Cholecystectomy, or gallbladder surgery, is one of the most common surgical invasions. When open surgery is performed, the gallbladder is removed via a big incision in abdomen. The aim of the operation is to eliminate discomfort connected to the gallstones appearing in a bladder.
The purpose of the gallbladder is to accumulate bile. The bile is needed to digest the fats, but bile can thickening and create the blockages, and there are some hard substances in the gall that are stay in gallbladder and became a base of growing gallstones. Gallstones cause the pain and, finally, become disturbing condition. They could cause infections and gallbladder attack.
Interventions on the gallbladder are among the most common operations in Germany. Around 175,000 women and men are operated on each year. The reason is usually that gallstones have caused complaints or complications. But they are often harmless; many people have gallstones without realizing it. If symptoms occur, they are faced with the question of whether they should only treat the symptoms or have surgery.
Gallstones arise from thickened bile. Up to one liter of bile is formed in the liver every day. It is important for the digestion of fats in the intestine. Most of the bile flows directly into the small intestine through the bile ducts after eating. The rest is stored and thickened in the gallbladder between meals. The gallbladder, a small pear-shaped hollow organ, is on the right side of the abdomen below the liver.
The operation to remove the gallbladder can in most cases be carried out gently using keyhole surgery. Nine out of ten patients are treated in this way. In this way, the instruments, camera lenses and light sources are guided into the inside of the body and operated there through significantly smaller incisions than in the “open procedure”. In principle, deaths from gallstones are extremely rare in Germany. The data fluctuate between 0.04 and 0.8 percent - in other words, one out of 2,000 operated patients dies on average as a result of the procedure. These are often high-risk patients, such as those with severe cardiovascular disease or pneumonia.
Common diseases of the gallbladder
In bile duct atresia, the bile ducts outside the liver are not properly formed before birth. The bile can not drain. Immediately after birth or a little later, the newborns get jaundice (jaundice). The bile flow can only be produced by surgically connecting a section of the intestine to the liver port. Often a liver transplant is necessary in the long term.
About 15% of women and 7.5% of men have gallstones. However, 75% of the gallstone carriers have no complaints. In the other gallstone carriers it comes more or less regularly to attack-like pain (colic), pressure or fullness in the upper abdomen, bloating and other complaints. Gallstones can cause the gall bladder to become inflamed, break a stone in the intestines or abdominal cavity, or cause a stone to "slip" into the common bile duct and block the bile duct into the duodenum, leading to jaundice, the biliary tract or the pancreas may become inflamed (cholangitis, pancreatitis) or an abscess may form in the liver Gallstones can be treated with medication, and the gallbladder is removed in an operation (cholecystectomy).
Inflammation of the gallbladder
Inflammation of the gallbladder can be acute or chronic. If the disease is not detected or treated in time, pus may accumulate in the gallbladder.
Because the gall bladder is close to the duodenum and the colon, inflammation of the gallbladder can cause the gallbladder to grow together with the intestinal wall and form a connection between the gallbladder and large intestine (fistula).
Inflammation of the bile duct
An inflammation of the bile ducts can be caused by blockages of the biliary tract by gallstones, by malignant tumors of the pancreas (pancreatic carcinoma) or by infection with bacteria, viruses or parasites.
Tumors of the gallbladder
Gallbladder and bile duct tumors can cause extrahepatic bile duct obstruction. Symptoms may be completely absent, but are often constitutional or reflect a bile duct obstruction. The diagnosis is based on the presentation of the bile ducts with ultrasound plus computed tomography, MRCP or ERCP. The prognosis is bad. Mechanical bile drainage can often relieve itching and prevent recurrent cholangitis.
Cholangiocarcinomas and other bile duct tumors are rare (1-2 / 100,000 individuals). Benign tumors of the biliary tract are very rare. Cholangiocarcinomas occur in the majority in the extrahepatic bile ducts: 60-70% in the hilum area (so-called Klatskin's tumor), about 25% in the distal ducts and the remainder in the liver. Risk factors include PSC, older age, liver fluence and choledochal cyst.
Gallbladder carcinomas are rare (2.5 / 100,000 people). It is more common in North American Indians, in patients with large gallstones (> 3 cm), and in patients with severe gallbladder calcification due to chronic cholecystitis (porcine gallbladder). Almost all (70 to 90%) of the patients also have gallstones. The median survival is three months. Healing is possible if the cancer is detected early (eg accidentally in a cholecystectomy).
Gallbladder polyps are usually asymptomatic benign mucosal linings that bulge into the lumen of the gallbladder. Most have a diameter more then 10 mm and consist of cholesterol ester and triglycerides. They are found in about 5% of people during an ultrasound scan. Other, less common, benign polyps are adenomas and inflammatory polyps. Small gallbladder polyps are incidental findings that do not require treatment.
