What Is the Gallbladder?

The gallbladder is a pear-shaped, hollow organ located just under the liver on the right side of the abdomen. It serves as a reservoir to store and secrete bile into the small intestine. The liver makes the bile (a thick yellowish-green liquid) and then it travels through a system of tube-like structures called bile ducts to be either stored in the gallbladder (for later use) or secreted into the small intestine to help break down ingested fats.

Purpose of Cholecystectomy

There are several forms of gallbladder disease that can be treated by cholecystectomy.

Gallstones

An abnormal condition called cholelithiasis (or gallstones) is one of the most common reasons for having a cholecystectomy. Substances in the bile can become solid, forming hard stones of various sizes (from very small grain-like stones to stones the size of golf balls). These stones result from various factors, such as too much cholesterol or excessive bile salts in the bile.

Approximately 15% of people aged 50 and older are affected by gallstones.

 As bile moves through the biliary system (the organs and ducts that are involved in the excretion and storage of bile), it’s common that the small stones become stuck in the bile duct that connects the gallbladder to the small intestine. These can cause severe pain and other complications such as pancreatitis (inflammation of the pancreas). The treatment for gallstones is usually the removal of the gallbladder.

Other Conditions

Other common reasons for cholecystectomy include:

• Acute biliary pancreatitis (a potentially life-threatening complication that may occur in those with gallstones).
• Biliary dyskinesia (when the gallbladder doesn’t empty properly, causing severe pain, nausea and intolerance of fatty foods)
• Inflammation of the gallbladder (cholecystitis)
• Large polyps of the gallbladder

Symptoms of Gallbladder Disease

There are some common symptoms of gallbladder disease that often result in cholecystectomy, including:

• Indigestion
• Nausea and vomiting
• Sharp abdominal pain
• Fever
• Jaundice (yellowish tinge to the skin and eyes due to gallstone blockage of the bile duct)

Types of Cholecystectomy Procedures

Two types of procedures are typically done to remove the gallbladder. The first is an open technique. This used to be the standard procedure, involving a large incision and longer wound healing time. According to a 2017 study, the open technique, commonly performed before the year 1991, involved a two- to six-day postoperative (after surgery) hospital stay.

A cholecystectomy may also involve an intraoperative cholangiogram (IOC), which is a live, real-time video X-ray of the bile ducts, taken during surgery. An IOC is performed to check for gallstones and ensure that the surgeon can properly view the common bile duct (an area that is sometimes difficult to differentiate due to the compact organization of these structures).

The second type of surgery, which is standard today, is a minimally invasive surgery performed using a laparoscopic technique. Laparoscopic surgery involves a tool called a laparoscope, with a small camera; the procedure is conducted with the aid of very small tools and a camera for viewing (where the surgeon can get a very clear view of the surgical site.

The laparoscope can perform therapeutic procedures—like the removal of the gallbladder—after the surgeon makes a few small incisions (between 0.5 to 1 centimeter/0.196 to 0.393 inches). The incisions are made for entry of the scope into the abdomen (as well as for a removal port to remove the gallbladder). Today, 92% of all cholecystectomy procedures are done via laparoscopic procedure.

Advantages of Laparoscopic Cholecystectomy

One of the biggest advantages to having a minimally-invasive cholecystectomy via laparoscopic surgery may be the fact that the in-hospital stay time is reduced from a two- to six-day postoperative (after a surgical operation) stay, to the same-day discharge (or up to a one day stay) for laparoscopic surgery. A 2015 study reported advantages of laparoscopic cholecystectomy, which include:

• Utilization of epidural anesthesia (which is associated with a lower incidence of complications after surgery than general anesthesia)
• Cost savings for the patient
• Increase in patient satisfaction
• Less post-operative pain
• Less bleeding during surgery (lower risk of the need for blood transfusion)
• Shorter length of recovery and hospitalization time
• Less scarring and better wound healing
  

Indications for Open Cholecystectomy

There are several reasons that the surgeon may perform an open cholecystectomy, instead of a laparoscopic procedure. These may include:

• Obesity
• Pancreatitis (inflammation of the pancreas)
• Extensive damage to the gallbladder (such as scars and inflammation)
• Pregnancy (third trimester)
• Severe liver problems.
• Scar tissue in the abdomen from past surgeries in the same area
• Difficulty viewing a person’s anatomy during a laparoscopic procedure
• Unsuspected bleeding that cannot be controlled during laparoscopic surgery
• Any other situation that prompts the surgeon to decide that open surgery is safer (may be determined after the laparoscopy procedure begins and the surgeon is able to get a good view of the anatomy).

Before Surgery

There are several preoperative (before surgery) measures that may be ordered by the surgeon before a cholecystectomy, these include:

• Stop eating and drinking liquids according to your surgeon’s instructions.
• Take a shower the night before surgery (you may be instructed to use antiseptic soap).
• Take only the medications your surgeon instructs you to take the morning of surgery (with just a small sip of water).
• Follow your surgeon’s instructions regarding which medications to stop taking before surgery (such as blood thinners and other medications).
• Arrange for someone to drive you home after surgery.

The Surgical Procedure

The Minimally Invasive (Laparoscopic) Procedure

The steps to having a laparoscopic gallbladder removal include:

1. General anesthesia will be given to put you to sleep during the procedure
2. A small incision is made near the belly button to insert a port (a small device that creates an opening to fill the abdomen with carbon dioxide gas; this gas is used to expand the abdomen for optimal viewing of the gallbladder, bile ducts, and adjacent organs).
3. A small camera is inserted through the port; the camera shows the surgery on a TV screen in the operating room.
4. Additional ports are inserted for the placement of small instruments.
5. The gallbladder is disconnected and taken out through one of three to four small incisions.
6. The surgeon closes the incision with small stitches, staples or surgical glue that will automatically disappear as the wounds heal (there is no need to have them removed after the surgery).

Robotic Surgery

The surgeon may use a surgical robot to perform the operation; a robot is guided by the surgeon via a viewing platform, the basic difference is instead of guiding the instruments by hand, the surgeon guides the robot to use the instruments that remove the gallbladder. This is commonly referred to as robotic surgery.

Advances in technology have resulted in smaller instruments and higher-quality imaging during laparoscopic surgery that allows surgeons to perform more precise dissection with minimal bleeding.

Open Surgery Procedure

The primary difference between an open cholecystectomy and one that is performed via laparoscopy is that during an open procedure a much larger (6-inch) incision is made in the abdomen, on the right side (below the ribs). The muscle tissue is retracted to reveal the gallbladder and the gallbladder is then removed using larger instruments (than those used during laparoscopic surgery). An open procedure takes approximately one to two hours to perform.