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UG07 Laparoscopic Cholecystectomy

Expires end of December 2019

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What are gallstones?Gallstones are ‘stones’ that form in your gallbladder(see figure 1). They are common and can run infamilies. The risk of developing gallstones increasesas you get older and if you eat a diet rich in fat.

Your doctor has recommended an operation toremove the gallstones along with your gallbladder(cholecystectomy). However, it is your decision togo aheadwith the operation or not. This documentwill give you information about the benefits andrisks to help you to make an informed decision.

If you have any questions that this document doesnot answer, ask your surgeon or the healthcareteam.

How do gallstones happen?Your liver produces a fluid called bile that isconcentrated by, and stored in, your gallbladder(see figure 2).When you eat food, your gallbladderempties bile into your intestines to help digest fats.Stones can develop in bile, particularly if you eata diet rich in fat.

For some people gallstones can cause severesymptoms, with repeated attacks of abdominalpain being the most common. Pain is due either tostones blocking the gallbladder duct (cystic duct)and preventing your gallbladder from emptying(biliary colic), or to inflammation of your gallbladder(cholecystitis). The pain can be so severe that youneed to be admitted to hospital.

If the stones move out of your gallbladder intoyour common bile duct, they can cause jaundice(your eyes and skin turning yellow), seriousinfection of your bile ducts (cholangitis) orinflammation of your pancreas (acute pancreatitis).These problems can be serious and can even causedeath.

What are the benefits of surgery?You should be free of pain and able to eat a normaldiet. Surgery should also prevent the seriouscomplications that gallstones can cause.

Your body will function perfectly well without agallbladder.

Are there any alternatives to surgery?Surgery is recommended as it is the onlydependable way to cure the condition.

It is possible to dissolve the stones or even shatterthem into small pieces but these techniques involveunpleasant drugs that have side effects and a highfailure rate. The gallstones usually come back.Antibiotics can be used to treat any infection ofyour gallbladder. Eating a diet low in fat may helpto prevent attacks of pain. However, thesealternatives will not cure the condition andsymptoms are likely to come back.

What will happen if I decide not tohave the operation?Your gallstones may not cause any symptoms. Ifyou have already had symptoms, it is likely thatthese will continue from time to time. There is asmall risk of life-threatening complications.

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What does the operation involve?If you are female, the healthcare teammay ask youto have a pregnancy test. They need to know ifyou are pregnant because x-rays are harmful tounborn babies. Sometimes the test does not showan early-stage pregnancy so let the healthcareteam know if you could be pregnant.

The healthcare team will carry out a number ofchecks to make sure you have the operation youcame in for. You can help by confirming to yoursurgeon and the healthcare team your name andthe operation you are having.

The operation is performed under a generalanaesthetic and usually takes about an hour. Youmay also have injections of local anaesthetic tohelp with the pain after the operation. You maybe given antibiotics during the operation to reducethe risk of infection. Your surgeon will uselaparoscopic (keyhole) surgery as this is associatedwith less pain, less scarring and a faster return tonormal activities. Your surgeon will make a smallcut on or near your umbilicus (belly button) so theycan insert an instrument in your abdominal cavityto inflate it with gas (carbon dioxide). They willmake several small cuts on your abdomen so theycan insert tubes (ports) into your abdomen. Yoursurgeon will insert surgical instruments throughthe ports along with a telescope so they can seeinside your abdomen and perform the operation(see figure 3).

Your surgeon will hold your gallbladder so theycan free up your cystic duct and artery. They willclip and then cut the duct and artery, and separateyour gallbladder from your liver.

Your surgeon will remove your gallbladder fromyour abdomen through one of the ports (see figure4).

Theymay inject dye (colourless contrast fluid) intoyour common bile duct and take an x-ray. If thex-ray shows stones in your common bile duct, yoursurgeon may remove the stones during theoperation or later using a flexible telescope that ispassed down your oesophagus (gullet).

