MEN'S HEALTH MATTERS:The gallbladder can often be removed using a minimally invasive technique
Q You wrote recently about gallstones and why they form. I found your article very informative as I have gallstones. I had a scan two months ago which diagnosed these gallstones, and I may have to have my gallbladder removed.
I am attending the hospital next week for an appointment and do not know what to expect. Why does the gallbladder have to be removed and how is it done? Are there any consequences to this operation?
AThe most common symptom of uncomplicated gallstones is pain under the right ribcage or occasionally in the right shoulder, resulting from an inflamed gallbladder.
The majority of people with gallstones do not have any symptoms, and gallstones are just detected on routine scanning of the abdomen for other reasons.
Ultrasound examination is a non-invasive and simple procedure using an ultrasound probe and some jelly spread on your skin. This probe uses sound waves to look at the internal organs.
The gallbladder is easily visualised and it may show stones in the gallbladder or in the common bile duct (tube running from gallbladder into duodenum).
If stones are suspected in the common bile duct or a patient has jaundice, then further imaging investigations will be required: computerised tomography (CT) scan (non-invasive X-ray that produces cross-section images of the body); or magnetic resonance imaging (MRI, a non-invasive test without X-ray exposure).
Occasionally, a flexible endoscopic tube with a distally placed ultrasound probe (endoscopic ultrasound) will be required to examine for very small gallstones or stones in the common bile duct.
Ultrasound or other examination also allows for inspection of the gallbladder wall – when very thickened from acute inflammation, surgery may have to be delayed until the inflammation settles.
If you are having symptoms from your gallstones you can have your gallbladder surgically removed, and full details of the procedure will be explained when you attend the hospital for your appointment.
Surgical removal of the gallbladder is referred to as cholecystectomy. This is usually a simple procedure and can often be performed using a minimally invasive (keyhole) approach called laparoscopy.
Surgery is not required for silent gallstones, ie, those not producing symptoms. In patients with pain induced by gallstones, repeated episodes of inflammation of the gallbladder may lead to severe infection or perforation – complications requiring emergency therapies.
Cholecystectomy entails general anaesthesia with several tiny incisions in the abdomen allowing insertion of hollow tubes that permit the surgeon to pass specially designed instruments to mobilise the gallbladder and cut the duct (cystic duct) that communicated between the gallbladder sac and common bile duct.
The gallbladder can then be removed safely through one of the small incisions. Recovery is usually very rapid and involves only one night in the hospital, and normal activity can be resumed after a few days at home.
An “open’’ surgical approach, ie laparotomy, (approximate 10cm incision) may be required in some individuals, especially if tests show the gallbladder has severe inflammation, infection, or scarring from other operations (not allowing for a safe minimally invasive approach).
Occasionally, a surgeon will change from laparoscopic to open surgery during an operation due to technical reasons such as difficulty defining the anatomy clearly or in some cases it is not possible to remove the gallbladder safely laparoscopically due to severe inflammation. “Conversion’’ to open surgery does not, however, happen that often.
The most common complication in gallbladder surgery is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and potentially dangerous infection. Most injuries are mild and can be treated non-surgically. Recovery following non-complicated gallbladder removal (whether using a minimally invasive or an open approach) is usually very quick, and resumption of normal activities can be achieved in the weeks following treatment.
The gallbladder is a non-vital structure and its removal does not in any way interfere with normal life, including strenuous or sporting activities. The bile continues to be secreted by the liver and is stored and released by the common bile duct directly into the intestine where it helps digestion.
If gallstones are present in the bile ducts, the doctor may use an endoscopic approach called ERCP (endoscopic retrograde cholangio pancreatography) to locate and remove the stones before or during gallbladder surgery.
Indeed, very occasionally a small gallstone in the bile ducts may become detected after surgery (ie cholecystectomy) and again an endoscopic procedure (ERCP) is required to remove the stone.
Gallstones are found very commonly in the general population, especially in western societies. The majority of people with gallstones will not have any symptoms and do not require any treatment. Those stones that do give rise to symptoms can be treated by simple surgery and complicated cases of gallstones are on the whole quite rare.
This weekly column is edited by Thomas Lynch, consultant urological surgeon, St James’s Hospital, Dublin with a contribution from Prof Dermot O’Toole, consultant gastro- enterologist/pancreatologist, St James’s Hospital, Dublin.
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