Cholecystectomy

The gallbladder stores bile made by the liver and squeezes it into the bile duct after a meal to help digest fat. Gallstones form when substances in bile, mainly cholesterol, crystallise into small stones or sludge. Many people never notice them, but when a stone blocks the outlet of the gallbladder it causes biliary colic, a severe pain in the upper right or middle abdomen, often after eating, and it can lead to infection and inflammation. Cholecystectomy removes the gallbladder together with its stones. It is preferred to removing the stones alone because a gallbladder that has formed stones usually forms them again. The body adapts well to life without a gallbladder, as bile then flows directly from the liver into the intestine. The operation is usually done laparoscopically, with a camera and fine instruments, and in some hospitals with robotic assistance or through a single small incision at the navel.

Surgery is recommended when gallstones cause symptoms or complications. The most common reason is repeated biliary colic: attacks of pain under the right ribs or in the upper abdomen, sometimes spreading to the back or shoulder, often with nausea after a fatty meal. Other indications are acute cholecystitis, an infected and inflamed gallbladder; gallstone pancreatitis, where a stone has passed and inflamed the pancreas; and stones that have moved into the bile duct and caused jaundice, which are usually cleared by ERCP before or after the operation. Gallbladder polyps of about 10 millimetres or more, or smaller polyps that are growing, are also an indication because of a small risk of cancer. Gallstones found by chance on a scan, without symptoms, usually do not need surgery, and the decision is made with your surgeon after weighing your symptoms, scan findings and general health.

Cholecystectomy is done under general anaesthesia. In the laparoscopic approach the surgeon makes three or four small cuts, usually 5 to 12 millimetres long, one of them at the navel, and fills the abdomen with carbon dioxide gas to create working space. A camera shows the area on a screen. The surgeon identifies the cystic duct and cystic artery, which connect the gallbladder to the bile duct and to its blood supply, and confirms the anatomy before clipping and dividing them, a safety step designed to protect the main bile duct. The gallbladder is then freed from the liver and removed in a small bag through one of the cuts. An X-ray of the bile ducts may be taken during surgery to look for stones. The operation usually takes about 1 to 1.5 hours. If inflammation, scarring or bleeding makes keyhole surgery unsafe, the surgeon converts to an open incision under the ribs.

Most adults with symptomatic gallstones are candidates, including older people, provided they are fit for general anaesthesia. Previous upper abdominal surgery, obesity, pregnancy and liver disease do not necessarily rule out the keyhole approach, but they shape the plan. Preparation includes an ultrasound scan confirming the stones, blood tests of liver function and clotting, and sometimes an MRI scan of the bile ducts (MRCP) or an ERCP if a stone in the bile duct is suspected. The anaesthetist reviews heart and lung health and medicines, and blood thinners and diabetes medicines are adjusted on medical advice. You fast for about six hours before surgery. After an acute attack of cholecystitis, surgeons usually prefer to operate within the first days or else after several weeks, and this affects when you should travel. International patients can usually send scans and blood results in advance for a remote assessment.

After a keyhole operation you are encouraged to walk within hours and can usually eat and drink the same evening. Many people go home the same day or the next morning; after open surgery the stay is usually about 3 to 5 nights. Pain from the small cuts is usually controlled with simple painkillers, and shoulder-tip pain from the gas used during surgery is common for a day or two. Most people return to desk work in about one to two weeks and to heavy lifting or strenuous exercise after about four to six weeks. For travel, a stay of about a week near the hospital allows a wound check and the early detection of problems, such as a bile leak, before a long flight. On the flight, walk around and drink fluids to lower the risk of blood clots. No special diet is needed in the long term, although lighter meals help in the first weeks.

Laparoscopic cholecystectomy is a routine and generally safe operation in experienced hands, but every surgery carries risk. General risks include wound infection, bleeding, a hernia at one of the cuts and blood clots. A bile leak from the cystic duct or the liver bed occurs in a small number of patients and is usually managed with a drain or an ERCP. Injury to the main bile duct is the specific complication surgeons work hardest to avoid; it is rare, but if it happens it can need further surgery. A stone left in the bile duct may later need removal by ERCP. Some people notice bloating or looser stools after fatty meals for a few weeks or months, and a small number have lasting symptoms that need further investigation. For most people, removing the gallbladder ends the gallstone attacks and allows a return to a normal diet and daily life.