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Keyhole surgery for gallstones
The anatomy of the biliary tree. The biliary tree transmits and stores bile, made in the liver, to the small intestine where it is used to help to digest fats. Bile is made in the liver and contains bile salts, bile acids, bile pigments and cholesterol. Bile is secreted into the biliary tree and stored in the gallbladder. After eating, bile is discharged into the small intestine, where it helps to digest fats.
Typically symptoms arising from gallstones are of moderate or severe pain in the right upper part of the abdomen. This pain can radiate around to the back and shoulder blades and may also be experienced in the lower chest. Occasionally this pain is mistaken for a heart attack. When the pain is present the patient may feel nauseated and vomit. If the pain persists for greater than 12 hours, it is likely that the patient has an infective complication of gallstones called cholecystitis. Some patients experience no symptoms from their gallstones. What are the complications of gallstones? Gallstones frequently cause abdominal pain and loss of appetite. Cholecystitis If infection develops in the gallbladder (cholecystitis) the patient may experience continuous pain, worse on movement, a fever, generalised malaise and nausea. Jaundice If gallstones pass from the gallbladder into the bile duct they can lead to obstruction of the flow of bile, leading to jaundice, where the eyes and skin become discoloured yellow, the urine becomes dark orange and the stools become putty coloured. Pancreatitis If the drainage pancreas gland is blocked the patient may experience pancreatitis which is inflammation of the pancrease gland. This causes severe abdominal pain and generalised illness.
Empyema A pus filled gallbladder is termed an empyema and is more common in older patients, particularly diabetics. Perforation of the gallbladder. Occasionally with severe infections, particularly in older patients, the gallbladder may perforate, leading to generalised biliary peritonitis. Small bowel obstruction Gallstones occasionally pass through an abnormal communication to the small bowel (fistula) leading to obstruction of the small intestine (gallstone ileus). This gives rise to pain, abdominal distension and vomiting. Gallbladder cancer Cancer of the gallbladder is associated with the presence of gallstones in most cases, but its incidence is extremely rare. How is the diagnosis of gallstones made? History Diagnosis is made by taking a careful history of the symptoms, followed by physical examination of the abdomen. Ultrasound The most reliable form of diagnostic test for gallstones is the ultrasound scan. Ultrasound uses harmless high frequency sound waves to show up gallstones and a thick walled gallbladder. If there are stones in the bile duct they may show up on an ultrasound and may also lead to increase in the width of the bile duct which can be measured by ultrasound. Futher information on ultrasound can be found here Magnetic resonance imaging Stones in the bile duct can be diagnosed by ultrasound scanning or magnetic resonance imaging (MRI). MRI uses strong magnetic fields to cause vibration which can be detected by a scanner. Futher information on MRI can be found here ERCP ( Endoscopic Reterograde Cholangio-pancreatography) is an endoscopic technique through the mouth (ERCP). ERCP can also be used to diagnose and remove gallstones within the bile duct. Futher information on ERCP can be found here
ERCP showing a large stone in the common bile duct. The patient was jaundiced and stents were inserted to decompress the obstruction.
Most patients with symptomatic gallstones opt for treatment in order to get rid or their symptoms and to prevent complications in the future. Patients with mild symptoms may benefit from lifestyle modification, such as a low-fat diet. However, many patients will be keen to avoid recurrent attacks of the severe pain that they have experienced in the past and to avoid complications in the future. For patients fit for a general anaesthetic, keyhole surgery to remove the gallbladder (laparoscopic cholecystectomy) is the gold standard treatment. This can be performed with a single overnight stay or as a day case in the majority of cases. Alternative treatments such as attempts to dissolve the gallstones and attempts to shatter them with ultrasound waves are generally felt to be too ineffective and to have too high a complication rate to be widely applicable. About keyhole surgery for gallstones. Laparoscopic cholecystectomy (keyhole surgery for gallstones) is one of the most widely performed abdominal operations. Surgeons with a special interest in keyhole surgery will perform in excess of 100 procedures each year. They will also be able to undertake more advanced techniques, such as x-raying the bile duct during the operation and exploring the bile duct by keyhole surgery in order to remove gallstones from the bile duct. Specialist keyhole surgeons achieve very low rates of conversion to open operation and avoid complications of surgery such as damage to the common bile duct. Bile duct injury is a serious complication, which may require major reconstructive surgery. Patients who experience an uncomplicated operation often go home the day following surgery or can occasionally be treated as a day case if their general condition and home circumstances are favourable. |
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Gallstones
form in the gallbladder when the balance between the cholesterol
content of the bile and the bile salt content of bile, leads to
cholesterol crystal formation and the subsequent development of
gallstones. The conditions for producing stone forming bile are
increased in women in the Western world, typically related to pregnancy
or contraceptive pill, overweight, severe weight loss and where
there is a family predisposition. Gallstones can also occur in men
and in children.
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