needle) is inserted into the abdomen to inflate the abdomen with carbon dioxide gas. This distends the abdomen and creates space to insert the instruments
  • The laparoscope and laparoscopic instruments with long handles are inserted through the incisions into the abdomen. The entire operation is then performed while viewing the organs magnified on a television screen
Gallbladder held by grasping forceps after being dissected off of liverSeparating cystic duct from surrounding tissues
  • The gallbladder is dissected off the surrounding structures. The cystic duct that attaches the gallbladder to the common bile duct is dissected and divided between metal clips
  • In some cases, a tiny catheter may be inserted into the cystic duct to inject dye and take X-rays to visualize any stones that may be blocking the common bile duct. If common bile duct stones are present, they may be removed with laparoscopic common bile duct exploration, by opening up the abdomen and exploring the duct or by ERCP (see below)
  • After the cystic duct is divided, the gallbladder is further dissected off the liver bed and a tiny artery that supplies blood to the gallbladder called the cystic artery is divided between metal clips. The gallbladder is then further dissected off the liver avoiding spillage of bile into the abdominal cavity
Clips placed on cystic ductCystic duct cut after gallbladder is removed
  • In some cases, the gallbladder is shrunk by suctioning out bile. The gallbladder is then removed through one of the ports in the abdominal wall and the tiny incisions in the abdominal wall are closed after removing any gas left in the abdominal cavity. When there is spillage of bile, the local abdominal cavity is thoroughly cleansed with saline solution and a small drain may be left in place. This may be removed the same evening or the next day, when drainage ceases

ERCP

  • ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is a procedure usually performed by an endoscopist. This procedure is useful when a stone obstructs the common bile duct
  • The common bile duct is approached using a special endoscope inserted through the stomach and small intestine to the entrance of the common bile duct
  • An X-ray study of the common bile duct is performed using a dye. A papillotomy (cutting the muscle of the lowest portion of the common bile duct) is performed to enlarge the duct opening and facilitate stone removal
  • A small catheter and instruments may be passed into the duct to remove the stones
  • A small catheter will occasionally be left in the duct for temporary drainage

Complications

The incidence of complications after cholecystectomy is relatively low.

  • Complications of a general anesthetic,
  • Postoperative bleeding
  • Injury to the bile ducts or right hepatic artery
  • Biliary leak
  • Wound infection
  • Injury to other abdominal organs
  • Pulmonary embolism
  • Deep vein thrombosis
  • Respiratory or urinary infections

After Surgery

The patient usually has minimal pain that is well controlled with medication. Frequently, patients are discharged home on the same evening after laparoscopic cholecystectomy or the next day morning with a prescription for pain medication. Patients eat a normal light diet on the day after surgery and may be able to return to light work in 3-4 days. It is preferable to avoid exertion and heavy work for a several weeks though one can take regular walks.