Gallbladder Surgery

Laparoscopic cholecystectomy is the surgical removal of the gallbladder using a laparoscope (a tube like instrument). This is commonly known as keyhole surgery and is safe and effective for most patients who have symptoms from gallstones.

It is necessary to remove the gallbladder as well as the gallstones as otherwise the gallstones will recur. There are usually three or four small cuts (incisions) made in the abdomen, however the number of the cuts and their positions may vary between patients. The telescope (‘laparoscope’) is passed into one of the small incisions to allow the surgeon to see inside the abdomen. Hollow tubes called ports are inserted through the other small incisions. Carbon dioxide is then blown into the abdomen (insufflated) to lift the abdominal cavity away from the liver, gallbladder, small bowel, stomach and other organs. The surgeon then puts instruments such as forceps and scissors into the other ports to help remove the gallbladder. Small clips are placed to block off the tube leading from the gallbladder to the other bile ducts (cystic duct) and the arteries leading to the gallbladder. These clips stay in your body and do not cause any problems. Once the gallbladder is taken out all the instruments are removed from the abdomen and the carbon dioxide gas is allowed to escape before the incisions are closed with dissolving sutures.

Benefits of having gallbladder removal surgery

The removal of the gallbladder will, in most people, relieve pain, nausea and vomiting, and it will also prevent complications and the gallstones from coming back.

Risks of not having your gallbladder removed

The symptoms of gallstones may get better, but can return if left untreated.

It is likely that if left untreated complications will develop, making treatment more difficult and increase the risks. Complications include inflammation of the gallbladder (cholecystitis), inflammation of the pancreas (pancreatitis), development of gallbladder cancer (gallbladder carcinoma) and blockage of the bile duct (choledocholithiasis), causing jaundice and infection (cholangitis).

Discomfort and after effects of laparoscopic cholecystectomy surgery

You can expect some discomfort in the abdomen, and pain-killing tablets (analgesia) can be given for this.

You may also have shoulder tip pain caused by the gas used during the operation: gentle walking may ease this. The discomfort should wear off within 4-5 days. If pain persists or you are concerned then you can contact A/Prof Adam Bartlett either at his rooms or on his mobile.

Risks and complications related to gallbladder removal surgery

Specific risks from laparoscopic cholecystectomy surgery include

Excessive bleeding inside the abdomen

What happens?

Damage to large blood vessels causing bleeding in one in three hundred people. This may be from the blood vessels and/or the liver bed.

What can be done about it?

Blood transfusion (one in one thousand people), and possible further surgery.

Injury to the bowels (gut)

What happens?

Injury to the gut in one in three hundred people, or other organs such as the bladder when the tubes and instruments are passed into the abdomen.

What can be done about it?

More surgery to repair the injured organs will be needed.

Need for open surgery

What happens?

Keyhole surgery may not work and the surgeon may need to do open surgery (1-2% of people).

What can be done about it?

Open surgery requires a larger incision (cut) in the abdomen and sometimes a longer stay in hospital.

Stones in the bile ducts

What happens?

An x-ray may be performed during surgery which shows up the bile ducts (cholangiogram). Some stones may have moved from the gallbladder into the bile tubes. These can usually be removed at the time of surgery.

What can be done about it?

An endoscopic procedure may be needed to remove the stones at a later date, if they cannot be removed during the operation. This is referred to as an ERCP.

Escape of stones

What happens?

Stones may spill out of the gallbladder and be lost inside the abdomen.

What can be done about it?

Rarely, if the stones cannot be found and removed they can cause abscesses, which may need draining.

Bile leak

What happens?

Small clips or ties that are put on the blood vessels or bile tubes and left in the body can come off. This can cause an internal bile leak in 1 – 2% of people.

What can be done about it?

This may require drainage in the x-ray (radiology) department, or further surgery which can usually be done through the previous keyhole scars. Rarely an open operation is needed.

Bile duct injury

What happens?

The bile duct can be damaged during the surgery by the instruments in one in one thousand people.

What can be done about it?

This can cause long-term problems with blockage, which may need further surgery.

Bleeding into the wound

What happens?

Possible bleeding into the wound after the surgery.

What can be done about it?

This can cause swelling, bruising or blood stained discharge. It rarely requires further surgery.

Hernia

What happens?

