Gallstones are the result of biliary solids precipitating out of the bile solution. They form into the gallbladder, a pouch attached to the liver and communicating with the bowel [duodenum] via the biliary [bile] ducts [small pipes].

Bile is a solution produced by the liver, is stored in the gallbladder and is released into the bowel following a meal to help in the absorption of fat. There are three types of gallstones: cholesterol [large, smooth and usually solitary], pigmented bilirubin stones [small, dark green and smooth, associated with anaemias] and mixed calcium bilirubinate stones, which represent 70% of all gallstones.

2. What symptoms may they cause?

They may cause a variety of symptoms, ranging from mild right upper quadrant pain following a meal [bilary colic or chronic cholecystitis] to severe pain with temperature [acute cholecystitis], up to obstructive jaundice and pancreatitis with serious systemic symptoms.

In 30-50% of patients gallstones will never cause any symptoms, however, 2% of people with non-symptomatic cholelithiasis develop symptoms annually [usually biliary colic or chronic cholecystitis], confirming that a full 50% of patients will develop symptoms in their life; the risk of serious complications is 5-15% in a lifetime.

3. What is cholecystitis?

Cholecystitis is the inflammation of the gallbladder, which is associated with obstruction of the cystic duct; in 85-95% of the cases it is associated with gallstones. It may be also caused by cancer, but the risk is less than 3%.

Cholecystitis in the absence of stones is not common, but it occurs more often in diabetic people or as a complication of burns and sepsis.

4. How is the condition diagnosed?

Only 15% of gallstones are visible on a plain X-Ray.

The ultrasound scan is the most useful investigation, being accurate in 93% of the cases, but is limited in detecting small stones.

The CT-scanning is also accurate in 90-93% of the cases, however is used only when the ultrasound is negative, while the clinical picture is suggestive of gallstones.

Endoscopic retrograde cholangiopancreatography [ERCP], an invasive test using a telescope [gastroscope] through the stomach to cannulate the bile ducts, is reserved for patients with obstructive jaundice; patients that passed a stone into the bile ducts [abnormal] liver function tests]; and in cases of pancreatitis.

5. What about treatment?

The treatment of choice for symptomatic gallstones is surgery [cholecystectomy]. It is usually undertaken on an elective basis, when the acute episode has settled [in 95% of the cases] with medical treatment. However, in the 5% of cases that does not settle within 48hours of treatment, in patients with sickle cell anaemia or in diabetic patients, emergency surgery is indicated, as the risk of severe complication reaches 10-15%.

Cholecystectomy is usually carried out laparoscopically [key-hole surgery] in the majority of the elective cases, but the open technique is more often used in complicated cases. You should bare in mind that when laparoscopic surgery is attempted, it may sometimes be difficult to remove the gallbladder and the surgeon may have to convert to the open technique, due to technical difficulties, like inflammation, adhesions etc. This is true in about 5% of the elective cases but jumps to 20% in cases of laparoscopic surgery for acute cholecystitis [emergency surgery].

6. What are the risks and results of surgery?

The surgical mortality of elective cholecystectomy is almost negligible [0.1-0.5%], depending on the age of the patient, the underlying medical conditions and the overall surgical risk. It goes to 2.5% for patients with acute cholecystitis and emergency surgery, however, it is far less than the mortality associated with the condition, which is 5-20%, depending on the type of complication that ensues cholelithiasis.

Of the patients operated on for cholecystitis secondary to cholelithiasis, 75-90% are relieved of their symptoms; 10-25% may retain mild symptoms that presumably are unrelated to the biliary tree. The latter may be caused by peptic ulcer, hiatal hernia and reflux, irritable bowel, food intolerance etc.; However, in a small percentage [1-2%] the cause may be biliary, like retained common bile or cystic duct stone, stenosis of the sphincter or biliary stricture.

Your Laparoscopic/Open Cholecystectomy

1. Before your operation

You may be called for a pre-admission visit about a week before the actual date to make sure you are fit and well for the operation.

