Keyhole Gallbladder Removal

Laparoscopic Cholecystectomy
Advanced Laparoscopic Surgery Wales (ALSW) specializes in the laparoscopic (keyhole) treatment of gallbladder diseases.Gallstones

Benefits of gallbladder surgery

  • Laparoscopic cholecystectomy is the surgical removal of a diseased gallbladder using the keyhole approach.
  • Laparoscopic cholecystectomy does not require cutting of the abdominal muscles resulting in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection and adhesions.
  • Laparoscopic (keyhole) cholecystectomy has replaced the open (conventional) cholecystectomy and is now the gold standard treatment for gallstones and inflammation of the gallbladder.

The gallbladder stores and releases bile which digests the fat in our diet.

Gallbladder

1. The gallbladder
The gallbladder is a reservoir for bile. It receives dilute bile from the liver, stores and concentrates it during the inter-digestive period and evacuates the more viscous gallbladder bile in response to seeing, smelling or eating food. Bile enters and leaves the gallbladder via the cystic duct. Fatty food is a potent stimulus for gallbladder emptying. Conditions which slow or obstruct the flow of bile lead to gallbladder disease.
2. Gallstones
Gallstone formation represents failure to maintain biliary solutes (cholesterol, bile pigment, calcium salts, etc.) in solution. Gallstones develop due to excess of one or other biliary solutes (cholesterol, bile pigment) or due to stasis of bile within the gallbladder. Gallstones may obstruct the normal flow of bile if they lodge in any of the ducts that carry bile from the liver to the small intestine.
3. Risk factors for gallstone formation
Risk Factors

  • Age: Increasing age
  • Body habitus: Obesity/ Rapid weight loss
  • Childbearing: Pregnancy
  • Drugs: Fibrates / Contraceptives / Postmenopausal Oestrogens/ Octreotide
  • Ethnicity: Scandinavians
  • Family: Maternal family history of gallstones
  • Gender: Females
  • Hyperalimentation: Total parenteral nutrition / Fasting
  • Ileal and other metabolic diseases: Ileal disease (Crohn’s disease), Resection or Bypass / High Triglycerides, Diabetes Mellitus, Chronic Haemolysis
4. Presentation of gallbladder stones
Biliary Colic
This is the most common presentation of symptomatic gallstone disease and is due to contraction of the gallbladder behind an obstruction caused by a stone. The patient would experience upper abdominal pain (under the rib cage) that may radiate to the upper back, occurring at least one hour after meals, lasting at least 30 minutes with/without associated nausea and vomiting.Acute Cholecystitis
Acute cholecystitis results from obstruction of the cystic duct by a gallstone that is complicated by infection. The patient would have the same symptoms as biliary colic with the addition of fever and severe abdominal tenderness.gallbladder distendedOperative photograph showing a distended, inflamed gallbladder in acute cholecystitis.Chronic Cholecystitis
In chronic cholecystitis, patients do not suffer with acute inflammation or biliary colic, but may experience fatty food intolerance with mild pain, acid reflux symptoms or diarrhoea following a fatty meal.
5. Investigation / Imaging
Ultrasound scanning (USS)
USS is the investigation of choice for initial imaging of the gallbladder disease. The normal gallbladder wall appears as a pencil-thin line on USS in the fasting patient.gallbladder distendedUltrasound scanning is most sensitive at detecting gallstones and provision of information on gallbladder thickness. Stones that are undetected by ultrasound are typically smaller than 2 mm and/or located in the neck of the gallbladder. Magnetic Resonance Imaging (MRI) is superior to ultrasound in localizing stones in the cystic duct and gallbladder neck.Cholangiography
Cholangiography is imaging of the ductal system to delineate the biliary anatomy or to rule out ductal stones. It is done if the patient is jaundiced, had pancreatitis or scans and/or blood tests suggesting the possibility of a ductal stone.
6. Treatment of gallstones
Laparoscopic Cholecystectomy (LC) is the gold standard treatment for symptomatic gallstones. It requires 3 to 4 small incisions in the abdomen to allow the insertion of surgical instruments and a small video camera.After the initial incisions, the surgeon inflates the abdominal cavity with carbon dioxide. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues.The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through separate small incisions.gallbladder distended

The cystic duct and the cystic artery are identified, skeletonised then clipped with tiny titanium clips. The gallbladder is separated from liver bed and removed through one of the small incisions.

This type of surgery requires meticulous techniques and specialist surgical skills. It is a safe procedure in the specialist hands. A straightforward case can be done in about an hour.

Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less pain, quicker healing, improved cosmetic results, and fewer complications. Most patients can be discharged on the same or the following day and may return to work in about a week.

Rarely, the laparoscopic cholecystectomy will be converted to an open cholecystectomy due to technical difficulty or in the interest of safety.

7. Common bile duct stones (CBD)
If a small stone passes out of the gallbladder, it may lodge in the common bile duct causing partial or complete obstruction of that structure. Clinically, this presents as jaundice with yellow discoloration of the skin and eyes to a varying degree. The presence of fever implies cholangitis which is extremely serious.In some cases, a stone may pass through the common duct and obstruct the outlet of the pancreatic duct leading to pancreatitis, inflammation of the pancreas.Ductal stones should always be cleared.
8. Management of bile duct stones
1. Laparoscopic (keyhole) clearance
This is an advanced laparoscopic technique employed in fit patients with mild cholangitis in the presence of gallbladder and common bile duct (CBD) stones. This technique has the distinct advantage of treating both conditions during the same setting, avoiding the potential serious risks of ERCP and preserving the biliary valve mechanism, the disruption of which especially in the young patients predisposes to cancer within the bile duct.
Gallbladder Operative 1Gallbladder Operative 2These are operative photograph demonstrating the use of ultra-thin scope (choledochoscope) and the removal of the stone from the bile duct laparoscopically.


2. Endoscopic Clearance of CBD stones
This should be utilised in elderly patients or in the presence of severe cholangitis.

This diagram is showing the entrapment of CBD stone within an endoscopic basket prior to its removal.


9. Statistics
Laparoscopic Common Bile Duct Clearance (LCBDC) is associated with a lesser risk of morbidity and mortality in the young (< 50 yr) and fit (ASA 1 & 2) patient compared with preoperative ERCP and subsequent laparoscopic cholecystectomy.Urgent laparoscopic cholecystectomy (ULC) for acute cholecystitis
ULC (emergency admission laparoscopic cholecystectomy) avoids the risks of failure of conservative treatment (20%) and of relapse while awaiting surgery (20%), obviates the need for a second admission, reduces overall hospital stay and can be performed safely with minimal conversion rates (Day Case Laparoscopic Cholecystectomy
50% of elective laparoscopic cholecystectomy might be suitable to be performed on day-case basis