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Prof. Dr. R. K. Mishra. MRCS,M.MAS (U.K).
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- What is gallbladder?
- What is the function of Gallbladder?
- What is gall stone & how the stone forms in gallbladder?
- What is cholecystitis?
- What other problem can effect the gallbladder?
- What is the treatment of gallstone or cholecystitis?
- How do you treat acute attack of cholecystitis?
- What are the surgical treatments available for cholecystitis?
- How is the laparoscopic operation done?
- Do you only remove the stones from the gall bladder?
- How can it be removed from such a small hole?
- Is their any danger from the telescope inside the body?
- Is there an increased risk of infection?
- What are the benefits of laparoscopic cholecystectomy?
- What is the recovery period?
- Is there any risk of clips applied during operation?
- Is this operation safe in a fat or child patient?
- Is every patient fit for laparoscopic cholecystectomy?
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What is gallbladder?
The gall bladder is that part of the digestive system which stores and secretes the bile salts that are used in the process of breaking down food into its adsorptive components. A lack of these salts leads to malabsorption maladies. The gall bladder is located on the right side of the body and is connected to the biliary tract system by the cystic duct.
What is the function of Gallbladder?
When we eat, bile is added to the food as it passes out into the duodenum. Bile is stored in the gallbladder, which serves reservoir of bile. When we eat, fatty foods, the gallbladder contracts and push extra bile out through the common bile duct and into the duodenum. Bile breaks the fatty material of food into tiny fragments that can be more easily absorbed by the intestine.
What is gall stone & how the stone forms in gallbladder?
Gall stone is the stone which develops inside the cavity of gallbladder. There are basically two types of gallstones. Most gallstones that occur in western civilizations are composed primarily of cholesterol. Therefore, ingestion of too much cholesterol is considered a risk factor. For women, the risk of cholesterol gallstones increases with age, use of oral contraceptive, rapid weight loss, family history of diabetes mellitus, and inflammatory bowel disease (Chrohn's disease and Ulcerative Colitis). The other types of stones are called pigmented stones. These are composed primarily of calcium bilirubinate. This is found in people who suffer from chronic hemolytic (the destruction of blood cells) states such as sickle cell disease. It is also commonly found in Asian and African populations. A family history of gallstones also increases the risk of stoneformation. In many cases, more than one of these factors plays a roll, but some people form stones without any known risk factors.
What is cholecystitis?
Cholecystitis is defined as inflammation of the gall bladder. Most commonly this problem; inflammation, arise in this system when the flow of bile is stopped or interrupted due to stone (90%) or if infection of biliary tract occurs.
The usual symptoms which causes problem in sudden acute inflammation is:
- Severe abdominal pain
- Fever
- Malaise
- Nausea
- Vomiting
- The attack may follow a large fatty meal.
What other problem can effect the gallbladder?
Some people develop polyps within the gallbladder. Polyps can cause inflammation similar to those caused by gallstones. Polyps are associated with a potential for cancer, but this is relatively rare. It is usually recommended that patients with gallbladder polyps have their gallbladder removed, even if they have only minor or no symptoms. Some time Gallbladder can be diseased without stone or polyp known as acalculous cholecystitis. In this condition gallbladder becomes inflamed if it simply fails to empty properly. The symptoms are the same as those experienced by patients with gallstones. In this condition some time it is essential to remove the Gallbladder.
What is the treatment of gallstone or cholecystitis?
Non symptomatic stone may be left untreated if the patient is not of high risk group like diabetes etc. The symptomatic stone should be removed altogether with gallbladder by surgery.
How do you treat acute cholecystitis?
