Gallbladder Surgery

Get Your Gallbladder Surgery Questions Answered

What does the gallbladder do?

The gallbladder's function is to add a small amount of stored bile to a meal when it reaches the duodenum (the first part of the small intestine after the stomach).  The gallbladder is like a cul-de-sac along the main road of the common bile duct.  The common bile duct drains bile made by the liver into the duodenum.  The gallbladder is a small branch off the main duct as it courses from the liver to the intestine.

A common myth is that the gallbladder stores all bile made by the liver, but it only stores a small amount.  The liver is the largest internal organ in the body and makes about 35 ounces of bile per day (about one liter - half of a 2-liter soda bottle).  The gallbladder only holds 1-2 ounces of fluid.  The most common cause of gallbladder disease is inflammation due to gallstones.  When the gallbladder is diseased, it no longer functions as a temporary storage for a small amount of extra bile.  When the gallbladder goes bad, the bile made by the liver simply bypasses the diseased gallbladder and flows into the duodenum throughout the day.  This is the same bile flow after the gallbladder is removed.  Many people do not realize that removing a diseased, non-functioning gallbladder does not change bile flow.  This change has already occurred as an inflamed gallbladder loses function.  If a neighborhood cul-de-sac was obstructed with cars (gallstones), you would continue driving on the main road (common bile duct).

What is bile for?

Bile helps break down fats into fatty acids to aid digestion and absorption.  The same amount of bile is available after gallbladder removal surgery as before.

What happens to all that bile when the gallbladder is removed?

After the gallbladder is removed, bile made by the liver still flows normally down the main bile duct (common bile duct) into the duodenum (first part of the small intestine after the stomach).  The only difference is that after gallbladder removal, it no longer stores a small amount of bile to add to a meal.  You still have normal digestion and absorption after gallbladder removal.

How big is the gallbladder?

The gallbladder is about the size of a small pear.

What causes gallstones?

Imbalances in the chemical composition of bile causes precipitation crystals which grow gallstones within the gallbladder.  Sludge or gritty, sandy bile can also form via the same process and causes the same problems as gallstones.  The bile system is composed of small ducts designed to handle liquid.  Stones or sludge debris can cause obstruction and inflammation of the gallbladder and bile ducts.  Hormonal changes affect the chemical balance of bile and therefore gallstones are more common in women.  Weight gain and rapid weight loss change bile composition as well.

How can you prevent gallstones?

The main thing you can do to reduce the risk of getting gallstones is to avoid serious weight gain followed by rapid weight loss.

I have gallstones.  Are they harmful?  Is it bad if I ignore this?

Gallstones can cause serious problems if they become lodged and block the bile ducts.  Gallstones can obstruct the gallbladder duct, the main bile duct or the opening into the duodenum that causes increased back pressure into the pancreatic duct.  Gallbladder removal is recommended once gallstone patients develop symptoms.  These symptoms are warning signs that you are headed for serious problems if left untreated.  Typical symptoms include abdominal pain, bloating, nausea and vomiting.  Gallbladder symptoms typically get worse with meals, especially greasy or fried foods.  These symptoms are warning signs that you are headed for serious complications caused by the gallstones.  The three main potential health risks of gallstones include cholecystitis, choledocholithiasis or gallstone pancreatitis.

Cholecystitis (inflammation of the gallbladder) occurs when a gallstone is lodged in the cystic duct (duct connecting the gallbladder to the common bile duct).  This can lead to infection in the gallbladder and become severe if not treated.  When gallstones migrate out of the cystic duct and become lodged in the common bile duct, this is called choledocholithiasis (gallstones in the main bile duct).  Since the common bile duct drains bile made in the liver into the intestine, a stone lodged here can cause jaundice (yellow skin color), light colored stool since bile is not mixing with the foods we eat and/or cholangitis (bacterial infection in the bile duct).  These can cause severe illness if not promptly treated.  If a common bile duct stone gets lodged in the sphincter of Oddi (bile duct valve leading into the small intestine), this causes back pressure in the pancreatic duct causing gallstone pancreatitis.  The common bile duct and pancreatic duct share an opening into the duodenum (first part of the small intestine beyond the stomach).  Gallstone pancreatitis can become severe if not promptly treated. The pancreatic tissues designed to digest protein in your intestines seep into your own tissues and essentially digest them. This can be a life threatening life changing event.

