Gallstones

Gallstones
Originally uploaded by Sapna Kapoor

Laparoscopic gallbladder surgery (Laparoscopic cholecystectomy)

Gallstones are removed along with the gallbladder through several small incisions in the abdomen in an operation known as a cholecystectomy. Most gallbladders should be removed using keyhole surgery techniques (Laparoscopic cholecystectomy) as this is now considered to be the best standard of treatment. The surgeon inflates your abdomen with air or carbon dioxide in order to see clearly. This is done under a full general anaesthetic and usually takes 30 - 60 minutes depending upon surgeon and patient’s condition, in total you spend 2 to 3 hours inside Operation Theater for pre and post operation procedures (mainly anesthesia).

A small telescope (or laparoscope) is passed through an incision next to the umbilicus and carbon dioxide put in to insufflate the abdomen and create a large space to visualize the gallbladder. Three other tiny incisions are made one at upper abdomen and 2 beneath the right rib cage to allow the passage of the specialized laparoscopic instruments. The surgeon then uses a video monitor as a guide while inserting surgical instruments into the other incisions to remove your gallbladder. The gall bladder (with the stones inside) is detached from the bile duct and the liver bed and subsequently removed through one of the incision. The wounds are then closed with stitches (Soluble or non soluble) or with metallic staples on the skin. Genrally the surgeon has to leave in a "drain" - a pipe leading out from the side incision to a plastic bottle which drains some blood, this is normally removed with in 24 to 48 hours depending upon the condition of patent/drained fluid amount.

You can go home the next day after this operation (Your surgeon is best judge). The exact procedure depends very much on the detailed findings at the time of the operation.



Before the operation and the day before the operation:
Your surgeon will ask you to get some tests done in advance, you can get these done a week or so before the operation, bring all reports with you when you take admission to hospital for operation.

Incase you have problems with your blood pressure, your heart, your lungs or you are going through any special therapy inform your surgeon or anesthetist in advance. Bring all your tablets and medicines with you to hospital. You will be checked for past illnesses and may have special tests, incase required.

Nursing staff “prepare” the patient for operation. They ask you to clear all body hair, cut hand & toe nails. Ladies don’t get upset when you are asked to cut your manicured nails and remove nail paint. Don’t wear any kind of jewelry or decorative threads.

Operation day, take bath and wear clothing provided to you by your hospital staff.

Walla!! You are physically ready for the operation. It is not a big operation (If Laparoscopic) so don’t worry.
Make sure you have a relative or friend who can come with you to hospital, take you home, and look after you for the first week after the operation.



After the operation

Your recovery is divided in to 3 phases and this phase begins in the recovery room, continues on the hospital and ends with a period of convalescence at home.

When the operation is over, you are moved to the recovery room for at least 2 hours. Your state of consciousness, your pulse, your oxygen level, your breathing and any drainage tubes are all monitored. You also have drainage tubes: pipes which draw away any secretions which might build up in the stomach.

In the evening (if you are operated in morning) or on the day following the operation, you will be made to get out of bed. All tubes and drains will be removed over the next day or so. You generally leave hospital on the day following the operation.
You begin eating again progressively, generally the evening after the operation, starting with drinks and then with semi-solid food little by little.

During Laparoscopic operation, your wounds are injected with a pain killing drug during the operation. They are usually only a little uncomfortable. Ask for tablets or even injections if the wounds are troubling you. You may feel blotted, this is caused by the special gas used to help the surgeon see clearly in your tummy during the operation. It settles down as body absorbs the gas. You may notice some discomfort in your shoulder tips for a day or two. A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. Do not make important decisions during that time.


During your convalescence, you will be able to eat normally. There is no need for a special diet, generally doctor’s advice to go slow with food and not take spicy & oily food for few days. Stick to the medicine routine advised by doctor.

Dressings are generally removed next day or day after in hospital or removed at home, either by yourself, or with the help of a nurse. You can wash the wound area as soon as the dressing has been removed with soap and tap water. Make sure that the wound should be clean & dry. Generally doctor’s advice not to use any lotion or cream on wound as soapy water is more adequate.

After laparoscopic ("keyhole") surgery do not expect that there will be no pain at all. There is very little pain - and most people are quite comfortable. The discomfort or stiffness is mostly around the right rib cage area and navel where punctures are made. Occasionally people have right shoulder and neck pain from gas used in the operation - but this subsides as the gas gets absorbed in a day or two. There is sometimes discomfort in the throat from the tube the anesthesiologist has to use, and maybe some soreness over the puncture made on the hand or wrist for a needle.

