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What does the gallbladder and bile do?

Bile is made in the liver. It is passed into tiny tubes called bile ducts. These join together (like the branches of a tree) to form the main bile duct. Bile constantly drips down the bile ducts, into the main bile duct, and into the gut.

The gallbladder lies under the liver on the right side of the upper abdomen. It comes off the main bile duct and acts as a ‘reservoir or storage tank’ which stores bile. The gallbladder contracts (squeezes) when we eat. This empties the stored bile back into the main bile duct and into the duodenum (the first part of the gut after the stomach).

Bile helps to digest food, particularly fatty foods.

What are gallstones?

Patients develop gallstones when the bile becomes thick, allowing cholesterol, bile and calcium to form crystals. Over some years, the crystals join together to form stones, which may be many and small, or single and large. About 1 in 3 women, and 1 in 6 men, form gallstones at some stage in their life. The risk of forming gallstones increases with pregnancy, obesity, age and if you take certain medicines.

What problems can gallstones cause?

Usually none. In over two thirds of people with gallstones the stones stay in the gallbladder and cause no symptoms. Gallstones are often found when the abdomen is scanned or x-rayed to find the cause of abdominal symptoms. If gallstones are found this does not always mean that they are the cause of symptoms. They may be, but gallstones are sometimes blamed for causing symptoms which are due to other causes.

About 3 in 10 people with gallstones develop symptoms or problems. These include:

Biliary colic: This is a severe pain in the upper abdomen. The pain is usually worst to the right-hand side, just below the ribs. It is caused by a stone that gets stuck in the exit to the gallbladder or the small tube (cystic duct) that takes bile from the gallbladder to the bile duct. The gallbladder then squeezes hard to dislodge the stone, and this causes pain. The pain eases and goes if the gallstone is pushed out into the bile duct (which then usually passes out into the gut, or if it falls back into the gallbladder. Pain can last just a few minutes, but more commonly lasts several hours. A severe pain may only happen once in your lifetime, or it may flare up from time to time. Sometimes less severe but niggly pains occur now and then, particularly after a fatty meal when the gallbladder contracts most.

Inflammation of the gallbladder : This is called cholecystitis. This can lead to infection in the gallbladder. Symptoms usually develop quickly and include abdominal pain, fever, and being generally unwell. You will normally be admitted to hospital to have this treated and usually require the gallbladder to be removed in due course.

Jaundice : This is uncommon complication of gallstones. It occurs if a gallstone comes out of the gallbladder, but gets stuck in the bile duct. Bile then cannot pass into the gut, and so seeps into the bloodstream. This causes you to go yellow (jaundiced). The stone often passes into the gut on its own and a scan (ultrasound or Magnetic Resonance MR) may confirm that this has occurred. However, it may be necessary to have a telescope test (ERCP) to improve a gallstone which has become stuck in the bile duct. (Note: there are many other causes of jaundice apart from gallstones.)

Pancreatitis: This is an inflammation of the pancreas. The pancreas makes a fluid rich in enzymes (chemicals which digest food). The pancreatic fluid travels down the pancreatic duct. The pancreatic duct and bile duct join together just before opening into the duodenum. If a gallstone becomes stuck here it can cause pancreatitis which is a painful and serious condition.

Other complications Occasionally occur such as severe infection of the bile duct (cholangitis), and other uncommon gut problems.

What treatments are available for gallstones?

1. Conservative Treatment ( i.e do nothing) 2. Operation

Over two thirds of patients with gallstones do not have any symptoms. If you are having no problems, gallstones are best left alone. If you do have pain or jaundice, it is likely that these will recur, although it may not be for several months. A low fat diet and antibiotics can reduce the frequency of attacks, but will not usually stop them completely. They do not cure the condition and symptoms are likely to come back. There is a small risk that you may develop the above mentioned life-threatening complications. Therefore, unless the risks of operation are considerable, surgery is often advised. Your doctor will discuss the risks in your case and advise you on what is best, but the final choice is yours.

Investigations before your Operation

Almost all patients get an Ultra sound scan to diagnose gall stones. This is where you have jelly put on your tummy and images are seen on a machine. Its somewhat similar to a “scan” that pregnant women have, though not quite the same. It gives the doctor an idea about the gall bladder, gall stones and the connecting tubes and helps in deciding further treatment direction.

If you have jaundice or pancreatitis, you may require a magnetic resonance scan (MR) to assess if the stone has moved from the bile or pancreatic duct.

If stones are found before your operation you may need to have a procedure called an ERCP, (Endoscopic Retrograde Cholangio Pancreatography). This is where a small telescope is passed down your oesophagus (gullet), to the gallbladder, in order to make sure that the bile ducts are clear of stones so that keyhole surgery to remove the gallbladder can be performed. Occasionally other surgical procedures may be needed if a stone gets stuck in the bile duct and cannot be removed by ERCP.

What are the benefits of surgery?

Cholecystectomy is the operation to remove the gallbladder. It is designed to treat the pain or to prevent further attacks of jaundice or pancreatitis. Bloating, belching wind, heartburn and bowel symptoms may not be due to gallstones and are not always made better. It is necessary to remove the gallbladder rather than just the stones. If only the stones were removed and the gallbladder left inside more stones would form. Gallstones are treated surgically by removing the gallbladder containing the stones. Your body will function perfectly well without a gallbladder and new stones will not be made.