Symptoms and complaints
In most patients with cholangiocarcinoma, the condition is manifested by the appearance of itching and painless occlusion, typically between the ages of 50 and 70 years. Early perihilar tumors cause only vague abdominal pain, anorexia and weight loss. Other signs may include fatigue, an acholeic stool, a palpable mass in the abdomen, a hepatomegaly or a gallbladder hydrops (Courvoisier sign in distal cholangiocarcinoma). Pain can be similar to biliary colic (as a manifestation of occlusion) or constant and progressive. Sepsis (as a result of acute cholangitis), although uncommon, can be triggered by an ERCP.
Manifestations of gallbladder carcinoma range from accidental detection in cholecystectomy performed to alleviate biliary pain, to cholelithiasis to advanced disease with persistent pain, weight loss and a palpable abdominal tumor or obstructive jaundice.
Most gallbladder polyps do not cause symptoms.
- Sonography (sometimes endoscopic), followed by CT cholangiography or MRCP
- Sometimes ERCP
The suspicion of cholangiocarcinoma and gallbladder carcinoma is due to unclear extrahepatic obstruction. The laboratory tests reflect the degree of cholestasis. In patients with primary sclerosing cholangitis, serum carcinoembryonic antigen (CEA) and CA19-9 are routinely used to detect bile duct carcinoma.
The diagnosis is based on ultrasound examination (or endoscopic ultrasound examination), followed by CT cholangiography or magnetic resonance cholangiopancreatography (MRCP) (liver and gallbladder imaging). CT is sometimes performed, it can give more information than sonography, especially in gall bladder carcinomas. If these methods do not provide a reliable result, ERCP will be required. The ERCP can not only image the tumor, but can also make a cytologic diagnosis with brush swabs so that sometimes an ultrasound or CT-guided needle biopsy becomes unnecessary. Contrast-enhanced computed tomography can be used for staging.
An open laparotomy is performed to determine the extent of the tumor, which then determines the further therapeutic procedure.
- In case of cholangiocarcinoma, stenting (or another bypass procedure) or occasional resection.
- In gallbladder carcinoma usually symptomatic treatment.
- In cholangiocarcinomas, a stent insert or a surgically created bypass relieves itching, jaundice, and perhaps fatigue.
Hilary cholangiocarcinomas, which show further spread in imaging, are supplied by PTC or ERCP through a stent. Cholangiocarcinomas in the distal duct are endoscopically supplied with a stent by ERCP. If there is a suspicion of localized cholangiocarcinoma, surgical exploration determines possible resectability through hilar resection or Whipple pancreatic ductectomy. However, a successful resection is often not possible.
A liver transplant is not indicated because of the high recurrence rate. Efficacy of adjuvant chemotherapy and radiotherapy for cholangiocarcinoma has not been proven to date.
The majority of gallbladder carcinomas are treated symptomatically.
Gall bladder attack is a sudden acute pain, which is spreading in the right shoulder blade area. Sometimes this condition could worsen with the symptoms of acute cholecystitis as fever, nausea, vomiting. The other symptoms are:
- Abdominal Pain;
- Pain After Meals;
- Whites of the Eyes Yellowing;
- Yellow Skin;
- Tightness of abdomen.
To avoid those unpleasant effects, a removing of the gallbladder together with the stones are performed. There are also some other causes of removing of the gallbladder.
Indications to Cholecystectomy are:
- Biliary dyskinesia;
The Types of Gallbladder Surgery
There are two main techniques to treat the gallbladder:
It is approximately 5-10 % when open rather than laparoscopic surgery for gallbladder is required. It is often performed in a complex treatment or when there are other complications, as inflammation, bleeding, and injury.
The laparoscopy is preferable always when possible but classical method through the big abdominal incision is also used.
Laparoscopic Surgery of Gallbladder
Development and implementation of laparascopic cholecystectomy is a milestone event in the sphere of gallbladder surgery, particularly in treatment of stones. Over a few years, laparascopic surgery gained recognition among the community of surgeons, and today the procedure is successfully incorporated in many German clinics.
Laparascopic cholecystectomy boasts a number of advantages versus laparotomy (involving dissection of the abdomen), such as shorter stays in hospital, lower risk of post-surgery aggravations and quick rehabilitation. Besides, laparoscopic gallbladder surgery has aesthetic benefits, since small incisions leave only minor scars.
It should be noted, however, that laparascopic cholecystectomy is a complex surgery that requires pinpoint accuracy and expertise in the topographic anatomy of the area and high-precision image-guided laparoscopic manipulation.
