The purpose of this page is to give you an overview of gallstones and
gallbladder surgery so that you are well-informed prior to your visit. Keyhole
gallbladder
surgery or 'Laparoscopic Cholecystectomy' is today the "gold standard" treatment
for gallstones. Several thousand gallbladder operations are performed in
Victoria each year. Although the surgery is sometimes considered minor, this is
not the
case and severe complications, although very uncommon, can occur.
Why choose Mr. Michael
Bickford for your gallbladder operation?
Michael has a major interest in the management of patients with gall stone
disease. This practice offers ALL of the procedural options that are required
for complete management of gall stones and their possible complications
including ERCP. Michael was one of the first in Australia to perform keyhole
surgery to remove the gallbladder and now has broad experience with in excess of
4000 operations performed.
Too much information! – just give me the basics!
OK, we understand that some people prefer just the very basics - so here they are. We assume you have gallstones and have had some episodes of pain caused by the gallbladder. These are the basic facts:-
The only effective treatment for gall stones is surgery to remove the gallbladder.
We remove the gallbladder and not just the stones because if you just remove the stones, more stones will form in the following months or years – back to square one!
You will get on perfectly well without your gallbladder.
Removal of the gallbladder is usually done with keyhole surgery but sometimes this is not possible and a large incision is necessary. This is for your safety.
You will probably be in hospital just one night and back to work in 7–10 days if keyhole surgery is possible; if not 4–5 days in hospital, 3–4 weeks off work.
Complications can occur. The main one is accidental damage to the bile duct during surgery. There is only about one chance in 1500 of this happening with an experienced surgeon.
Choose your surgeon carefully and make sure you ask everything you want to know before surgery is performed.
If you want to know more just read on!
Where is the gallbladder and what does it do?
Click on the button above to launch an interactive web
based presentation on Gastro
Intestinal Tract & Hepato Biliary System.
What are gallstones and how do they form?
Gall stones are formed in the gallbladder and vary in size, shape and colour. Some stones contain a large amount of cholesterol and these stones tend to be yellowish in colour. Others are dark green or black in colour and these are pigment-type gall stones.
The liver manufactures bile which travels down the bile duct. Some of the bile is then directed into the gallbladder and concentrated. In susceptible people, the concentration of bile triggers the formation of crystals that slowly grow to form gall stones. This process usually occurs over a number of years, but can occasionally occur quite suddenly such as during rapid weight loss.
Who gets gallstones?
Gall stone prevalence increases with age and by the time we reach our later years, approximately 15% of the population will have developed gall stones. Females are more prone to developing gall stones than males. During pregnancy the function of the gallbladder is diminished and resulting bile stasis appears to make stone formation more likely. Excess weight is another factor that increases gall stone formation and this relates to increased cholesterol content in the bile. Gallstones sometimes run in families.
What are the usual symptoms of gallstones?
When you eat a meal, especially a fatty meal, a hormone is released which causes the gallbladder to contract and squeeze concentrated bile into the bowel. Bile is necessary for the digestion of fat which (when not in excess) is essential to health. Sometimes a stone jams in the outlet of the gallbladder and blocks the bile from getting out of the gallbladder. The gallbladder continues to contract against the stone and this is what causes the pain of a gallbladder attack. In many cases the gall stone will release spontaneously and symptoms disappear. Episodic attacks of pain ranging from mild to very severe are the most common symptoms of gallstones. The pain often occurs during the night or after a fatty meal. The pain is usually situated in the upper part of the abdomen and under the right ribs. The pain often radiates around and into the back on the right side. Occasionally the pain is felt in the lower chest and the symptoms can be confused with a heart attack. If the gall stone fails to release, the gallbladder may become acutely inflamed and this condition is known as acute cholecystitis. In some cases, this may lead to a serious infection with gangrene of the gallbladder. Other symptoms such as nausea, flatulence (belching) and intolerance of fatty foods are often attributed to gall stones but these can be caused by other conditions and may or may not improve after the gallbladder is removed.
How are gallstones diagnosed?
Ultrasound of the abdomen is the standard way of diagnosing gall stones. This is a painless examination that allows the stones within the gallbladder to be seen in the majority of cases. Blood tests to measure the function of the liver and the pancreas may also be used to determine the likelihood of stone migration from the gallbladder into the bile duct. More complicated tests including imaging of the main bile ducts may be necessary involving CT or MRI scans. Occasionally ERCP
is necessary to diagnose and remove stones from the bile ducts.
