Stones tend to form within the gall bladder due to a variety of factors, including diet, lifestyle, pregnancy and rapid weight gain or loss. Most gallstones consist of cholesterol. They can be very small, like sand, or quite large, and the amount of problems that they cause does not correlate with size or number.
Once gallstones have formed, contraction of the gall bladder can trigger a bout of pain. Intake of fatty foods tends to stimulate contraction of the gall bladder. A careful low-fat diet can help minimise the frequency and severity of attacks.
The majority of people who have gallstones do not have any symptoms at all. Such gallstones are usually discovered on scans, and surgery is not required to remove them.
Gallstones can cause sharp attacks of upper abdominal pain. Attacks often tend to occur after meals, especially with fatty foods. Stones that move out of the gall bladder into the bile duct can cause more serious problems such as jaundice and pancreatitis (inflammation of the pancreas).
Several treatments have been tried for gallstones, including medications to dissolve stones and ultrasound waves to break them into smaller pieces. None of these has provided good long-term results. Removal of the stones without removal of the gall bladder has also been associated with high rates of recurrent problems. The mainstay of treatment therefore remains an operation to remove the gall bladder.
In at least 10% of patients, symptoms do not improve after removal of the gall bladder. It may then be realised that they are due to other factors, such as reflux, acidity, or irritable bowel. Scans usually cannot determine if the gallstones are causing your symptoms. It is therefore important to have a good clinical opinion prior to considering surgery.
An ultrasound scan is usually the best test to identify gallstones. In a few patients, your doctor will also ask for an MRI scan, which is better at looking at the bile duct and identifying any bile duct stones. If you are claustrophobic or have metalwork in your body, please let the team know, as that may preclude an MRI scan.
The operation is carried out under general anaesthesia. The aim of the operation is to remove your gall bladder through small cuts, avoiding a large incision if possible. The first cut is made near the navel, through which a camera is inserted. Your abdomen will be inflated with carbon dioxide gas to create room to operate. The body quickly absorbs carbon dioxide and the discomfort from this gas therefore dissipates within 12-24 hrs. Three other smaller cuts are made close to the rib edge, through which instruments are inserted into the abdomen.
The main step of the operation is to identify and safely clip the cystic duct, a tube that joins the gall bladder to the bile duct. This needs to be carried out carefully, in order to avoid any bile leakage or damage to the bile duct. The gall bladder is then removed through the incision at the navel, which may need to be enlarged a bit if the gall bladder or stones are large.
The surgery normally takes 45-90 minutes. Your surgeon may want to take an Xray of your bile ducts during the operation. It is also possible that the surgeon may need to convert to the conventional open approach during the operation.
Laparoscopic cholecystectomy offers substantial advantages over the open operation, and is associated with better outcomes. However, a few complications, such as bile duct injury, are more common after the laparoscopic approach. The risks that you should be aware of include:
Occasionally, the operation will not be possible to carry out by keyhole surgery and will be converted to the traditional open procedure. The main factors that result in a need to convert include intense scarring or inflammation around the gall bladder, and adhesions from previous operations. Open cholecystectomy remains a safe and effective alternative in these circumstances.
Most patients are able to get out of bed, start eating and mobilise a few hours after the operation. You should be able to go home later the same day. You will be given painkillers to take and advised on how to take them. The incisions are closed with internal dissolvable sutures and covered with glue; this provides a waterproof dressing with no external sutures to remove and no dressings required. You will be provided with a telephone number at the Manor hospital to contact in case of any problems or questions. Mr. Soonawalla will arrange to see you after several weeks to check on your progress.
Absence of a gall bladder does not seem to affect most patients. It is likely that for most patients with gallstones, their gall bladder function was poor prior to surgery, and therefore they do not notice any change. Most patients report marked improvements in pain, such that they are able to eat more confidently without fear of an attack. Staying on a healthy low-fat diet is a sensible approach for the long term.
The gall bladder provides extra bile to help digest fatty food. After having the gall bladder removed, some patients notice indigestion and diarrhoea, particularly after eating fatty food. This is usually mild and easily managed with diet control. It is rare for patients to have persistent diarrhoea that requires medications to treat.
You should be looking for a surgeon who does this type of surgery frequently, is known to have good results, and can deal with difficulties if they arise. Your GP will refer you to a surgeon who they know and have faith in. You are also free to ask the surgeon about the numbers of such operations that they carry out, whether any of their patients have experienced a bile duct injury and how they would deal with such an eventuality.