Robotic or Laparoscopic
Surgical procedure for removing the gall bladder, often performed to treat gallstones or gallbladder-related issues, alleviating pain and ensuring digestive health.
The gallbladder is a pear shaped small membranous sac, serves as a reservoir to store bile, and situated beneath liver on the right side.
Approximately 1000 mL of bile is produced by the liver per day and gall bladder has a capacity to store bile about 50ml.
Bile is a concentrated green-yellow fluid, required for digestion. Cholesterol, bilirubin, and bile salts are the important constituents of bile
Bile produced by the liver passes through the tiny channels that eventually lead into a larger tube called the common bile duct, which leads into the duodenum, proximal part of small intestine, where it mixes with food.
Important function of bile
(1) Bile assist in fat metabolism
(2) Bile is also required to excrete certain substances, such as bilirubin, specific drugs, and toxins
A hormone called cholecystokinin causes the gallbladder to contract and deliver bile into the intestine. The gallbladder consists of three sections: the fundus, body, and neck.
Gall Stones: 40% patients are suffering from gall stones. Gallstones are crystallized or solid concretions form inside the gallbladder. Stone formation only takes place when the gall bladder is diseased or not working properly. About 80% patients carrying gall stones remains asymptomatic.
Biliary pain, however, will develop annually in 1% to 2% of individuals who were previously asymptomatic. Those who started to develop symptoms may continue to have major complications (cholecystitis, choledocholithiasis, gallstone pancreatitis, cholangitis) occur at a rate of 0.1% to 0.3% yearly.
Gallstones form due to the crystallization of excess cholesterol in bile , sluggish emptying of bile from the gallbladder, biliary obstruction from various causes, such as strictures in the bile duct or neoplasms, may also lead to gallstones.
Size of gall stones: Some patients have few to hundreds of tiny gallstones. Other patients will have a single gallstone as large as 3 to 5cm. No matter what the size of the stone, it is important that symptomatic stones can lead to more serious complications of gallbladder disease, electively planned surgery after the diagnosis of stone tend to have fewer complications and a shorter recovery.
Based on the type of compositions, there are
2 main types of gallstones
Cholesterol gallstones: The liver secretes too much cholesterol into the bile, which becomes supersaturated with cholesterol. Due to Impaired contractility of diseased gallbladder, bile may not be able to release normally and becomes stagnant. The cholesterol gallstones basically composed of cholesterol but it may contain other components. Cholesterol gallstones are the most common type of gallstones. The colour of the cholesterol is usually yellow or white as it mainly consists of fat and cholesterol
Pigment gallstones: These stones formation takes place only when bile contains too much bilirubin and these stones are dark brown or black in colour,
Mixed pigmented stones: The third type of gallstones is mixed pigmented stones, a combination of calcium substrates such as calcium carbonate or calcium phosphate, cholesterol, and bile.
Causes of gallstones
There are three main mechanisms in the formation of gallstones:
1. Normally, bile contains enough chemicals to dissolve the cholesterol excreted by the liver. But if the liver excretes more cholesterol than bile can dissolve, the excess cholesterol may form crystals and eventually stones.
2. Bilirubin is a chemical produced after the breakdown of red blood cells. Certain liver diseases like liver cirrhosis, biliary tract infections, and blood disorders make too much bilirubin and the excess bilirubin contributes to gallstone formation.
3. Impaired contractility of the gallbladder prevents the bile emptying and concentrated bile contributes to the gall stone formation
Risk factors for gallstones
Pregnancy (decreased contractility of the gallbladder due to Progesterone)
Obesity (increased biliary secretion of cholesterol)
Hormone replacement therapy and certain medications (estrogens and somatostatin analogs)
Stasis of the gallbladder
Female gender (Estrogen increases bile cholesterol and decreases gallbladder contractility)
Rapid weight loss (biliary stasis)
Bile malabsorption (Crohn disease, ileal resection
Diabetes (reduced gallbladder wall contractility due to neuropathy)
Gallstones can develop due to presence of some other disease condition like:
Liver cirrhosis, a condition in which fibrosis of the liver takes place, which deteriorate the normal function of liver
Bile duct infection
Hemolytic anemia (due to rupture of red blood cells)
Autoimmune intestinal diseases such as Crohn’s disease.
