Gallstones and Gallbladder Disease - Surgery

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• Possible or known injury to major blood vessels.
• Internal structures not clearly visible.
• Unexpected problems that cannot be corrected with laparoscopy.
• Common bile duct stones that cannot be removed with laparoscopy or subsequent ERCP.
• Previous endoscopic sphincterotomy.
• A thickened gallbladder wall.

Complications and Side Effects of Surgery.

• Pain and fatigue are common side effects of any abdominal surgery. Patients should abstain from light recreational activities for about two days and from work and more strenuous activities for about a week.
• There is a relatively high incidence of nausea and vomiting after laparoscopic cholecystectomy, which can be treated with injections of metoclopramide. Preoperative anti-nausea agents, such as granisteron, may prevent these effects. One study reported that patients who received a local anesthesia at the incision sites (in addition to general anesthesia) before surgery had less pain and nausea afterwards.
• Injury to the bile duct. Bile duct injury is the most serious complication of laparoscopy. It can include leakage, tears, and the development of narrowing (strictures) that can lead to liver damage. In order to minimize such injuries, some experts recommend that surgeons perform laparoscopy with a procedure called cholangiography, in which a dye is injected into the bile duct and x-rays are used to view the duct. Bile duct injury has been a more common problem than with the open procedure but increasing surgical experience and the use of cholangiography is reducing this complication and studies are now reporting more comparable rates between the two procedures.
• In about 6% of procedures, the surgeon misses gallstones or they are spilled and remain in the abdominal cavity. In a small percentage of these cases, the stones cause obstruction, abscesses, or fistulas (small channels) that require open surgery.
• As with all surgeries, there is a risk for infection, but it is very low.

Patients should not be shy about inquiring into the number of laparoscopies the surgeon has performed. (It should not be fewer than 40.) Obese patients were originally thought to be poor candidates for laparoscopic cholecystectomy, but recent research indicates that this surgery is safe for them.

Open Cholecystectomy

Before the development of laparoscopy, the standard surgical treatment for gallstones was open cholecystectomy (surgical removal of the gallbladder through an abdominal incision), which requires a wide incision and leaves a larger surgical scar. The patient usually needs to stay in the hospital for 5 to 7 days and may not return to work for a month. Complications include bleeding, infections, and injury to the common bile duct. The risks of this procedure increase with other factors, such as the age of the patient or if the surgeon needs to explore the common bile duct for stones at the same time.

Other Procedures

Percutaneous Cholecystostomy. Percutaneous cholecystostomy is a procedure that may be used in seriously ill patients with severe gallbladder infection who cannot tolerate immediate surgery. It is also the standard treatment for patients with acalculous cholecystitis (gallbladder inflammation without stones). This procedure uses a needle to withdraw fluid (aspirate) from the gallbladder. A drainage catheter is inserted through the skin and into the gallbladder while the fluid drains out. In some cases, it may be left in place for up to 8 weeks. After that time, if possible, laparoscopy or an open cholecystectomy may be performed. Without a laparoscopy, recurrence rates with this procedure are high.

Gallbladder Aspiration. With this procedure, fluid is aspirated in one procedure while the gallbladder is viewed using ultrasound. It does not require an indwelling catheter afterward and may have fewer complications than percutaneous cholecystostomy.

Investigative Procedures

Mini-Laparotomy Cholecystectomy. Mini-laparotomy cholecystectomy uses small abdominal incisions but, unlike laparoscopy, it is an "open" procedure and the surgeon does not operate through a scope. The surgical instruments used are very fine caliber (2 to 3 mm in diameter, or about a tenth of an inch). Eventually this technique may reduce operative time and improve results compared to laparoscopy.

Needlescopic Cholecystectomy. Procedures that use even fewer and smaller incisions than laparoscopy are being developed. There are many variations, including those referred to as twin-port, mini-site, or mini- or micro-laparoscopic surgeries. These procedures make even fewer incisions (two to three) and smaller ones (1.2 to 3 mm, or less than a tenth of an inch). It should be noted, however, that these procedures still require one large incision (10 to 12 mm, or about half an inch). They are still investigative and have some disadvantages:

• Fiberoptics, used to view the surgical areas, do not provide light that is as bright as light in conventional laparoscopy.
• The instruments are very fragile.
• The field of vision is very limited.

Although experience is very limited, studies are showing promise for reducing postoperative pain and improving recovery time beyond that of standard laparoscopy.

Telerobotic Surgery. In one high-tech experiment, a woman in Stasbourg, France had her gallbladder successfully removed by surgeons in New York using laparoscopy controlled by a remote robotic device. The procedure took 54 minutes and was free of complications.

Review Date: 06/12/2006
Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital