Gallstones

Gallstones are common with up to 25% of the adult population having them.  The majority of people who have gallstones get no problems from them, and they are commonly found on investigations into other symptoms.  However, they can result in a number of symptoms, including abdominal pain (usually in the right upper abdomen), nausea, vomiting and jaundice (the skin turning yellow, caused by impaired drainage of bile from the liver).  Pain results from stones causing a blockage in the duct that drains the gallbladder; this is called biliary colic.  It is common for fatty foods to bring on biliary colic, since the fat makes the gallbladder contract.  If the blockage persists the gallbladder can become inflamed (“cholecystitis”); patients complain of severe pain, fever and vomiting, and often need emergency hospital admission.  Gallstones can also get into the duct that drains the liver, leading to jaundice or causing inflammation of the pancreas gland (“pancreatitis”).  All of these complications of gallstones can range in severity from mild attacks to life threatening episodes.

The gallbladder is a small pear-shaped pouch in the upper right part of the abdomen, adjacent to the liver.  It stores bile that the liver synthesizes.  Bile is a digestive fluid that helps to break down fatty food.  If a patient has symptoms that mean the gallbladder needs to be removed, the body can function well afterwards since the bile still drains into the gut.

How are gallstones investigated?

A detailed history often indicates that a patient’s symptoms are due to gallstones.  Often there is little to find on physical examination, although there may be evidence of jaundice or abdominal tenderness.  The most useful test to diagnose the presence of gallstones is an ultrasound scan of the abdomen.  This simple, pain-free test (commonly used to scan pregnant women) uses a probe that emits high frequency sound waves, which demonstrate gallstones as the sound waves are reflected off the stones.  Occasionally, further tests are necessary, either to ensure there is no other serious underlying problem, or to assess the ducts that drain the liver and gallbladder.  These most commonly are MRI and CT scans.  Additionally, sometimes patients need a specialized endoscopy (camera) test called an ERCP.  Your surgeon will be able to tell you which tests you need and why.

How are gallstones treated?

Asymptomatic gallstones, found incidentally on a test, can often be safely left alone.  However, there is an argument to consider removing them prior to them giving symptoms, and certainly once the patient has symptomatic gallstones, surgery to remove the gallbladder is appropriate in most people.  Other treatments have been tried, including dissolving the stones and using high-frequency sound waves (lithotripsy) to break them up.  However, removal of the gallstones, together with the gallbladder, remains the gold-standard treatment.

Gallbladder removal (cholecystectomy)

Most gallbladder removal surgery is performed using laparoscopic, keyhole surgery.  This is called a laparoscopic cholecystectomy.  Under a general anaesthetic, 4 small cuts sized 5 – 10mm are made on the abdomen to allow the insertion of operating ports.  Carbon dioxide gas is inserted into the abdominal cavity to create some space for the operation to be performed.  The laparoscope (a long, thin telescope with a light and camera lens at the tip) is passed through one of the ports, whilst operating instruments are inserted through the others.  The gallbladder is freed off the liver and the duct that drains the gallbladder and the arterial blood supply is clipped and divided.  Once the gallbladder is fully freed off the liver it is removed through one of the ports.  The gas is released and the skin incisions closed with dissolvable sutures.  Most gallbladder operations can now be completed using keyhole surgery; however, occasionally it is not possible to finish the surgery laparoscopically and, in this case, a larger incision is necessary.

Most gallbladder operations are done as a day case, although you will feel sore for a few weeks after the operation and will need to take painkillers for this.  It is common to feel pain in the abdomen, as well as pain “referred” to the shoulder tip; the latter of these usually disappears after 48 hours.

What are the risks of laparoscopic cholecystectomy?

Laparoscopic cholecystectomy is a commonly performed, and generally safe, operation.  For most people, the benefits in terms of improved symptoms are much greater than the disadvantages.  However, all surgery carries an element of risk.  Specific complications of laparoscopic cholecystectomy are uncommon, but can include bleeding, infection, leakage of bile from the bile ducts, or accidental damage to other organs in the abdomen (such as the bile duct, bowel, bladder, liver or major blood vessels) requiring further surgery to repair the damage.  There is a chance that it will not be feasible to complete your operation laparoscopically and a larger incision will be necessary.  In the longer term, some people experience ongoing abdominal symptoms, such as pain, bloating, wind and diarrhoea.  These may require further investigation and treatment.

Your surgeon will be able to discuss with you the risks involved in the surgery and answer any questions you might have.

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