Cholecystectomy is an operation done to remove the gallbladder, most often because of gallstones. It is done under general anaesthesia, by either the open (conventional) method, or laparascopically, using a small video camera inserted into the abdomen.
Why is it done?
The gall bladder is a small pouch located under the liver. It releases stored bile which is needed for digestion, whenever food is eaten. The gall bladder may form gallstones (made of cholesterol deposits and mixed salts and minerals), become inflamed, infected or obstructed. Gallstones may obstruct the gall bladder outlet, the main duct or even a duct to the pancreas, causing pancreatitis. Cancer can also occur in the gall bladder. In these cases, cholecystectomy may be needed.
How is it done?
Under general anaesthesia, one of two access routes is used: either
- Open, in which case the surgeon makes a 10-15cm cut in the upper abdomen to expose the gall bladder and surrounding structures; or
- Laparoscopic, when several small cuts are made in the abdomen through which instruments are inserted. The abdomen is inflated with carbon dioxide to lift the belly, giving the surgeon a better view and more room in which to work. A laparoscope with a small video camera is inserted through a second opening, and operating instruments through a third. More recently, a new technique allows this all to be done through a single “port”.
Not all patients are suitable for laparoscopic surgery, especially if they have had previous abdominal surgery which leaves adhesions, making laparoscopic work impossible or too dangerous. Many cases are begun laparoscopically, then converted to the open style if adhesions are seen.
Once the gall bladder is seen, the important structures such as the main and accessory ducts, the common bile duct and main blood vessels are identified. The ducts and blood vessels of the gall bladder are then dissected free, clipped shut with surgical clips, and cut. The gall bladder is freed from its bed under the liver, and removed intact. Bleeding sites from the liver bed and surrounding tissues are cauterised. The surgeon may place a temporary drain in the abdomen before closing the incisions.
In experienced hands, laparoscopic surgery takes about an hour, which is longer than conventional cholecystectomy, but patients seem to have less pain, and heal more quickly.
Gallstone problems occur more often in overweight persons: these patients coming for surgery have a higher operative risk due to the obesity itself, and the associated problems such as diabetes and hypertension.
As laparoscopic surgeons gain more experience and skill, the complication rate becomes almost the same as that for open procedures. The most important complications are:
General, as for any abdominal surgery :
- Anaesthetic problems
- Damage to surrounding tissues
Specific to cholecystectomy
- Bile leak - if a small bile duct is missed and not clipped shut before being cut off, bile leaks into the abdomen. This is a serious condition needing immediate attention.
- Common bile duct injury - major injuries will need special surgery to repair the problem, which may take months to heal. The bile duct may heal but become narrowed in the future, causing further problems. The overall mortality rate of common bile duct injury is up to 5 percent.
- Bleeding: this is more common in laparoscopic procedures, with bleeding from the liver bed or from the sites used for inserting instruments. Also, arteries and veins may not be properly clipped or tied off, causing heavy bleeding when the gall bladder is finally removed. Converting to an open operation may be necessary to control the bleeding.
- Infection may occur if infected gall bladder contents are spilled into the operative area.
Cholecystectomy is generally a safe operation, with a good result. Serious complications are rare, and generally related to the inexperience of the surgeon.
In uncomplicated cases, patients can expect to be discharged from hospital within 3-4 days for open procedures. Laparoscopic patients are often discharged the next day, and they resume normal activities much sooner than do patients who have had open procedures.
(Dr A G Hall)