Cholecystectomy – Laparoscopic

The condition

The gall bladder is a small pear shaped organ that is attached to the underside of the liver. The gall bladder stores bile – a fluid that helps digest fat. The bile flows into the gut along a small tube- the bile duct.

Gall stones may form in the gall bladder and may cause pain, bloating, nausea and vomiting.
Sometimes stones may travel into the bile duct and cause a blockage. If this occurs, the person may turn yellow (jaundiced) and need urgent treatment.One in 5 people develop gall stones, although not everyone will have problems. However, those people who do have problems, may go on to develop complications if it is not treated.

Complications include inflammation of the gall bladder, inflammation of the pancreas and blockage of the bile duct causing jaundice and infection.

The procedure:

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

There are usually about four small cuts (incisions) about 0.5 – 2.5cm long, made in the abdomen.
The number of cuts and their positions may vary between patients.

A telescope is passed into one of the small cuts to allow the surgeon to see inside the abdomen. Hollow metal tubes called ports are inserted in the other small cuts. Carbon dioxide is blown into the abdomen to lift the abdominal wall away from the liver, gall bladder, small bowel, stomach and other organs. The surgeon puts instruments such as forceps and scissors into the other ports to help remove the gall bladder.

Metal clips are placed to block off the tube leading from the gall bladder to the other tubes (ducts) and the arteries leading to the gall bladder. These clips stay in your body. Once the gall bladder is taken out, all instruments are removed from the abdomen. The carbon dioxide gas is allowed to escape before the small cuts are closed with staples or stitches.

Sometimes during surgery an examination if the bile duct is required to look for gallstones. To do this a Contrast medium is injected and X-rays are taken of the bile duct.

My anaesthetic:

This procedure will require an anaesthetic.

What are the benefits of having this procedure?

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

What if I don’t have the procedure?

The symptoms of gallstones may get better but can return if left untreated. It is likely that complications will develop, making treatment more difficult and increasing the risks.

Alternative treatments

Please note that some alternative treatments may not be available or suitable for everyone.

Oral Dissolution Therapy
Oral dissolution therapy is the taking of chemicals by mouth to dissolve the gallstones. It is most effective for patients who are not overweight, in a younger age group, have small or single gall stones and a gall bladder that is working well.

It has a 50% risk of gallstones recurring within 5 years and a poor outcome for patients with large gallstones. It is only recommended for those patients who are not fit enough to have surgery or who choose not to have surgery. The drugs may be poorly tolerated with unpleasant side effects.

Open Cholecystectomy
Open cholecystectomy is surgical removal of the gall bladder through an abdominal cut about 10cm long below the right rib cage.

This is a safe alternative to laparoscopic cholecystectomy but requires a longer hospital stay and longer recovery time.

Cholecystostomy
Drainage of the gall bladder along with stone removal is usually performed on patients who are too sick to have the gall bladder removed.

Recovery after your procedure

After the operation, the nursing staff will closely watch you until you have woken up. You will then return to the ward to rest until you are ready to go home, usually within 24 hours. If you have any side effects from the anaesthetic, such as headache, nausea, vomiting, tell the nurse looking after you, who will give you some medication to help.

Pain
You can expect to have pain in the abdomen. The nurse can give you pain killers for this, so it is important to let the nurse know. You may also have shoulder tip pain, caused by the gas used during the operation. Gentle walking will help to ease this. Your pain should wear off within 4.5 days. If it does not, tell your doctor.

Diet
You may have a drip in your arm, this will come out soon after you recover from the anaesthetic. To begin with, you can take sips of water, then increase from fluids to solids until you are able to manage a normal diet in 2 days after the procedure.

Wounds
You may have either clips or stitches and your wounds covered with stick-on or spray-on dressings. You may also have a tube (drain) in your side. This is usually removed the day after surgery. You can shower the day after surgery. Stick-on dressings should be replaced in they get dirty or fall off. Keep your wounds clean until healed and no seepage is present.

Your lungs and blood supply
Take ten deep breaths every hour to move lung secretions and prevent chest infection. At all costs, avoid smoking after surgery as this increases your risk of coughing (which is painful) and chest infection. It is very important after surgery that you start moving as soon as possible. This helps prevent blood clots forming in your legs and possibly going to your lungs. This can be fatal.