Laparoscopy indications are the same as laparotomy indications, since both pursue the universal goal of gallbladder removal. Chronic calculous cholecystitis is the key indication, and neither size nor number of concrements (gallstones), nor the length of the disease, should be regarded as major factors in choosing between traditional laparotomic and laparoscopic surgery.
chronic calculous cholecystitis: cholesterosis and polyps; acute cholecystitis (the first 48 hours following the beginning of the onset); asymptomatic cholecystolithiasis (silent gallstones).
- Indications for laparoscopic surgery in patients dealing with ‘silent cholecystolithiasis,’ particularly with small-size and large-size concrements, arise from the fact that weakness or absence of symptoms do not rule out the possibility of aggravations, such as migration of small-size stones to the cystic or choledochous bile duct or gallbladder wall necrosis caused by large stones.
Contraindications for laparoscopic cholecystectomy
General contraindications include diseases and conditions, which put the necessity of laparoscopic examination or operation to doubt in cases whereby they can cause serious aggravations, such as:
- pronounced cardiac and pulmonary disorders;
- incorrigible blood coagulation disorders;
- generalized peritonitis;
- late pregnancy;
- class II and Class III obesity.
Local contraindications can be revealed both prior to and during a laparoscopic examination or surgery:
- intrahepatic problems;
- pronounced cicatrical/infiltrative gallbladder neck and hepatoduodenal ligament abnormalities;
- mechanical jaundice and acute pancreatitis;
- gallbladder malignancy;
- history of upper abdominal surgeries.
- pre-operative assessment.
Laparoscopy requires a thorough clinical examination, which should be as extensive as those performed prior to traditional gallbladder surgeries. Ultrasonic test is mandatory as long as it appears to be the most effective cholecystholithiasis diagnostic method.
Laparoscopic cholecystectomy stages
Laparoscopic surgery comprises several phases:
- pumping gas into the abdominal cavity (carbon dioxide or nitrogen oxide);
- introduction of instruments into the abdominal cavity through trocars to examine abdominal organs;
- separation of adhesions, extraction of the elements of the hepatoduodenal ligament (gallbladder artery and duct), their dissection and closure (clipping);
- extraction of the gallbladder from the liver;
- extraction of the gallbladder from the abdominal cavity, final revision of abdominal organs and completion.
- post-surgical rehabilitation lasts one to two weeks depending on the type and intensity of professional and physical workload.
It takes about a week or more to return to the normal activities, maybe, less for patients who had laparoscopy. There is no special diet.
During a several months after cholecystectomy the patient could experience the old signs as gallbladder is still there. It is a paradox, but you should have the same symptomatic treatment as before when having gallbladder attack. How is it possible? It easily could mean that the stones are still presented but now in a bile duct, that is called choledocolithiasis. Treatment of this condition could be done with endoscopic retrograde cholangio-pancreatography.
Side Effects and Complications
With removing the gallbladder the problem of the bile stones is not removed, as it is could appear in liver and bile duct.
The regulation of bile is impaired, sometimes you could have too little bile produces or, opposite, is too much, which is harder to control.
There are some other effects, but the main thing is that you should think enough before having gallbladder removal, as the same signs could be a result if different diseases and getting cholecystectomy you might have all the problems again but without gallbladder.
For successful treatment, it is very important to choose a right place for the procedure, where you could have complete examining with a specialist. The many German hospitals have specializes liver centers which treats with the problems of the liver, bile ducts, gallbladder using the comprehensive methods. The precise diagnostic is a base of the correct treatment, sometime it is difficult to make a choice between surgery and non-surgical methods. If you have some doubts, please apply for a consultation in one of the clinics in Germany.
How is life without a gallbladder?
The removal of the gallbladder has no significant effect on the production of bile, which is still available for digestion. Is the gallbladder an unnecessary organ?
Definitely not! The gallbladder itself is not responsible for the production, but serves as a sort of container for the liquid. If this is not enough, it will not be possible to deliver a large amount to the small intestine, but only the amount that the liver can produce.
As a result, the supporting function of digestion is restricted to a certain extent.
Specifically, this means:
- Many people do not feel any effects on their diet after gallbladder surgery.
- Few people have a fundamentally intact digestive system, but have problems with large, high-fat meals.
- Very few people have general problems with digestion.
If a particular, often flatulent food is not tolerated, this manifests itself some time after the operation through complaints such as flatulence, abdominal pain or diarrhea. The technical term for this is Postcholezystektomiesyndrom (post = after, chole = bile, cyst = bladder, ectomy = distance, syndrome = symptom complex).