Gallbladder removal (Cholecystectomy)

The surgical procedure for removing the gallbladder is called a cholecystectomy. The gallbladder is an organ located under the liver on the right side of the stomach. It stores a digestive fluid called bile, which is produced in the liver. When certain components (cholesterol and bilirubin) of bile are high, it leads to the hardening of bile that then gets deposited inside the gallbladder to form stones (gallstones).

Gallstones block the gallbladder and cause pain, bloating, nausea and vomiting. In such cases, cholecystectomy is done to remove the stones and relieve symptoms.

You might have to get a cholecystectomy done if your gallbladder is not functioning normally or if you have any symptoms caused by gallstones, such as:

• Indigestion
• Bloating
• Heartburn
• Gas
• Nausea and vomiting
• Pain in the upper right or upper middle part of the stomach (epigastrium) after eating

Cholecystectomy may also be indicated for the following conditions:

• Gallstones >3cm (symptomatic or asymptomatic and acute or chronic)
• Gallbladder polyps >1cm
• Individuals with compromised immunity who have gallbladder disease
• Biliary dyskinesia (a condition in which bile does not flow out of the gallbladder properly)
• Individuals awaiting organ transplantation
• Sickle cell anaemia

This surgery is also recommended for people who have the following complications from gallstones:

• Gangrenous cholecystitis (death of gallbladder tissue and perforation of the wall of the gallbladder)
• Acalculous cholecystitis (inflammatory disease of the gallbladder)
• Gallstone pancreatitis (gallstones leave the gallbladder and block the opening from the pancreas to the intestine, thus blocking the flow of bile)

Laparoscopic cholecystectomy is recommended when a person has gallstones. An open cholecystectomy might be needed instead of a laparoscopic procedure when an individual has gallstones along with any of the following conditions:

• Major scarring from previous surgeries
• Bleeding disorder
• If it is difficult to visualise the area of the gallstones through the laparoscope
• Pancreatitis
• Pregnancy (third trimester)
• Severe liver problems
• Obesity
• Unexpected bleeding during laparoscopic surgery

Gallbladder removal is not done in people who have:

• Inability to tolerate general anaesthesia or laparotomy
• Last stage liver disease
• Coagulopathy (a bleeding disorder)
• Had surgery in the upper part of the stomach before 
• Calcified gallbladder wall (calcification/hardening of the gallbladder due to excessive gallstones)
• Cholecystenteric fistula (an abnormal connection between the gallbladder and gastrointestinal tract)
• Invasive gallbladder carcinoma (gallbladder carcinoma that has spread from the tissue it began in)
• Mirizzi syndrome type II (gallstone impaction in certain areas that can lead to obstructive jaundice)

The following preparations would be needed before this surgery:

• You will have to get the following tests done:
  • Blood tests, including electrolytes, complete blood count and liver and kidney tests
  • Urinalysis
  • Abdominal ultrasound
  • Chest x-ray or electrocardiogram may be required for some people
  • X-ray of the gallbladder
  • Endoscopic retrograde cholangiopancreatography (to diagnose and treat problems of the biliary and pancreatic ducts)
  • Hepatobiliary iminodiacetic acid scan (imaging technique to diagnose conditions in the gall bladder, bile ducts and liver)
  • Magnetic resonance cholangiopancreatography (imaging procedure that uses magnetic resonance to view the biliary and pancreatic ducts)
• You need to inform your doctor or nurse if you take any medicines, vitamins or other supplements or if you are pregnant.
• A week before the surgery, you will be asked to stop taking aspirin, ibuprofen, vitamin E, warfarin and any other medicines that may put you at a higher risk of bleeding during the operation.
• You should stop eating four hours before the operation. If you have to take medicines, take them with a sip of water.
• You may drink clear liquids up to two hours before the operation if your doctor permits.
• You must inform the anesthesiologist if you have any allergies, neurologic disease, heart disease, stomach problems, lung disease, endocrine disease, and smoking or drinking habits. 
• You should quit smoking before your surgery as it will reduce the rate of respiratory and wound complications after the surgery.
• You might go home the same day after laparoscopic surgery and in one or two days after an open procedure if you do not have any complication.
• You should also tell your doctor if you are sensitive or allergic to latex, tape and anaesthesia medicines.

Right before surgery:

• You need to sign a consent form to give permission to the doctor for the surgery.
• Shower the previous night or the morning of your surgery.
• You will be asked to take off all jewellery and change into a hospital gown.
• You should clean your groin and abdominal area with a mild antibacterial soap.
• Brush your teeth and rinse your mouth using mouthwash.
• You need not shave the surgical site.

On the day of surgery, reach the hospital on time and follow the doctor’s instructions. The following steps will be taken before the surgery:

• An intravenous line will be inserted in your vein to provide you with fluids and medications.
• A small needle with medicines will be inserted in your back to give you spinal anaesthesia.
• A tube will be placed down your throat so that you can breathe during the surgery.