Exercise
You will feel tired for a few days after surgery. Take things easy and return to normal duties, as you feel able to. It takes about 14 days to recover and you should not drive during the first 7 days. Do not lift heavy weights (more than 3/5kg) for at least two weeks after surgery.
This is to prevent a rupture where the cuts were made and allow healing to take place inside.

Notify the hospital Emergency Department straight away if you have:

• Large amounts of bloody discharge from the cuts on you abdomen.
• Fever and chills.
• Pain that is not relieved by prescribed painkillers.
• Swollen abdomen.
• Swelling, tenderness, redness at or around the cuts.
• Yellowing of your eyes and skin.
• Vomiting

What are the general risks of this procedure:

There are risks and complications with this procedure. They include but are not limited to the following:

• Infection can occur, requiring antibiotics and further treatment.
• Bleeding could occur and may require a return to the operating room. Bleeding is more common if you have been taking blood thinning drugs such as Warfarin, Asprin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin).
• Small areas of the lung can collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
• Increased risk in obese people of wound infection, chest infection, heart and lung complications, and thrombosis.
• Heart attack or stroke could occur due to the strain on the heart.
• Blood clot in the leg (DVT) causing pain and swelling. In rare cases, part of the clot may break off and go to the lungs.
• Death as a result of this procedure is possible.

What are the specific risks for this procedure

• Excessive bleeding
  Damage to large blood vessels causing bleeding in 1 in 300 people. This may be from the blood vessels and/or the liver bed.
  This might lead to an emergency blood transfusion (1 in 1000 people) and abdominal surgery.
• Other organ injury
  Injury to the gut in 1 in 300 people or another organ such as the bladder, when the tubes and instruments are passed into the abdomen.
  More surgery to repair the injured organs will be needed.
• Gas embolus
  Rarely, gas that is fed into the abdominal cavity can cause an embolus (gas bubble). The embolus can travel to the heart, lungs or brain. This may cause heart and breathing complications.
  This may require emergency treatment and can be life threatening.
• Need for open surgery
  Keyhole surgery may not work and the surgeon may need to do open surgery (1 in 10 people).
  Open surgery requires a bigger cut in the abdomen and a longer stay in hospital.
• Stones in the bile tubes
  Some stones may be found outside the gall bladder in the bile tubes. An x-ray using contrast media may be done during surgery to show up the tubes. The contrast media can cause allergic reactions in some people.
  Further surgery may be needed to remove the stones.
• Escape of stones
  Stones may spill out of the gall bladder and be lost inside the abdomen.
  Rarely, if the stones cannot be found and removed by the surgeon, they can cause abscesses, which may need draining.
  Stones in the bile duct
  Stones may be left behind in the bile duct.
  This may need further treatment.
• Bile leak
  Metal clips or ties that are put on blood vessels or bile tubes and left in the body sometimes come off. This can cause internal blood leak, an infection or a bile leak in 1 in 200 people.
  This may need surgical drainage.
• Bile duct injury
  The bile duct can be damaged during the surgery by the instruments. The average risk is 1 in 1000.
  This can cause long-term problems with blockage, which may need further surgery.
• Wound infection
  The wound may become infected causing pain, redness and possible discharge or abscess. The rate of risk is about 1 in 25 people.
  The wounds are small and wound infections are usually minor and treated successfully with dressings and/or antibiotics.
• Bleeding into the wound
  Possible bleeding into the wound after the surgery may occur.
  This can cause swelling, bruising, blood stained discharge. This may be painful, or become infected which will need antibiotics.
• The wound may not heal normally
  The scar can thicken and turn red and may be painful.
  This is permanent and can be disfiguring.
• Hernia
  A weakness can happen in the wound with the development of a hernia.
  Hernias usually need to be repaired by further surgery.
• Adhesions (bands of tissue)
  Adhesions (bands of scar tissue) can form and cause bowel blockage and possible bowel damage. This can be a short or long term complication.
  This may require further surgery to cut the bands (adhesions) and free the bowel.
• Surgery does not help
  Symptoms experienced before surgery may persist in 1 in 7 people after surgery.
  This may be due to another gut problem.
• X-ray dye
  An allergic reaction to the injected Contrast is rare.
  Increased risk in smokers
• Smoking slows wound healing and affects the heart, lungs and circulation.
  Giving up smoking before the operation will help reduce the risk of wound infection, chest infection, heart and lung complications and thrombosis