The Gall bladder and you
- Part 1 -

Dr Jugindra S *

Gallbladder and hepatic artery :: Pix - Wikipedia/Anatomist90

Laparoscopic cholecystectomy is the commonest laparoscopic operation done worldwide. Since the incidence of gall bladder stone is very high in this part of the country, many patients have queries in their minds which have been brought up during treatment. Some of the doubts have been answered in this article. Individual problems need to be discussed personally.

What is gallbladder ?

The gallbladder is a small sac attached to the surface of the liver and is normally seen on the right side of the upper abdomen. It is connected to the bile duct which comes from the liver.

What does it do?

It stores bile made by your liver, which you do not need.

How do I get bile which I do not need?

When food enters your small bowel (duodenum) from your stomach, a message is sent to the liver: "Make bile!" The liver obeys and bile flows along bile ducts into the small bowel. There it mixes with your food to help digest it. Once all the food passes further down your bowel and out of the duodenum, a message is sent to the liver: "Stop!" The liver shuts off its bile production, but a few drops of bile still form. This bile collects in the gallbladder.

What happens to this bile if I have no gallbladder?

It flows into your intestines and is processed there. There is no significant aftereffect due to this excess bile flow.

What causes gallstones?

For poorly understood reasons, the normal balance between substances found in the bile may change. When such bile lies stored in the gallbladder, it starts to form crystals. These crystals slowly grow in size to form stones. In India, and especially in Manipur, where typhoid infection rates are very high, such infections which affect the gallbladder are also a major cause of initiation of gall stones.

Do all stones cause pain?

No. Stones may lie quietly for years without giving you any trouble.

Do all stones need treatment?

Stones, which cause no pain, can safely be left alone. The usually larger stone is an exception – it is associated with a higher incidence of gallbladder cancer and should be removed even if there are no symptoms. Another rare condition is the "proclaim gallbladder". This condition leads to cancer in over 25% of cases, so these gallbladders should always be removed, even if they do not bother their owners. Since diabetics tend to have many complications of gallstone disease, many surgeons also suggest diabetic patients have their gallbladders removed if there are stones, even if the symptoms are relatively minor.

Is it wise to leave alone stones, which cause pain?

No. Once they start to cause you pain, trouble is statistically likely to get worse with time. Such gallstones, if untreated could pose a significant threat to your later health. Gallstones which cause symptoms should be treated.

Can I wait before undergoing treatment?

Usually there is no urgency at first. However, since you know you are likely to run into greater trouble in time, waiting does not make much sense. A healthy person should not wait to later life when operative risk may be greater.

Does the number or size of my stones matter?

Apart from the unusually large stone mentioned above, the size or number of stones does not matter once they begin to bother you. Any number or size of stones can cause pain. Even one small stone may be quite dangerous because it can travel along the bile ducts.

Do you remove just the stones, or the whole gallbladder?

Once the balance between the substances in your bile is changed, crystals will form and stones will grow whenever the bile is stored in the gallbladder. If all stones were removed, but the gallbladder left, new stones will begin to form. Therefore treatments which get rid of stones only are temporary. Successful treatment requires removal of the gallbladder along with the stones.

What sorts of treatments are available?

Stones can be crushed with shock waves, administered by laser or ultrasound, melted with drugs, or removed surgically.

Which of these treatments is best for me?

Surgery is the best choice for most people. Drug treatment is very useful if you are seriously ill and the risk of surgery is too high. Unfortunately, only about 2/3 of stones can be melted with drugs. Making them smaller as they melt has risks having them travel in the bile ducts to cause greater trouble because stones will continue to form in the gallbladder. In order to maintain stone free, drugs must be maintained for lifetime. Shock wave treatment has many of the same drawbacks as drug treatment.

What effect will losing the gallbladder have on me?

Because it stores bile you do not need for digestion, you will not miss the gall bladder. Its removal should not alter your digestive or any other function significantly. Only a few patients report increase in bowel movements. In the majority of instances the increase is not severe and settles in a few months.

Is surgery safe?

All operations have some potential complications. Gallbladder surgery is the commonest operation done by most general surgeons. With today's advanced technology, medicine and anesthesia, the majority of these common operations go without problems, even in high risk patients. Most complications occur in patients needing emergency gallbladder surgery.

What choice do I have in the types of surgery available?

Laparoscopic cholecystectomy is the surgery of choice worldwide. It is also known as "band-aid surgery" because four band-aids are all that is required for the dressing after surgery. Whereas traditional open surgery needs up to a week's hospital stay and 4-8 weeks off work. Laparoscopic cholecystectomy can be done as an out-patient and most people return to work within one to two weeks.

What is laparoscopic cholecystectomy?

Laparoscopic cholecystectomy (keyhole removal of the gallbladder) is a new way of surgically removing the gall bladder. Instead of cutting the patient open, a small pipe is introduced into the abdomen. Through this pipe goes a thin video camera, which projects an image of the insides onto a large TV screen. Guided by what he sees on the screen, the surgeon can introduce other thin instruments and perform the necessary operation. The surgeon and his operating team can see the organs within the abdomen magnified up to 20 times. Therefore the vision is far better than the conventional open surgery.

How does this differ from the standard operation?

1. There is much less pain. This is the most important factor why this key-hole operation has become most popular with patients throughout the world. Less than 5% of patients need injections to control pain after leaving the recovery room.

2. Hospital time is reduced. In many centers in the world it is routinely done as an out-patient procedure.

3. Time loss from work and normal activities is lessened. In most studies. 90% of patients are back to work within one week of surgery.

4. No ugly visible scar marks are left behind as in open surgery.

5. Less medicine is required during and after operation than open surgery.

To be continued...