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Ques: What Is Gallbladder?

Ans: Gallbladder is a small, pear shaped organ, tucked under the liver in the upper right part of the abdomen. Normal gallbladder stores a small portion of bile produced by the liver and concentrates bile by removing water. Liver produces about 1.5 litres of bile in 24 hours. Most of the bile flows to the first part of the small intestine (duodenum) directly. Gallbladder releases only about 150 ml bile into the small intestine when food is eaten and aids in the digestion of fatty food.

Ques: How Do Gallstones Form?

Ans: When the ratio of bile salts, cholesterol and fluid inside the gallbladder becomes unbalanced, some of. the chemicals solidify and form gallstones (a kind of sediment). In majority of patients, cholesterol is the major solid component. While reasons for gallstone formation may be multiple and vary from one person to other, generally:

  •   Gallstones, are four times more common in females than males.
  • Gallstones are more common in females who had pregnancies and are overweight.
  • Excess fat in the diet is one of the risk factor.
  • Long fasting hours, contraceptive pills, typhoid may be some contributing factors.

However, the cause of gallstone formation may not be apparent. Also no age is exempt and gallstones may form even in a thin, teenager or a child.

Our youngest patient was six years old.

Ques: What Are The Symptoms Of Gallstones?

Ans: While some gallstones may have no noticeable symptoms, most often they are the cause of pain and other problems.

In the Gallbladder

The stones may be silent, cause pain in upper abdomen lasting for a few hours (biliary colic) with nausea, vomiting, bloating, heartburn and back pain. After many years of irritation, stones may cause cancer of the gallbladder. North India has the highest incidences of gallbladder cancer in the world. Detection of cancer may be difficult’ in a gallbladder which has become small and contracted.

In the Cystic Duct

Gallstones may block the cystic duct causing retention of fluid in the gallbladder (mucocele) or super added infection (acute cholecystitis) resulting in prolonged pain, fever and loss of appetite. Patients having acute cholecystitis need hospitalisation and injectable antibiotics.

Ques: What Is The Treatment Of Gallstones?

Ans: Cholecystectomy: The only effective cure for gallstones

Once stones have formed in the gallbladder, removal of stones with the gallbladder is the only acceptable and effective treatment for permanent cure. are formed due to fault in the gallblad-der (infection, incomplete emptying, excess water absorption), therefore the gallbladder must be removed. Since the gallbladder is already infected, has decreased capacity (due to stones and shrinkage) and is often non-functioning, the digestion is not affected by Gallbladder removal. This also eliminates the risk of subsequent cancer. If only stones are removed, the gallbladder will form new stones in the majority of patients. This approach is therefore not accepted. There is no effec-tive medicine to cure gall stones.

Ques: How Is Diseased Gallbladder Removed?

Ans: The traditional way to remove the diseased gallbladder was through a 15 to 20 cm incision in the abdomen, cutting skin; fat, and three layers of muscles underneath, which were then stitched back in layers (open surgery). Now, the same surgery can be performed through tiny skin punctures, without damaging underlying muscles. The technique is called Laparoscopic cholecystectomy.

Ques: What Are The Benefits Of Laparoscopic Surgery?

Ans: The benefits of laparoscopic procedure over open surgery are impressive. By decreasing injury to skin and muscles, the resultant pain and discomfort are reduced. Oral intake can be started by the same evening. Most of the patients can be discharged from the hospital the next day as compared to three to five days after open surgery. After laparoscopic cholecystectomy, recovery time (at home) is usually around five days as compared to three-six weeks for open surgery. Tiny punctures of laparoscopic surgery are cosmetically superior to long scar of conventional surgery

Ques: How Do I Plan For Cholecystectomty?

Ans: Once the diagnosis is made, the following facts should be kept in mind:

  • It is better to undergo the procedure before any complication (acute cholecystitis, jaundice) has occurred. Presence of complications increases hospital stay and may require additional investigations and procedures thereby adding to discomfort, morbidity and cost. Presence of complications also increases the operating time, chances of conversion to open surgery and prolongs hospital stay and recovery.
  • Small/multiple stones have higher potential of slipping out of the gallbladder through the cystic duct into the common bile duct and producing serious complications like jaundice or pancreatitis. They should be treated early.
  • If you have diabetes, you live alone, travel frequently or have to travel abroad, it is better to get rid of the disease at the earliest.
  • After cholecystectomy, there is no risk of recurrence of gallbladder stones since the organ at fault has been removed.
  •  Removal of the gallbladder generally leads to no permanent disability or deficiency of the digestive system since in majority of patients, the gallbladder was already non-functioning. In others, the digestion, including that of fatty food, returns back to normal in four-six weeks after which one can enjoy all kinds of food.
  • In an otherwise healthy person, laparoscopic cholecystectomy is a safe and simple procedure. While most surgeons use 11 mm instruments for laparoscopic cholecystectomy, we use finer instruments with significantly smaller punctures of three to five mm for this procedure and no stitches are required (sutureless mini/micro laparoscopic cholecystectomy).

