J.M.C 38 YEAR OLD, HAS A FAMILY HISTORY OF GALLSTONES.

FEMALE FROM
CEBU, CITY ADMITTED @ VSMMC. WITH A 3-DAY HISTORY OF EPISODIC PAIN
IN THE UPPER RIGHT ABDOMEN. ASSOCIATED WITH NAUSEA AND
VOMITTING. AND JAUNDICE IS PRESENT.

MEDICATIONS: RAMITIDINE 5O MG, IVTT EVERY 8 HRS.

TRAMADOL 50 MG, IVTT EVERY 6 HRS.
CEFAZOLINE 50 MG, IVTT EVERY 8 HRS.

[edit] Cholelithiasis
[edit] Signs and symptoms

A large gallstone is visible in the fundus of the gallbladder on this ultrasound image

Gallstones may be asymptomatic, even for years. These gallstones are called "silent stones" and
do not require treatment.[3][4] Symptoms commonly begin to appear once the stones reach a
certain size (>8 mm).[5] A characteristic symptom of gallstones is a "gallstone attack", in which a
person may experience intense pain in the upper right side of the abdomen, often accompanied
by nausea and vomiting, that steadily increases for approximately 30 minutes to several hours. A
patient may also experience referred pain between the shoulder blades or below the right
shoulder. These symptoms may resemble those of a "kidney stone attack". Often, attacks occur
after a particularly fatty meal and almost always happen at night. Other symptoms include
abdominal bloating, intolerance of fatty foods, belching, gas and indigestion.

A positive Murphy's sign is a common finding on physical examination.

You are here: Home » Surgical Care » Cholecystectomy to Remove Gallbladder

Cholecystectomy to Remove Gallbladder
Sep 07, 2010 2 Comments by HealthWriter

Anatomy
The gallbladder is a small pear-shaped, gray-blue*, sac-like organ located on the undersurface of
the right lobe of the liver in the upper right portion of the abdomen. Ducts (tubes) connect the
gallbladder to the small intestine (duodenum). The gallbladder is divided into the fundus, body
and neck. The liver makes 3-5 cups of bile every day. The main function of the gallbladder is to
collect and store the digestive juice called bile that is secreted by the liver. The bile is then
passed through cystic ducts into the bile ducts and ultimately into the intestine to aid in the
digestion process when food is eaten, especially fatty foods. When the gallbladder is taken out,
this function is taken over by the liver and its ducts. Problems with the gallbladder interrupt the
total functioning of the digestive system. (*shown as green in the image)

Gallbladder problems include:

• cholelithiasis (gallstones), where solid components of the bile form stones of various sizes.
Gallstones can get in the bile duct, blocking the flow of bile causing swelling of the gallbladder
and pain in the abdominal area. Cholelithiasis is associated with abdominal pain in the right
upper quadrant all the way up to the right shoulder and may occur after fatty meal. Symptoms of
jaundice may also accompany cholelithiasis. Gallstones are found in about 15% of men and 30%
of women in the U.S.

• cholecystitis, which is the inflammation of the gallbladder due to infections. The most common
symptoms of cholecystitis is sharp abdominal pain on the right side along with nausea, bloating,
fever, vomiting and jaundice if gallstones are in the common bile duct. Cholecystitis can happen
suddenly (acute) or over a longer period of time (chronic).

• perforated gallbladder is a condition where the gallbladder leaks or bursts. This happens
rarely, but it can be life threatening.

Gallstones are usually diagnosed by ultrasound—a safe, painless, and non-invasive technique
that uses high frequency sound waves to create an image of the gallbladder and gallstones. In
order to relieve symptoms and complications, the gallbladder is removed surgically, called
cholecystectomy.
Cholecystectomy Procedure
Cholecystectomy is the surgical removal of the gallbladder. More than 500,000 procedures are
performed each year in the U.S. Cholecystectomy is usually done for gallstones and can be
performed in two ways:
• open cholecystectomy
• laparoscopic cholecystectomy

