Laparoscopic or keyhole removal of the gall bladder was one of the first procedures to utilize using the laparoscopic surgical technique. The procedure has been in use since 1993 in Australia, with many thousands of the procedures being performed. The advantage of this technique in terms of small incisions, diminished pain, short hospital stay and early return to normal activity were so obvious that it has quickly become the standard method of gall bladder removal.

What does the gall bladder do?

The gall bladder is a small pear-shaped organ attached to the side of the bile duct by a small secondary duct, the cystic duct. The bile duct is a tube that carries bile from the liver to the small intestine. When the patient is fasting, the lower end of the bile duct closes and bile back-flows into the gall bladder. There it is concentrated by the gall bladder, absorbing the water in the bile. When a patient eats a fatty meal, the gall bladder squeezes out the bile to help absorb the fats. If stones are present, at this point, they can cause the gall bladder to go into spasm and this causes severe pain. The only way to prevent this and the other problems that can occur with gall stones is to remove the gall bladder. Since the gall bladder is only one of the mechanisms of fat digestion, its removal does not cause any major interference with the patient’s digestive process. In many cases of patients with stones, the gall bladder is not functioning and so digestion of fats is not affected by its removal.

What causes gall stones?

A number of causes have been suggested. It is thought that some people secrete more cholesterol than others. As the gallbladder concentrates the bile stored in it, the cholesterol precipitates forming crystals and that these adhere together forming the stones. The stones then tend to enlarge or multiply especially if there is any infection involved. Pregnancy, obesity, weight loss and a family history of gallstones are factors that increase the chances of developing gallstones.

What problems do they cause?

The main symptom is pain, known as gall stone colic. This commonly occurs in the mid upper abdomen or under the right ribs. It tends to radiate around the rib margin and into the back. It can be precipitated by eating fats. It is severe and can last some hours. The pain usually goes but frequently recurs. In some cases infection sets in, cholecystitis, and the patient develops severe pain under the right ribs with fever. Intravenous antibiotics are necessary to treat the infection and the problem usually takes 3-4 days to settle. More mild symptoms such as burping, flatulence and heartburn can also occur with gallbladder disease. If a gallstone passes down the cystic duct into the bile duct it can block the flow of bile leading to jaundice. This is a surgical emergency requiring removal of the obstruction especially if infection sets in. A stone in the bile duct may also cause inflammation of the pancreas causing a serious condition known as pancreatitis. Rarely, if the stones are left for many years, cancer of the gall bladder may develop.

Should I have the gall bladder removed?

If the gall bladder is causing symptoms or if multiple small stones that can escape into the bile duct are present, then removal of the gall bladder is advised. If there is a solitary large stone causing no symptoms then it can be left, although these can cause problems later in life. The surgery, when performed, entails removal of the whole gall bladder with the stones inside. To remove only the stones could result in them reforming after several years and problems returning.

How is the surgery performed?

The laparoscopic removal of the gall bladder (cholecystectomy) is performed under general anaesthetic so that the patient must be in reasonable health. Four punctures are made in the abdominal wall. The first is in the umbilicus. After inflating the abdominal cavity with CO2, a telescope attached to a tiny video camera is introduced and the abdominal contents inspected. The gall bladder is readily located and is grasped with forceps. It is freed from attachments to the liver. A small tube, the cystic duct, connecting the gall bladder to the bile duct is dissected free of the fatty tissue that encases it and a catheter inserted into it. Dye is injected down this and an x-ray of the main bile duct, which takes bile from the liver to the intestine, is taken. This is to confirm that no gallstones have entered the bile duct where they could cause a blockage leading to obstructive jaundice. Once the Xray has been completed, the cystic duct and the little artery feeding the gall bladder are clipped with little metal clips and divided. The gallbladder is then dissected away from the liver and removed through the small incision beneath the umbilicus. It is like a small bag that passes through the little incision once the stones and bile have been emptied out of it.

Open operation, laparotomy, may have to be performed if there are difficulties experienced in identifying the anatomy and there is a danger of damaging vital structures such as the bile duct. This can occur if there has been chronic or acute infection in the gall bladder or where there is abnormal anatomy. Open surgery may also be necessary when the abdomen is full of adhesions due to previous surgery as these can prevent views of the abdominal cavity and of the gall bladder. Other reasons for open surgery include a history of bleeding disorders and with pregnancy.

	The gall bladder as first seen	Cystic duct and artery stripped of tissue
	Duct and artery clipped	Gall bladder being cleared from liver

What are the complications of surgery?

• Damage to the bile duct can lead to leakage or even obstruction of bile flow. Laparotomy to drain or repair the bile duct may be necessary if this occurs. This is a serious problem but is rare with an incidence of less than 2%.
   
• Bleeding from blood vessels feeding the gall bladder or liver. This is usually controllable at the laparoscopy but may require further laparotomy to stop the bleeding. If the bleeding starts after the surgery has been completed, the patient may have to return to the operating theatre to stop the haemorrhage. Again this is a very rare complication.
   
• Damage to other organs or blood vessels. This is extremely rare and the incidence is minimised by using a special blunt tipped instrument to enter the abdominal cavity through the incision beneath the umbilicus.
   
• Gas embolism. This can occur when the CO2 which is being used to keep the abdomen inflated enters an open blood vessel and passes to the heart. This has never occurred in my experience.
   
• Pulmonary embolism. This occurs when clots form in the deep veins of the legs and pass up the veins to the lung blocking the flow of blood to the lungs. This has never occurred in my experience and should be less likely than with open surgery, as patients are in less pain and are moving about more freely on the day of surgery. Blood thinning injections and calf compressors are used during the surgery to help prevent this complication.  Other medical problems such as allergic reactions, heart attacks, pneumonia and strokes can occur but are exceedingly rare.
   
• Wound infections are not uncommon especially in the umbilical wound, which can be contaminated by the bacteria in the gall bladder as it is removed. These are usually minor and respond to antibiotics but can be painful and a nuisance in the short term.
   
• Keloid scars. These are thickened scars to which some patients are prone. With the small incisions, scarring is minimal in most cases.

How long will I be in hospital and how long off work?

Usually patients can go home 1-2 days postoperatively. One week off work is sufficient for sedentary workers. For those who do heavy lifting I advise four weeks off to allow the umbilical wound to settle and strengthen.

Postoperative diet

Usually patients can eat a normal diet as the fats in the diet no longer cause gall bladder colic when eaten. However, occasional fats can cause loose bowel actions and rumbling stomach discomfort when eaten and in that case, patients should adhere to a low fat diet.