Gallstone surgery: the whys and hows

Gallstones are hard deposits that can form in the gallbladder, potentially causing problems that need surgical intervention. In this article, a consultant upper gastrointestinal surgeon, Mr James Hewes, explains the risks of gallstones, and what a surgical removal involves.

What are gallstones?

The gallbladder is a small pear-shaped organ that is located under the liver on the upper right side of the abdomen. Its purpose is to store and process bile, which is used to break down food, especially fats, and it is produced by the liver. When there is an excess of cholesterol and/or bilirubin in the bile, or if the gallbladder fails to empty properly, stones can form in the gallbladder. They can be as small as a grain of sand or as large as a marble, single or multiple. The risk of developing gallstones increases as you get older or if your diet is rich in fat. Gallstones are common and can run in families.

Most of the time gallstones cause either no or only very mild symptoms. Occasionally they cause troublesome symptoms and rarely can lead to complications that can be serious. 

What are the symptoms of gallstones?

Most gallstones cause no symptoms however typical presentations include:

• Abdominal pain in the upper right or band-like across the upper abdomen. This can be intense and sharp, and can come on suddenly after eating a fatty meal, but not always. The pain may also radiate to the shoulder blade or back and cause nausea or vomiting. This is a colicky type pain that can last for up to a few hours and is called biliary colic.
• Gallstones can cause an infection of the gallbladder called cholecystitis. Rarely a gallstone can dislodge from the gallbladder and get stuck in the bile duct. This can cause jaundice (yellow discolouration of the skin or eyes), a serious infection of the bile duct (cholangitis) or pancreatitis that can also be serious or even life threatening

It doesn’t matter how many or how large the stones are as any size or number can cause problems.

How are gallstones diagnosed?

Investigations to confirm the presence and location of gallstones include:

• Abdominal ultrasound, MRI scans (MRCP) or blood tests to look for abnormal liver function or inflammation
• If a stone is impacted in the bile duct then an endoscopic procedure called an endoscopic retrograde cholangio-pancreatography (ERCP) can be performed to extract it under sedation. 

Surgery for gallstones

The procedure to remove the gallbladder is called a cholecystectomy. It is performed under a general anaesthetic and takes approximately 1 hour. It is laparoscopic (keyhole) surgery that causes less pain and scarring, a faster recovery and earlier return to normal activities compared with the traditional open technique. Due to the findings at surgery though it is possible that the open technique may be needed if this is safest for you. This will be explained to you by your surgeon in detail beforehand.

Your surgeon will make four small incisions each about 1 inch (2cm) long beside your belly button and underneath the ribs on the right hand side. They will then inflate the abdomen with carbon dioxide to ensure a good view. They will then dissect the gallbladder away from the liver and clip and divide the artery and duct. The gallbladder containing the stones will be removed and sent to the laboratory. Occasionally a drain is left in for a short time after surgery to drain off any excess fluid. During surgery the surgeon will usually visualise the bile ducts to check the anatomy or for any other stones. This is called a cholangiogram and is either with an xray or ultrasound.

Most of the time surgery is straightforward, but if there is a lot of inflammation then it can be challenging. Occasionally the safest option is to perform a partial cholecystectomy where not all of the gallbladder is removed. Most patients have the same benefit as a complete cholecystectomy. Very rarely the gallbladder can’t be safely removed and a discussion will be had with the surgeon about the next steps should this be the case.

Most patients recover well and are discharged home the same day once the anaesthetic has worn off, and can resume normal activities quickly. As with all operations complications can occur and these will be discussed in detail with you before the operation so you can make an informed decision about surgery.

Gallstones are a common problem. Surgery to remove the gallbladder should allow you to be free from pain and able to eat a normal diet afterwards, and also protect you from potentially serious complications in the future.