Symptoms of gallbladder stones
Gallstones are very common and routinely asymptomatic and most patients are unaware about their gallstones. Gallstone pain only occurs when stone tries to slip into the gallbladder neck or block any duct in the biliary system Gallstone pain can get settle in few minutes but sometimes it requires hospital emergency. Patients with gallstone disease typically present the symptoms of an intermittent episode of sharp and constant pain in the right upper quadrant abdominal pain, sometimes associated with acidity, nausea, and vomiting.
Patient may experience the following symptoms:
Pain in the upper right portion of abdomen or center of abdomen under breastbone
After intake of greasy food abdomen pain towards right side
Epigastric pain that radiates towards mid back, right shoulder Nausea or vomiting
Complications of gallstones
Diabetics are more susceptible to infections, due to high blood sugar levels. The morbidity and mortality in diabetes are mostly due to severe inflammation in diabetes and silent presentation.
If you are diabetic, you need surgery on priority basis. In the diabetic patient’s pain is not common and infection in the gall bladder can happen due to poor supply of blood, which leads to severe complications like empyema, gangrene, and severe infections
Gallstones can block any duct of the biliary system that carry bile especially the cystic duct which enters into the common bile duct, these obstructions can aggravate the symptom like biliary colic, inflammation and infection.
Gallbladder inflammation leading to cholecystitis:
Obstruction of the common bile duct resulting into jaundice and infection
Obstruction of the pancreatic duct responsible for pancreatitis
Cholecystitis: When stone blocks the gallbladder due to inflammation severe pain in the right upper quadrant of abdomen is often experienced by the patients. This condition is cholecystitis.
Choledocholithiasis: This condition is very rare and only 10% of symptomatic gallstone patients landed up with these complications. In this condition gall stone obstruct the common bile duct and prevent the flow of bile which causes jaundice
Infections: This serious life-threatening condition develops in approx. 20% of cases where patients present the symptoms like fever, rapid heart rate and confusion. Infection can spread to other body part and blood vessels can cause septicemia. Following conditions are responsible for infection and can increases the morbidity and mortality:
Gangrene or abscess: Untreated acute cholecystitis can cause necrosis of the tissue which causes poor blood supply to the tissue and gangrene develop. Diabetic patient, male above 50 and patient having a history of cardiovascular diseases are at the highest risk.
Perforated Gallbladder: It’s a life-threatening condition where distended or contracted gall bladder perforate or rupture. Patients having gallstones for long duration and the diabetic patients are at high risk. Perforated gall bladder can cause abdominal infection which is very dangerous.
Empyema: The prevalence of empyema is not very common; it occurs in only 2% to 3% of patients with symptomatic gallstone disease. Necrosis or gangrene causes pus formation, gallbladder become thickened and patients experience severe abdominal pain for more than 7 days. This condition can be life threatening,
Fistula: In the symptomatic gallstones, inflamed gall bladder can adhere to the bowel and perforates, as a result a channel develop known as fistula. Immediate surgery required in this condition to avoid infection
Gallstone Ileus: Chronic inflammation of gallbladder when not treated on time may develop a channel between the gall bladder and intestine. The stone may slip out from gallbladder into the intestine, known as gallstone ileus. Ileus can result into infection and increases morbidity.
Cholangitis: Blockage in the bile duct due to gallstone can results into jaundice, fever and infection known as cholangitis.
Pancreatitis: Pancreatic duct carries enzymes from pancreas into the intestine for food digestion. Before entering into the small intestine it joins the common bile duct. If any stone or sludge is present in the bile duct, it can obstruct the pancreatic duct and the condition is known as pancreatitis.
