Gallbladder and bile ducts
What is the gallbladder?
The gallbladder is a pear-shaped sac, located under the right lobe of the liver. Its main function is to store the bile produced by the liver. When we eat fatty foods, the gastrointestinal tract releases cholecystokinin, which causes the gallbladder to contract. Thus, the green fluid, bile, is released from the gallbladder, and through tubular ducts, such as the cystic duct and the biliary duct, it reaches the small intestine. There the bile helps in the digestion of fatty substances.
Many of the problems in the gallbladder are caused by the presence of gallstones. They are formed mainly from cholesterol and bile salts in the gallbladder or bile duct that settle, initially forming crystals or the so-called ‘sludge’.
The causes of gallstone formation are not completely known, but there are factors that increase the likelihood of gallstone formation. Factors that contribute to the development of stones include:
- female sex
- use of contraceptives
- sudden weight loss from starvation
- prolonged parenteral nutrition
- gastric bypass
By taking fatty food, the gallbladder contracts and the stones are moved. If these stones move into the cystic duct, they block the flow of bile and cause the cyst to swell, resulting in acute abdominal pain, vomiting, indigestion, and occasionally fever. In addition, if the gallstone passes through the cystic duct, it can block the common bile duct, causing jaundice (yellowing of the skin) or if it also blocks the pancreatic duct, pancreatitis.
The presence of gallstones can be accompanied by symptoms (acute abdominal pain, vomiting, indigestion, heartburn, etc.) but most of the time it is asymptomatic, and gallstones are discovered incidentally. The safest, most painless, and economic method of diagnosis is ultrasound.
When is surgery necessary?
Cholecystitis is inflammation and infection of the gallbladder that is most often due to the presence of gallstones. Cholecystitis is more severe and dangerous in diabetics. Surgical removal of the gallbladder is the appropriate treatment for cholecystitis
In cases of cholecystitis in very seriously ill patients who cannot go through surgery, the condition is treated by placing a percutaneous tube and draining the contents of the gallbladder.
The presence of stones alone is not an absolute indication for cholecystectomy. However, cholecystectomy is often recommended to avoid potential complications in the future.
Gallbladder polyps are found in 1-5% of the population. They can be benign, dysplastic or even malignant. Benign tumors include cholesteroliths (cholesterol crystals), inflammatory polyps and adenomyomas. Most of the time polyps are asymptomatic. There is no way to tell for sure whether a polyp is benign or malignant until after surgery and when the polyp is examined. According to international scientific data, the recommendation is for a cholecystectomy in case a polyp larger than 5 millimeters is found. For smaller polyps, monitoring is recommended.
When the gallbladder does not have the ‘power’ to contract and expel the bile, pain similar to the colic of gallstones is caused. The definition of dyskinesia is when the gallbladder ejection fraction is below 35% and is measured by scintigraphy (HIDA scan).
In earlier years, the removal of the gallbladder required a large incision in the right hypochondrium (see image), hospitalization for several days (4-6), and a lot of pain after the surgery. In the 1990s, things changed and now this operation is performed with laparoscopy or, more recently, robotic surgery.
The emergence of laparoscopy, in the early nineties, transformed cholecystectomy altogether. In laparoscopy, a laparoscope (a small telescope attached to a special camera) is inserted through a tube 5-10 millimeters in diameter, allowing the surgeon to view the patient’s internal organs 10 to 15 times larger than they actually are. At the same time, other tubes with a diameter of 3-5 millimeters are inserted into the abdomen, allowing the surgeon to work inside. If, at the discretion of the surgeon, an intraoperative cholangiography or an investigation of the bile duct (choledochoscopy) is necessary, this can be executed through the same incisions. However, in a small number of patients, less than 1% (when it comes to a specialized surgical team), this method cannot be applied, due to special conditions. The decision to have an “open” operation is at the discretion of the surgeon before or even during the operation.
What are the advantages of laparoscopic cholecystectomy over open surgery?
Laparoscopy has may advantages, such as:
- minimal surgical trauma (one 1 cm incision and three 0.5 cm incisions)
- speedy recovery
- minimal blood loss
- short hospital stay
- lower hospitalization cost
- quick return to work
- 10-15x image magnification and better lighting of the surgical field
- minimal postoperative pain
- virtually eliminated trauma-related postoperative complications (perfusion, dehiscence, hernia, chronic pain, etc.)
- fewer respiratory and cardiovascular complications
- smaller risk of post-operative adhesions
In laparoscopic cholecystectomy complications are extremely rare and patients return to their normal activities very soon. They are discharged the day after surgery.
Laparoscopic cholecystectomy with 2-3mm mini needlescopic laparoscopic instruments
For patients seeking the best cosmetic result, the use of mini laparoscopic tools by our team offers the same safety during surgery and invisible incisions that do not even require stitching after the operation.
Single site laparoscopic cholecystectomy and robotic cholecystectomy
The next step in the laparoscopic method is the operation being performed through only one small hole at the navel (single port), without requiring other small incisions. The cosmetic result is excellent. Recently, the robotic method for the removal of the gallbladder has gained popularity.