gihealth.com

Laparoscopic Cholecystectomy

Advances in Gallbladder Surgery

Jan W. Maratta, M.D. Like most body organs, you never think of your gallbladder unless it malfunctions. Part of the complex digestive system, the gallbladder is a small, pear-shaped muscular sac underneath the liver in the right upper part of the abdomen. Its function is to store bile, a fluid made by the liver, which aids in the digestion of fatty foods. Once food is in the small intestine, the bile travels to the intestine through small tubes, or bile ducts. However, when the amount of bile and fluid in the gallbladder becomes unbalanced, gallstones can form.

Who Gets Gallstones?

Anyone can. In fact, gallstone disease is quite common in this country affecting about 1 in 10 adults, or more than 25 million Americans. About 1 million new cases are diagnosed each year. The risk is higher in women and rises with multiple pregnancies, obesity, age, and family history. In terms of health care dollars, surgery to remove gallstones is the most common and costly digestive disease spending an estimated annual $5 billion in health care dollars.

What Causes Gallstones?


Nobody really knows, but the majority of gallstones are made from cholesterol crystals clumped together like snowflakes in a snowball. These gallstones appear brown or yellow in color. Some stones are made of black pigment. Stones tend to grow for a few years and then tend to stabilize. Most stones are less than an inch in size.

What Are The Symptoms of Gallstones?


Most gallstones never cause any symptoms (asymptomatic) and are never discovered. Sometimes asymptomatic gallstones are found during the course of routine tests and x-rays. However, some stones lead to serious complications like pain, jaundice, or infection due to blockage of the liver or pancreas.

Non-Surgical Treatment


In some individuals, avoiding fatty foods may help reduce the frequency of gallbladder symptoms. Unfortunately, there is no special diet that can dissolve gallstones or reduce symptoms reliably. For a while there was interest in drugs to dissolve gallstones and the use of shockwaves to destroy them, but these techniques did not prove to be very successful. In time, the gallstones just came back and caused more problems. Only surgical removal of the gallstones and the gallbladder has been shown to correct the problem.

Gallstones Who Needs Surgery?


Although many individuals have gallstones, surgery is not usually advised for those without symptoms. However, when symptoms of pain, jaundice, or infection occur, surgery is usually necessary. Once symptoms occur, they tend to reoccur and often lead to complications due to blockage of the bile or pancreatic ducts by stones. Surgery is done to remove the diseased gallbladder and any stones within it. This corrects the immediate problem and helps prevent future symptoms. If surgery is not done, the stones can cause lifethreatening problems like rupture of the gallbladder, peritonitis, pancreatitis, liver jaundice or severe infection.

Open Cholecystectomy


Over the past 100 years, gallbladder surgery traditionally meant surgically opening up the abdominal wall and removing the gallbladder through about a 6-inch incision just below and parallel to the right ribcage. This technique, called an open cholecystectomy (Koh lee cyst EK toe me), usually requires about a week in the hospital and a good six weeks of recovery time at home. Because of the large incision, the healing process is often quite painful and much time is lost from work and normal activities.

Laparoscopic Cholecystectomy


Today through advances in medical technology, the gallbladder can be removed through a much smaller incision by using a laparoscope — a thin, telescope-like tube. This procedure is called laparoscopic cholecystectomy. Also referred to as "keyhole" or "minimally invasive" surgery, the laparoscopic surgical procedure is performed through three or four small incisions each less than a centimeter. The laparoscope is inserted into one incision, providing a light and a tiny videocamera which is attached to a video monitor. This magnifies the image up to 20 times allowing the surgeon to directly view the gallbladder, the liver, and other internal organs in exquisite detail. Other special instruments areinserted through several small puncture sites to assist in the surgery. The gallbladder is removed through a small incision in your navel. The surgery usually takes approximately one hour. This technique was first developed by gynecological surgeons in the 1970's and approved for gallbladder surgery in 1988. Today 95% of gallbladder surgery is done with the laparoscope.

Clearing The Bile Ducts


If your surgeon suspects that stones have migrated out of the gallbladder into the bile ducts, he may request a special procedure called ERCP before surgery to remove the stones. A specialist called a gastroenterologist usually does this exam. If stones are found in the bile ducts at the time of surgery, it is sometimes possible to open the bile ducts and remove them with the laparoscope.

