Gallstone Surgery - Types, Symptoms, Risks & Complications

1. What is a Gallstone?
2. Causes of Gallstones
3. Symptoms of Gallstones
4. Why is gallstone surgery required?
5. Preoperative tests and diagnostics
6. Methods of gallstone removal surgery
7. Post operative care and recovery
8. Risks and complications

What is a Gallstone?

Gallbladder stones or more commonly known as gallstones are small and hardened deposits of digestive fluid found in the gallbladder. Gallstones can be about the size of a grain of sand and in some rare cases, can grow to the size of a golf ball. Most gallstones are asymptomatic and do not require any surgery but in some cases these gallstones can lodge themselves into bile ducts which causes inflammation and pain in the gallbladder. In such cases, surgery is almost always required. The condition of having gallstones is called Cholelithiasis. 

Causes of Gallstones

Some of the most common reasons for occurrence of gallstones are:

• Too much cholesterol: Your body needs bile for digestion. It usually dissolves cholesterol but when cholesterol levels are too high, bile may be unable to do so and extra cholesterol results in formation of stones. 
• Presence of too much bilirubin in your bile: Excess of bilirubin in the gallbladder can contribute to the formation of gallstones. 
• Your gallbladder doesn't empty correctly: If the gallbladder doesn't empty correctly, particles in the gallbladder like cholesterol and calcium salts can thicken up and result in formation of gallstones. 

Symptoms of Gallstones

Gallstones are usually asymptomatic and do not need any surgical intervention. Sometimes however, these gallstones start to block the movement of bile from the gallbladder and become very painful. In such cases where gallstones become symptomatic, surgery is almost always required. Some of the most common symptoms of gallstones are: 

• Sudden and intense pain in the upper right portion of your abdomen
• Back pain
• Nausea and vomiting 
• An upset stomach
• Pain in right shoulder

If you are experiencing any of the above mentioned symptoms, it is recommended to consult them with your healthcare provider.

Why is gallstone surgery required?

Your gallbladder is an essential part of a network of organs that passes bile between each other called a biliary system. Due to formation of gallstones, the flow of bile through your gallbladder can be blocked and cause it to back up in nearby organs. As bile continues to build up, the pressure in organs and ducts also continues to increase and causes severe pain. If gallstones are left untreated, they can result in some serious complications such as: 

Gallbladder disease: Gallstones are one of the most common causes behind gallbladder diseases. When gallstones get stuck in bile ducts, it causes the bile in them to back up into your gallbladder and nearby organs causing inflammation and can even cause infection. Continued buildup of bile in the gallbladder can also result in complete failure of the organ. 

Gallstone pancreatitis: A gallstone that blocks the pancreatic duct can cause inflammation and pain in your pancreas. If left untreated, this blockage can cause the pancreas to stop functioning completely. 

Cholangitis: Inflammation in the bile ducts can lead to infection and cause bile ducts to become narrow even further. Cholangitis can cause long term bile flow problems. 

Jaundice: Backed up bile can leak into your bloodstream and make you sick. The bilirubin content is yellow in colour and becomes visible through the skin and whites of the eye. 

Liver disease: A blockage anywhere in your biliary system can cause the bile to back up into your liver. This can cause inflammation in the liver and prolonged buildup may even lead to an infection. If your liver stops functioning correctly, the whole biliary system can break down. 

Preoperative tests and diagnostics

Tests: Before the surgery, your doctor will perform some general tests and diagnostics to assess your pulse, blood pressure, blood type and ECG. Your doctor may also perform some imaging tests to determine the size and location of the gallstones such as: 

1. Abdominal ultrasound: An abdominal ultrasound is performed to determine the exact location of a gallstone. In an ultrasound, sound waves are sent through your abdomen. If there is presence of gallstones, the sound waves bounce off of them and reveal the locations of the gallstones.  
2. HIDA Scan: This test is generally performed to determine how well your gallbladder functions and detect if any gallstones have become lodged in the bile ducts. The procedure involves a radioactive isotope being injected into your veins. Once the isotope has been injected, you will be monitored for about an hour and the doctor can deduce how well your gallbladder empties. 
3. ERCP: Endoscopic Retrograde Cholangiopancreatography is a procedure often used to detect any gallstones that have become lodged in the bile duct that leads from the liver to the small intestines. 