Treatment of acute Cholecystitis depends on the severity of the attack. In severe cases, therapy initially is supportive with IV fluid replacement and nasogastric suction (a tube placed through the nose into the stomach) for the first day or two. Surgery is then performed to remove the gallbladder. Cholesterol stones in patients who are not surgical candidates, or in those who show no sign of cystic duct obstruction, may be treated with medications aimed at dissolving the stones. There are a significant number of patients who will require surgical removal of the gallbladder to permanently alleviate symptoms. In fact, patients who are against surgery are at increased risk for developing perforation of the gallbladder, which carries about 25% mortality rate.
What are the surgical treatments available for cholecystitis?
One is conventional and other is laparoscopic.
Explaining laparoscopic surgery is best accomplished by comparing it to traditional surgery. With traditional or 'open' surgery, the surgeon must make a cut that exposes the area of the body to be operated on. Until a few years ago, opening up the body was the only way a surgeon could perform the procedure. Now, laparoscopy eliminates the need for a large cut. Instead, the surgeon uses a laparoscope, a thin telescope-like instrument that provides interior views of the body. These days laparoscopic cholecystectomy is the gold standard treatment for cholecystitis or gall stone. Laparoscopic method has now virtually replaced the open procedure for the treatment of gallbladder disease.
How is the laparoscopic operation done?
During a laparoscopic gall bladder operation, the surgeon grasps the gall bladder from one instrument and with other instrument he frees its duct and artery. These are then clipped or tied off and the gall bladder removed from the liver bed. After ensuring that there is no bleeding or injury, the gall bladder including the stones is removed with one of the cannulas. The skin is closed with absorbable sutures. Patient should be able to go home in 12-24 hours after surgery.
Do you only remove the stones from the gall bladder?
No, the gall bladder is removed with the stones exactly like it would have been in an open operation.
How can it be removed from such a small hole?
Human body has a great capacity to stretch. The holes can stretch quite easily whiteout any harm to the body. In a way, it is similar to child birth.
Is their any danger from the telescope inside the body?
No, the telescope is used only to see and is not involved with the operation. Operation is done by long cylindrical instruments which is always under the vision of surgeon on monitor.
Is there an increased risk of infection?
No, the small cuts mean that less of the body is exposed to infection. The less post-operative wound infection is one of the advantage of laparoscopic surgery.
Is there any risk of clips applied during operation?
Yes; there are some reports of internalization of clips and stone formation. Only of the clips which is used for the cystic ducts are sometime causing problem, so most of the experienced surgeons are now not use the clip for cystic duct.
What are the benefits of laparoscopic cholecystectomy:
- Less post-operative pain
- Faster recovery
- Short hospital stay
- Less post-operative complications like wound infection, adhesion, hernia, etc.
- Cost-effective in working group
What is the recovery period?
The patient can start drinking liquids soon after coming out of the anaesthesia which is about 4 hours after the operation. They can start eating soon thereafter. The patient is allowed to get off the bed 4 hours after the surgery and walk to the toilet to pass urine. They are usually allowed to go home the next day, can climb stairs and the majority can get back to routine activity in 5 days and back to work in about 10 days.
Is this operation safe in a fat or child patients?
The operation is ideally suited for the fat patient as the thickness of the tummy wall is immaterial when putting in the telescope and instruments. This is in contrast to an open operation where the fatter patient has a deeper and larger cut causing more bleeding, stitches, and pain. The children can also very well tolerate laparoscopic intervention. The instrument used to do laparoscopy in child patients are less in thickness than adult patients. usually 5 mm and some time 3 mm.
Is every patient fit for laparoscopic cholecystectomy?
No. Most surgeons would not recommend laparoscopic cholecystectomy in those with pre-existing disease conditions. Patients with cardiac diseases and COPD should not be considered a good candidate for laparoscopy. Laparoscopic cholecystectomy may also be more difficult in patients who have had previous upper abdominal surgery. The elderly may also be at increased risk for complications with general anaesthesia combined with pneumoperitoneum. Laparoscopy does add to the surgical risk in patients with a lowered cardio-pulmonary reserve with regard to the consequences of the pneumoperitoneum and a longer operative time.
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