Laparoscopic Surgery for Gallbladder Stones
 
What is gallbladder?
Gallbladder is a pear-shaped organ attached to the undersurface of the liver. Its main function is to collect and store bile (a digestive liquid) produced by the liver. After eating, the gallbladder contracts and releases the bile. The bile is carried via a small tube called the cystic duct and then larger tubes called bile ducts into the small intestine where it helps in the digestion.

What are gallstones and how are they formed?
Gallstones are solid clumps of cholesterol or pigment material that form in the gallbladder. When the concentration of bile components like cholesterol or bile pigments increases, they precipitate to form solid crystals. These crystals then stick together and form gallstones. Why some people form gallstones is not clearly known, and therefore there is nothing one can do or avoid in the diet to prevent the gallstones from forming.

What symptoms do patients with gallstones experience?
Patients with gallstones often get severe abdominal pain ? in the right upper side - particularly after eating fatty food. If a gallstone blocks the common bile duct, jaundice (yellowing of the skin) can develop. Patients with gallstones may also suffer complications such as infection and inflammation of the gallbladder (cholecystitis) or of the pancreas (pancreatitis). Some people who have gallstones have no symptoms and these people are said to have so-called "silent" gallstones.

How are gallstones diagnosed?
Gallstones are usually diagnosed by a relatively simple test called ultrasonography. In this test a jelly is applied to the skin and a probe is moved over the abdominal wall to capture images of the internal organs.

How are gallstones treated?
Not all patients who have gallstones require surgery. In most instances those who do not have any symptoms (silent gallstones) may not require treatment. However, a decision not to operate should be taken only after consulting a specialist because when left alone gallstones are likely to cause complications.

Once a patient develops symptoms because of gallstones they do not go away on their own. Some patients can be temporarily managed with medicines or by making dietary adjustments, such as cutting down on fat intake. However, this treatment is not a permanent solution to the problem. Treatment with homeopathic or ayurvedic medicines is never able to dissolve gallstones. Taking these types of medicines in the hope that the gallstones will ?melt away? carries the risk of the patient developing serious complications. Surgical removal of the gallbladder (cholecystectomy) is the best treatment for patients in whom the gallstones cause symptoms.

What are the side effects of removing the gallbladder?
It is important to understand that a gallbladder that forms gallstones is a diseased organ and is not functioning normally. Therefore removal of such a diseased gallbladder is not associated with any side effects. Over a period of time, the function of storage of bile is taken over by the bile ducts and there is no impairment of the digestive process.

How was the gallbladder operation performed in the past?
In the past, the gallbladder was removed by making a large incision on the abdomen (open cholecystectomy). This incision invariably caused a lot of pain after the operation and as a result the patient had to stay in the hospital for about week. Even after discharge the overall recovery required several weeks. The risk of infection was higher in this larger incision.

How is the gallbladder operation performed around the world today?
Today, all over the world the removal of gallbladder is performed by laparoscopic cholecystectomy. Instead of a fifteen to twenty cm incision of an open operation, the laparoscopic cholecystectomy is carried out through four small punctures each of which is ? to 1 cm in length. As the incisions are small, the pain after the operation is minimal and therefore the recovery is much faster. The chances of infection in the incisions are almost negligible.

How is laparoscopic cholecystectomy performed?
It is important to note that laparoscopic cholecystectomy is a major operation performed under general anaesthesia. The surgeon passes a cannula (a narrow tube) into the abdomen in the region of the umbilicus. A telescope connected to a camera and a cable carrying bright light is passed inside the abdomen through the cannula. The camera is connected to a television monitor so that a magnified view of the patient's internal organs appears on the screen. The surgeon and his team conduct the operation by observing the television screen. The surgeon then inserts other cannulas and passes long, thin instruments inside the abdomen through them. Using these instruments the gallbladder is separated from its attachments and is removed through one of the openings. After removal of the gallbladder, the small incisions are closed with a few stitches.

What if the operation cannot be performed by the laparoscopic method?
In a small proportion of patients (1% - 3%) during the operation the surgeon may decide to convert the laparoscopic operation to a traditional open one. This is required if the organs cannot be visualised safely or handled effectively. Conversion to an open operation is never considered a complication. In fact, it reflects a sound judgement on the part of the surgeon who is interested in safeguarding the patient?s safety.

What happens after laparoscopic cholecystectomy?
The patient does experience some amount of pain for about 12 ? 24 hours after laparoscopic cholecystectomy depending on individual tolerance. Also, some nausea and vomiting is not uncommon in the first 12 hours. Patients are always given medications to relieve the pain and take care of the nausea. Usually, the patient is allowed to drink fluids within 6 to 8 hours of surgery and is able to have meals from the day after surgery. Activity is dependent on how the patient feels, but all patients are encouraged to get up and walk as soon as they are comfortable. Most patients go home within a 48 hours after laparoscopic cholecystectomy as compared to five to seven day following the traditional open operation.  Some patients, particularly the elderly and those with other medical problems like diabetes may have to stay in the hospital a little longer. In general, patients recover completely within 7 to 10 days.

How soon can a patient go back to work?
In our society patients often prefer to take things easy for weeks after any operation because of a fear that they may harm themselves by being active. After laparoscopic cholecystectomy the recovery is quite rapid. Soon after returning home the patients are allowed all activities they feel comfortable with. Depending on the nature of their job, most patients are able to return to work within ten to fifteen days following a laparoscopic cholecystectomy. Patients with light, desk jobs usually return in a few days while those involved in heavy lifting may require a little more time.

Are there any risks involved in laparoscopic cholecystectomy?
While there are risks associated with any kind of operation, the vast majority of patients undergoing laparoscopic cholecystectomy experience no complications. It is important to remember that before undergoing any type of surgery - whether laparoscopic or traditional ? it is important to make sure that the surgeon performing the operation is well trained and experienced. In the hands of such surgeons the risks of laparoscopic cholecystectomy are negligible.

Is laparoscopic cholecystectomy very expensive?
In the minds of people there are certain misconceptions about laparoscopic surgery ? one of them being that this surgery is affordable only to the rich. However, today laparoscopic surgery is offered at hospitals ranging from small charitable ones to large private corporate hospitals. Depending on the hospital and the type of room the patient chooses for admission, the cost of operation does vary but this is comparable to the cost of open cholecystectomy. 

Thus it can be said that laparoscopic cholecystectomy is a technique that has truly revolutionised the treatment of patients with gallstones. It should be comforting for the patients to know that they need no longer dread the pain after a gallbladder operation and be anxious about long stay in the hospital.