Benefits of Laparoscopic Cholecystectomy


Both the traditional open and laparoscopic techniques of gallbladder removal have possible risks and complications such as infection, excessive bleeding, or injury to surrounding organs. However, there are several important benefits of laparoscopy over open surgery:
  • The laparoscopic procedure results in less discomfort after surgery, primarily due to the tiny incisions used in the laparoscopy, as opposed to the large incision required for a standard, open cholecystectomy.
  • These small incisions result in tiny scars instead of a long scar giving a much better cosmetic result.
  • Laparoscopic cholecystectomy shortens the hospital stay. Most people go home the day of surgery and do very well. This allows the patient to recover in the privacy and comfort of his or her own home and saves health care dollars.
  • The laparoscopic procedure, in comparison to the open cholecystectomy, results in a faster recovery time. Most patients return to normal daily activities in 3-5 days. This means less time lost from work. This rapid recovery is particularly appealing to young and middle-aged adults with busy career and family responsibilities.
  • Laparoscopic cholecystectomy has been proven to be as safe, if not safer, than the traditional open technique.
Typically, Only 3 or 4 Small Incisions are Necessary Risks of Laparoscopic Cholecystectomy

The risks of laparoscopic cholecystectomy are similar to those of open procedure and include bleeding, infection, injury to other organs, and possible injury to the bile ducts. Fortunately, when done by an experienced surgeon, the complication rate is low. Sometimes during laparoscopic surgery, special circumstances and variations in anatomy force the surgeon to stop and switch to the open procedure. This "conversion rate" is usually less than 5%. For a small percentage of patients, the loss of the gallbladder is a shock to their system and they may develop a problem with bowel urgency and watery diarrhea after eating. This symptom can usually be controlled with special medications and often disappears over time.

Preparation for Surgery


Before surgery, diagnostic tests must be done to demonstrate that gallstones are present and most likely the cause of your symptoms. You will meet with the surgeon to review your symptoms, past medical and surgical history, medications, and the risks and benefits of surgery. The options available will be discussed.

You will be admitted to the hospital the morning of the procedure. Because laparoscopic gallbladder removal is performed under general anesthesia, you cannot eat or drink anything after midnight the day before your surgery. Be sure your doctor knows if you are diabetic or on any blood thinners such as Coumadin. Aspirin products can increase bleeding and should be avoided for one week before surgery if possible. Tylenol is not a problem.

During the Surgery


After you are asleep, the instruments are inserted and carbon dioxide gas is infused into the abdominal cavity. This lifts the abdominal wall upward making room for the surgeon to visualize the organs. The gallbladder is carefully dissected free and severed from the liver using electronic instruments and special surgical clips. The surgeon empties the gallbladder and pulls it out through one of the incisions. The gas is removed and thesmall incisions are closed and covered with Band-Aids.

Gallbladder Being Lifted Away After the Surgery


Immediately after surgery, you are taken to the recovery room for several hours. For the first few hours, you will experience some pain from the small incisions. This can be controlled with medication. Once the anesthetic has worn off and there are no signs of complications, you are permitted to return home. This is often the same day, or occasionally, the following morning.

Recovery at Home


At home, you will be able to care for yourself, take a shower, and eat a regular diet. At first you may be sore and find that you tire easily. You may even need a nap during the day. You may need to take some medication for pain for several days. Be aware that many pain medications can cause constipation. You can prevent this by taking a fiber supplement such as Citrucel daily and increasing your fluid intake. Simple laxatives may be needed. In several days you will be able to return to your normal activity and you may return to work as soon as you feel strong enough. If you exercise, you can resume a fitness program or sports in about a week.

What to Watch for at Home


Complications are uncommon with laparoscopic surgery, but you should contact your doctor if you develop persistent nausea or vomiting, fever over 101 degees, severe pain, swelling or redness at your incisions, or drainage from your incisions.

Summary


Gallstones are a common problem and gallbladder removal is one of the most successful of all surgeries. The laparoscopic removal of the gallbladder is often the best way to stop the pain and symptoms of gallstones. If you are experiencing abdominal pain, discomfort, or vomiting, it is important for you to contact your primary care physician who can refer you to a specialist for further evaluation. If surgery is indicated, your options will be discussed thoroughly, providing you with enough information to feel comfortable to make your decision. As a surgeon, I am dedicated to utilizing my skills and new procedures in order to decrease the pain, complications, and the recovery time of surgery. This laparoscopic procedure does all of this, along with safely and effectively removing the gallbladder.


< back