Most patients are up and around doing domestic activity within 5 days. It is recommended, however, that patients take at least two weeks off work to allow full recovery, and those with strenuous jobs may benefit from having 4 weeks rest.

Recovery is faster. Progressively, you can get back into your usual routine: after 2 to 3 weeks if you have been operated on by laparoscopy.

Possible Complications
Complications are unusual but are rapidly recognized and dealt with by the doctors. If you think that all is not well, please ask the nurses or doctors. Wound infection is a rare problem and settles down with antibiotics in a week or two. Aches and twinges may be felt in the wound for up to few months. Occasionally there are numb patches in the skin around a wound which get better after 2 to 3 months. Sometimes you may feel uneasiness and some pain at/around your naval due to stitch done inside, it will subsequently reduce and disappear. In some patient loss appetite and some nauseating feeling is also observed after few days or few weeks.

Consult your surgeon incase you have any of the above.

Common language for terminology used –

Acute cholecystitis - severe inflammation of the gall bladder due to gall stones and secondary infection.

Acute pancreatitis - severe inflammation of the pancreas caused by gall stones

Bile - a yellowy/brown fluid produced by the liver. About half a litre a day is produced.

Bile ducts - the tubes beneath the liver which collect the bile and drain into the duodenum

Biliary colic - Severe griping pains in the gall bladder caused by gall stones

Cholecystectomy - removal of the gall bladder

Chronic cholecytitis - prolonged inflammation of the gall bladder over many years causing the gall bladder to become scarred and shrink giving rise to prolonged and dull pain in the upper abdomen

Empyema of the gall bladder - Severe inflammation which leads to pus formation within the gall bladder

Jaundice - a yellowy discolorisation of the skin and eyes usually caused by liver disease or obstruction of bile flow down the bile ducts. Gall stones within the bile duct can cause 'obstructive jaundice'.

Laparoscopy - a telescope (keyhole) examination of the inside of the abdomen

Laparoscopic cholecystectomy - the keyhole removal of the gall bladder

Symptoms

Many patients with gallstones never experience symptoms. However, as many as one-half of all gallstone patients eventually experience one of the following:

Colic -- Colicy pain usually occurs after meals when the gallbladder contracts. During this process, gallstones can lodge in the outlet neck of the gallbladder or even in the main bile duct to the intestine. This situation causes intermittent, often severe pain, which is experienced in the upper-middle or right side of the upper abdomen, or even in the right shoulder and, sometimes, under the breast bone. Colic attacks last from a few minutes to several hours.

Gallbladder Inflammation -- Occasionally, the stones irritate the gallbladder to such an extent that active and acute inflammation results. This condition produces steady, dull, and usually severe pain in the upper-right abdomen. This is known as acute cholecystitis. It is a serious condition.

Yellow Jaundice -- When a gallstone becomes permanently lodged in the main bile duct, the bile flow is blocked and cannot reach the intestine. Therefore, bile backs up in the liver and spills into the blood. The skin turns yellow, the urine dark and, perhaps, the stool white, since it is bile that colors the stool brown.

Other Symptoms -- Gallstones are frequently blamed for causing indigestion, nausea, and intolerance to fatty foods. However, it has been found that persons without gallstones experience these symptoms as frequently as those with stones. Therefore, the physician cannot be certain that gallstones are causing these symptoms.

As gallstones move into the bile ducts and create blockage, pressure increases in the gallbladder and one or more symptoms may occur. Symptoms of blocked bile ducts are often called a gallbladder “attack” because they occur suddenly. Gallbladder attacks often follow fatty meals, and they may occur during the night. A typical attack can cause steady pain in the right upper abdomen that increases rapidly and lasts from 30 minutes to several hours, pain in the back between the shoulder blades and pain under the right shoulder

If stones escape from the gallbladder they can block the bile ducts and cause pain, fever and yellow jaundice.
For confirmation an ultrasound scan is done which usually identifies the majority of stones.

Gallbladder

The gallbladder is a pear-shaped organ that rests under the liver in the right upper abdomen. The liver produces bile, a yellow liquid needed by the intestine to help digest fat and oils. Ducts, or tubes, carry bile from the liver to the gallbladder and on to the intestine. Bile is stored in the gallbladder, which contracts periodically to force the bile into the intestine.

