Specializing in
General Surgery
Treatment of Gallbladder Disease
2. Diagnosis of Gallbladder Disease
4. Conversion to Open Cholecystectomy
5. Laparoscopic Cholecystectomy
Diseases of the gallbladder and bile ducts are the fourth leading cause of adult surgical hospitalizations in the United States. It is estimated that approximately 15 to 20 million Americans have gallstones and about 600,000 Americans undergo cholecystectomy (or removal of the Gallbladder) each year. Until recently this could only be done through a large painful abdominal incision, the procedure that we now refer to as the open cholecystectomy. Over the past few years a new standard has emerged---Laparoscopic Cholecystectomy---a procedure by which the gallbladder and stones are removed through several very small incisions with the aid of a scope.
Before proceeding with our discussion of gallbladder disease and treatment, let's first look at gallbladder anatomy and function. After swallowing, food passes down the esophagus into the stomach. The stomach is a sac-like organ in the mid upper abdomen. While its muscular walls churn the food, it secretes digestive enzymes and acid. Once the food is transformed into a liquid state, it passes to the first part of the small intestine which is called the duodenum.
The liver is a large organ in the upper right portion of the abdomen. One of the many functions of the liver is to produce bile. Bile, which is a combination of digestive enzymes and waste products, plays an important role in the digestion of fats. The bile passes from the liver into a tube-like structure called the common bile duct which empties into the duodenum. Just before it reaches the duodenum, the common bile duct passes through the head of the pancreas and meets with the pancreatic duct which drains very potent digestive enzymes produced by the pancreas. The gallbladder is a pear-shaped sac attached to the underside of the liver. It is connected to the common bile duct by a tube- like structure called the cystic duct. The gallbladder's primary function is to store and concentrate bile. After fatty food is eaten, the gallbladder will contract pushing bile into the common bile duct and duodenum.
Sometimes instead of concentrating the bile into a thick syrup, chemicals in the bile can solidify and form stones. Most gallbladder problems are caused by gallstones. These stones can range from the size of a grain of sand to the size of the gallbladder itself. They can be solitary or there can be more the a hundred. Sometimes the stones are "silent" and do not cause any symptoms or problems. However, often the stones can irritate the wall of the gallbladder and cause it to become inflamed or infected. This is particularly apt to happen if a stone blocks passage of bile through the cystic duct. This condition can cause upper abdominal pain often radiating to the back, nausea or vomiting, indigestion or heartburn. Many times the symptoms will subside after several hours. Symptoms which persist, especially if associated with fever, often indicate an infection of the gallbladder. This can be very serious and can sometimes progress to gangrene of the gallbladder.
Occasionally a stone can slip thru the cystic duct out of the gallbladder into the common bile duct. The stone can then potentially lodge at the outlet of the common bile duct and block the flow of bile completely. When this occurs the bile accumulates in the blood stream causing the patient to become yellow or jaundiced. If this blockage is associated with infection of the bile, a life-threatening condition known as cholangitis results.
Sometimes a stone lodged at the outlet of the common bile duct can obstruct the pancreatic duct which empties potent digestive enzymes from the pancreas. This can cause pancreatitis, a serious and sometimes life-threatening complication of gallstones.
The Diagnosis of Gallbladder Disease
Although there is a considerable overlap in symptoms between gallbladder disease and other common gastrointestinal diseases, the history of a patient's symptoms and a thorough physical exam will often provide clues as to the presence of gallbladder disease. In addition, this information may uncover complications of gallbladder disease or may suggest other causes of the patient's symptoms.
Pain is the most common symptom associated with gallbladder disease. This pain is most often in the mid-upper or right upper portion of the abdomen and sometimes radiates to the back. Frequently it occurs several hours after a heavy meal. The pain will usually subside after several hours. Persistent, unrelenting pain can be a sign of acute cholecystitis or infection of the gallbladder. The attacks of pain are often associated with nausea with or without actual vomiting.
Some patients have little if any pain, but suffer frequent indigestion, heartburn or a bloated feeling. These, however, are non-specific symptoms and be caused by other conditions other than gallstones, in which case removal of the gallbladder will not relieve these symptoms. Fever and jaundice often indicate complications of gallbladder disease and dictate emergency treatment.
