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Gallbladder removal

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Introduction


A cholecystectomy (pronounced co-lee-sist-ect-omy) is an operation to remove the gallbladder.

The gallbladder is a small, pear-shaped pouch in the upper-right part of your abdomen (tummy). It stores bile, the digestive fluid produced by the liver that helps to break down fatty foods.

Bile is made from cholesterol, bile salts and waste products. When these substances are out of balance, small, hard stones called gallstones can form. Gallstones often cause no symptoms and in many cases remain undetected. But they can cause pain, fever, jaundice, vomiting and nausea.

If your gallstones cause severe symptoms, you may be advised to have a cholecystectomy.

Types of cholecystectomy

There are two ways of performing a cholecystectomy:

Laparoscopic (keyhole) cholecystectomy

This is the most common way of having your gallbladder removed. The operation is carried out using a tiny camera and surgical instruments that are inserted through small incisions (cuts) in your abdomen.

It may soon be possible to have keyhole surgery through a small incision. This is due to be reviewed by NICE (National Institute for Clinical Excellence) in late 2010.

Open cholecystectomy

The gallbladder is removed through one large cut in your abdomen. This technique is called open surgery. It is a more invasive operation than keyhole surgery, you need to be in hospital for longer and it takes longer to recover. Open surgery is rare in modern practice.

Cholecystectomies (laparoscopic and open) are performed under general anaesthetic (you are asleep during it).


How a cholecystectomy is performed


Before your operation

You will need to attend a pre-assessment appointment a few days before your operation. The appointment may involve having some blood tests and a general health check to make sure that you are fit for surgery.

It is also a chance for your surgeon to check that you can have a laparoscopic (keyhole) cholecystectomy. If you have developed complications, such as inflammation or gallstones in the bile duct, open surgery may be required.

Laparoscopic (keyhole) surgery

Three to four small cuts (each about 1cm or less) are made in your abdomen. One cut will be by the belly button and the others will be on the right side of your abdomen.

Your surgeon will then inflate your abdomen using carbon dioxide gas. This is harmless and makes it easier for them to see your internal organs.

A laparoscope (a long thin telescope with a tiny light and video camera at the end) is inserted through one of the cuts in your abdomen. This allows your surgeon to view the operation on a video monitor.

Using especially designed surgical instruments, your surgeon will then remove your gallbladder.

Sometimes, if there is a risk of gallstones in the bile duct, an X-ray of the bile duct (operative cholangiogram) will also be performed during the operation. If gallstones are found, they can sometimes be removed during keyhole surgery. If complications occur, a surgeon may have to convert to open surgery.

Bile duct stones can also be removed post-operatively (after your operation) with a special endoscopy called an ERCP, or Endoscopic Retrograde Cholangio-pancreatography.

After the gallbladder has been removed, the gas in your abdomen will be allowed to escape through the laparoscope. The cuts in your skin will be closed with dissolvable stitches and covered with dressings.

The operation takes 60 to 90 minutes and is usually done as a day case, so you can go home that day.

Open surgery

Very rarely, an open cholecystectomy may be recommended over keyhole surgery, for example if you have had major surgery and have extensive adhesions (scarring in the abdomen). In these cases it may be difficult or dangerous to remove the gallbladder using keyhole surgery.

If complications arise during keyhole surgery, such as bleeding, it may be necessary to convert to open surgery. There is a one per cent chance of unexpected conversion from keyhole to open surgery occurring.

Open surgery usually takes longer to perform than keyhole surgery and you will need to stay in hospital for longer.


Complications of a cholecystectomy


Removal of the gallbladder is a relatively quick and safe procedure but like all operations, there are small risks. Complications arise in about 5% of cases.

Risks from general anaesthetic

There are a number of serious complications associated with having a general anaesthetic, but these are very rare. Complications include allergic reaction and death. Being fit and healthy before your operation reduces the risk of any complications occurring.

Bleeding

Bleeding (haemorrhage) can occur after your operation, although this is rare. If bleeding does occur, it may require a further operation through the same keyhole scars as your first operation.

Infection

An infection can occur after any type of abdominal operation. Simple wound infections can be treated with a short course of antibiotics, as can infections inside your abdomen.