Gallstones

How Do Gallstones Form?
Bile is composed of a variety of chemicals, including cholesterol, salts, and certain pigments. The gallbladder absorbs water from the bile, causing it to thicken. In some people, tiny crystals form from the cholesterol and pigments. These crystals gradually grow until one or even hundreds of gallstones develop. About 80 percent of gallstones are composed of cholesterol, while the remainder are made of pigments, salts, and other chemicals.
Do we need gallbladder?

Fortunately, the gallbladder is an organ people can live without. Your liver produces enough bile to digest a normal diet. Once the gallbladder is removed, bile flows out of the liver (where it is made) through the hepatic ducts into the common bile duct and directly into the small intestine, instead of being stored in the gallbladder. Because now the bile flows into the small intestine more often, softer and more frequent stools can occur in about 1 percent of people. These changes are usually temporary, but talk with your health care provider if they persist. In most people, this has no or little effect on digestion.

Why Gallstones form?

Scientists believe cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or not enough bile salts, or when the gallbladder does not empty completely or often enough. The reason these imbalances occur is not known.

The cause of pigment stones is not fully understood. The stones tend to develop in people who have liver cirrhosis, biliary tract infections, or hereditary blood disorders—such as sickle cell anemia—in which the liver makes too much bilirubin.

The mere presence of gallstones may cause more gallstones to develop. Other factors that contribute to the formation of gallstones, particularly cholesterol stones, include sex, family history, weight, diet, rapid weight loss, age, ethnicity, Cholesterol-lowering drugs or Diabetes.
Important points to know

* Gallstones form when bile hardens in the gallbladder.
* Gallstones are more common among older adults; women; American Indians; Mexican Americans; people with diabetes; those with a family history of gallstones; people who are overweight, obese, or undergo rapid weight loss; and those taking cholesterol-lowering drugs.
* Gallbladder attacks often occur after eating a meal, especially one high in fat.
* Symptoms can mimic those of other problems, including a heart attack, so an accurate diagnosis is important.
* Gallstones can cause serious problems if they become trapped in the bile ducts.
* Laparoscopic surgery to remove the gallbladder is the most common treatment

General Comments
The keyhole operation should be straight forward. Patients are often surprised how quickly they get back to normal health. These notes are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctor.

Other options –
Open surgery (Performed if Laparoscopic cholecystectomy is not possible)

Laparoscopic gallbladder surgery is the best method of treating gallstones that cause symptoms, unless there is a reason that the surgery should not be done.

Laparoscopic surgery is used most commonly when no factors are present that may complicate the surgery. Conditions that may require an open surgery instead of a laparoscopic surgery include:

* Severe inflammation or infection of the bile duct (cholangitis).
* Inflammation of the abdominal lining (peritonitis).
* High pressure in blood vessels in the liver. This is caused by cirrhosis of the liver (portal hypertension).
* Being in the third trimester of pregnancy.
* A major bleeding disorder or use of medicines to prevent blood clotting (blood thinners or anticoagulants).
* Scar tissue from previous abdominal surgeries. Scar tissue may make laparoscopic surgery more difficult.
* A severe lung disease, such as emphysema, because the way the abdomen is inflated with air for surgery may make it harder to breathe.

Depending on the surgeon's experience and how severe your condition is, laparoscopic surgery also may not be an option if you have:

* Sudden (acute) inflammation or infection of the gallbladder (although laparoscopic surgery is being done more often in this situation).
* Active inflammation or infection of the pancreas (pancreatitis).
* A minor bleeding disorder.
* Gallstones in the common bile duct. A separate procedure called endoscopic retrograde cholangiopancreatography that is done before or after the laparoscopic surgery can remove stones in the common bile duct.
* Excessive body weight.

Nonsurgical Treatment (This is not used usually)

Nonsurgical approaches are used only in special situations—such as when a patient has a serious medical condition preventing surgery—and only for cholesterol stones. Stones commonly recur within 5 years in patients treated nonsurgically.

· Oral dissolution therapy. Drugs made from bile acid are used to dissolve gallstones. The drugs ursodiol (Actigall) and chenodiol (Chenix) work best for small cholesterol stones. Months or years of treatment may be necessary before all the stones dissolve. Both drugs may cause mild diarrhea, and chenodiol may temporarily raise levels of blood cholesterol and the liver enzyme transaminase.

· Contact dissolution therapy. This experimental procedure involves injecting a drug directly into the gallbladder to dissolve cholesterol stones. The drug—methyl tert-butyl ether—can dissolve some stones in 1 to 3 days, but it causes irritation and some complications have been reported. The procedure is being tested in symptomatic patients with small stones.

Acknowledgements

The above information is based on personal experience and information I have collected from various websites.