This saves you from apprehension and discomfort of suture / clip removal.

Evaluating your condition

Detailed history and physical examination may help in identifying gallbladder problem and ruling out other causes of pain. Ultrasound has high accuracy (98%) for diagnosing gallstones and associated acute cholecystitis. It may reveal information if stone has passed into the bile duct Blood tests may also suggest possibility of stone in the common bile duct. Occasionally MRCP, ERCP or CT scan may be required.

Your Surgical Experience

Conventionally, the surgery is performed through four tiny punctures. Through the navel, the surgeon inserts a laparoscope which is attached to a lightweight, medical grade video camera. The camera sends images to a monitor, allowing the surgeon and his team to see inside the body.

Through other punctures, specially designed instruments are inserted.

The gallbladder is disconnected from its attachments and removed through the highest incisions.

After treatment, the infection may resolve or lead to pus formation (Empyema). Empyema is more common in patients with diabetes, who are also prone to perforation of gallbladder and leakage of pus (pericholecystic abscess).

The procedure is performed under general anaesthesia. While each case has unique characteris-tics, It generally takes about 20 to 30 minutes for the procedure and only 24 hours hospital stay is required.

Because of our extensive experience in laparoscopic surgery, number of stones, size of the stones, size of the gallbladder, presence of acute cholecystitis etc. do not influence the decision against laparoscopic cholecystectomy. Even excessive obesity, in our hands, does not go against laparoscopic procedure. Our specialisations include surgery for weight loss (Laparoscopic Sleeve Gastrectomy and bypass).

In our hands, Laparoscopic cholecystectomy can be safely performed in a large number of patients despite previous (multiple) abdominal operations, second trimester of pregnancy and associated diabetes and heart conditions. With good hospital backup, today there are very few contraindications for laparoscopic surgery.

During laparoscopic cholecystectomy, if at any stage it is felt that it is not safe to continue, the. procedure may be converted to open surgery.

The conversion rate to open surgery varies from centre to centre and surgeon to surgeon. Im-portant factors influencing conversion rate are experience and skill of the surgeon and quality of the instruments.

Accepted conversion rate is about two or five percent. Conversion in hands of our team is less than 0.1 percent and is generally limited to patients having pus in the gallbladder, multiple previous surgeries or when lung/cardiac condition during surgery prompts conversion to open surgery. In case of conversion, gallbladder is removed through the smallest possible incision.

Risks and Complications

Any gallbladder surgery has risks and complications.

These include:

  • Excessive bleeding
  • Infection
  • Injury to abdominal organs
  • Injury to common bile duct
  • General anaesthesia carries little more risk in patients with diseases of the heart, lungs, kidneys and other systemic problems.

Each Center and each surgeon has a complication rate different from others.

Dr. Kriplani’s large experience of laparoscopic surgery and excellent infrastructure of anaesthesia make the procedure safer and simpler in our setup. In around 12,000 laparoscopic cholecystecto-mies, technical complications have been encountered in only 0.1% of our patients. There has been no technical complication in our last 5000 patients. We have even removed gallbladder laparo-scopically in patients on whom cholecystectomy was attempted else where earlier and part or whole of the gallbladder was left behind due to technical difficulties.

Ques: What Is Single Incision Laparoscopic Surgery?

At Fortis Memorial Research Institute, the team is specially skilled and instead of making four cuts, the gallbladder is removed with one 12 mm cut through the belly button which is completely hidden (scarless). Ask your doctor for more information.

Ques: What All Should I Know About The Surgery?

Ans: Before Surgery

Your general health will be checked with routine blood and other tests. Before admission, an Anaesthesiologist will go through your reports along with physical examination.

Don’t take aspirin or other blood thinning medication for five days before surgery. Smoking should be stopped before surgery.