If a patient has gallstones but no related symptoms, generally, you can observe for symptoms to develop.  The exception to this is if you have diabetes.  Diabetic patients have decreased sensation of sensory nerves.  This can lead to a "silent MI", a heart attack without typical symptoms or a diabetic patient can step on a thumbtack unaware due to the decreased sensation in their feet and get a severe infection of their foot that can lead to amputation even in this day and age.  Similarly, diabetic patients can develop severe cholecystitis without typical symptoms.  This can lead to complications by waiting until the inflammation becomes severe.  Therefore, patients with gallstones and diabetes should consider gallbladder removal to prevent complications due to severe gallbladder disease.

Can't you just go in there and remove the stones and leave the gallbladder?

This would be like trying to salvage the appendix in appendicitis.  Like the appendix, when serious inflammation or infection affect the gallbladder, it will never function normally and needs to come out.  Once appendix and gallbladder tissue reach this degree of inflammation, they need to be removed to avoid serious complications.  At this point the organs have no function and may create a serious problem if left untreated.

Can you get gallbladder disease without gallstones?

Yes.  Some patients have classic symptoms of cholecystitis (inflammation of the gallbladder) with no gallstones on ultrasound.  In these cases, a HIDA scan (gallbladder function study) can diagnose acalculous cholecystitis (gallbladder inflammation without stones).  The HIDA scan is a nuclear medicine study where a radiotracer that is excreted in the bile is injected through an IV (intravenous) catheter.  As this tracer works its way through, the scan will highlight the liver, the bile duct, and the gallbladder.  Then, an IV medication (CCK-cholecystokinin) is administered that causes the gallbladder to contract or empty.  If the HIDA scan is completely normal, generally, the patient's symptoms are not caused by the gallbladder.  There are several findings on the HIDA scan that may indicate the need for gallbladder removal.  1.) If the gallbladder does not appear on the scan (non-visualization), this is consistent with cholecystitis.  2.) If the ejection fraction after CCK administration is less than 35%, this is consistent with acalculous cholecystitis.  3.) If the CCK administration causes the same symptoms the patient has been having, this strongly suggests that gallbladder inflammation is causing the patients symptoms and correlates with symptom resolution after cholecystectomy (gallbladder removal).  This is true even if the ejection fraction was normal.

What are the typical symptoms of gallbladder disease?

The classic symptoms of gallbladder disease include nausea and attacks of pain in the right upper abdomen that radiates around to the back, usually between the shoulder blades.  Vomiting can occur with severe attacks.   These symptoms are worse with eating, especially greasy or fried foods.  High fat and high protein meals maximally stimulate the gallbladder to empty.  Commonly, patients will have attacks of pain that occur a couple of hours after dinner.  It is also common to have vague symptoms.  Some patients have right sided scapular (shoulder blade) pain.  Some patients have heartburn as their main symptom.  Some patients say they have a "sensitive" stomach and certain foods do not agree with them.  Some patients have excruciating chest pain and race to the emergency room thinking they are having a heart attack.  Their cardiac workup is normal, and they then learn they have gallstones as the cause of their symptoms.

What is ERCP?

Endoscopic Retrograde Cholangiopancreatography.  The word endoscopic describes the procedure done with a flexible scope that is passed down through the mouth into the small intestine to access the bile duct opening.  The term retrograde is used because the scope can look sideways to find the duct opening.  Cholangiopancreatography is a fancy way to say that dye is injected to x-ray the bile and pancreatic ducts.  ERCP procedures can diagnose gallstones in the common bile duct and remove them.  A sphincterotomy describes cutting of the sphincter muscle during ERCP to facilitate stone removal.

Can the gallbladder perforate?

Yes.  Gallbladder perforation is rare, but it can happen.  You typically see this in patients who wait too long before seeking medical care for their symptoms.

Can you get cancer of the gallbladder?