For about 1 in 20 people it will not be possible tocomplete the operation using keyhole surgery. Theoperation will be changed (converted) to opensurgery, which involves a larger cut usually justunder your right ribcage.

Your surgeon will remove the instruments andclose the cuts. They may insert a drain (tube) inyour abdomen to drain away fluid that cansometimes collect.

What should I do about mymedication?Let your doctor know about all themedication youtake and follow their advice. This includes allblood-thinning medication as well as herbal andcomplementary remedies, dietary supplements,and medication you can buy over the counter.

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What can I do to help make theoperation a success?If you smoke, stopping smoking several weeks ormore before the operation may reduce your riskof developing complications andwill improve yourlong-term health.

Try tomaintain a healthyweight. You have a higherrisk of developing complications if you areoverweight.

Regular exercise should help to prepare you forthe operation, help you to recover and improveyour long-term health. Before you start exercising,ask the healthcare team or your GP for advice.

You can reduce your risk of infection in a surgicalwound.

• In the week before the operation, do not shaveor wax the area where a cut is likely to be made.

• Try to have a bath or shower either the daybefore or on the day of the operation.

• Keep warm around the time of the operation.Let the healthcare team know if you feel cold.

What complications can happen?The healthcare teamwill try tomake the operationas safe as possible but complications can happen.Some of these can be serious and can even causedeath.

Using keyhole surgery means it is more difficultfor your surgeon to notice some complications thatmay happen during the operation. When you arerecovering, you need to be aware of the symptomsthat may show that you have a seriouscomplication. You should ask your doctor if thereis anything you do not understand. Any numberswhich relate to risk are from studies of people whohave had this operation. Your doctor may be ableto tell you if the risk of a complication is higher orlower for you.

Your anaesthetist will be able to discuss with youthe possible complications of having ananaesthetic.

General complications of any operation• Pain. The healthcare team will give youmedication to control the pain and it is importantthat you take it as you are told so you can moveabout and cough freely. After keyhole surgery, itis common to have some pain in your shouldersbecause a small amount of carbon dioxide gasmaybe left under your diaphragm. Your body willusually absorb the gas naturally over the next 24hours, which will ease the symptoms.

• Bleeding during or after the operation. Rarely,you will need a blood transfusion or anotheroperation.

• Unsightly scarring of your skin.

• Developing a hernia in the scar, if you have opensurgery, caused by the deep muscle layers failingto heal. This appears as a bulge or rupture calledan incisional hernia. If this causes problems, youmay need another operation.

• Infection of the surgical site (wound). It is usuallysafe to shower after 2 days but you should checkwith the healthcare team. Let the healthcare teamknow if you get a high temperature, notice pus inyour wound, or if your wound becomes red, soreor painful. An infection usually settles withantibiotics but you may need another operation.

• Blood clot in your leg (deep-vein thrombosis –DVT). This can cause pain, swelling, heat or rednessin your leg, or the veins near the surface of yourleg to appear larger than normal. The healthcareteamwill assess your risk. Theywill encourage youto get out of bed soon after the operation andmaygive you injections, medication, or special stockingsto wear. Let the healthcare team knowstraightaway if you think you might have a DVT.

• Blood clot in your lung (pulmonary embolus), ifa blood clot moves through your bloodstream toyour lungs. Let the healthcare team knowstraightaway if you become short of breath, feelpain in your chest or upper back, or if you coughup blood. If you are at home, call an ambulance orgo immediately to your nearest Emergencydepartment.

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Specific complications of this operationKeyhole surgery complications

• Damage to structures such as your bowel,bladder or blood vessels when insertinginstruments into your abdomen (risk: less than 3in 1,000). The risk is higher if you have hadprevious surgery to your abdomen. If an injury doeshappen, you may need open surgery. About 1 in3 of these injuries is not obvious until after theoperation.

• Developing a hernia near one of the cuts usedto insert the ports (risk: 1 in 100). Your surgeonwill try to reduce this risk by using small ports (lessthan a centimetre in diameter) where possible or,if they need to use larger ports, using deeperstitching to close the cuts.

