MBBS FRACS • Upper Gastrointestinal, Advanced Laparoscopic and General Surgery • Perth, Western Australia

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Gall Bladder conditions

Gallstone disease is very common in Australia, affecting 1 in 10 adults. It is commonly and successfully treated with laparoscopic ('key hole') gallbladder surgery (laparoscopic cholecystectomy).

Anatomy

The gallbladder is a small muscular organ attached to the underside of the liver, which is situated under the margin of the right ribs. The gallbladder is connected to the liver and small bowel by a series of ducts ('extrahepatic ducts').

Its function is to store bile produced by the liver. Bile is needed to aid the digestion of fat. When needed, the gallbladder contracts and releases the stored bile into the bile duct and then the small bowel.
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Anatomy of the gallbladder and bile duct

Symptoms

Gallbladder and bile ducts

Gallstones can interfere with this process by blocking the flow of bile. They can cause obstruction of the gallbladder, bile duct and/or pancreas. The symptoms produced are dependent on the level of obstruction caused by the gallstone. Typically, the pain is centred in the upper abdomen or under the right rib margin and may extend around into the back. Quite often the patient will notice a 'new' back pain. Other symptoms include jaundice (skin and eyes turning yellow), nausea, vomiting and fever. There may also be nausea, abdominal bloating and indigestion.

Gallstones are concretions within the gallbladder and bile ducts. They are not actually stones. There are two groups of stones:
  1. Cholesterol stones
  2. Pigment stones
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Cholesterol stones
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Pigment stones
There are certain factors that predispose to gallstone formation:
  • Obesity, pregnancy, rapid weight loss (of any cause).
  • Certain medical conditions: Crohn's disease, certain haematological (blood) diseases
  • Being female.

Diagnosis of gallstone

This involves a combination of clinical presentation picture, blood test and ultrasound examination.
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Ultrasound of gallstone.

Management of gallstones

Various treatments have been tried in the past to manage gallstones.

This included dissolution of the gallstones and blasting the gallstones with ultrasound waves. Unfortunately these methods have been found to be ineffective and are no longer accepted as treatment of choice for gallstone disease. Almost invariably the patients treated by these methods often return with symptoms within a year. They have also been found to develop more complications than those treated with surgery.

Removal of the gallbladder has not been associated with any long-term impairment to digestion as the bile is still able to flow directly from the liver into the small intestine.

Surgery

Laparoscopic cholecystectomy (Key hole gallbladder surgery)

The most common method to deal with gallstone disease is laparoscopic cholecystectomy (key hole gallbladder surgery). This is successful in about 99% of cases. Thus only 1% of cases will require conversion to open procedure. This surgery is performed under general anaesthesia.

Four small incisions are made in the abdomen. A laparoscope (small telescope with a camera at the end) is inserted through the incision at/near the belly button. A video system is attached to the laparoscope to enable the surgeon to visualise the gallbladder during surgery.

The cystic duct and artery are dissected and displayed. The surgeon will then insert a plastic tube into the cystic duct to perform an x-ray study to see whether a stone is present in the duct. If there is a stone in the common bile duct, the surgeon will remove this laparoscopically (provided it is safe to do so). The gallbladder is then removed.

At the end of the surgery, a small drainage tube may be left in the operative area to drain any fluid that may accumulate after the surgery. This drain is typically removed in 1–2 days after the surgery.

Complications

Overall complication rates for laparoscopic cholecystectomy are approximately 2–3%. The possible complications associated with laparoscopic cholecystectomy are:

1. Conversion to an open procedure
This occurs when the surgeon feels that it is not safe to proceed with laparoscopic surgery. This is commonly due to the amount of scarring in the tissues around the gall bladder. This can be due to previous surgery or infection of the gallbladder. When this decision has been made, a larger incision is made just below the margin of the right ribs and the operation performed through this incision. As the incision is bigger than those of laparoscopic cholecystectomy, the patient typically will spend longer in hospital (about 1-2 weeks) and will take longer to return to normal activities. (Average 4-6 weeks).
Mr Ahmad's open conversion rate is less than 1%.

2. Bile duct injury
This occurs in 1 in 350 operations. This is a figure obtained through large studies, which include those of relatively new and inexperienced surgeons. Most of these injuries are minor. These are treated by insertion of a stent (temporary tube) into the bile duct. No long-term sequelae should result. A major bile duct injury (which is very rare) may require a further major open operation.

3. Bile leak
This is uncommon and usually settles without the necessity for another operation. Very occasionally, a further laparoscopic procedure is needed to wash the area and for insertion of a drainage tube. On occasions, the patient may also need to have an ERCP to deal with this problem. This procedure is done by inserting a gastroscope (a flexible telescope) through the mouth (whilst the patient is under heavy sedation) and a stent (plastic tube) is then placed into the bile duct.

4. Infection
Typically, at the incision at the belly button. This tends to settle with antibiotics.
  • Bleeding.
  • Other intra-abdominal organ injury.
  • Other complications with surgery generally:
  • Cardiovascular problems.
  • Wound infections.
  • Blood clots in the legs.

Postoperative management

Patients typically will be discharged the following day.

Prior to discharge patients will be given detail instruction on how to manage their post-operative pain and dressing.

As for every patient of Dr Ahmad, the patient will be contacted by the Post Operative Care Consultant a few days post discharge, to ensure smooth uncomplicated recovery. A follow up appointment will then be organised.

Patients are typically recommended to organise 1–2 weeks off work and a period of 4 weeks of ‘light duty’.
Mr Hairul Ahmad MBBS FRACS
Upper Gastrointestinal, Advanced Laparoscopic and General Surgery
Perth, Western Australia
Practice Details

Suite 12, Waikiki Specialist Centre,
221 Willmott Drive, Waikiki WA 6169

Please call (08) 9592 2298 for an appointment.
Fax: (08) 6314 1524
or email us

Office hours

9am–4pm Monday to Friday

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