Yes.  Gallbladder cancer is rare, but it does happen.  The gallbladder is always sent to the pathology lab after surgery and examined microscopically for malignant cells.  If cancer cells are found in the gallbladder, this typically requires resection of the gallbladder liver bed and adjacent lymph nodes.

What about gallbladder polyps?

In general, gallbladder polyps less than 1cm in size can be followed with repeat ultrasound in 6-12 months to monitor for size increase.  If a polyp grows rapidly on repeat ultrasound or grows larger than 1cm, the gallbladder should be removed so that it can be sent to the lab for microscopic testing.  Polyps greater than 1 cm in size are more likely to be malignant (cancerous) and should be removed.  If a patient has biliary symptoms (attacks of pain, nausea, vomiting with eating), the gallbladder should be removed regardless of polyp size.  In this case, the "polyp" seen on ultrasound is more likely to be a stone.  If the ultrasound sees a movable density in the gallbladder, it is likely a gallstone.  If the density does not move, it is more likely to be a polyp.  Many "polyps" on ultrasound are stones that are adherent to the gallbladder wall and do not move.  If a patient has gallbladder polyps and biliary symptoms, the gallbladder needs to be removed.  The microscopic examination of the gallbladder after surgery will then determine if the polyps are benign or malignant.

How do they remove the gallbladder?

Gallbladder removal surgery (cholecystectomy) is performed using minimally invasive surgery, also called laparoscopic surgery or robotic-assisted laparoscopy.  This involves 4 small incisions and is usually done as an outpatient procedure (home the same day).  Until the 1990s, gallbladder removal was done through a large open incision and patients spent a few days in the hospital.

How do I live without a gallbladder?

Diseased gallbladders that require removal are not working normally.  These gallbladders are typically full of stone and sludge debris and chronically inflamed.  They are not functioning normally to add a small amount of bile to a meal.  As gallbladder disease progresses, bile simply flows from the liver to the small intestine ignoring the gallbladder.  In many diseased gallbladders the cystic duct (gallbladder duct) is completely blocked with stones, sludge, or scar from chronic inflammation.  Many patients with diseased gallbladders have not had normal gallbladder function for years.  They ask how they can live without a gallbladder not realizing they have not had normal bile storage function for a long time.  A diseased gallbladder will reach the point where it is not providing any function other than pain, nausea, vomiting and the risk for cholecystitis, cholangitis, or gallstone pancreatitis, all of which can make you much sicker.

Do you have diarrhea after gallbladder surgery?

Most patient do not have diarrhea after gallbladder surgery because they had no gallbladder function long before it was removed.  The body has already adapted.  Even when the gallbladder is normal and healthy, most of the bile produced by the liver drains into the duodenum (small intestine after the stomach) throughout the day.  The gallbladder holds a small amount of bile that it adds to a meal but plenty of bile is always available for digestion.  There are many causes for diarrhea after surgery (antibiotics, etc) but it is commonly blamed on gallbladder removal.  Some patients do get diarrhea after gallbladder removal that is related to the new bile flow.  This typically improves over time as the body adapts.  Most patients have already adapted to this long before removal as the gallbladder's function declined over time.

Do gallstones pass on their own like kidney stones?

You can pass gallstones out of the gallbladder into the main bile duct, but they can cause severe problems with blockage of the bile or pancreatic ducts.  The difference with kidney stones is that once kidney stones pass, they generally do not cause further problems.

Can I just do a gallbladder flush?

Through the years there have been many attempts at dissolving gallstones, "flushing" the gallbladder, breaking them apart with different energy sources, pulling them out of the gallbladder with endoscopy, etc.  The reason these methods do not work is that they leave the diseased gallbladder behind and the stone formation and symptoms will continue.  This would be like trying to save the appendix in appendicitis.  Once the appendix and gallbladder go bad, the best treatment is removal of the diseased organ.

What is the recovery time after surgery?

Most patients go home the same day (outpatient) and are off pain medications within a few days.

How much time do I need to take off work?

The lifting restriction in 15 lbs. in each hand and no core exercises.  You should take it easy for a few days to reduce pain.  Patients are typically back to work within 3-7 days for office type jobs, 7-10 days for light duty jobs and 4-6 weeks for high intensity physical work.

 

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