Laparoscopic Cholecystectomy

The gallbladder is a small pear-shaped organ found under the liver in the upper part of the abdomen. It stores bile that is produced by the liver. Bile aids digestion by breaking down dietary fats. When fatty food is eaten, the gallbladder contracts, squeezing bile via a series of ducts into the small intestine where it does its work.

Most gallstones appear when the amounts of bile, cholesterol and other fluids in the gallbladder become unbalanced and that fluid solidifies. It is unknown why this occurs in some people but not in others. Risk factors for gallstones include:

• Family History
  
• Ageing
  
• Obesity
  
• Rapid weight loss
  
• Gender (more women than men)

Provided gallstones stay deep within the gallbladder, they don’t usually cause problems. If they block the outlet of the gallbladder or move into the ducts between the gallbladder and the intestine, they can cause obstruction. The bile can back up leading to one or more of a number of conditions including:

• Biliary colic – painful gallbladder contractions
  
• Cholecystitis – gallbladder inflammation
  
• Cholangiitis – bile duct inflammation
  
• Pancreatitis – inflammation of the pancreas

Biliary colic can cause pain, usually in the upper abdomen, which often extends to the back. The pain may be associated with nausea and vomiting and occur after a meal. Cholecystitis and cholangitis may be associated with fevers and jaundice. In pancreatitis, the pain is typically severe, constant and gnawing. The spectrum of cholecystitis, cholangitis and pancreatitis ranges from mild requiring pain relief and supportive care, to severe requiring prolonged hospital admission and intensive care support.

There is no known treatment or diet that can prevent gallstones.

If gallstones are causing any of the above problems, the gallbladder is not working properly and should be removed. If it is not removed, symptoms can get worse, and complications can develop. Once the gallbladder has been removed, bile can still flow from the liver to the bowel and your digestion will still function normally.

This is removal of the gallbladder using ‘keyhole surgery’. Following general anaesthesia, a small tube (port) is inserted in the abdomen just under the bellybutton (umbilicus) through a 1cm incision. The abdomen is inflated with carbon dioxide through that tube. A camera attached to telescope-like tube (laparoscope) is then inserted through that port into the abdomen allowing visualisation of the abdominal organs on a video screen.

Three more 5mm incisions are made on the right side of the upper abdomen through which 3 small ports are inserted. These allow passage of the surgical instruments that will be used to remove the gallbladder.

The gallbladder is carefully dissected off the liver down to the cystic duct that joins it to the biliary system. A plastic tube is inserted into the cystic duct, dye is injected into it, and an x-ray examination of the bile ducts (intraoperative cholangiogram) is done to ensure that the ducts are clear of stones. The cystic duct is clipped and divided, and the gallbladder is then put into a bag and removed via the umbilical port.

This is removal of the gallbladder via an incision in the upper abdomen. Other than a larger abdominal incision, and direct rather than laparoscopic visualisation of the abdominal organs, the operation proceeds similarly to a laparopscopic cholecystectomy. This was standard procedure prior to the advent of laparoscopic surgery. It is now reserved for situations where laparoscopic surgery has failed or is not possible. Conversion to open cholecystectomy may be necessary in some patients with:

• Severe chronic infection of the gallbladder
  
• Abnormal anatomy
  
• Intra-abdominal scar tissue due to previous surgery
  
• Intra-operative complications that cannot be fixed laparoscopically

The benefits of laparoscopic cholecystectomy include:

• Less discomfort after surgery
  
• Less time in hospital
  
• Recovery in days rather than weeks
  
• Small, rather than large incisions
  
• Small, rather than large abdominal scars

Conversion to open cholecystectomy is becoming less and less common.

Prior to your operation you may need to attend a Preadmissions Clinic. Your fitness for surgery will be assessed, tests may be ordered and referrals to other specialists arranged if required.

You cannot eat for 6 hours prior to your operation. You may sip water for up to 2 hours prior to your operation. Fasting decreases the risk of vomiting and aspiration during induction of anaesthesia. Aspiration can cause pneumonia and a prolonged stay in hospital.

Laparoscopic cholecystectomy is done under general anaesthesia. You will be asleep during the whole procedure. The anaesthetist will discuss the anaesthetic with you prior to your operation. They will see you in the pre-operative area and accompany you to the operating theatre.