Although gallbladder disease can affect anyone, certain people are more likely to be afflicted. Women are affected more often than men. Gallstones are also more likely to occur in those patients who are overweight and after the age of forty.
However, there are certainly plenty of exceptions to the stereotype of overweight female gallbladder patient in her forty's. Gallbladder disease can affect people of all ages, although it is rare in children. It can affect men and thin people as well as overweight females. Pregnancy increases the risk of developing gallstones, and those with close relatives with gallbladder disease are more often affected.
Once gallbladder disease is suspected further tests are obtained to help confirm the diagnosis as well as to detect possible complications of gallbladder disease and other disease conditions. These, in turn, may affect the recommended plan of treatment.
Gallbladder ultrasound is the most frequent study used to diagnose gallstones. The study utilizes a device that emits painless high-frequency sound waves. Echoes from the sound waves are electronically processed to create an image of internal organs.
Under certain circumstances other imaging studies such as a oral cholecystogram or biliary scan may be helpful in diagnosing gallbladder disease.
The oral cholecystogram has been mostly replaced by the gallbladder ultrasound. This study consists of x-rays of the gallbladder obtained after pills containing an opaque dye are taken by mouth. The oral cholecystogram can sometimes be helpful in diagnosing chronic or recurring gallbladder problems when gallbladder ultrasound is normal.
The biliary scan can demonstrate blockage of the cystic duct which occurs with acute cholecystitis. A radionuclide dye is injected intra-venously and under normal conditions is excreted in the bile and concentrated in the gallbladder as seen here.
With blockage of the cystsic duct, the dye is seen in the liver, bile ducts, and intestine, but not in the gallbladder. If the gallbaldder is visualized, acute cholecystitis is very unlikely.
Blood tests are used to assess liver and pancreas function. Abnormalities in these test may suggest a stone in the common bile duct or sometimes suggest a cause of symptoms other than gallbladder disease. If a stone in the common bile duct is suspected, an ERCP is usually recommended prior to surgery. During this procedure a scope is passed through the mouth into the duodenum and dye injected into the bile duct and x-rays taken. If stones are seen in the bile duct they can usually be removed by widening the outlet of the bile duct and extracting the stones with instruments passed through the scope.
Many gallbladder type symptoms can be caused by other problems such as gastritis, peptic ulcer or hiatal hernia. An upper GI x-ray or upper GI endoscopy where the esophagus, stomach and duodenum are actually visualized with a flexible scope may be useful in evaluating these possibilities.
As noted, about 15 million people in the United States have gallstones, and about half of these people have no symptoms. In most instances, no treatment is recommended in those patients who do not have symptoms. Occasional exceptions to this trend are diabetics and young people. Diabetics have a higher incidence of mortality from acute cholecystitis. Young people have a significant risk of eventually developing complications from gallstones.
Once the patient begins having symptoms from gallbladder disease, these symptoms will usually recur and often eventually lead to complications if left untreated. Several treatment options are available:
Medications can be given in an attempt to dissolve gallstones. Unfortunately, this takes a long time, is often unfeasible or unsuccessful, is expensive, and the stones often recur once the medication is stopped.
Gallstones can sometimes be broken up with sound waves by a procedure known as lithotripsy. The small fragments can then pass out of the gallbladder and common bile duct and into the intestine. Unfortunately, this is not always effective, and the stones tend to recur.
Because of these limitations, cholecystectomy (removal of the Gallbladder) remains the standard of treatment for gallstones and gallbladder disease. Until recently this could only be done through a large painful abdominal incision, the procedure that we now refer to as the open cholecystectomy. Over the past few years a new standard has emerged---Laparoscopic Cholecystectomy---a procedure by which the gallbladder and stones are removed through several very small incisions with the aid of a scope.
Laparoscopic cholecystectomy holds several distinct advantages over the standard open cholecystectomy. These advantages have led to its rapid acceptance as the treatment of choice for most types of gallbladder problems.
