Gallbladder Removal Surgery (Cholecystectomy)
What is a Gallbladder?
The gallbladder is a sac-like structure that is attached to the underside of the right lobe of the liver in the right upper abdomen and under the rib cage. Its function is to store and concentrate bile between meals.
Bile is manufactured in the liver and released into the small intestine through the common bile duct. It is critical for the digestion and absorption of fat in our diet. When we eat a meal and the fat in that meal contacts the surface of the first part of the small intestine, that intestine releases a hormone into the bloodstream that causes a contraction of the gallbladder. The concentrated bile in the gallbladder is then released into the intestine to help absorb the fat ingested with the meal and is returned to the liver and recycled.
When the gallbladder doesn’t contract or empty appropriately, the bile in the gallbladder can begin to precipitate or form crystals of cholesterol or bile pigments. The earliest visible sign of this is called cholesterolosis, and this is when small crystals of cholesterol attach to the inside lining of the gallbladder. If the crystals do not break off and get passed into the intestine, they can enlarge and form polyps and then stones.
Stones can range in size from a few millimeters to stones so large they completely fill the gallbladder. When the gallbladder contracts to empty and if it contains crystals, stones or sludge (best described as muddy, thickened bile), patients can experience pain in the upper mid-abdomen, under the sternum (breast bone) or under the right rib cage. The pain can also radiate to the back. This pain is referred to as colic as it can be cramping in nature and severe. Most of the time, it occurs after meals. It can be associated with gas, bloating, urgent bowel movements and diarrhea. Acid reflux symptoms are also reported with gallbladder attacks. The stones, especially the smaller ones (it only takes one), can lead to the blockage of the gallbladder and this can cause an infection called cholecystitis. In severe cases, cholecystitis can progress to a gangrene of the gallbladder in a few hours.
Another problem is when the smaller stones can be passed into the main bile duct and cause jaundice or pancreatitis or both. Pancreatitis is a dangerous inflammation of the pancreas, which makes enzymes to help digest food. With pancreatitis, these enzymes become activated in the pancreas and can cause severe damage and even death. In some cases, abnormal function of the gallbladder called biliary dyskinesia can lead to the symptoms described above. No stones are present, but the symptoms are still fairly severe. Dyskinesia usually progresses to gallstones, but many patients have their gallbladders removed at this stage.
Causes, Risk Factors & Prevention
In many cases, there is a family history of gallbladder problems, so it is possible to inherit an increased risk for gallbladder disease. Obesity increases the risk of gallbladder disease. Long periods of fasting, such as with dieting, can lead to gallstones. Diseases that lead to turnover of red blood cells and increased processing of bile pigments by the liver, such as sickle cell disease, can lead to bile pigment gallstones. The best way to prevent gallbladder problems is to maintain a healthy weight and eat a well balanced diet.
Detection, Tests & Imaging
Your primary care physician will often suspect gallbladder problems during a history intake and physical exam. The previously described symptoms along with tenderness in the right upper abdomen will lead to further testing. Blood work, including liver function tests, can be abnormal. The first imaging study is usually an ultrasound or a sonogram. This is the gold standard for detecting gallbladder polyps or stones. CT scans and an MRI can also be used to diagnose gallbladder and bile duct problems. A special test called an HIDA scan can also be used if the ultrasound does not reveal stones. For the scan, patients are given an isotope intravenously that is concentrated by the liver and excreted into the bile ducts. If the gallbladder is obstructed, it will not visualize on the scan. This is an abnormal test that shows obstruction of the duct to the gallbladder, usually by a small stone that is too small to be seen with an ultrasound. If the gallbladder fills with the isotope, then the patient is given the same hormone the small intestine makes when fat is ingested, called cholecystokinin or Kinetic. This causes the gallbladder to contract and the amount of fluid it empties is calculated. The ejection fraction, or how much the gallbladder empties, is normally greater than 40%. Any amount less than that is abnormal. In some cases, ejection fraction is zero -- this is indicative of significant disease of the gallbladder. Your physician uses these tests and information to determine if gallbladder surgery is needed.
There are three ways to remove the gallbladder (cholecystectomy). Open gallbladder surgery to remove the gallbladder is now only done in cases where there is severe infection or inflammation. It requires an incision under the right rib cage or in the upper midline of the abdomen. This requires a few days in the hospital for pain management and then a 4 to 6 week recovery.
The two most common techniques now involve the laparoscope or robotically assisted laparoscopic surgery. The robotically-assisted gallbladder surgery, preferred by some surgeons, allows the operating surgeon to control the laparoscopic instruments with robotic arms. The surgeons control the laparoscope and operating instruments from a console using hand controls and a monitor that shows the image from the laparoscope. This technique usually involves three punctures -- one at the belly button or umbilicus for the laparoscope and two others that are placed by surgeon’s preference for the operative instruments. With the laparoscopic cholecystectomy, there are usually three or four punctures. Again, one is placed at the umbilicus for the laparoscope and then, for the operative instructions, two in the upper midline (Dr. Martin’s technique) or three across the right upper abdomen (Dr. Woodyard’s technique). These two outpatient procedures are usually done as a same-day surgery. Recovery is much quicker and usually leads to full recovery by two weeks.
Most patients return to their preoperative diet, although, in most cases, a low fat diet is preferable. There can still be foods that can cause problems and need to be avoided. Diarrhea can occur but is usually effectively treated with medication.