Cholecystectomy can be done in two ways, open and laparoscopic. Mostly cholecystectomy is performed laparoscopically, which is also called keyhole surgery. An open cholecystectomy might be performed if you have conditions like an inflamed gallbladder.

• Open cholecystectomy: A single cut will be made under your ribs on the right side of your abdomen or in the upper part of your abdomen through which the doctor will remove your gallbladder. Sometimes, one or more drains may be placed in the incision to drain the fluids or pus.
• Laparoscopic cholecystectomy: In this procedure, the surgeon will make about three or four small cuts on your abdomen.
• Through one of the cuts, he/she will fill carbon dioxide gas into your abdomen. This will cause your abdomen to swell up allowing the doctor to look at your gallbladder and nearby organs easily.
• Next, the surgeon will insert a laparoscope (a thin flexible stick with a camera) into one of the incisions.
• The surgeon will put in other surgical tools in your abdomen through other incisions and remove your gallbladder.
• Finally, he/she will remove the tools and allow the carbon dioxide to escape through the incisions.

Both open and laparoscopic surgeries are completed as follows:

• The gallbladder will be sent for testing.
• The incisions will be stitched or closed with surgical staples. 
• A dressing, sterile bandage or adhesive strips will be used to cover the wounds.

The benefits of laparoscopic cholecystectomy are as follows:

• Less discomfort
• A shorter stay in the hospital
• Quick recovery as compared to open surgery
• Smaller scars than open surgery

Both procedures take about one to two hours. You can expect the following after surgery:

• You shall be moved to the recovery room, and your heart rate, breathing rate, blood pressure, oxygen saturation and urine output will be closely monitored. Once your vitals are stable enough, you will be shifted to a hospital ward.
• Generally, your hospital stay will last for about three to five days after the surgery. However, if you have undergone a laparoscopic cholecystectomy on an outpatient basis, you may be discharged home from the recovery room itself.
• When you wake up, you might have a thin plastic tube inserted through your nose into the stomach to remove the air that you swallow. This tube will be removed when your bowels start working normally. You cannot eat or drink until the tube is removed.
• You might have one or more drains in the incision if an open procedure was performed. These drains will be taken off in a day or so.
• You might be given liquids to drink a few hours after the surgery, depending on your situation. Solid foods will gradually be added to your diet.
• You will be asked to wear stockings to prevent blood clot formation in your legs.
• Your doctor will ask you to breathe into an instrument called an incentive spirometer, which helps keep your lungs in good condition to prevent you from developing pneumonia.

The following are some things that you would be asked to be careful about after discharge from the hospital:

Wound care:

• Make sure to keep your surgical wound clean and dry and do not touch it with dirty hands. 
• Unless your doctor suggests otherwise, you can take a shower after the second day of surgery. However avoid taking a tub bath until your stitches, staples or steri-strips are removed. The Steri-Strips fall off in seven to 10 days. The scars will heal in about four to six weeks and become softer.
• If you have glue over the incision, allow the glue to flake off on its own.
• Whenever possible, try to not wear tight or rough clothes as these clothes may rub against your surgical wound and delay healing

Pain:

• You may feel some pain from the remaining carbon dioxide in your stomach. The pain may last a few days but will get better each day. 
• Avoid standing for long periods of time as it may lead to pain.
• Your healthcare provider may recommend you painkillers to manage pain after the surgery.

Nutrition:

• You should continue to drink about eight to 10 glasses of water every day. 
• Add more high-fibre foods in your diet to help regulate your bowel movements.

Activity:

• It generally takes one to three weeks to resume normal activity. 
• You should slowly increase your activity. 
• Make sure to walk every hour to prevent blood clot formation.
• You must not lift heavy items or do strenuous activity for a minimum of four to six weeks.

When to See the Doctor?

You must immediately visit your doctor if you experience the following symptoms:

• High fever (over 101^°F or 38.3^°C)
• Chills
• Swelling, tenderness or redness on the abdomen
• Stomach cramps
• Absence of bowel movement for two to three days after surgery
• Persistent severe pain that may or may not be getting worse
• Continuous vomiting
• Yellowing of skin 
• Increased drainage or odour from the incision

Cholecystectomy has the following risks or complications associated with it:

• Wound infection
• Pneumonia
• Heart complications such as a heart attack
• Urinary tract infection
• Blood clots
• Kidney failure
• Common bile duct injury or leakage from it
• Retention of the stone in the common bile duct
• Injury to the small or large intestine
• Damage to the blood vessels going to the liver
• Pancreatitis
• Hernia (bulging of tissue or organ) at the incision site
• Liver injury

Usually, the follow-up visit with your doctor will be two to three weeks after surgery.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.