Risks, Benefits, and Complications of Cholecystectomy

The benefit of having your gallbladder removed is relief of pain and most likely stop gallstones
from coming back. If you don’t have gallbladder surgery, you risk the possibility of your
symptoms getting worse, infection or the gallbladder bursting and infecting your abdominal
cavity. Although there is some risk with all surgery, gallbladder removal is a very common
surgery and the risks are small. Possible complications involved in open cholecystectomy are:
• bleeding
• injury to the common bile duct
• numbness
• raised scars
• hernia at the incision site
• puncture of the intestine
• wound infection
• abscess formation
• respiratory problems (pneumonia)
• deep vein thrombosis (blood clots)

Risks are lower with laparoscopic cholecystectomy. However, while inserting instruments and
performing surgery, there is risk of injury to the common bile duct, which is the connection
between the liver and the gallbladder. Minor injuries to the common bile duct are treated non-
surgically, but major injuries can cause severe infection and pain and need corrective surgery.

Preparing for Cholecystectomy

Like any other surgical procedure, you will have to sign an informed consent that says you
understand the procedure, its risks and potential complications and agree to have the surgery.

You shouldn’t have anything to eat or drink after midnight before the day of surgery. You can
usually take your daily medicines on the morning of surgery with a sip of water. Talk to your
surgeon before taking blood thinners that morning.

Anesthesia

Both surgical techniques are done under general anesthesia by a general surgeon. You will meet
with the anesthesiologist before your operation. Be sure to let them know any problems you have
had in the past with anesthesia or surgery. Also let them know if you:
• have any allergies
• have loose teeth or dental work
• have heart or lung disease
• have any health condition including stomach problems
• smoke, use alcohol or drugs
• take vitamins or supplements
• take daily medicines and what those are

With general anesthesia you will be asleep during the surgery and will not feel any pain.

What to Bring to the Hospital

• Insurance card and picture identification (driver’s license)

• Advance Directives
• Your glasses or dentures
• Loose fitting, comfortable clothes
• List of any medicines you take every day

Do not bring anything of value to the hospital such as jewelry, money, or electronics. The
hospital will not be responsible if they are lost or stolen.

Prior to Cholecystectomy

You will get an ID bracelet on admission and taken to a presurgery area to change into a gown
and have an IV placed in your arm or hand. The IV will be used to give you medicines and
fluids. You may receive medicine to help you relax before they take you to surgery.

Open Cholecystectomy

This is the older procedure involving a 4 to 6 inch up-and-down incision in the right upper
portion of the abdomen, or a slant incision just below the ribs on the right side. The peritoneum
is cut and the gallbladder is removed. The incisions are then closed. In order to prevent
accumulation of fluid at the incision site, drains may be used. The drain is usually removed in the
hospital. The procedure takes about 1-2 hours. If there are no complications following surgery,
you will be in the hospital for one to three days followed by 4 weeks’ rest at home before you
can get back to your normal lifestyle. In more complicated cases, it may be 4 to 8 weeks before
you get back to normal activity.

Laparoscopic Cholecystectomy
Laparoscopy – shows instruments in the abdomen and the abdomen distended from the gas
pumped inside.

Laparoscopic cholecystectomy, often called “lap choly” is the latest procedure and is extensively
used worldwide. During laparoscopic cholecystectomy, the surgeon makes four very small
incisions (slits) of less than half an inch each. One slit is at the belly button, two are on the right
side below the ribcage, and one is in the upper portion below the sternum, or breastbone. A tube
is inserted into one of the slits and the abdominal cavity has been filled with carbon dioxide gas
to inflate the area so the surgeon can see to work inside. A laparoscope is inserted in one of the
other slits. A laparoscope is long tube with a small video camera and light on the end. This
camera is connected to a video monitor, where the surgeon gets a good view of the organs and
can perform the surgery accurately. The other incisions are used to insert various instruments to
grasp and remove the gallbladder. The surgeon guides the laparoscope while watching the view
it provides on a video monitor. The gallbladder is separated from the common bile duct and
removed with a grasper tool through one of the incisions. Once the gallbladder is removed, the
carbon dioxide gas is removed and all incisions are sutured or closed with tape strips. The
procedure takes 1-2 hours.

In about 1 in 30 to 40 cases, the surgeon may start with laparoscopic surgery, but complications
may cause the technique to be changed to open surgery. Complications include a severely
diseased gallbladder, not being able to see the organs clearly, or the instruments cannot be used
without risks. It’s important to know that even though you are expecting to have a laparoscopy,
there is a chance of having an open cholecystectomy.