• Surgical emphysema (crackling sensation in yourskin caused by trapped carbon dioxide gas), whichsettles quickly and is not serious.

Cholecystectomy complications

• Leaking of bile or stones. Your surgeon canusually deal with this at the time of surgery butyou may need another operation.

• Retained stones in your common bile duct. Yoursurgeon may remove the stones during theoperation or later using a flexible telescope.

• Continued pain.

• Needing to go to the toilet more often becauseyou no longer have a gallbladder controlling theflow of bile into your intestines (risk: 3 in 100). Youmay get diarrhoea (risk: 1 in 100). Your doctor maygive you some medication to slow down yourbowel.

• Inflammation of the lining of your abdomen(peritonitis) caused by a collection of bile or blood.

• Bile duct injury, which is potentially serious (risk:3 in 1,000). You may need another operation.

• Allergic reaction to the equipment, materials,medication or dye. This usually causes a skin rashwhich settles with time. Sometimes the reactioncan be serious (risk: less than 1 in 2,500) or evenlife-threatening (risk: 1 in 25,000). The healthcareteam is trained to detect and treat any reactionsthat might happen. Let your surgeon know if youhave any allergies or if you have reacted to anymedication or tests in the past.

• Bowel injury, if your bowel is stuck to yourgallbladder (risk: less than 1 in 500).

• Pancreatitis, if a stonemoves into your commonbile duct (risk: 3 in 1,000). This is serious and youmay need another operation.

• Serious damage to your liver or its associatedblood vessels. This is rare but you may needanother operation.

• Tissues can join together in an abnormal way(adhesions) when scar tissue develops inside yourabdomen. Adhesions do not usually cause anyserious problems but can lead to bowelobstruction. You may need another operation.

How soon will I recover?

In hospitalAfter the operation you will be transferred to therecovery area and then to the ward. You shouldbe able to go home the next day. However, yourdoctor may recommend that you stay a littlelonger.

You need to be aware of the following symptomsas they may show that you have a seriouscomplication.

• Pain that getsworse over time or is severewhenyou move, breathe or cough.

• A high temperature or fever.

• Dizziness, feeling faint or shortness of breath.

• Feeling sick or not having any appetite (and thisgets worse after the first 1 to 2 days).

• Not opening your bowels and not passingwind.

• Swelling of your abdomen.

• Difficulty passing urine.

If you do not continue to improve over the firstfew days, or if you have any of these symptoms,let the healthcare team know straightaway. If youare at home, contact your surgeon or GP. In anemergency, call an ambulance or go immediatelyto your nearest Emergency department.

Returning to normal activitiesTo reduce the risk of a blood clot, make sure youfollow carefully the instructions of the healthcareteam if you have been given medication or needto wear special stockings.

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You should be able to return to work after 2 to 4weeks, depending on howmuch surgery you needand your type of work.

Your doctor may tell you not to do any manualwork for a while. Do not lift anything heavy for afew weeks.

Regular exercise should help you to return tonormal activities as soon as possible. Before youstart exercising, ask the healthcare team or yourGP for advice.

Do not drive until you are confident aboutcontrolling your vehicle and always check yourinsurance policy and with your doctor.

The futureYou should make a full recovery and be able toreturn to normal activities and eat a normal diet.If your pain continues or you develop jaundice, letyour doctor know.

SummaryGallstones are a common problem. An operationto remove your gallbladder should result in youbeing free of pain and able to eat a normal diet.Surgery should also prevent the seriouscomplications that gallstones can cause.

Surgery is usually safe and effective butcomplications can happen. You need to knowabout them to help you to make an informeddecision about surgery. Knowing about them willalso help to detect and treat any problems early.

Keep this information document. Use it to help you if youneed to talk to the healthcare team.

AcknowledgementsAuthor: Mr Simon Parsons DM FRCS (Gen. Surg.)Illustrator: Medical Illustration Copyright ©Medical-Artist.com

This document is intended for information purposes onlyand should not replace advice that your relevant healthcareteam would give you.

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