Following the operation, you will wake up in the recovery area. You will feel a little disoriented and may feel a little nauseous. Immediate post-operative pain is usually minimal. It is quite common to have some shoulder discomfort. This occurs because the gas that is used to inflate the abdomen causes irritation of the diaphragm.

The staff in recovery are equipped to help you. Once you are awake and oriented, you will be taken to a ward bed. After a few hours, and once the nurses are satisfied that it is safe, you can get out of bed. Gentle activity such as walking is encouraged.

Some people may be able to go home on the same day as their surgery. Most people stay in hospital for at least one night.

There are no dietary restrictions or special dietary supplements that are required after laparoscopic cholecystectomy. You may eat whatever you choose though for most people, a light, healthy diet is preferred. You may require opiate-based medication for pain relief for the first day or so. After that, simple analgesia such as paracetamol and ibuprofen should be sufficient. You may bathe and shower. The wound is waterproof and can get wet.

You can resume most normal activities after three to five days. You should avoid strenuous physical activity, vigorous exercise and heavy lifting (>5kg) for four weeks after your operation. It increases the risk of a hernia through one of the abdominal incisions. Once this period has passed and you feel that you have recovered, you may return to your normal physical activities.

Post-operative swelling around the wound is normal and usually resolves within a month or so. No specific wound management is needed in the first two weeks while the dressings are on. After this, gentle scar massage is advisable for 10 minutes two or three time a day for 6 months. You may use whatever moisturising lotion you like (e.g. sorbolene, bio-oil etc.) but creams with Vitamin E should be avoided for the first post-operative month. Alternatively, you can keep the scar covered with a silicon strip for 12 hours a day for 6 months. These strips are available from the chemist but are quite costly.

Initially the scar will be pink. Over 6-12 months, the scar will fade until it becomes pale.

General Risks of Surgery
These may include nausea and vomiting following your anaesthesia, minor allergies to medications or antiseptic solutions, blood clots in the operative wound and minor wound infections.

More serious complications may occur in patients who have pre-existing risk factors. They are rare in otherwise well people. They include severe allergic reactions, blood clots in the legs (deep venous thrombosis) which can travel to the lungs (pulmonary embolus), cardiovascular complications such as heart attack, delayed wound infection and chest infection.

Intra-abdominal Bleeding
This is uncommon. If it does occur, the source is usually the artery that went to the gallbladder (cystic artery), or the liver. It is often self-limiting, requiring no intervention. Very rarely it can be severe requiring a trip back to the operating theatre and a blood transfusion.

Bile Leaks
This is rare and occurs due to a hole in the one of the ducts of the biliary system. Sometimes, the cystic duct cannot be secured, and a bile leak will be predicable. A drain is placed during the operation to control the leak until it stops. This can take days to weeks. Rarely, part of the biliary system is inadvertently damaged leading to an unrecognised bile leak that becomes apparent in the days after surgery. This may require a return to the operating theatre in order to control the leak.

Damage to intra-abdominal organs
Inadvertent injury to nearby organs such as the small intestine, stomach, pancreas, spleen or major blood vessels is rare. If it does occur, a return to the operating theatre may be required to repair it.

Wound infection
These can complicate any type of surgery and can usually be treated with a short course of oral antibiotics. Uncommonly, IV antibiotics or further surgery is required.

A follow-up appointment should be arranged in rooms three to six weeks after your operation for a discussion regarding pathology and to check on your progress and recovery. At this appointment, your wounds will be assessed, and any further investigations and management arranged.

There is no specific law covering surgery and driving. It is not advisable to drive immediately after surgery. In general, in order to return to driving, you must:

1. Have a valid drivers’ licence
   
2. Be able to control your vehicle during an emergency
   
3. Be able to testify in court as to your capacity to drive

Your car insurer may not cover you following an accident if:

1. You have had recent surgery (‘recent’ is not clearly defined)
   
2. You are taking pain or sedative medications that may impair your concentration or judgement

Aim to return to driving when:

1. You are pain free
   
2. You have full range of motion
   
3. You are not taking strong pain medications or sedatives
   
4. Your reaction time is not compromised

If you are in doubt, do not drive. Call your insurer for advice.

  - Driving Safety and Medicines PDF
NSW Government fact sheet

If you have any questions, please do not hesitate to contact us.

Ph: 02 8307 0977
Fax: 02 8088 7420
Email: info@drgideonsandler.com