Other complications and related biliary tract conditions:
Gallbladder Cancer: It appears from the current available evidence that there is a strong association between large gallstones and gallbladder cancer1. Larger stones (> 3 cm) have the greatest risk of developing gallbladder cancer, especially in patients with symptomatic gallstone disease. 1. Annals of Medicine and Surgery (Volume 61, January 2021, Pages 93–96)
Approx. 80% of people with gallbladder cancer suffer from symptomatic or asymptomatic gallbladder stone diseases. Gallbladder cancer is not very common but prognosis of gallbladder cancer is poor. Symptoms of gallbladder cancer appear once the disease has reached an advanced stage. Most common symptoms are involuntary weight loss, loss of appetite, recurrent vomiting and anemia. At early stage before the spread of cancer beyond the mucosa (inner lining), removing gallbladder can reduce the mortality. Elective surgery of gallbladder stones can avoid these life-threatening complications
Tissue growth that protrude from the gall bladder wall into the gall bladder interior are known as polyp. Gall bladder polyps are an incidental ultrasound finding.
Gall bladder polyps are of two types :
Polyps less than 3 cm and not causing symptoms can be monitored via ultrasound. Gallbladder polyps can cause acute cholecystitis and exhibit symptoms of pain, indigestion, and discomfort. Surgery is recommended to avoid complications.
Diagnosis of Gall Bladder Stones
Whole abdomen ultrasound after 12 hours fasting is one of the best diagnostic options to visualize the stones. Ultrasound can also give a view of the patients’ gallbladder like wall thickening and infections or blockage. Gall bladder wall thickening can differentiate between cholecystitis and cholelithiasis. Wall thickening greater than 3 mm can intemperate patient is having cholecystitis
HIDA scan, ERCP and MRCP are done to scan the biliary tract for any obstruction
Blood tests are recommended for the identifications of infection signs due to gall stones like liver function test, CBC, procalcitonin etc. (e.g., raised ALP is a sign of gall stone obstruction, CBC to identify whether there is any infection in the bloodstream, S. Amylase, and lipase to rule out pancreatitis before surgery)
Treatment of Gall Bladder Stones
The first line of treatment for a symptomatic patient is fasting to rest the gall bladder
IV fluids to prevent dehydration.
Antibiotics to treat infections
Elective laparoscopic surgery is the best treatment of gallstones as soon as the diagnosis established. It can avoid other complications as well as life threatening situations
Cholecystectomy treats symptomatic gallstones. Laparoscopic surgery can be done by minimal access The laparoscopic approach is the standard of care.
Advantages of Laparoscopic surgery
From surgeon’s perspective laparoscopic surgery provides a magnified view of operating area and better visualization
From patient’s perspective:
Patient feel less pain and post operative discomfort
Patient can ambulate after a few hours of surgery
Early discharge and less financial burden
Patient can resume work within a week
6–8 hours of fasting are required before surgery. Nothing by mouth after midnight on the day of surgery (no water, no food). The Patient can be admitted on the same day of surgery or one day prior to surgery, as directed by the surgeon’s office. Insurance formalities before admission can be completed at the surgeon’s office.
Pre-operative evaluation is done for all patients, like few blood investigations and some investigations like a chest X-ray, ECG, or echo, and other investigations depending on the underlying health issues. These tests can be done on an OPD basis or after admission as well. If the patient wishes to have investigations performed after admission, they must be admitted one day in advance. All the patients should be assessed by anesthesiologists to determine their fitness for surgery. Certain medications can interfere with the procedure, like aspirin and warfarin. Patients may have to stop these medicines prior to surgery.
Please follow the instructions provided by the physician regarding taking your morning medications on the day of surgery. If you are instructed to take your morning medications, please take them with a small sip of water.
You may be asked to sign a consent form that gives permission for the procedure. Read the form carefully and ask questions if anything is not clear.
After these formalities, the patient can be shifted to the operation theatre.
Once after reaching the operation theater, anesthesiologist will create a IV access by inserting canula into your vein
A tube will be inserted through your throat known as intubation, The anesthesiologist will monitor your heart rate, blood pressure, breathing, and oxygen level during the surgery.
After completing the process of anesthesia, the surgeon will start surgery.
Through four tiny cuts on the abdomen which is hardly 1cm centimeters, a surgeon can do surgery. These cuts are made to insert instruments and small telescopes for performing surgery.
Duration of the surgery is 45 minutes to 1 hour, depending on the severity of the disease, like gall bladder inflammation or infection.