2. Coming into hospital

You will be asked to come in either the day before or the morning of your operation without drinking anything after midnight. Please bring with you all the medicines you are taking to show to the doctor.

You will be received in the ward by a nurse who will note your personal details and ask about any other conditions you suffer from. You will also be visited by a member of the surgical team that will perform your operation, and the doctor who will give you anaesthesia. Many people are concerned about anaesthetics, so please ask the anaesthetist if you have any specific worries so that he may reassure you. All of these people are ready to answer any questions that you may have, so please ask.

The operation site needs to be shaved. You will be shown exactly where when you arrive on the ward.

You will be asked to sign a consent form that the procedure has been explained to you and you agree to go ahead.

3. The operation

This is usually performed under general anaesthesia. Local anaesthesia may be occasionally used perioperatively to reduce the immediate postoperative pain.

For laparoscopic surgery there are 4 small incisions that are shown on the diagram below. Through the incision around your belly button gas is introduced, to allow good view of the gallbladder. The camera is then introduced and the procedure is carried out through the other 3 small port-holes. Only rarely an intra-operative cholangiogram will be necessary and only rarely a drain will be inserted. The wounds are closed by dissolvable stitches and sticky tapes.

In case we have to convert to the open technique, the standard operation involves a 6-8cm cut below your right rib cage. In almost all cases the skin stitches used are dissolvable.

4. Mobilisation and going home

.  You may experience some shoulder pain, which is caused by irritation of the diaphragm from the gas. It usually resolves within 24hours.

.  You will be able to make a few steps and go to the bathroom when you recover from anaesthesia and then walk the same evening. The earlier the patient is out of bed and walking the better; however, for the first week take things easy. You will increase your activities gradually.

.  It is more likely that you will be sent home the evening after surgery; sometimes you may have to remain for 1-3 days.

.  Three times a day take a short walk [a few hundred meters would do, but more if you wish] to avoid stiffness of the muscles and joints. Some slight discomfort is normal.

.  In the first week after surgery you may need to take a mild pain killer, such as paracetamol, to relieve discomfort. Some times the surgeon may prescribe a stronger pain killer [diclophenac] for the first 3 days.

.  Occasionally, some severe local twinges of pain may occur in some patients and may persist for a couple of months.

5. What next?

.  The wound is waterproof after 4-5 days and a shower can be taken at this time.

.  You should avoid driving for 7-10 days, for two reasons: firstly, the effects of anaesthetics linger on and your reaction times may be slower than normal. Secondly, in an emergency, because of pain, your response time may be prolonged, and it is essential that you are able to perform an emergency stop without pain. If in doubt, delay until you are happy.

.  Walking, swimming, cycling and light exercise are allowed as long as the wound is comfortable.

.  Avoid lifting heavy objects and all strenuous sports for 4 weeks

.  In the majority of cases there is no need for follow-up. However, if you feel so, or if you have any problem the surgeon will be happy to see you again.

6. What complications should you look for?

.  Sometimes a little blood will ooze from the wounds for the first 12-24 hours. This usually stops on its own. If necessary, press on the wound for 10 minutes. If bleeding continues after doing this twice, phone your General Practitioner or the ward.

.  Some skin bruising is usually present after 2-3 days but should cause no concern as it disappears in 7-10 days.

.   It is usual to have some thickening around the wound. This is scar tissue ands will soften up within a few months. The scar will be red to begin with but will fade with time and leave a white line. However, if the thickening is accompanied by excess swelling, redness and much pain may represent wound infection and you should see your General Practitioner who will prescribe antibiotics. Extremely rarely the infection is deep and may not respond to antibiotics. Rarely the same symptoms that you had before surgery may occur. The reason may be either residual stone or one of the causes of post-cholecystectomy syndrome. You should ring your GP or the ward immediately.

7. Return to normal activity?

You can return to work when you feel sufficiently well, generally after a week to ten days.

If you have a job that involves much standing and weight lifting, you may need up to six weeks off work. Your General Practitioner will advise you about returning to work in the light of your progress after the operation.