Because the incisions are very small, not only are the scars much less moticeable, but there is also much less pain associated with the procedure. Since there is much less pain, patients are much more mobile and active post-operatively and are usually able to return home the same day. After the first week there are no physical restrictions, whereas with open cholecystectomy patients must refrain from heavy lifting and sports for six weeks Patients are usually able to return to work much sooner, and even those patients who do heavy physical work can often resume their jobs in a week or two.
The prompt return to normal activities, reduces the risk of post-operative pneumonia, phlebitis, muscle-wasting and other complications. Also the incidence of wound infection is lower with laparoscopic cholecystectomy. Otherwise the risks of laparoscopic and open cholecystectomy are quite similar.
Conversion to Open Cholecystectomy
Although in most cases laparoscopic cholecystectomy is our preferred surgical approach, occasionally we must convert to an open cholecystectomy if we do not feel it would be safe to continue laparascopically. In our experience this happens less than 5% of the time with elective cholecystectomies and about 10% of the time with emergency cholecystectomies.
Several conditions may force conversion to open procedure. Sometimes previous surgery can cause extensive intra-abdominal scarring. This may cause intestine to become adherent to the abdominal wall or liver obscuring the surgeon's view of the gallbladder area and increasing risk of injury to the intestine. Usually, but not always, this scar tissue can be divided and the gallbladder still removed laparoscopically.
There is considerable variation in the anatomy near the junction of the gallbladder and the common bile duct. This fact combined with the distortion caused by gallbladder inflammation or scarring sometimes makes it impossible to confidently identify the important structures in this area. Usually blood loss is quite minimal. However, occasionally introperative bleeding may obscure visualization preventing control of the bleeding laparoscopically. Complications such as injury to the intestine or bile ducts usually require conversion to an open procedure. Rarely, an unexpected finding may require immediate intervention utilizing an open approach. If a common duct stone is present and cannot be removed endoscopically, then an open procedure is usually utilized to remove the stone and gallbladder.
Every operation is associated with potential complications. The complications of laparoscopic cholecystectomy are similar to open cholecystectomy. As noted, some complications are less frequent with the laparoscopic approach. The risk of intestinal injury is probably slightly higher with laparoscopic cholecystectomy. Although precautions are taken to minimize the risk of intestinal injury during placement of trocars, the presence of intra- abdominal adhesions or scarring increase this risk.
Procedure: Laparoscopic Cholecystectomy
Laparoscopes have been used for intra-abdominal diagnostic and minor surgical procedures for many years. However, major operative procedures have not been technically feasible until the past few years. The first major development in broadening the use of the laparoscope in more complex operative procedures was the development of video cameras which could project the laparoscopic image on a TV screen. This allowed the entire operative team to view the procedure simultaneously and freed the surgeon's hands from manipulating the scope.
The second key step in the movement toward the minimally invasive approaches for major operative procedures was the development of specialized instruments which could be passed through the small incisions. With these developments the surgeon can now dissect, cauterize, clip, staple, and suture through very small incisions just as he could much larger incisions.
The laparoscopic approach actually has other advantages besides smaller, less painful incisions over conventional open approaches. The visualized structures are magnified and often the anatomical structures are better visualized. A disadvantage of the laparoscopic approach is the surgeons inability to touch and manipulate the tissues with his hands. Sometimes the touch and feel of the tissues is as important as visualizing them.
Laparoscopic cholecystectomy derives much of its advantages over conventional, open cholecystectomy by virtue of the much smaller incisions utilized. With the traditional open cholecystectomy an incision about 6 inches long is usually made in the right upper abdomen near the gallbladder. With laparoscopic cholecystectomy, four small incisions are usually made. A 1/2" incision is made just above the navel. This incision is used for passage of the laparoscope. Another 1/2" incision is made in the upper abdomen just below the breastbone, and two more incisions, each about 1/4" long are made in the right upper abdomen. These three incisions are used to pass the dissecting instruments.
Because total relaxation of the abdominal wall muscles is required to conduct any laparoscopic procedure, general anesthesia is utilized with the patient completely asleep.