Immediately after the operation, you will be taken into the Post-Operative Unit, or recovery room, for approximately 1 to 2 hours. Anesthesiologist will monitor closely your vitals and pain after extubating until you are awake and then you will be transferred to your room.
Patients may feel nauseated after surgery due to side effects of anesthesia. After few hours this feeling should pass
Patients can walk or go to the bathroom after 4 hours of surgery.
After 6 hours of surgery patients are given clear liquids, once the patients tolerate liquid diet, soft diet can be given to the patient and IV fluids can be stopped, and the patient can be shifted to oral medications.
On the next day of surgery, surgeon will shift patient to oral medications
Once the patient pass motion, a normal diet can be started.
If patient is not able to pass motion next day of surgery, no need to worry, due to pain killer medications, prolong fasting its common. In case of not passing motion for 2 days’ laxatives can be started as per surgeon’s instructions
The incision sites can be covered with waterproof adhesive bandages, which can be removed after checking the wound during follow-up visit. The patient can take shower and may gently wash over waterproof bandages, avoid rubbing or pressing.
Visit surgeon office after one week
Recovery After Surgery
Patients can do light normal activities after discharge. After one week, patients may return to all normal activities, as you desire (avoid strenuous activities, sudden lifting that causes increased discomfort)
After taking 7 days’ rests patients can resume their work
A full recovery from open gallbladder surgery could take about minimum six weeks.
Patients should avoid driving till the time pain is there.
Walk around frequently to prevent blood clots.
Drink plenty of fluids to prevent dehydration.
Don’t lift heavy objects for four to six weeks.
You may go up and down stairs as desired.
Diet after surgery
Take a balanced meal on time that includes fruits, vegetables, salad, legumes, grains and poultry.
Avoid heavy and greasy food
Avoid prolong gapping in the meal timing
Take small portion size
Maintain adequate hydration
Frequently Asked Questions
How common are gall bladder diseases and who are at risk?
Gall stones are common in India, about 40% males and 60% females between the 20 ‘s to 40’s age group are more prone to this disease. Children and old aged people are less likely to develop gall stones.
What are the common symptoms of gall stones?
Symptoms include severe right upper quadrant pain, which may or may not need injectables. This pain can subside with medicine or sometimes require a hospital emergency.
How long does it take the gall bladder stone to become problematic?
Gallbladder stones size does not matter. Even a tiny stone can slip into the common bile duct and block the pancreas and block the liver, causing jaundice and pancreatitis and it’s a very serious complication. Sometimes tiny stones get impacted in the neck of the gall bladder and produce pus in the gall bladder known as empyema, sometimes it perforates the gall bladder. Bigger stones greater than 3 cm are responsible for gall bladder cancer
Is gall bladder disease a lifestyle disorder?
Yes, it’s a lifestyle disorder, people who skip breakfast, have a sedentary lifestyle and consume fatty food are more prone to develop gall stones.
What are the preventive measures
Managing weight and avoiding a crash diet to some extent prevent gall stones. This happens because fast weight loss causes your liver to have more cholesterol.
Can patient live without a gallbladder?
Gallbladder stones develop when the gall bladder is diseased and not functioning properly. Liver ducts will release bile when required for digestion. However, instead of being stored in the gallbladder, the bile will move directly to the small intestine. No significant difference patients can find after gall bladder removal.
What are the dietary changes required after gallbladder removal
After gallbladder removal, patient can eat and drink everything, whatever they were taking before surgery. No such dietary restrictions.
Dietary changes may include: gradually increasing the amount of high-fiber in the diet, eating too much fiber too soon after surgery may cause bloating or diarrhoea.
limiting your consumption of fatty foods, avoid prolong gapping in the meal and maintain adequate hydration
Is obesity responsible for gallstones
Being obese or overweight increases your risk. This is because it can make your bile richer in cholesterol.
Is it possible to remove only stone not gallbladder
Gallbladder stone develop only when gall bladder is not functional. Removing only stone cannot solve the purpose, as gall bladder is diseased. Its better to remove complete gall bladder to avoid complications due to diseased gall bladder
Is there lifetime restriction of fatty food
You must avoid fatty food only during initial days of gallstones surgery. You do not have to restrict yourself to fatty food due to gallstones surgery