Food and medications: Before surgery, your doctor may ask you not to eat or drink anything 12 hours leading up to the surgery. It is also important to inform your doctor if you take any medications or supplements. You may continue to take them as prescribed but your doctor may instruct you to temporarily stop taking certain medications to reduce chances of any complications during or after the surgery as much as possible. If some medications cause your blood to be thinner, taking them before surgery can increase the chances of excessive bleeding significantly. 

Methods of gallstone removal surgery

In a standard gallstone removal procedure, your surgeon performs a cholecystectomy or in simpler words, surgically removes the gallbladder completely along with the gallstones to make sure there is no recurrence. There are primarily 2 methods to remove the gallbladder - Open cholecystectomy and Laparoscopic cholecystectomy. 

• Open cholecystectomy: An open cholecystectomy is a more conventional and invasive method of gallbladder removal. In an open surgery, the gallbladder is removed via a single, large and open incision made in the abdomen. The entire procedure is performed under general anaesthesia meaning you will not be awake during the procedure. In an open cholecystectomy, the surgeon begins by making a 6-7 inch incision near your abdomen on the right side of your body. The surgeon will pull back the muscle and tissues around the incision to get a better view of the gallbladder and then surgically remove it, along with the gallstones, with the help of special surgical tools. Before the incision is sutured, the surgeon will check if there is presence of gallstones in the pancreas or bile duct and remove them as well. Once the surgeon is sure that there are no gallstones remaining, the incision is sutured and you will be moved to a recovery area. 
• Laparoscopic cholecystectomy: As compared to an open cholecystectomy, laparoscopic cholecystectomy is a more advanced and minimally invasive procedure to remove the gallbladder. Similar to open surgery, laparoscopic cholecystectomy is performed under general anaesthesia meaning you will not be awake during the procedure. In a laparoscopic cholecystectomy, instead of one large incision, 4 smaller incisions are made near your abdomen on the right side of your body. The surgeon will then insert a thin wire with a small camera on top, called a laparoscope, through one of the incisions to get a live feed of your gallbladder on a monitor. Using the life feed, the surgeon will then insert special surgical tools through the rest of the incisions and surgically remove the gallbladder along with all the gallstones. The surgeon will make sure there is no presence of gallstones in the pancreas or the bile ducts and then suture the incisions. You will then be moved to a recovery area. 

Post operative care and recovery

The recovery process and time for a gallstone removal surgery often depends on the method of surgery performed. 

Recovery after laparoscopic cholecystectomy: Most laparoscopic procedures are performed on an outpatient basis meaning, you can go home on the same day of surgery. However, you may require a friend or family member to drive you home or accompany you in a taxi afterwards. Your doctor may prescribe some medications for pain management and quicker recovery. Avoid any strenuous activities and exercises for at least 2 weeks but you should be able to return to your normal lifestyle during this time period. 

Recovery after open cholecystectomy: Open cholecystectomy is a more conventional method of gallbladder removal and hence also has longer recovery time. After an open surgery, you may need to spend a couple days in the hospital. Once you are allowed to return home, you will be asked to call a friend or family member to drive you home. Generally, recovery after an open cholecystectomy takes around 5-6 weeks to fully heal and return to normal activities. 

Risks and complications

Removal of the gallbladder is a relatively safe procedure. Like with any other surgical procedure however, there is a slight risk of complications. Some of the most common complications during and after a gallbladder removal surgery are given below: 

Infection: It is possible to develop an internal wound after a gallbladder surgery. Such wounds can lead to internal infections. If you exhibit symptoms such as increasing pain, redness, forming of pus and swelling, it is advised to contact your healthcare provider as soon as possible. 

Excessive bleeding: While excessive bleeding during a gallbladder removal surgery is rare, it can still happen. In case of heavy bleeding during surgery, your surgeon may need to perform additional surgical procedures to control it.

Injury to the bile duct: The bile duct could be injured either during or after your gallbladder removal surgery. If it happens during the surgery, it is possible to repair it straight away. If it happens after the surgery however, you may need another surgery.

Injury to organs surrounding the gallbladder: While rare, the surgical instruments used in a gallbladder removal surgery can injure the surrounding organs and tissue such as bowel, intestines and blood vessels. Sometimes these injuries are noticed after the procedure and may require another surgical procedure.

Bile leakage: Occasionally, bile fluid can leak out into the abdomen after the gallbladder is removed. Symptoms of a bile leakage include stomach pain, feeling sick and a swollen tummy. Sometimes the bile can be drained off without surgery but if the condition is persistent, you may require another surgery.