Bile leakage

When the gallbladder is removed, special clips are used to seal the tube that connects the gallbladder to the main bile duct, draining the liver. However, bile fluid can occasionally leak out.

Sometimes this fluid can be drained off. In rare cases, an operation is required to drain the bile and wash out the inside of the abdominal cavity.

Injury to the bile duct

The most serious complication of gallbladder surgery is injury to the bile duct, which occurs in about 0.5% of cases. If the bile duct is injured during surgery it may be possible to repair it straight away. In some cases, complex and major corrective surgery is needed after your original operation.

Injury to intestine, bowel and blood vessels

The keyhole instruments used to remove the gallbladder can injure surrounding structures, such as the intestine, bowel and blood vessels. The risk is increased if the gallbladder is inflamed.

This type of injury is rare and can usually be repaired at the time of the operation. Sometimes they are noticed afterwards and a further operation is needed.

Deep vein thrombosis

Some people are at a higher risk of blood clots developing during surgery. These usually occur in the leg veins. You may be given compression stockings to wear during the operation to prevent this from happening. See DVT for more information.


Recovering from a cholecystectomy


Recovery after a laparoscopic (keyhole) cholecystectomy is usually quick. Most people - over 90% - are able to eat and drink and leave hospital within two hours of having surgery. In some cases, you may be advised to stay one night and go home the next day.

After open surgery you will have to stay a few days in hospital and your recovery time will be longer.

Side effects

Side effects after a cholecystectomy are usually temporary and mild. They may include:

  • Feeling sick. You may feel sick as a result of the anaesthetic or painkillers you have been given. This should pass quickly.
  • Pain in the abdomen and shoulders. This is a result of the gas used to inflate your abdomen and should pass after a couple of days. Painkillers can be taken to relieve any pain or discomfort.
  • Diarrhoea. This can come from bile irritating your digestive system. Eating high-fibre food such as brown rice and wholemeal bread will help to firm up your stools. Your doctor may also be able to prescribe a firming agent to help.

Getting back to normal

After leaving hospital, most people can be back to normal, including working and doing gentle exercise, within 7-10 days.

Driving

You can start driving again when you can do an emergency stop without any discomfort. Some insurance companies do not insure drivers for a number of weeks after surgery, so it is best to check what your policy says before starting to drive.

Wounds

If you had open surgery your stitches may need to be removed afterwards. You will be given an appointment for this before you leave hospital.


'I was having my appendix out and the surgeon spied the gallstones - all 19 of them'


Phyllis Long, aged 60, had surgery to remove her gallstones after doctors discovered 19 of them when removing her appendix.

"In 1994, during a medical by my GP, she noticed that I had quite a few gallstones (about seven) and advised that I get them and my gall bladder removed. She said that the condition was called cholecystipis and that once my body had produced the gallstones, my gall bladder would continue to store calcium and produce more. But, as the stones weren't affecting my appetite or my general health, I decided against surgery.

"Ten years later, when I was having my appendix out, the surgeon spied the gallstones - all 19 of them. He strongly urged me to have them removed. It wasn't a life-threatening condition, so I wasn't particular worried about them, but I had been experiencing some symptoms.

"I'd been feeling a lot of pain after eating cream or dairy products. It was a peculiar pain because it was in behind my ribs and went right through into my back. The discomfort was becoming more frequent, so when the surgeon confirmed what I had suspected - that I had more gallstones - I decided to take action.

"Ten months later I went in for elective surgery with the surgeon who removed my appendix. I opted for keyhole surgery, called laparoscopic cholecystectomy, as it was less invasive with a far lower chance of infection, and I wouldn't be scarred.

"The surgeon removed 19 gallstones and my gall bladder. I was in the clinic for four or five nights, as I had low blood pressure, but recovered relatively quickly from the surgery. Although movement was slightly restricted for about 10 days, I was able to eat little and often. I was a bit anxious about going to the toilet, but after about ten days, everything returned to normal.

"Since the surgery, the pain caused by eating dairy products has totally disappeared, and I haven't experienced any further discomfort. I haven't had any other problems since and am so glad that I finally had the surgery."


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