Gallstone Surgery
Gallstone Surgery
Gallstones form in the gall bladder which is a blind ending sac attached to the bile duct which drains bile out of the liver (See Fig 1. below).
What are gallstones?
Bile is produced in the liver and is a mixture of the byproducts of metabolism and important components for digestion. Most of the bile drains directly from the liver, through the bile duct into the duodenum but some enters the gall bladder. The gall bladder partially empties after eating but there is always residual bile remaining. It is in this static pool of bile that there is a tendency for the insoluble components of the bile to precipitate out and form stones.
There are two basic types of gallstone.
Cholesterol gallstone.
Pigment gallstones form when there is too much bilirubin in your bile.
What symptoms are gallstones likely to cause?
The commonest symptom that gallstones cause is pain. This occurs when a stone moves within the gallbladder and blocks its outlet (the cystic duct). The pain is intense, in the upper abdomen and may be associated with pain in the back and shoulder tip, This is known as
Biliary Colic. If a patient with biliary colic continues to have pain after several hours and develops signs of an infection it is likely that the impacted stone has remained lodged in the cystic duct and that the bile trapped in the gall badder has become infected. This is a more serious condition and is known as Acute Cholecystitis.
Stones that move out of the gall bladder can lodge in the common bile duct [see figure 1]. This may lead to pain very similar to that of biliary colic but by blocking the main duct leading from the liver it results in the products of the liver accumulating in the blood. The most obvious external manifestation is the development of a yellow pigmentation in the skin and the whites of the eyes jaundice. The urine will also become very dark (often described as tea like) and the stools will become very pale. This picture is known as obstructive jaundice. In patients with obstructive jaundice if the bile is infected there is a very serious risk of septicaemia and such patients are altogether more severely unwell than those with gallstones contained within the gall bladder. This combination of an obstructed bile duct and infection is known as ascending cholangitis, and is a clinical emergency. As can be seen from the diagram below, the common bile duct enters the duodenum with the pancreatic duct. In patients unfortunate enough to lodge a stone at the confluence of these two ducts there is the risk of not only cholangitis but also back pressure on the pancreas resulting in acute pancreatitis. Pancreatitis can vary from a self limiting minor illness to a very significant life threatening disease. The first and major symptom is severe upper abdominal pain.
Should I have treatment for my gallstones?
There is no answer to this question that fits all patients we are all different. The important points to consider are :
The severity of the symptoms experienced.
The frequency with which symptoms are being experienced.
Your general level of fitness which will determine the risks associated with any treatment.
It is likely that if you have had symptoms related to your gallstones they will return at some stage but it is impossible to say when. The best guide is what has already happened i.e. someone experiencing biliary colic on a monthly basis is likely to continue with this pattern of pain unless the gallbladder is removed. Alternatively someone who had an attack of pain 5 years ago and has not had another attack is less likely to suffer another episode in the near future but the risk is still there. If you have had a severe illness with your gallstones i.e. pancreatitis or cholangitis it is more advisable to undergo a cholecystectomy.
Is there an alternative to surgery?
The short answer, which is correct in most cases, is no.
What does surgery involve?
The operation to remove the gallbladder is known as a cholecystectomy. It involves securing the cystic duct, which connects the gallbladder to the common bile duct, and dividing it. Thereafter the cystic artery, which is the blood vessel feeding the gallbladder has to be secured and divided. The gallbladder can then be removed from the undersurface of the liver. Generally cholecystectomy is performed using a laparoscopic (or keyhole) approach. This involves 4 small incisions to allow a camera to be placed within the abdomen thereafter instruments are inserted to manipulate the gallbladder clip the cystic duct and artery and divide any adhesions between the liver and the gall bladder.
Are there any risks associated with surgery?
Surgery is an invasive procedure requiring general anesthesia so there are always risks associated with any operation but every precaution will be taken to minimize these.
What if my gallstones have moved out of the gallbladder?
If there is any suggestion from your history or your scans have shown there is the possibility of stones in the common bile duct it is likely that you will need to undergo a further type of scan (a Magnetic Resonance Chaogiogram [MRC]) to confirm or refute this. If stones are present in the common bile duct these can either be removed with an endoscope a procedure known as an ERCP, or at the time of any planned surgery. If the stones in the common bile duct are removed surgically this does involve a slightly longer and bigger operation. The decision on whether to remove stones surgically or by ERCP will be dependent upon the size of the stones, the symptoms they are causing and subsequent management plans.