Cholecystectomy

Liver makes bile, which flows out through a narrow channel called bile duct, to the small intestine. At its lower end, the bile duct has a tight sphincter causing a bottle neck narrowing. Towards its lower end, another organ called pancreas joins the bile duct. Bile mixed with pancreatic juices flow out into the small intestine and serve to digest food. Alongside the bile duct exists important blood vessels supplying the liver. Gallbladder is a small ‘pouch-like cul-de-sac’ of the bile duct. Its only function is to store bile.

Bile in the gallbladder can form stones which are usually made up of cholesterol, calcium, bile pigment, and combination of the above substances, in about 30% population.

In many instances, stones may be asymptomatic (silent gallstones). At other times, they give us a variety of symptoms ranging from intermittent gripping pain (biliary colic), constant pain with other symptoms like fever and inflammation (cholecystitis), jaundice (stone dropped out of the gallbladder blocking the bile duct, causing bile infection and back-pressure on the liver) and pancreatitis (gallstones passing distally into the bile duct and blocking pancreas duct, causing inflammation of pancreas).

In many instances, stones may be asymptomatic (silent gallstones). At other times, they give us a variety of symptoms ranging from intermittent gripping pain (biliary colic), constant pain with other symptoms like fever and inflammation (cholecystitis), jaundice (stone dropped out of the gallbladder blocking the bile duct, causing bile infection and back-pressure on the liver) and pancreatitis (gallstones passing distally into the bile duct and blocking pancreas duct, causing inflammation of pancreas).

Depending on the severity of symptoms, treatment differs. Some patients are asymptomatic and do not need surgery. Patients with symptoms related to gallstones will need to be assessed by specialists. Few of them can settle with antibiotics and painkillers. Some, who are extremely ill, may require hospital admission. Every eligible patient with symptomatic gallstone disease should be offered cholecystectomy, an operation to remove the gallbladder. Patients who have jaundice from gallstones stuck in the bile duct, requires an urgent endoscopic intervention called ERCP to clear the bile duct of the culprit stone(s). Following this, all such eligible patients should also be offered cholecystectomy. NICE guidelines recommend that all suitable patients are offered laparoscopic cholecystectomy (operation to remove the gallbladder with the stones) as soon as practically feasible. In some patients who are unfit for a general anaesthetic, treatment options include symptomatic treatment, ERCP and placing a drain in the gallbladder under radiology guidance under local anaesthetic.

Some medicines are used to dissolve gallstones. But the length of time taken for this process is unpredictable. Moreover, gallbladder can form new stones in time, causing recurrent symptoms. Again, some of the symptoms caused by gallstones (gallbladder perforation, sepsis, pancreatitis, jaundice, etc) can be very serious and life threatening for patients. Cholecystectomy is usually performed as a day case operation (admission in the morning, discharge in the evening) and on balance, is a recommended option for every eligible symptomatic patient.

Cholecystectomy is an operation to remove the gallbladder, performed under general anaesthesia. It is a common key-hole surgery (laparoscopic procedure, using very small incisions) and most often done as a day case. In 5% cases, based on intra-operative findings, the surgeon may opt to convert the operation to open procedure through an upper midline or upper abdominal transverse scar. Hence patients are consented for both open and laparoscopic procedures at the outset.

Risks include bleeding, infection, incisional hernia, bile leak, thromboembolism, general anaesthetic complications and injury to the bowel, liver or bile duct; the latter is reported to happen in <0.3% cases.There is also a small chance of post-operative diarrhoea and persistent symptoms of retained stones. In some instances, when the junction of gallbladder and bile duct is significantly inflamed, dissection in this area is deemed dangerous as it may increase the risk of bile duct injury or damage to the blood supply of liver. In these circumstances, your surgeon may choose to perform sub-total cholecystectomy (removing majority of the gallbladder with the stones and leaving back a small cuff of gallbladder attached to the bile duct). Although deemed safe as per guidelines, subtotal cholecystectomy carries a 2% risk of symptom recurrence. Additionally, a standard low risk of death (0.1%) related to surgery or anaesthetic complications is also quoted routinely with this operation.

On the day of operation, you will be fasting for at least 6 hours before the scheduled time of your operation. You will arrive to the hospital with an overnight bag. You will be assigned your bed. The operation normally lasts two hours, following which you will be back in your cabin bed. If the operation goes as planned, you should be fit for discharge later in the day or early next day morning (especially for patients whose operations take place later in the day). Your discharge will be nurse-led. You will need pain killers after your surgery and the sutures placed are usually dissolvable. You will receive a discharge letter when you leave the hospital specifying your post-operative follow-up plan. You will be expected to refrain from driving for at least 24 hours after a general anaesthetic and may need a week after your operation, to be on light activities only.

It is important to know that gallbladder is not essential for life. One can live a healthy life without a gallbladder.

Prior to booking patients for laparoscopic cholecystectomy, clinicians routinely take multiple clinical factors into account. Depending on their assessment, some patients are better suited for an NHS hospital with adequate intensive care facilities. Although this assessment is best done through a detailed consultation with your specialist(s), some of these factors are as follows, but are not limited to:

1. Patients with a higher body weight (BMI more than 40).

2. Patients with significant pre-existing medical conditions, especially related to heart and lungs.

3. Patients who had a previous independent abdominal operation, especially above the level of the belly button, which can cause intra-abdominal adhesions.

4. Patients who had previous complications of gallstones include severe pancreatitis, gallbladder perforation, drains put in the gallbladder or even several bouts of acute inflammation. These latter factors can result in significant adhesions around the gallbladder and it can make the operation technically challenging, with a higher risk of conversion to open procedure.