What is the Gallbladder?
The gallbladder is a pear-shaped structure that is found attached to the liver. The bile duct is a tube that transports bile from the liver to the small intestine. The gallbladder is attached to the bile duct by a small tube called the cystic duct. Bile is collected in the gallbladder between meals and empties into the bile duct through the cystic duct during a meal.

What is the bile duct?
The bile duct is long tube-like structure that connects the liver to the intestine. The liver makes bile that is required for the digestion of food. The bile from the liver is transported to the intestine by the bile duct.

The top half of the bile duct is associated with the liver while the bottom half of the bile duct is associated the pancreas through which it passes on its way to the intestine. It opens in the part of the intestine called the duodenum into a structure called the Ampulla.

Blockage of the bile duct by a cancer or scarring from injury prevents the bile from being transported to the intestine and the bile accumulates in the blood. This condition is called jaundice and the skin and eyes becomes yellow from the accumulated bile in the blood. This condition also causes severe itchiness.

Jaundice is commonly causes by conditions such as pancreatic cancer caused by blockage of the bile duct passing through the cancerous portion of the pancreas, bile duct cancer, blockage by a stone in patients with gallstones and from scarring after injury to the bile duct during gallbladder removal.

What are gallstones?
Gallstones are stone-like substances that are found in the gallbladder. There are two types of gallstones: pigment stones and cholesterol stones. In the majority of patients cholesterol stones are present. In many people the cause for gallstones appears to be interaction between hereditary causes and the diet. Certain population groups such as the Latino population have a an increase tendency to form gallstones.

Gallstones are formed when the bile that is produced by the liver becomes very enriched with fatty substances. In the majority of patients with gallstones, the gallbladder wall is abnormal due to many previous episodes of inflammation. Removal of the stones only is associated with rapid development of new stones in the gallbladder.



What symptoms do gallstones cause?
Gallstone causes symptoms that are usually associated with eating a fat rich meal. Many patients develop pain in the right upper part of the abdomen that may last from few minutes to few hours. Some patients complain of indigestion, feeling fullness, and discomfort in the upper part of the abdomen after a meal.

How are gallstones diagnosed?
Gallstones are diagnosed by a radiological test called ultrasound. In this test the radiologist utilizes an instrument that sends sound waves to the gallbladder. The sound waves detect the stones, which are then seen on the ultrasound. An ultrasound is an excellent test for gallstones and diagnoses the stones in more than 98% of all patients with gallstones.


What are the complications associated gallstones?
Gallstones can cause many serious complications. Some of the complications that are caused by gallstones include:

- Acute cholecystitis. In this condition a stone blocks the cystic duct and therefore the gallbladder cannot empty its content into the bile duct. The secretions in the gallbladder accumulate and become infected. Patients often develop a bad infection of the gallbladder with severe pain in the upper part of the abdomen, fevers, and other symptoms such as nausea and vomiting. Patients usually require admission to the hospital for treatment with antibiotics and emergent removal of the gallbladder.

- Jaundice. Jaundice develops when a stone passes from the gallbladder through the cystic duct into the bile duct and blocks the bile duct. Patients present with a yellowish discoloration of their skin associated with severe itchiness. An emergency procedure by a gastroenterologist is often required to remove the stones from the bile duct.

- Acute pancreatitis. In some patients passage of the stone from the gallbladder into the bile duct is associated with injury to the pancreas. Pancreatitis is one of the most severe complications of gallstones. Of all patients that develop pancreatitis, 85% of the patients get better very quickly however in 15% the attack can be severe and lead to hospitalization that may extend for many days to weeks in an intensive care unit. Pancreatitis develops with severe pain in the abdomen and back that is associated wit nausea, vomiting, and fevers.

- Cancer of the gallbladder. In some patients when gallstones are present over many years (usually more than 15 years) there is an increase risk of cancer in the gallbladder.

How are gallstones treated?
Gallstones are treated by removal of the gallbladder by a procedure called cholecystectomy. Cholecystectomy can be performed through an open surgical incision and by laparoscopic surgery. In the past the gallbladder was removed through an open surgical incision.


Laparoscopic cholecystectomy
Today the almost all gallbladder surgery is performed by laparoscopic surgery. Laparoscopic gallbladder surgery is associated with a shorter hospitalization, less pain and discomfort after the surgery and a rapid recovery allowing many patients to go back to work within a short period of time after the surgery.