There are no serious long-term consequences of cholecystectomy, although many patients find that their bowel actions are a little looser for a while afterwards. Surgery should result in you being free of pain and able to eat a normal diet. It should also prevent the complications that gallstones can cause. A laparoscopic cholecystectomy is probably the most common minimally invasive operation, with some 50,000 being carried out annually in the UK, and 5,00,000 in the USA. The laparoscopic (Keyhole) approach requires different skills from the traditional “open” operation, but is safe providing that the surgeon is properly trained and experienced.

What does the operation involve?

As in any laparoscopic procedure, the operation begins by passing carbon dioxide gas, usually through a small incision placed just under the umbilicus (navel, belly button). When the abdomen (tummy or belly) is sufficiently stretched, four special tubes are placed across the tummy, the so-called “keyholes”. One is used for the video camera, the others to manipulate the gallbladder away from the lower right edge of the liver, using electronic scissors. The cystic duct and the artery to the gallbladder are clipped with metal clips(that cause no problems) and divided. The gallbladder containing the stones is finally removed through one of the keyholes, and the keyholes closed with dissolving stitches or glue. The gallbladder will usually be sent to the pathology laboratory for examination.

Sometimes, a small plastic drain is inserted through the skin for a day or two to take away any excess fluid or blood. The drain and its removal do not hurt.In about 5 in 100 patients, it will not be possible to complete the operation using the Key-Hole technique. The open operation involves the same steps as described above. However, this operation is carried out through a single, larger cut, usually just under the right ribcage. This will result in a longer hospital stay and recovery.

With laparoscopic cholecystectomy, you probably will only have to stay in the hospital overnight and be back to normal in about one week. With open cholecystectomy, you would need to stay in the hospital for about 5 to 7 days and it may take up to six weeks to recover. However, once you have recovered, there is no difference between the Key-Hole and Open surgery.

What are the benefits of Laparoscopic surgery?

The main advantage of laparoscopic surgery is not the obvious cosmetic one, but the reduced level of pain. This is the principal reason for its popularity. Unlike traditional open surgery, laparoscopic surgery to remove the gallbladder can be done without cutting the muscles of your abdomen. The incision is also much smaller, which makes the recovery quicker. The less painful the surgery is, the quicker you recover.

With laparoscopic cholecystectomy, you may return to work more quickly, have less pain after surgery, have a shorter hospital stay, and have a shorter recovery time.

Who shouldn’t have this type of surgery?

If you had surgery in the area of your gallbladder before, if you tend to bleed a lot, or if you have any problem that would make it hard for your doctor to see your gallbladder, an open surgery may be better for you. Your doctor will decide which type of surgery is appropriate for you.

What can I do to help make the operation a success?

Lifestyle changes

If you smoke, try to stop smoking now. There is strong evidence that stopping smoking several weeks or more before a general anaesthetic reduces your chances of getting complications. If you are overweight, losing weight will reduce your chances of developing complications.

Medication: You should continue your medication unless you are instructed otherwise. If you are on warfarin or aspirin, you will need to stop taking it before the operation. Make sure your surgeon is aware you are on these drugs and follow the advice about stopping it.

What risks or complications can occur?

Generally speaking, laparoscopic surgery is safe in the hands of an experienced surgeon.

Some surgeons may prescribe medication to reduce the risk of complications. Most operations are successful with few complications. However, every procedure has risks and potential complications. Those most relevant to this operation are listed below. Please discuss them with your doctor if there is anything you do not understand.

Complications can be related to the anaesthetic, general complications of any laparoscopic operation and complications specific to this operation.

Preparing for your operation

Before your operation you will be seen by an anaesthetist. he will check whether you are fit for surgery and will be able to answer any questions that you may have.

The Pill: because of the slight increased risk of blood clot formation, if you are taking the pill, it is recommended that you stop at least 4-6 weeks before your surgery. You will need to use an alternative method of contraception during this time. Please check with your doctor as practice varies from place to place.

Hormone Replacement Therapy: If you take HRT, then you do not need to stop this before your surgery.

Most patients will be given an injection in their abdomen to thin the blood or/ and may have to wear compression stockings during the operative period to help prevent clots forming in their legs.

This practice varies from place to place & depends on your risk of getting blood clots. Ask your doctor regarding the current medical practice in your area.

What arrangements do you need to make?

You must be collected by a responsible adult and escorted home in a car or taxi. Public transport is not recommended.

You must have a responsible adult at home with you for at least 24 hours after your surgery.

You must not drink alcohol, operate machinery or cycle for the first 24 hours.

Preparing for your surgery

Do not eat or drink anything for 6 hours before your operation. Stop smoking the day before. Remove any nail varnish and/ or jewellery before you come into hospital. Do not bring any valuables in with you. Take a bath or shower before arriving on the ward.

Complications of Surgery

The future

Most patients make a full recovery and can return to normal activities including a normal diet. A small number of patients may have persistent pain or jaundice. If either occurs, you should consult your doctor.

Summary

Gallstones are a common condition best treated by surgery. If left untreated , they can occasionally cause serious complications.

Surgery is very safe and effective. However, risks and complications can occur. You need to be aware of them in order to make an informed decision about surgery. Knowing about them will also help with early detection and treatment.

If you are worried about anything, whether in hospital or at home, ask your doctor. They should be able to reassure you or identify and treat any complications.

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