CHOLECYSTECTOMY

Cholecystectomy (pronounced kō-lē-sis-tĕk-tə-mē) is the medical term for surgical removal of the gallbladder. The gallbladder is a small organ located on the under surface of the liver in the upper abdomen on the right side. Its normal function is to store bile, a substance made by the liver that helps to digest food, and to squeeze and empty bile in response to eating a large meal.

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WHY TAKE IT OUT?

There are several different medical conditions that would cause your doctor to suggest consulting a surgeon for cholecystectomy.

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Biliary dyskinesia is a condition in which the gallbladder does not squeeze as it should to empty bile in response to eating a large meal. These patients typically have symptoms after eating, which consists of bloating, upper abdominal discomfort, and occasional nausea. On ultrasound, the gallbladder looks essentially normal, however on nuclear imaging, the gallbladder does not empty well, thus the diagnosis is made. There are no medications that help the gallbladder squeeze better, therefore to eliminate symptoms the best course of action is cholecystectomy.

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Symptomatic Cholelithiasis (gallstones) is a condition in which gallstones are formed within the gallbladder due to high cholesterol content of bile. Many people have gallstones, but not all have symptoms. Symptoms arise when one or more gallstones get stuck in the duct through which bile empties when the gallbladder squeezes. This results in pain in the right upper abdomen after eating along with nausea and occasional vomiting. On ultrasound, the gallbladder has stones or sludge in it, but otherwise looks normal. No nuclear imaging is necessary. In the past attempts were made at treating this with medication which would dissolve the stones, however it did not work well. We have come to the conclusion that cholecystectomy is the best course of treatment for this disease.

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Cholecystitis is a condition in which the gallbladder is inflamed and infected. This occurs, nearly 95% of the time because of long-standing gallstones. These gallstones block the duct and the gallbladder becomes engorged with bile. Bile stasis results in infection and the patient presents, usually to the emergency department, with complaints of intense abdominal pain, nausea, vomiting, and occasionally fever and chills. On ultrasound, the gallbladder is enlarged and full, there are stones present, and the wall of the gallbladder is thickened with some fluid around the wall. On laboratory work-up, the infection count is elevated but the liver enzymes are typically normal or very mildly elevated. The appropriate treatment is cholecystectomy, and thereby remove the infection source.

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Choledocholithiasis is the presence of gallstones (which originated in the gallbladder) within the common bile duct. The common bile duct is very important because it is the passageway by which bile empties into the intestine. Many patients present with jaundice (yellowing of the skin), itching, upper abdominal discomfort or pain, and nausea. Cholangitis is the more serious form of this disease in which infection has set in due to blockage of the bile system by stones. Cholangitis has a high mortality (death) rate. On ultrasound, the gallbladder usually has stones and can be inflamed or normal. The common bile duct is noted to be enlarged due to the blockage. On lab evaluation, the bilirubin level in the blood is high due to the blockage. The first step in management of this problem is removal of the stones from the common bile duct. This is done most easily by a gastroenterologist through a procedure similar to an esophagogastroduodenoscopy (EGD). The gastroenterologist is able to canulate the small duct from the inside of the intestine and extract the stone. Typically, the following day, a cholecystectomy is performed, because as mentioned above these gallstones originated in the gallbladder. In cholangitis, there may be a delay between removal of the stone from the common bile duct by the gastroenterologist and cholecystectomy due to how critical the patient is at the time.

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Gallbladder cancer is rare, thankfully. It is frequently found in later stages where surgical removal and cure is not an option as gallbladder cancer usually has no symptoms. These can occasionally be found during routine cholecystectomy for suspected gallstones. At which point an additional, larger operation may be necessary depending on the depth of tumor involvement. Once the gallbladder is removed, a portion of the liver must be removed as well in those patients. Due to the aggressive nature of gallbladder cancer, the treatment tends to be just as aggressive. Unfortunately, su

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HOW WILL IT BE TAKEN OUT?

Laparoscopic cholecystectomy is one of the most common operations performed in the United States. It is performed using four small (largest, 1cm) incisions and instruments placed through these incisions to safely and efficiently remove the gallbladder. The abdomen is filled with carbon dioxide to create space for the surgeon to work. The gallbladder is manipulated so that the surgeon is able to clearly visualize the ducts, being careful to divide the cystic duct and avoiding the common bile duct. The gallbladder is then separated from the undersurface of the liver with electrocautery, then removed from the abdomen through the incision near the umbilicus (belly button) as it is typically the largest of the four.

Intra-Operative Cholangiogram is a procedure that may be performed during the gallbladder removal in which a small catheter is placed through the cystic duct and into the common bile duct. Contrast dye is pushed through the catheter while an X-Ray image is being taken. This allows for full visualization of the bile duct system. This is typically done to examine for stones that may have inadvertently fallen into the common bile duct during manipulation of gallbladder removal. It is also an excellent tool for the surgeon to confirm that the duct he/she is about to cut is actually the cystic duct and not the common bile duct.

 

Open cholecystectomy is surgical removal of the gallbladder through a single, larger incision in the right upper abdomen. This operation is done less frequently and is only usually done because laparoscopic removal is not possible or safe. The muscles on the abdominal wall are cut allowing access into the abdominal cavity. The gallbladder is clearly visualized hanging off the undersurface of the liver. The gallbladder is first taken off the liver with electrocautery down to the artery that supplies blood to the gallbladder. This is clipped or tied and divided. Lastly the cystic duct is clipped or tied and divided and the gallbladder is removed. Frequently a drain is left in the space and comes out of the abdominal wall beneath the incision. The abdomen wall muscles are closed with suture and the skin is closed with sutures or staples as by preference of the surgeon.

 

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WHAT ARE THE RISKS OF THIS PROCEDURE?

Every surgical procedure has risks, regardless of how large or small the surgery.

Infection - The risk of infection increases when the gallbladder is taken out for the purpose of infection, such as cholecystitis. A dose of antibiotics is frequently given prior to surgery of all cholecystectomies to prevent infection.

Bleeding – Anytime skin is cut, there is a risk of bleeding. Bleeding can occur at the level of the skin resulting in bruising or can occur at the location of the gallbladder and the liver resulting in a hematoma inside the abdomen which typically presents two or three days after surgery with abdominal pain. These rarely require re-operation and the hematoma is typically reabsorbed by the body.

 

Injury to the Common Bile Duct – This is the most feared complication of cholecystectomy, and thankfully rare, occurring in 1 to 2 of 1,000 cholecystectomies. The common bile duct is essential as it is the passageway by which bile empties from the liver. If this duct is injured, a much larger operation is necessary to reconstruct the duct.

Injury to other Intra-abdominal Organs – This is also quite rare, but any organ is a possibility. If any injuries occur and are noticed during the initial operation, they are typically repaired at that time. If it becomes apparent after the operation, a second operation may be necessary. The incidence of injury is typically higher for those patients who have had previous abdominal operations.

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WHAT SHOULD I EXPECT BEFORE AND AFTER SURGERY?

Prior to surgery, your primary care physician will refer you to a surgeon for removal. The surgeon will get basic information concerning your health, perform a physical examination, and order any remaining laboratory tests which have not already been performed by your PCP. You will be counseled on all the risks of the operation at this visit and scheduled for surgery. You will also be instructed on which medications must be stopped several days before surgery, such as aspirin, Plavix, or Coumadin (warfarin).