A weakness can happen in the wound, with the protrusion of intra-abdominal contents – called a hernia.

What can be done about it?

Hernias usually need to be repaired by further surgery.

Adhesions (bands of scar tissue)

What happens?

Adhesions can form and cause bowel blockage. This can be a short or long-term complication. This is much rarer in laparoscopic (keyhole) surgery than open surgery.

What can be done about it?

This may require further surgery to cut the adhesions and free the bowel.

Surgery does not help

What happens?

Symptoms experienced before surgery may persist in some people after surgery.

What can be done about it?

This may be due to another gut problem or irritable bowel syndrome which will be investigated appropriately.

Increased risk in obese patients

What happens?

An increased risk of wound infection, chest infection, heart and lung complications and thrombosis.

Increased risk in smokers

What happens?

Smoking slows wound healing and affects the heart, lungs and circulation.

What can be done about it?

Giving up smoking before the operation will reduce the risk of wound infection, chest infection, heart and lung complications and thrombosis (blood clots).

Alternative treatment or options for patients with gallstones

There are some alternative treatments; however these may not be available or suitable for everyone.

Oral dissolution therapy

Oral dissolution therapy using ursodeoxycholic acid (Urso) can be used to disolve cholesterol stones. It isnt funded for this indication in New Zealand, is often associated with side effects, needs to be taken for years, and it has a 50% risk of gallstones recurring within two years. It is usually only recommended for those patients who are not fit enough to have surgery.

Open cholecystectomy surgery

Open cholecystectomy refers to the surgical removal of the gallbladder through an abdominal incision about 10cm long (laparotomy) below the right rib cage. This is a safe alternative to a laparoscopic cholecystectomy but is usually associated with a longer stay in hospital and may be associated with a longer recovery period. For some patients it may be the only method by which the gallbladder can be removed safely.

Cholecystostomy

Cholecystostomy referes to the drainage of the gallbladder. It involves insertion of a drain through the skin and into the gallbladder under radiological guidance). it is usually performed on patients who are too sick to have an operation, and is only done in the presence of acute infection of the gallbladder.

How long will I be in hospital after a laparoscopic cholecystectomy

Most patients will come into hospital on the day of their operation, and stay one night.

If the operation is able to be early in the day, and it is straight forward, then it may be possible for you to go home the same day.

How should I prepare for my laparoscopic cholecystectomy operation

If you smoke you should try and stop as smoking as it increases the risks of surgery (see above).

Your general practitioner may be able to help you with this. Prior to the operation you will get instructions telling you when you should stop eating and drinking. Your stomach must be empty for at least 6 hours in order to make the general anesthetic safe. They will also give you directions where to present for surgery.

If you take tablets to thin the blood such as Aspirin, Warfarin or Clopidogrel, then you need to let your surgeon know as they may need to be stopped prior to surgery.

It is okay to continue to take your regular medication with a small sip of water on the morning of your surgery. If you are unsure please ask.

After the cholecystectomy operation

Will I need pain relief after a laparoscopic cholecystectomy?

With any laparoscopic procedure you can expect some soreness in the wounds and you may also have some discomfort in the abdomen relating to your gallbladder surgery. This will mostly be during the first 24 – 48 hours. We will give you pain killers to take home that you should take regularly for the first few days. If you have prolonged soreness and are getting no relief from the prescribed pain medication you should make contact with A/Prof Bartlett or his rooms to ensure that you don’t need to be seen. Occasionally patients may experience shoulder-tip pain but this should settle very quickly; gentle walking or use of a heat pack will help to ease this. The discomfort should wear off within 4 – 5 days and most people are back to normal level of activity by one week.

Wound care post a cholecystectomy

The wounds are covered with dressings that should stay on for the first three days. The dressings are waterproof so you can shower if you wish. The steristrips, beneath the dressing can be left on as long as you wish, as they help to keep the skin edges close together. The sutures are dissolving so you do not need to get them removed. Some people use Bio-oil or Vitamin E cream on their wounds to help healing, and this can be applied once the dressings have been removed. If you have any concerns about your wounds at any time, please either contact A/Prof Bartlett, his rooms or your GP. It is occasionally necessary to leave a small tube (drain) in your side during the operation. This is just a precaution and it is usually removed the day after surgery.

How soon can I drive after a laparoscopic cholecystectomy?

