Laproscopic Gall Bladder Surgery

What is GallBladder?

The gallbladder is a pear-shaped organ that rests beneath the right side of the liver.
The purpose of gallbladder is to store and concentrate bile produced by the liver. Bile is released from the gallbladder after eating, aiding digestion. Bile travels through narrow tubular channel (bile duct) into the small intestine (called common bile duct or CBD).

What are Gallstones?
Gallbladder stones or gallstones are crystalline masses formed abnormally in the gall bladder or bile ducts from bile pigments, cholesterol, and calcium salts. Gallstones can cause severe pain and blockage of the bile duct. When the wall of the gallbladder is diseased then it produces the stone and polyps etc.”

The two main types of gallstones are:

Cholesterolstones: Usually yellow-green in color, approximately 80% of gallstones are cholesterol stones.

Pigment stones: These stones are smaller and darker and are made up of bilirubin.”

Who is at risk for gallstones?

Women are more prone than men
People in their 30’s and 40’s
Overweight men and women
People with rapid/ sudden weight loss
Pregnant women, women on hormone therapy and women who use birth control pills for a prolonged period”

Symptoms & Diagnosis

Symptoms of gallstones are severe abdominal pain often called as gallstone ‘attack’ (colic) because they occur suddenly. Gallstone attacks often follow fatty meals, and they may occur during the night. A typical attack can cause the following:
Severe pain in the right upper abdomen that increases rapidly and lasts from few minutes to several hours
Pain in the back between the shoulder blades
Pain under the right shoulder
Nausea or vomiting
Other insignificant symptoms of gallstones include:
Abdominal bloating (gas formation)
Recurring intolerance to fatty foods
Belching
Indigestion
Many patients with gallstones have no symptoms, these patients are said to be asymptomatic and these stones are called ‘Silent stones’.”

Complications of gallstones may include:

Recurrent severe abdominal pain or vomiting.
Jaundice due to blockage of the common bile duct due to stones.
Acute pancreatitis (swelling of pancreas) which can have catastrophic sequel of multi-organ failure and other serious complications. It may be fatal if severe.
Pus formation in the gallbladder (Empyema).
Gangrene and perforation of the gallbladder.
Cholangitis (life threatening infection of biliary system).
Associated with Cancer of gallbladder in the long term.
Gall bladder Polyp
Gall bladder polyp include all mucosal projections into the gall bladder lumen and include cholesterol polyps, adenomyomas, inflammatory polyps, adenomas and other miscellaneous polyps. Most of this ultimately leads to formation of stones or in malignancy inlarge polyps.

Biliary Pancreatitis

Bile duct and pancreatic duct open in intestine through common opening. Gallstones, produced in the gallbladder, can block the bile duct, stopping pancreatic enzymes from traveling to the small intestine and forcing them back into the pancreas. The enzymes then begin to irritate the cells of the pancreas, causing the inflammation associated with pancreatitis. This is very serious clinical condition with severe sufferings. In many severe cases it may be fatal as well.

 

Gallbladder stones and association with Gallbladder cancer
Association of gall bladder stones with gall bladder cancer is well established. It is a well-documented medical fact that more than 85% gallbladder cancers have shown to have gall bladder stones as well.

The female gender, multiple child births and obesity are also some of the factors that are associated with higher risk of developing gall bladder cancer. The evidences point towards the environmental and genetic factors playing an important role in development for gallbladder cancer. The basis for development of cancer in the setting of gallbladder stones likely occurs through chronic irritation and local production of carcinogens. The larger the gallstones (more than 2-3 cm in diameter), the greater the association with gallbladder cancer. Stone more than 3 cm is considered as pre-malignant condition.

GALL BLADDER STONES

Symptomatic Management:

Treatment of symptoms of pain with injectable or oral painkillers.
No medical therapy is available for gallstones as such which can cure the disease. Injectable or oral antibiotics and supportive medications are available for treating the infection and overcoming the acute attack.
Gallbladder removal is one of the most commonly performed laparoscopic surgical procedures.
Gallbladder removal surgery with minimum invasive techniques is also termed as “Laparoscopic Cholecystectomy” or “Lap Chole”.
Surgery: Surgery to remove the gallbladder (cholecystectomy) is the only way to cure gallstones. This can be done by conventional (open) method or a well-established endoscopic (laparoscopic) method which is now the ‘Gold Standard’.

The surgery is called Laparoscopic Cholecystectomy (Lap. Chole). For this operation, the surgeon makes few tiny punctures in the abdomen and inserts surgical instruments and a miniature telescope with amounted video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts and vessels. The gallbladder is then removed through one of the small incisions. Recovery usually occurs within few hours in most of the cases in the hospital, followed by few days of rest at home. As there is no damage to the muscle (muscles are not cut) during laparoscopic surgery, patients have less pain and negligible wound complications.

If the surgeon finds any difficulty in the laparoscopic procedure, the operating team may decide to switch over to open surgery. It is called open surgery because the surgeon has to make a 5 to 8 inch incision in the abdomen to remove the gallbladder. Open surgery has faded into the background with the laparoscopic technique providing significant advantages and ease for the patient.

What if a stone slips into the Common Bile Duct (CBD)?
Slippage of the stone(s) in CBD may cause pain or jaundice or both. This situation requires an endoscopy (ERCP) for removing the stone(s). This should preferably be done before surgery. However it may also be done after the operation.

How do we confirm if a stone is in the CBD?
Sometimes a stone in the CBD may not show on ultrasound; however patient may have symptoms which are indicative of the same. In this event, the patient requires magnetic resonance cholangiopancreatography (MRCP – an MRI scan) which shows the presence of stones in the common bile duct.

What is ERCP?

The surgeon may use endoscopy through mouth for removing CBD stones before gallbladder surgery. Once the endoscope is in the small intestine, the surgeon locates the opening of the bile duct. An instrument on the endoscope is used to cut the duct, and the stone is captured in a tiny basket and removed with the endoscope. This two-step procedure is called ERCP andEPT.”