Gallbladder Surgery

Doctors are not sure why stones form. They seem to occur when there is an imbalance between the chemicals in the bile or when there is a problem with the ability of the gallbladder to expel the bile. It is commonly thought that the hormone estrogen slows down the contraction of the gallbladder.

Gallstones occur more commonly in:

• Women
• Pregnancy
• Rapid weight loss
• Obesity

Yes. There are no long term consequences to removing the gallbladder. If the gallbladder has stones, it is already functioning poorly. The bile duct running between the liver the small bowel enlarges slightly after the gallbladder is removed to take over the bile storage function.

Some people can live their whole lives with gallstones and not experience any problems at all. However, a significant number go on to have symptoms and even life-threatening complications.

Gallstones can cause:

• Severe pain
• Fever
• Jaundice
• Blood poisoning (sepsis)
• Inflammation of the pancreas (a serious problem – pancreatitis)
• Rarely blockages of the bowel

Technically, it is much safer to remove both the gallbladder and stones together. If there are gallstones present, the gallbladder is not functioning properly. There would be no guarantee that gallstones would not form again and cause more problems.

Most commonly, the gallbladder and stones are removed with laparoscopic or “Key-hole surgery.” The operation involves the surgeon making four or more small (5-10mm) incisions on your abdomen. Carbon dioxide gas in then pumped into the abdominal cavity to give the surgeon a space to operate in. A fibreoptic telescope and long instruments are then inserted into the abdomen and the gallbladder is removed along with the stones.
A special X-ray called a cholangiogram is performed during the surgery to ensure no gallstones have escaped from the gallbladder into the bile duct.
The surgeon will secure the stump of the gallbladder and the gallbladder artery with titanium clips that will remain in your abdomen. These do not cause any harm and will not set the metal detectors off at the airport. They do not interfere with MRI.

Conversion to an open operation is not considered a failure in keyhole surgery. Sometimes the surgeon will consider it necessary to make a bigger cut on your abdomen to finish the operation. This is often done if there is a stone that has moved out of your gallbladder and is difficult to retrieve with keyhole surgery. Open operation is performed when the surgeon feels that they cannot complete the operation safely with keyhole surgery. Key-hole surgery can also be more difficult if there has been previous surgery. This is another common reason to convert to open operation. This is considered sound judgment. Open operation involves a slightly longer recovery period.

Other alternatives are:

• Breaking the stones into small fragments with a shock wave (lithotripsy). The danger in this technique is that the small stone fragments can block the flow of bile from the liver and lead to severe infections or inflammation of the pancreas. This technique is only effective in very specific circumstances. This is usually only after surgery has been tried or the patient is too ill for an anaesthetic
• Dissolving therapy. This therapy is unreliable and does nothing to change the reasons the gallstones formed in the first place. It does not stop them from coming back.

Even though the incisions are small, gallbladder removal is still a major operation. Whilst laparoscopic surgery is considered a relatively safe and low risk operation, like all surgery there are a number of serious complications that may occur. It must be stressed, these complications are very rare. Complications are dealt with on a case by case basis. Some of these complications are:

General Risks

• Death: approx. 1/10,000 risk for all patients having this type of operation.
• Bleeding: usually occurs in the first 24 hours and may require further surgery. This bleeding may be from the abdominal wall or from the gallbladder bed.
• Other blood vessel problems: heart attack, stroke. This is very rare.
• Infections: Wound, pneumonia, urine, intra-abdominal, IV line related.
• Clots in the legs that may travel to the lungs and be fatal.
• Wound pain, abnormal (keloid) scarring or hernia of the wound.
• Bowel obstruction due to hernia or adhesions.
• You may require a blood transfusion (this is rare).

Risks Specific to Laparoscopic Cholecystectomy

• Injury to the bile duct – this is very uncommon (1/40000), but if it occurs may result in further operations, infections, liver resection and rarely liver transplantation.
• Leakage of bile into the abdominal cavity related to failure of the titanium clips used to seal the pipe the gallbladder was attached to. This may lead to a further operation. Additionally there may be leakage of bile from the liver bed.
• Retained gallstones: Gallstones may float out of the gallbladder and up into the bile ducts in the liver. These stones are difficult to detect at operation. Rarely, you may experience another attack of pain caused by a retained gallstone and need a further procedure to remove this stone.
• Injury to any organ in the abdomen: bowel, aorta, liver, stomach. This is rare.
• Gas embolism – a bubble of carbon dioxide gets into a blood vessel and causes life threatening heart problems. This is very, very rare.
• Re-operation: if the surgeon has to re-operate for any reason, this may be done with keyhole surgery or an open operation.

