Gallbladder SurgeryCredit: Wiki Commons

Your doctor has recommended that you have gallbladder surgery.  Many patients question if the operation is really necessary.  They want to know  what exactly is wrong with the gallbladder and why it needs to be removed.


Common signs and symptoms related to gallbladder problems include pain, which can be very severe, located in the right upper quadrant of the abdomen.  Sometimes this pain is said to "radiate" through to the back, just under the tip of the scapula on the right.  Other symptoms include nausea, vomiting, gas, diarrhea, chills, and fever. A number of tests may be ordered by your doctor if the symptoms are persistent.  The symptoms are usually caused by gallstones (known as cholelithiasis), but they can also be caused by a non-functioning gallbladder--a condition known as biliary dyskinesia.



Although many people have gallstones, they are frequently asymptomatic (not causing any problems).  This situation does not require surgery or any type of procedure.  One simply is made aware that the stones are present and that they could potentially cause a problem in the future.  Then again, they may not ever cause a problem.  Your doctor will need to order several tests to determine if your gallstones are symptomatic (causing symptoms) prior to making a recommendation for surgery.  It is possible for gallstones to exist for many years without causing any problems. Symptoms can occur if the gallstones become stuck in the tube leading out of the gallbladder--this tube, or duct, is known as the cystic duct.  More serious symptoms can occur if a gallstone gets lodged in the Common Bile Duct. There can be severe pain associated with a gallstone attack, and these attacks become more frequent and more severe as time progresses..

The tests needed to determine whether or not a patient's symptoms are due to a the gallbladder generally include lab work, an ultrasound (which will show any gallstones, if they are present) and, possibly, a HIDA scan--a test that determines the function of the gallbladder.  It is possible for there to be no stones and yet the gallbladder does not contract or function normally.  This situation, known as biliary dyskinesia, generally also requires removal of the gallbladder.  The HIDA scan, which may or may not be necessary, determines if the gallbladder is functioning properly.

Gallbladder ultrasoundCredit: Wiki Commons


A HIDA Scan of the GallbladderCredit: Wiki Commons



Gallbladder with gallstonesCredit: Wiki Commons

The basic function of the gallbladder is to store bile, a substance made by the liver that is excreted into the intestine for the process of digestion.  The bile made in the liver flows into the intestine when we are eating a meal. However, between meals the bile gets stored in the gallbladder.  Then, when we eat, a hormonal signal causes the gallbladder to begin contracting and the bile is forced down the bile ducts and into the intestine.

When the bile that is sitting in the gallbladder becomes supersaturated with bile salts, lecithin, and cholesterol, gallstones can form.  Gallstones can be as tiny as a grain of sand and as large as a golf ball. They may be spherical or irregular in shape; smooth or with multiple edges. Patients may have just one single stone or there may be many.  When the stones are small, like grains of sand, the gallbladder is often said to have "sludge" in it.  But this "sludge" can cause problems just as easily as a large, golf-ball sized gallstone.  A gallbladder attack, or biliary colic, as it is known, occurs when a gallstone or sludge blocks the cystic duct leading from the gallbladder.  An even more serious situation occurs when the gallstone travels partially down the main duct  (Common Bile Duct) and causes a blockage, but that is beyond the scope of this article.


In the case of biliary dyskinesia, the typical finding is that the tube leading out of the gallbladder (known as the cystic duct) is of a very small caliber and the thick bile is not able to be forced through it by a gallbladder that does not contract normally.  Although there is no blockage, the inability of the bile to flow normally out of the gallbladder causes the same type of pain that occurs when the gallbladder is obstructed, or blocked, by a gallstone.

In either of these cases, gallbladder surgery cures the problem.  Gallbladder surgery, also known as cholecystectomy,  is a commonly performed surgery which is done to remove an inflamed, obstructed, or non-functioning gallbladder.  Gallbladder pain, also known as biliary colic, is usually described as pain in the right upper quadrant of the abdomen, just under the ribs,  that occasionally passes through to the back. The pain sensation usually intensifies after meals, especially meals of fatty or fried foods.

Laparoscopic surgery (a minimally invasive surgical procedure) is the most common method of performing gallbladder surgery.  During this procedure, known as a laparoscopic cholecystectomy, the surgeon removes your gallbladder using a laparoscope--a camera that is inserted into the abdomen--along with other surgical instruments through four small incisions.  Many people mistaken believe that the laparoscope is a laser. It is not---it is merely a video camera that provides an enhanced view of the abdominal cavity through a small incision.  Carbon dioxide gas is then used to inflate the abdominal cavity so that the internal organs can be viewed clearly.  The remainder of the surgical instruments are then inserted through the other small incisions in order to remove the gallbladder.