Navel should be cleaned thoroughly with soap and water for two-three days before surgery to remove any dirt or concretions.

The day before surgery, you can take normal dinner. Do not eat or drink anything after midnight. Oral Medicines for diabetes should be stopped on the day of surgery. Medicines for blood pres-sure, heart disease or asthma can be taken at six am in the morning with a sip of water. If your surgery Is scheduled In the afternoon, you will be given intravenous fluid after admission.

What to bring along

  • All investigation reports
  • Doctors prescription
  • Insurance details (receipt of bills)
  • On going medications
  • Jewellery and other valuables to be left at home

In the Hospital: On the day of surgery

After the operation you will be kept in the recovery room for one to three hours and given oxygen by mask. The decision to shift you to the room is taken by the anaesthesiologist and depends on many factors. Oxygen may be continued in the room. You may experience nausea and may even vomit in the first few hours. This should not cause any worry. Sitting up in the bed and taking deep breaths will reduce the feeling of nausea. You will find small bandages covering your incisions. The drip inserted in your vein to give you fluid may stay overnight. You may also have some discomfort in your right shoulder. This is temporary and will go away by itself. Shoulder pain decreases on lying flat in the bed. In the room you can move and sit up in the bed and turn to any side.After a few hours you can walk to the washroom. Walking enhances blood circulation through your body, improves lung function and decreases pain.

The drip can be temporarily discontinued for walking to the washroom.

You are generally allowed to have liquids by mouth five hours after the procedure. You should first sit up, take deep breaths and have a few sips of water. Gradually you can increase the amount and later can have tea or clear soup. Do not refuse any medication/injection. Each medicine has more than one purpose and is given to hasten your recovery.

The day after surgery

You can have normal breakfast in the morning and semi-solid food in the day (khichri, porridge, bread, toast, biscuits, cookies). Some bloating of abdomen may be present which will decrease after passage of wind and stool. Since nothing much was taken by mouth the day before, one generally does not pass stools and hence should not strain.

You will be generally discharged on the next day of operation unless there is some medical/social reason. You can walk normally and can climb stairs slowly.

At Home

Take soft diet for two days. Normal, home cooked food with less cooking oil can be started three days after surgery. During first week avoid whatever does not suit your stomach. It is helpful to take small frequent meals. Milk, Coffee and citrus juices should be avoided for a week. Soft fruits can be easily digested. Prescribed medication also helps in decreasing gas and acidity. Some patients may have loose stools during this period.

Your Clinic Appointment

You should fix up an appointment with your surgeon seven to ten days after surgery.

Call earlier if you .have any significant symptom like fever, vomiting etc.

Collect your histopathology report of the gallbladder before meeting your surgeon.

The bandages will be removed on your visit if they have not come out earlier. After removing the dressing, apply some skin cream on the cuts twice a day for five to seven days. Some patients may have minor serum discharge from one of the wounds. Do not worry and just mop it dry with clean cloth and apply antiseptic ointment neosporin.

Your dressings are water proof. You can take a bath 48 hours after surgery.

Do not rub over the dressings. The skin punctures are sealed with glue and there is no stitch or clip on the skin. Do not worry if bandages come out. They need not be replaced. Water can flow over bandages. One can start going outdoors after three days and return to normal activity in five to seven days. If you do not pass stool 48 hrs after surgery, push two dulcolax suppositories through the rectum to help you evacuate.

Medication

  • If you have not passed motion despite laxatives three days after surgery, use enema. ‘Proc-toclys enema’ is available in all medical stores and is easy to use. You also need to increase roughage in the diet, take plenty of water and increase activity.
  • If you feel colicky abdominal pain add Tab Eldicet 1 Tab three times a day 30 mins before meal for three days. If pain is not relieved take cap. Spasmo-proxyvon twice a day for two days.
  • If you feel bloated add Tab Festal-N one Tab three times a day with meal for one week.
  • If you feel acidity, add Tab Razo 20mgs. twice a day in the morning empty stomach and 30 mins before dinner for seven days.
  • If you have loose stools omit night laxative. You may also take Tab Norflox 400 mgs. twice daily for three days if stools are watery or more than four to five times a day, take electrol powder in water and drink plenty of fluids to avoid dehydration.

Your Clinic Appointment

You should fix up an appointment with your surgeon seven to ten days after surgery.

Call earlier if you .have any significant symptom like fever, vomiting etc.

REQUEST AN APPOINTMENT