The need to convert from laparoscopic to open surgery is more common if:
• you are over age 65
• male
• have a history of acute cholecystitis
• have had prior abdominal surgery
• have a high fever or high bilirubin
• repeated gallbladder attacks
• other diseases that limit your activity
After Cholecystectomy
You will be taken to the recovery room until you wake up and are past any problems from the
surgery. Careful attention is given in recovery as with any major surgery. Your blood pressure is
monitored closely as well as your pulse, breathing and temperature.

Moving and deep breathing will help prevent fluid in your lungs and pneumonia. An effective
way to breath deeply is to take a deep breath and hold it for 5 seconds. Take 5 to 10 deep breaths
every hour while you are awake. Because of the anesthesia and not moving around, your risk of
getting blood clots in your legs is increased. During surgery you may have had sequential
compression stockings to help prevent blood clots. After surgery, it is important to get up as soon
as possible and walk around to prevent blood clots.

It’s normal to feel tired for several days and you may need more sleep than usual. Don’t drive
until your pain is under control without narcotics and your surgeon says it’s OK.

After Open Cholecystectomy

You may not be able to breathe deeply due to the effects of anesthesia or because of pain. Pain
medications will be given to relieve pain. Be sure to let the nurses know if the pain medicine is
not working. Controlling pain is very important; you want to feel like moving around and taking
deep breaths, which will help prevent complications that can make your recovery take longer.
Doing deep breathing exercises is very important in preventing pneumonia. The nurses will show
you how to support to the incision with a pillow (splinting) while doing deep breathing exercises
or coughing. Your incision site is checked for drainage and infection.

Your diet will start out as intravenous fluid and then slowly you will be given a regular diet as
your bowel activity returns to normal and any nausea has stopped. It’s normal to have loose
bowel movements for a few days after surgery. Pain medicine can cause constipation. If you are
constipated increase the fiber in your diet or try a stool softener. Foods high in fiber include
grains, fruits and beans.

You will go home in about 3-5 days. Slowly increase your activities. Do not lift of do any
strenuous activity for 3-5 days. Returning to normal activities takes four to six weeks after
surgery depending on your overall health and whether you had any complications.

Wound Care. Do not soak in a bathtub until your stitches or staples are removed and your
wound has healed. It’s OK to take a shower unless your surgeon tells you not to. Protect the new
skin of your incision from the sun as it can cause darker scarring; keep it out of the sun or wear
sun screen for at least a year. Wear clothes that don’t rub against your incision. Change your
bandages just as your surgeon prescribes and always wash your hands before and after touching
near your incision site. Your scar will heal in about 4 to 6 weeks; it will get softer and fade over
the next year. The feeling around your incision will come back in a few weeks or months.

After Laparoscopic Cholecystectomy

Pain from surgery can probably be controlled with pills. The abdominal pain can be
accompanied with nausea and/or vomiting. Let the nurses know if you are nauseated; they can
give you medicine to relieve the nausea. Liquids are OK to drink within 6 to 8 hours of surgery;
solid food is allowed the day after the surgery. Pain medicine can cause constipation. If you are
constipated increase the fiber in your diet or try a stool softener. Foods high in fiber include
grains, fruits and beans.

Discharge from hospital is generally the same day. Slowly increase your activities. Do not lift of
do any strenuous activity for 3-5 days. Returning to normal activities takes around 7 to 10 days.
However, if you have other health conditions, you may have a longer hospital stay and a longer
recovery period.

Wound Care. Do not soak in a bathtub until your steri-strips fall off (7-10 days) and your
wound has healed. It’s OK to take a shower unless your surgeon tells you not to.

Biopsy
After the procedure, the gallbladder is sent for biopsy to confirm the diagnosis of either
cholelithiasis or cholecystitis. The biopsy also helps to detect cancer. If cancer is detected, the
patient might need to undergo another surgery to remove part of the liver or lymph nodes that are
affected.

When to Call Your Surgeon

When you are discharged the nurses will tell you when to make an appointment for follow-up
with your surgeon. Stitches or staples will be removed at follow-up. If you think you have a
fever, take your temperature.