The anesthesiologist continuously monitors the patient's heart rhythm and rate, the patient's blood oxygen, as well as the rate and quantity of anesthetic agents and oxygen being administered. The operation is conducted under sterile conditions to minimize the risk of infection.
Normally the intra-abdominal organs lie rather compactly with minimal space between the organs and the wall of the abdomen. By inflating the abdomen with carbon dioxide gas, a space is created to visualize organs and to maneuver the instruments.
The initial dissection is undertaken to expose the cystic duct which connects the gallbladder to the common bile duct and the cystic artery which provide the main blood supply to the gallbladder. Anatomical variations are quite common here and both of these structures must be clearly identified and dissected free. Following dissection of the cystic artery and cystic duct a stapling device is passed through the upper trocar and these structure are clipped. A scissors is then passed and the cystic duct and artery are divided.
The gallbladder is then dissected from the liver bed. This can be done either with an electro-cautery or a laser. We and most surgeons prefer the electro-cautery since we feel that it is safer and easier to control. When used for dissection, both the laser and the electro-cautery coagulate small blood vessels while cutting. After the gallbladder is completely dissected free from the liver bed, a grasping forceps is passed through on the trocars and the gallbladder is pulled through one of the two larger incisions. Sometimes it is necessary to crush and/or remove some of the stones from the gallbladder so that it can fit thru the small incision. Occasionally it is necessary to enlarge the incision to extract the gallbladder. The incisions are then usually closed with dissolvable suture.
At that stage there is still have some discomfort around the incisions, the right side of the abdomen, and sometimes even in the right shoulder. The right shoulder pain is known as "referred pain" and is caused by irritation of the area of the abdomen above the liver usually from the carbon dioxide gas. This resolves after several days. The incisional discomfort is also mostly gone within a week. Pain medication is prescribed, but this is usually not needed after several days. Many patients will have a bloated feeling in the abdomen which passes as the gas in the abdomen is reabsorbed.
There are no hard and fast rules regarding diet after laparoscopic cholecystectomy. Once healing is complete you should be able to eat anything you could eat prior to the operation. However, for the first week or two after surgery some foods may disagree with you. Some patients will experience diarrhea. Some patients will experience constipation. In time bowel habits will revert to their preoperative state.
After Laparoscopic Cholecystectomy we recommend that the patient refrain from any heavy lifting or sports for about a week. After that there are no activity restrictions. In fact we encourage the patient to be active. You should be aware that you will tire easily for the first week or two after surgery. When this happens, listen to your body and rest. The patient can walk up and down steps immediately. You can resume driving a car when you feel you can drive safely. We urge common sense and a cautious attitude. If you are still taking pain medication and having incisional discorfort, you will not be able to react apppropriately to drive safely. Showers can be taken on the second day after surgery. Bandages are optional at this stage, but if bandages are being worn over the incisions, then they should be replaced with dry ones. Soaking in a tub or swimming should be avoided for a week to ten days after surgery.
If no heavy lifting is involved, patients can return to work as soon as they feel able to perform their jobs satisfactorily. For most people this is a week or two after laparoscopic cholecystectomy, and it is often a good idea to work only part time for the first few days back. No two patients are exactly alike, and the timing of your return to work will be mutually determined by you and your doctor.
Many patients ask, "What is life like without a gallbladder?" As we described previously the gallbladder does have a function. However, after removal of the gallbladder the body compensates so well that you will never miss it. The pain associated with typical "gallbladder atttacks" is almost always relieved. Heartburn, "acid indigestion", nausea, bloating, cramps and other GI symptoms can be caused by other conditions and are sometimes not affected by cholecystectomy. There is no need to adhere to any special diet just because your gallbladder has been removed.
We hope that you find this information about gallbladder disease and treatment informative and useful. The surgeons at Foris Surgical Group have performed more than 2,000 Laparoscopic Cholecystectomies and were among the first surgeons in Maryland to utilize this innovative procedure. We are proud of our results and the safety record that our extensive experience and expertise have enabled us to acheive.
Max Wingerd, MD, FACS
Click Here for more information about Dr. Wingerd
Location:
Frederick, MD 21702 Fax: (301) 662-5288
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