What is a laparoscopic cholecystectomy?
Laparoscopic cholecystectomy is a procedure in which the gallbladder is removed by laparoscopic techniques. Laparoscopic surgery also referred to as minimally invasive surgery describes the performance of surgical procedures with the assistance of a video camera and several thin instruments.

During a laparoscopic surgical procedure, small incisions of up to half an inch are made and plastic tubes called ports are placed through these incisions. The camera and the instruments are then introduced through the ports which allow access to the inside of the patient. The camera transmits an image of the organs inside the abdomen onto a television monitor.The surgeon is not able to see directly into the patient without the traditional large incision. The video camera becomes a surgeon’s eyes in laparoscopy surgery, since the surgeon uses the image from the video camera positioned inside the patient’s body to perform the procedure.

Benefits of minimally invasive or laparoscopic procedures include less post operative discomfort since the incisions are much smaller, quicker recovery times, shorter hospital stays, earlier return to full activities and much smaller scars. Furthermore, there may be less internal scarring when the procedures are performed in a minimally invasive fashion compared to standard open surgery.

How safe is laparoscopic gallbladder surgery?
Laparoscopic cholecystectomy is a very safe operation. The overall complication rate is less than 2%. The complication rate for laparoscopic gallbladder surgery is similar to the complication rate for traditional open gallbladder surgery when performed by a properly trained surgeon.

How is laparoscopic cholecystectomy performed?
Many thousands of laparoscopic cholecystectomy have been performed in the USA and this operation has an excellent safety record. Some of the important steps in the operation are as follows:

• General anesthesia is utilized, so the patient is asleep throughout the procedure.

• An incision that is approximately half an inch is made around the umbilicus ( belly button), three other quarter to half inch incisions are made for a total of four incisions. Four narrow tubes called laparoscopic ports are placed through the tiny incisions for the laparoscopic camera and instruments.

• A laparoscope (which is a long thin round instrument with a video lens at its tip) is inserted through the belly button port and connected to a special camera. The laparoscope provides the surgeon with a magnified view of the patient's internal organs on a television screen.

• Long specially designed instruments are inserted through the other three ports that allow your surgeon to delicately separate the gallbladder from its attachments to the liver and the bile duct and then remove it through one of the ports from the abdomen.

• Your surgeon may occasionally perform an X-ray, called a cholangiogram, to exam for stones in the bile duct.

• After the gallbladder is removed from the abdomen then the small incisions are closed
  

What happens if at surgery the surgeon cannot complete the operation with laparoscopic techniques?

In a small number of patients if excessive scarring is present or the anatomy of the structures is not clear then for safety reasons the surgeon may decide too convert the operation to an open surgical operation through a traditional large surgical incision. Less than 5% of all laparoscopic cholecystectomy procedures are converted to open procedures.

The decision to convert to an open operation is strictly based on patient safety. Factors that may increase the risk of converting to the "open" procedure include obesity, a history of prior abdominal surgery causing dense scar tissue, acute cholecystitis or bleeding problems during the operation.

What are the risks of laparoscopic gallbladder surgery?
Complications of a laparoscopic cholecystectomy are infrequent and the vast majority of laparoscopic gallbladder patients recover and quickly return to normal activities. Some of the complications that can occur include bleeding, infection, leakage of bile in the abdomen, pneumonia, blood clots, or heart problems.

Surgical injury to an adjacent structures such as the common bile duct, duodenum or the small intestine may occur rarely and may require another surgical procedure to repair it. If the gallbladder is accidentally or deliberately opened during the procedure stones may fall out of the gallbladder and in to the abdomen that may give rise to later scarring.

How long will you be in the hospital?
Once a diet is tolerated, patients leave the hospital. Most patients go home the next day after a laparoscopic cholecystectomy. Some may even go home the same day the operation is performed. This compares with a five day stay following the open cholecystectomy procedure.

What is the recovery period and how soon can you go back to work?
Patients will probably be able to get back to normal activities within a week's time, including driving, walking up stairs, light lifting and work. Activity is dependent on how the patient feels. Walking is encouraged. Patients can remove the dressings and shower the day after the operation. In general, recovery should be progressive, once the patient is at home.
Most patients are fully recovered and may go back to work after seven days.
Often, this depends on the nature of your job since patients who perform manual labor or heavy lifting may require two to four weeks of recovery.

What should you be concerned about after going home?
The development of fever, yellow skin or eyes, worsening abdominal pain, distention, persistent nausea or vomiting, or drainage from the incision are indications that a complication may have occurred. You should contact your surgeon under these circumstances.