If you have any of the following, you should contact your surgeon right away:
• Pain that gets worse or will not go away with your pain medicine
• A fever of more than 100.5°F
• Vomiting
• Strong abdominal pain
• No bowel movement or cannot pass gas for 3 days
• Watery diarrhea that lasts longer than 3 days
• If you have drainage from your incision
• If the edges of your incision separate

[edit] Causes

Gallstone risk factors include overweight, age near or above 40, female, and pre-menopausal;[6]
the condition is more prevalent in caucasians than in people of other races. A lack of melatonin
could significantly contribute to gallbladder stones, as melatonin both inhibits cholesterol
secretion from the gallbladder, enhances the conversion of cholesterol to bile, and is an
antioxidant, capable of reducing oxidative stress to the gallbladder.[7] Researchers believe that
gallstones may be caused by a combination of factors, including inherited body chemistry, body
weight, gallbladder motility (movement), and perhaps diet. The absence of such risk factors does
not however preclude the formation of gallstones.

No clear relationship has been proven between diet and gallstone formation; however, low-fiber,
high-cholesterol diets and diets high in starchy foods have been suggested as contributing to
gallstone formation. Other nutritional factors that may increase risk of gallstones include rapid
weight loss, constipation, eating fewer meals per day, eating less fish, and low intakes of the
nutrients folate, magnesium, calcium, and vitamin C.[8] On the other hand, wine and whole grain
bread may decrease the risk of gallstones.[9] Pigment gallstones are most commonly seen in the
developing world. Risk factors for pigment stones include hemolytic anemias (such as sickle-cell
disease and hereditary spherocytosis), cirrhosis, and biliary tract infections.[10] People with
erythropoietic protoporphyria (EPP) are at increased risk to develop gallstones.[11][12]

[edit] Pathophysiology

Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile
salts. Besides a high concentration of cholesterol, two other factors seem to be important in
causing gallstones. The first is how often and how well the gallbladder contracts; incomplete and
infrequent emptying of the gallbladder may cause the bile to become overconcentrated and
contribute to gallstone formation. The second factor is the presence of proteins in the liver and
bile that either promote or inhibit cholesterol crystallization into gallstones. In addition,
increased levels of the hormone estrogen as a result of pregnancy, hormone therapy, or the use of
combined (estrogen-containing) forms of hormonal contraception, may increase cholesterol
levels in bile and also decrease gallbladder movement, resulting in gallstone formation.

[edit] Diagnosis

[edit] Treatment

Medical

Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid, but it may be
required that the patient takes this medication for up to two years.[13] Gallstones may recur
however, once the drug is stopped. Obstruction of the common bile duct with gallstones can
sometimes be relieved by endoscopic retrograde sphincterotomy (ERS) following endoscopic
retrograde cholangiopancreatography (ERCP). Gallstones can be broken up using a procedure
called lithotripsy (extracorporeal shock wave lithotripsy).[13] which is a method of concentrating
ultrasonic shock waves onto the stones to break them into tiny pieces. They are then passed
safely in the feces. However, this form of treatment is only suitable when there are a small
number of gallstones.

Surgical
Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of
cholelithiasis. Only symptomatic patients must be indicated to surgery. The lack of a gallbladder
may have no negative consequences in many people. However, there is a significant portion of
the population — between 5 and 40% — who develop a condition called postcholecystectomy
syndrome[14] which may cause gastrointestinal distress and persistent pain in the upper right
abdomen. In addition, as many as 20% of patients develop chronic diarrhea.[15]

There are two surgical options for cholecystectomy:

• Open cholecystectomy: This procedure is performed via an incision into the abdomen
(laparotomy) below the right lower ribs. Recovery typically consists of 3–5 days of
hospitalization, with a return to normal diet a week after release and normal activity
several weeks after release.[3]
• Laparoscopic cholecystectomy: This procedure, introduced in the 1980s,[16] is performed
via three to four small puncture holes for a camera and instruments. Post-operative care
typically includes a same-day release or a one night hospital stay, followed by a few days
of home rest and pain medication.[3] Laparoscopic cholecystectomy patients can generally
resume normal diet and light activity a week after release, with some decreased energy
level and minor residual pain continuing for a month or two. Studies have shown that this
procedure is as effective as the more invasive open cholecystectomy, provided the stones
are accurately located by cholangiogram prior to the procedure so that they can all be
removed.[citation needed]