What are Gallstones?

Gallstones are “stones” within the gallbladder. They can vary widely in size, from the size of a grain of sand to the size of the whole gallbladder. Big gallstones aren’t necessarily worse than small ones, and one gallstone can cause as much trouble as a thousand.

Usually gallstones are made of cholesterol. But that doesn’t mean you eat too much cholesterol, or even that there is too much cholesterol in your blood. Sometimes the cholesterol level in you bile is even normal. Your bile has several components – some keep the cholesterol dissolved and some make it crystallize. If these components get out of balance the cholesterol will crystallize into gallstones.

 

Treatment of Gallstones

At the moment, the best cure for gallstones is removal of the gallbladder along with the contained stones (surgical removal of the gallbladder is called cholecystectomy). There are medications that will actually dissolve gallstones under certain circumstances, but this course of treatment is presently FDA approved only for patients who can’t or won’t undergo cholecystectomy. That’s the bad news.

The good news is that, over 95% of the time, the gallbladder and stones can be removed laparoscopically (through a scope). This procedure has been named and misnamed many other things (minimally invasive cholecystectomy, laser cholecystectomy, Band-Aid cholecystectomy), but basically it means the removal is performed using a scope to see and long narrow instruments to work inside the abdomen.

These instruments and the scope are usually placed through four small incisions in the abdomen. Two of these are half inch incisions – one at the umbilicus (belly button), and one just to the right of the midline under the rib cage. The other two are quarter inch incisions over on the right side of the abdomen. Usually a Band-Aid is all that is needed for a dressing.

Sometimes the gallbladder can’t be safely removed through the laparoscope. This can be due to unusual anatomy or to a difficult dissection. If this happens the procedure has to be converted to an “open” cholecystectomy. This means that instead of four small incisions and a trip home, you wake up with a traditional incision under the right side of the rib cage, and a two to four day hospital stay.

Laparoscopic cholecystectomy is not safer or significantly cheaper than the traditional “open” cholecystectomy performed through an incision. It is, however, less painful, and allows for a quicker return to previous activity. Laparoscopic cholecystectomy is also an outpatient procedure, with most patients returning home the same day.

 

What are the risks of surgery?

As with any surgery, there is a risk of bleeding, infection, or anesthetic reaction with laparoscopic cholecystectomy. Another risk that is more specific to cholecystectomy (whether open or laparoscopic) is an injury to the main bile duct. This can occur because the surgeon has to dissect around the “cystic” duct which drains the gallbladder into the main bile duct. The risk of a bile duct injury is less than 1%, but if it occurs it usually requires another operation (or sometimes operations) to fix it.

 

Alternatives

As indicated above, there are medications that dissolve gallstones under certain circumstances. These have not been shown to offer any advantage over cholecystectomy in most patients, and so they are only approved for use if cholecystectomy is not an option.

Flare-ups of cholecystitis can be treated with antibiotics, and more often than not this will resolve the immediate problem. Sometimes (most commonly in certain stages of pregnancy) gallstones with flare-ups of cholecystitis are treated with antibiotics to delay the need for cholecystectomy. In the presence of gallstones and symptoms, however, it is generally safer to perform cholecystectomy than to wait for an episode of cholecystitis and then try to treat it with antibiotics when it occurs.

 

Before Surgery

You can expect to get most of your preoperative instructions when you go for your Same Day Surgery preoperative evaluation appointment. Usually you are not supposed to eat or drink anything after midnight, but the anesthesiologist will frequently make adjustments to this, especially if there are medications you need to take after midnight.

When you finish your appointment they will probably be able to tell you what time to show up on the day of surgery. As the surgery schedule for that day becomes clearer, however, you may get a phone call the day before your planned surgery modifying the time somewhat.

 

Day of Surgery

On the day of surgery you’ll come in, get an i.v., and get some sedative just before surgery to help you relax. You probably will not remember a whole lot more because the sedative has the side effect of making you forget.

 

After Surgery

After the operation the next stop is Recovery Room, usually for about an hour of intensive monitoring. If everything is routine you can expect to go straight back to the Same Day Surgery area. If you are too uncomfortable for that you will probably need to go to a bed on the floor for several hours.

After you get home it’s normal to have some oozing from the small incisions. Sometimes this is more than a Band-Aid will absorb, and a piece of gauze is needed to keep the fluid from getting on your clothing. Usually light pressure and/or ice packs will slow the drainage. It is very rare for this oozing to be a problem, but if you keep saturating gauze dressings we need to know about it and may need to check it.

Another surprise that can be alarming is discoloration of the skin around one or more incisions. Sometimes you won’t see this for several days, because it takes time for the “bruise” to reach the surface. If the color is bluish-brownish-greenish-yellowish or some combination of these it’s probably normal. If it’s red, especially if it feels thickened and increasingly painful, we may need to check it.

Within twelve hours the incision should be “sealed”. By the morning after surgery it is OK to bathe or shower with soap and water. If you need to clean up before then, stick to a sponge bath.

 

Activity

You’ll be somewhat sore after you get home – usually your belly button will be the worst spot. But it is OK to resume your previous activity as tolerated. You don’t have to worry that you are going to “pull something loose”. It is rare for these small incisions to have any problems, but if they do it’s going to happen anyway – early return to previous activity does not make it any worse. The pain is there to tell you when to stop, though, so pay attention to it.
You can usually return to light duty work in 1-2 weeks and heavy duty work in 2-4 weeks.

 

Diet

There won’t be any new limitations on your diet. You may even find that you can eat more types of foods after your cholecystectomy than you could before.
What to Expect Some patients have some loose stools for a week or two after cholecystectomy. This can be treated symptomatically, but please let us be involved. Prescription pain medication includes a narcotic which slows bowel activity. The combination of narcotic pain medication and anti-diarrheal agents can cause a swing too far in the other direction (constipation).

 

Do I Need My Gallbladder?

You probably won’t miss your gallbladder long term. There are theoretical uses for the gallbladder to store bile and then release it at meal time. The extra bile may allow you to extract a few more calories from a fatty meal. Some people also think that after cholecystectomy the constant drip of bile into the intestine (rather than a sudden flow at meal time) allows some of the bile to go upstream into the stomach, where it can cause irritation which may eventually result in ulcers. As a practical matter most people don’t notice any difference after cholecystectomy, except for the incisions.

 

 

For more information or to schedule a consultation, please call us at (828) 327-9178.

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