Pain Relief

Every effort will be made to minimize the discomfort. Your surgeon and nurses will be monitoring your level of pain control frequently.
It is very common to have pain in the right shoulder after keyhole surgery. This is due to the effect of the gas pumped into your abdominal cavity during the surgery. The pain typically disappears one day after surgery.
On the first day after surgery, there may be a moderate amount of discomfort at the site of the operation. You will have a few choices for pain relief.

There are two major types of pain relievers after keyhole surgery.

• Panadol: You will be amazed the power of regular panadol. It will cut down the need for the very strong pain pills. It does not cause constipation. Do not take more than 8 tablets a day.
• NSAIDs (Indocid, Brufen, Mobic): Also excellent pain relievers. They do not cause constipation.Must be used very cautiously in the elderly and those with kidney   problems.They may cause stomach ulcers.  If you experience any pain in the upper abdomen you must stop this medication immediately and seek advice.
• Morphine, Fentanyl (narcotics): It is uncommon to need an injection of these powerful painkillers after the first day of surgery. I will discuss your pain relief to take home with you prior to discharge. It is not usual to have to go home after keyhole surgery with narcotic pain relievers.

Drain tubes

Sometimes you will wake up after surgery with a soft plastic drain tube in your abdomen. Your surgeon will advise when this needs to be removed.

Eating

If it was routine gallbladder surgery you will be allowed to have fluids four hours after you wake up and a light diet the following day. It is very common to feel slightly nauseated for 12 hours following surgery.

Urinating / Bowel Movements

After any surgery a patient may have trouble passing urine. This is uncommon and temporary. Occasionally a catheter needs to be inserted to help you pass urine.
There may be some disturbance to your bowels in the week after surgery. Discuss this with your doctor if this occurs.

Activity

It is usual to be discharged one – two days after routine gallbladder surgery. It is very important to begin light activity shortly after surgery. This is to prevent pneumonia, clots in the legs and loss of general condition. You can expect to have to wear stockings on your legs whilst in hospital to prevent clots and have an injection of heparin twice a day under the skin for the same reason. Increase your activity as you feel able.

Your Incision

You can expect to have a waterproof dressing over your incision for the first five days. You will be discharged with this dressing on. You will be able to shower with this dressing. It is quite common to have a small amount of leakage from the wounds.
You can peel the dressing off 5 days after the surgery. The wounds should be healed by this time. You may get the wounds wet after 5 days. It is common for the wounds to be bruised.
Most commonly you will not have stitches to remove, they will be of the dissolving type.
Your incision may be slightly red along the cut. This is normal. You may gently wash dried material around your incision and let water run over it. Pat dry with a towel. Do not rub soap or moisturizer into your incision for at least 4 weeks or until it is fully healed. After this you may rub vitamin E cream along the wound.
It is normal to feel a ridge along the incision. This will go away. It is normal to have a patch of numbness under the wound.
Over the next few months your incision will fade and become less prominent.

Length of Stay in Hospital

On average most patients will expect a 1-2 night hospital stay for routine gallbladder surgery. This time however differs greatly for individual patients and individual operations.

Other Important Information

You can expect to see your surgeon every week day. On weekends or in times when your surgeon is operating elsewhere, you will see one of the practice partners. All are very experienced in this type of surgery and commonly assist each other in the operating theatre.
We will make every effort to keep you informed of your progress. We are always honest and open with you and your family. Feel free to ask questions.

What can I eat after I have my gallbladder removed?

There are no restrictions on your diet. Obviously a low fat diet is considered healthy, however eating fat will not cause any recurrence of pain.

How you may feel

It is quite common to feel very tired and to want to have daytime naps for the first two weeks after surgery. Listen to your body and rest when you need to. This is transient and can be expected to resolve in 2-4 weeks.

Activity

• Do not drive until you have stopped taking narcotic pain medication and feel you could respond in an emergency.
• You may climb stairs.
• Don’t lift more that 10 kg for 4 weeks after keyhole surgery. (This is about the weight of a briefcase or a bag of groceries) This applies to lifting children, but they may sit on your lap.
• You may start some light exercise when you feel comfortable.
• You may swim after 2 weeks
• Heavy exercise may be started after 6 weeks – but use common sense and go slowly at first.
• You may resume sexual activity when you feel ready unless your doctor has told you otherwise.

Costs to be incurred from this surgery

There will not be any out of pocket expenses for your surgery. Your health fund will be billed directly. Outpatient consultations are not covered by the health funds and an account will be sent to your home address. You will get some of the money for outpatient consultations back from Medicare.
There will be an out of pocket charge from Queensland X-Ray for the x-ray performed during your operation. You are welcome to discuss this with them on 34210444.
Your anaesthetist may also charge an out of pocket fee. You should ask them ahead of time about this cost. Ask who will be performing your anaesthetic and you can make enquiries with them as to any out of pocket expenses.
You will also have to pay any hospital excesses that your policy dictates.