I have gallstones but no symptoms!
Sometimes gallstones are diagnosed during tests for other conditions, but there have been no symptoms of gall bladder disease. In general we don't recommend removal of the gallbladder in this situation, but each person and situation is different. If, for example, you had gallstones without symptoms and planned to spend a year in the Outback, Antarctica or travelling the world there may be a place for removing the gallbladder even though you have no symptoms. We recommend careful discussion with your surgeon before embarking on gallbladder removal in the absence of symptoms.
I have symptoms of gallstones but no gallstones!
It is recognised that a very few people can have gall stone type symptoms
without gall stones being found. This condition is challenging for both patient
and doctor and requires very careful consideration and multiple diagnostic tests
before going ahead with surgery. In the absence of gallstones no guarantee can
be given about relief of symptoms by surgery to remove the gallbladder.
What are the complications of gallstones?
Some people will endure repeated attacks of gallbladder pain over many years without any complications occurring. However, complications can and do occur and the following should be considered very carefully if you decide not to have surgery for your gallstones. The major complications of gallstones are:
Acute cholecystitis (inflammation of the gallbladder). The stone gets stuck in the outlet of the gallbladder and does not release. First there is a chemical reaction of the bile literally starting to digest the gallbladder causing inflammation and unremitting pain. Then the bacteria naturally occurring in the gallbladder get into the act and the resulting infection makes the situation worse and can lead to gangrene of the gallbladder. Emergency surgery is usually recommended and keyhole surgery may not be possible.
Jaundice (yellow discolouration of the skin and eyes). This occurs when a stone gets stuck in the main bile duct and blocks bile going from the liver to the bowel. There is a backup of bile into the liver which then cannot function properly. Bile is absorbed into the bloodstream and this stains the skin and other organs a yellow colour. Secondary infection of the bile ducts can occur (cholangitis) which can be life threatening. The stone(s) must be removed from the bile duct urgently by ERCP or surgery.
Pancreatitis. A stone in the main bile duct can interfere with the pancreas and cause pancreatitis. This is potentially a life threatening illness and requires hospital treatment by an experienced surgical team.
Cancer. Although rare, cancer of the gallbladder can occur and may be fatal. Cancers usually occur when gallstones have been present for 20 years or more.
What treatment is recommended for symptomatic gallstones?
Providing you have significant symptoms related to gallstones, in almost every case we will recommend keyhole (laparoscopic) surgery to remove the gallbladder. Exceptions are occasionally made for the elderly in whom the attacks are not frequent or severe or those with major illnesses which could make the operation more dangerous than the gallstones.
Can gallstones be treated without surgery?
No. There are no satisfactory means of treating gallstones other than surgery. Both ultrasound disintegration and chemical dissolving of gallstones with tablets have been tried. In only a very few patients is the treatment successful, but even in these cases the stones almost always recur within months or a year or two.
Why take out the gallbladder, why not just remove the stones?
Good question! Firstly, removing just the stones from the gallbladder is extremely difficult and much more dangerous than taking out the gall bladder. More importantly, even if you could just have the stones removed safely, they would almost certainly form again in the coming months or years and it would be back to square one!
How will I get on without a gallbladder?
Quite well actually! The function of the gallbladder is to concentrate and store bile. When you eat a meal, particularly a fatty meal, a large amount of concentrated bile is released into the duodenum. This enables a very large amount of fat to be digested at once. Eating large amounts of fats (which are very high in calories) was, in hunter/gatherer times, very important for survival. In the days of refrigerators and three meals a day this is no longer necessary and may be harmful. With the gallbladder removed, bile is released in small amounts continually into the duodenum. This is adequate for all normal eating situations. However if, after removal of the gallbladder, you were to eat a huge amount of fat at one sitting (which you should NOT do at any time), the fat may not be digested but will pass through the bowel and give you nasty diarrhoea.
The Operation to Remove the Gallbladder - Laparoscopic Cholecystectomy
Laparoscopic cholecystectomy is the medical term for removing the gallbladder
using keyhole surgery. In Australia, laparoscopic cholecystectomy has been
performed for over 13 years. Michael Bickford has extensive experience with this
technique and and was one of the first surgeons in Australia to adopt this
revolutionary operation. The procedure is performed under a general anaesthetic
(that means you are completely asleep!), with only 4 tiny (less than 2cm)
abdominal incisions needed to complete the operation. A telescope with a camera
and light source is inserted through one of the tiny incisions so that the
gallbladder and surrounding structures can be visualised on a television
monitor. The view obtained is very clear and actually magnified to allow precise
dissection of the delicate structures surrounding the gallbladder. Special
dissecting instruments are inserted through the other incisions to allow the
gallbladder to be removed safely. The operation usually takes less than an hour.
The following procedural video of a
laparoscopic cholecystecomy is presented
by
Ethicon Endo-Sugery.
Please note this video is of an actual procedure and contains graphic imagery.
Where are the incisions (cuts) made for surgery? For keyhole surgery four tiny (0.5 to 1.5 cm) cuts are made in the approximate positions shown on the diagram. If open (non-keyhole) surgery is required the cut is about 15-20 cm long under the right ribs as shown.
Is keyhole surgery always possible?
Unfortunately not. For routine surgery, where the gallbladder is not acutely inflamed, at least 95% of gallbladder operations can be performed safely using keyhole surgery. Sometimes, even in routine surgery, it is not possible to be sure exactly which structure is which. This can be related to scarring around the gallbladder from previous attacks of gallbladder pain or sometimes to unexpected bleeding during the operation. In this instance the major concern is that we do not cut the wrong structure. Cutting the main bile duct by error is something we avoid at all costs. If we are in any doubt about the exact anatomy we abandon the keyhole operation, make an incision under the ribs on the right side and safely complete the operation the old
"open" way. Where the operation is performed as an emergency, up to 50% of operations will need to be done with the large incision. If you do wake up after the operation with a large incision instead of keyhole surgery you should be reassured that your surgeon placed your safety and long term health before the convenience of a keyhole operation.
What are the risks of gallbladder surgery?
Warning! This section is not and is not intended to be a comprehensive account of possible complications. Possible complications must be discussed with your surgeon prior to operation.
All surgery involves some risk. Risks can be broken down into two groups, those related to surgery in general and those specific to the operation being performed. Risks of surgery in general include risks of anaesthetics, infections inside the abdomen and in the wound, lung problems, blood clots in the leg or lungs and even death. Death from routine gallbladder surgery is exceptionally rare but has happened. If you have other health problems such as heart or lung problems, diabetes, smoking or excess weight the general risks of surgery are increased. The major risk specific to the laparoscopic cholecystectomy operation is damage to the main bile duct system. This is a very major complication with potentially serious long term problems. This has always been a risk in gallbladder surgery and in the early days of laparoscopic cholecystectomy there was an increase in the number of bile duct injuries. The risk of accidental damage to the main bile ducts with an experienced surgeon is now of the order of one chance in 1500. Other possible complications specific to the laparoscopic cholecystectomy
include bile leakages and infection forming under or around the liver.
What if stones have escaped from the gallbladder into the main bile duct?
Stones can escape from the gall bladder into the bile ducts which carry bile from the liver and gallbladder to the bowel (duodenum). Sometimes these stones can pass harmlessly through the bile ducts and into the duodenum causing either no symptoms or some short lived pain rather like a gallbladder attack. If we suspect gallstones in the main bile ducts before operation we will arrange either a special CT or MRI test to confirm this or will perform an X-Ray of the bile ducts during the keyhole operation to remove the gallbladder. Depending on individual circumstances we may recommend pre-operative ERCP (see below) to remove the stones Alternatives are removal of the stones at operation (either keyhole or through a larger incision) or ERCP after the surgery. If we find bile duct stones unexpectedly at operation we will usually leave these and arrange ERCP in the early postoperative recovery period. Michael has the expertise to decide which of these options is best for each individual patient. The best and most appropriate treatment will be undertaken.
How long will I be in hospital?
Where the operation is completed laparoscopically (keyhole surgery) more than 90% of patients will be able to go home on the day after surgery. Return to normal activities (other than very heavy occupations) is usually possible in 7-10 days. If you needed the open operation (large incision) then hospital stay would be around 4-5 days and return to normal activities in 4-5 weeks.
Costs of the procedure
We will provide you with a full explanation of the costs of the
operation to assist you in deciding to proceed. They will vary depending on your
level of private health insurance.
The Next Step
If you decide to take the next step you will need to ask your
local doctor for a referral to see Mr. Michael Bickford. This referral will need
to include information on your medical history, any past and current medication
you are taking and any investigations you may have had. Once you have this
referral simply contact Mr. Michael Bickford's consulting suites on (03)9210
7277 to make an appointment.