Laparoscopic cholecystectomy is easily the most frequent method to remove the gallbladder today, however, you must always keep in mind that cholecystectomy cannot always be performed laparoscopically and, in some cases, a larger incision is required.  The removal of the gallbladder through this larger incision is known as an open cholecystectomy, and typically carries a longer recovery period with it than a laparoscopic cholecystectomy does.  The gallbladder can usually be removed (85% of the time) through the laparoscopic approach, but there are times when it becomes necessary to convert to an open procedure (with a large incision) due to the amount of inflammation around the gallbladder or an inability to accurately identify the important bile ducts and other structures near the gallbladder.

Laparoscopic gallbladder removal usually lasts about 1 hour and can turn out to be performed as an outpatient. You will be provided detailed post-operative instructions along with a prescription for pain medication for any discomfort you may feel. You should avoid heavy lifting for several weeks after the procedure. This is a preventative measure after any surgery that allows the incision to heal.  Most patients can resume working within a week after the procedure, if they are not performing manual labor or heavy lifting.

The overall risk of laparoscopic gallbladder surgery is very low. But, as with any surgical procedure, laparoscopic cholecystectomy also has risks. Every precaution will be taken by your surgeon and operating team to minimize any possible risks or complications. All risks and benefits from this procedure will be explained to you before your surgery is scheduled, and you will be given detailed information about what you can expect before, during, and after surgery.

Patients generally undergo a pre-operative appointment to have blood work and other tests (such as an EKG and chest x-ray, if they are deemed necessary) completed prior to their surgery.  They are then admitted to the hospital the morning of the procedure.  Laparoscopic gallbladder surgery is performed under general anesthesia, therefore, you will not be able to eat or drink anything after midnight the day before your procedure. Be sure your surgeon knows if you are diabetic or taking any blood thinners such as Coumadin. Also be aware that aspirin can cause bleeding complications and should be avoided for at least one week prior to surgery if possible.


What To Expect After Gallbladder Surgery

These are some of the problems that some, but not all, patients experience:

Whether you have laparoscopic or open gallbladder surgery, you should expect to have some post-operative pain.  Although this pain is much less for those that have the laparoscopic approach, it is still an operation and the incisions will require time to heal.

Some patients will experience some post-operative nausea. This is primarily due to the anesthesia and usually subsides within a day or two.

Because your gallbladder has been removed, the bile made by the liver can no longer be stored in it.  This means that there is a constant flow of bile into the intestines.  The intestines will eventually absorb any excess bile, but some patients can experience diarrhea for several days after surgery until the intestines start to absorb the excess bile.  In rare cases, the diarrhea persists.  This can be corrected by taking a medication called cholestyramine for a short period of time while the intestinal capacity to absorb the bile is increasing.  The diarrhea ALWAYS goes away.

This is a situation that is unique to laparoscopic surgery.  It is caused by the gas (carbon dioxide) which is used to inflate the abdomen for the procedure.  The gas gets trapped under the diaphragm and causes an irritation that results in what is known as "Referred Pain".  In this instance, the irritated diaphragm "Refers" pain to the right shoulder.  Most patients never experience this annoyance but, if it occurs, it will go away in several days.


A Word about "Alternative Treatments"

Many patients ask if surgery is really necessary.  The answer is simple and clear--YES.  In the past, there were medications available that were used to dissolve gallstones.  The problem was that as soon as the medicines were stopped (after dissolving the stones), the gallstones came right back.  The medications were exceedingly expensive and they did not cure the problem.

There are numerous websites that also claim to have a "special concoction" of one type or another that can dissolve gallstones.  The scientific fact is that none of these methods work.  The only reliable way of preventing gallstones from causing symptoms of pain, nausea, vomiting or very serious complications such as biliary obstruction, jaundice, pancreatitis (inflammation of the pancreas), or cholangitis ( a life-threatening infection of the bile ducts which can rapidly become fatal) is to remove the gallbladder and the stones contained within it.

Most people become anxious when surgery is recommended.  Be certain to ask your doctor all of your questions (write them down before your appointment so that you will remember them) and educate yourself so that you understand what to expect before, during, and after your gallbladder surgery.  With proper education and understanding the experience will be much less frightening and you will be able to quickly recover and get back to your normal daily routine.