Legally you are not permitted to drive for 24 hours following a general anaesthetic. It is usually recommended that you abstain from driving for at least 48-72 hours after laparoscopic cholecystectomy. Before driving you should ensure that you could perform a full emergency stop, have the strength and capability to control the car, and be able to respond quickly to any situation that may occur. Please be aware that driving whilst unfit may invalidate your insurance, and you should check with the conditions of your insurance policy as they do vary.

How will my diet be affected by a laparoscopic cholecystectomy?

You may have a drip in your arm, which will come out soon after you recover from the anesthetic. To begin with you can take sips of water and then increase from fluids to solids. Some people feel nauseous after a general anesthetic but this is usually short-lived and can be helped by anti-sickness medication. When you are fully awake after your operation, you can start eating and drinking what you want, starting with plain food and if this is well-tolerated then you can resume a normal diet. Most people find that they have less appetite for the first week after a gallbladder operation – this is normal and you should only eat as much as you feel comfortable with.
There are no specific dietary restrictions after removal of your gallbladder
As you are still producing bile which helps to absorb fats your digestion will be normal. However, in a few patients the system can take a while to ‘reset’ and this may result in some indigestion with bloating, colicky pain and/or diarrhea. This is usually self-limiting but may last for several weeks.

Will my bowels and bladder be affected post operation?

The nurses will ensure that you have passed urine before you leave the hospital, although you may find that the force of your stream is not back to normal for 24 hours. This is the result of the opiate analgesia and pain from trying to contract your abdominal musculature. Some patients find that they are prone to constipation immediately following surgery. This can be due to the painkillers and/or immobility after an operation. You can take laxatives if you wish, or it is often best to increase your fluid intake, and modify your diet to take kiwi fruit, prunes and alpine tea.

Will my mobility be affected by a laparoscopic cholecystectomy?

For the first few days after surgery you should take frequent short walks around the house to avoid the possibility of postoperative clots in the legs and chest. After a week you can take brisk walks outside the house. Normal aerobic exercise activity such as swimming and jogging or going to the gym can be resumed in 2 weeks. It is safe to play golf after three weeks but this may still be uncomfortable. Any heavy lifting should be avoided for the first month. Sexual intercourse can be resumed when comfortable.

Sleep and rest post surgery

You may feel more tired than normal in the first few days after your operation. This is perfectly normal and you should rest whenever you feel tired.

Is bruising normal after a laparoscopic cholecystectomy?

Bruising may develop around the wounds which may look quite alarming. However, it is nothing to worry about and will fade in 2 – 3 weeks. If you are concerned please make contact withl either A/Prof Bartlett, his rooms or your GP.

Personal hygiene

You can shower with your dressings on as they are waterproof. Once the dressings have been removed it is okay with shower or bath as you wish. Pat the wounds dry with a clean towel and then leave them open to the air.

How soon can I return to work after a laparoscopic cholecystectomy?

You can return to work as soon as you feel up to it. This will depend on how you are feeling and the type of work that you do. If you have a relatively sedentary job then you may feel ready to return within 3-4 days. If you are involved in manual labor or heavy lifting you need to avoid straining for at least two weeks.

Will I need a follow up appointment after the laparoscopic cholecystectomy operation?

Following discharge, we will be in touch with you at around day three, then again at around day 10-14 after surgery.  The pathology of the gallbladder can take up to three weeks to be reported and we will make sure that this is communicated to you as soon as we receive it. However, if you have any concerns or problems, prior to this appointment please contact A/Prof Bartlett or his rooms to make an appointment. If you are acutely unwell, then you need to go to the hospital emergency department, and leave a message with A/Prof Bartlett or his rooms.

How will removing my gallbladder affect me?

Most patients do not notice any difference after a cholecystectomy, particularly if the gallbladder is not functioning at the time of the operation because of stones or inflammation. Indeed many patients feel a lot better with relief of their pain and more energy. Some patients may find that they are temporarily unable to digest fatty foods as easily after the operation, and in these cases a fatty meal may cause bloating, colicky discomfort, flatulence and occasional diarrhea. Usually the bowel adjusts and most people find they are able to take a normal diet within 6 – 8 weeks of surgery. Only about one in a hundred people are troubled with persistent diarrhea and this can be treated with tablets that sequest the bile salts.