BMI=Body Mass Index. A healthy 6-foot-tall person will weigh much more than a healthy 4-foot-tall person. Therefore, BMI takes height and weight into account and is a better indicator for how unhealthy you are at a given weight. The BMI formula is your weight in kilograms divided by your height in meters squared. Most insurance policies that cover bariatric surgery will approve the surgery if your BMI is greater than 40, or 35 with two weight-related health conditions (diabetes, high blood pressure, etc).
The BMI ranges are as follows:
20-25 Normal weight
35-40 Severe obesity
40+ Morbid obesity
Patients with BMI greater than 40 are high risk for dying at a younger age, hence the term morbid obesity.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Most patients go home the same day (outpatient) and are off pain medications within a few days.
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.
A hernia is a hole in a muscle through which intestines can herniate.
An inguinal hernia (groin hernia) is where the intestines can herniate through a hole in the muscle of the inguinal region (groin).
An incarcerated hernia is when the intestine herniates through the hole in the muscle and is unable to be reduced. This can be caused by edema (swelling) of the intestine due to irritation such that the intestine is too large to retract back through the hole in the muscle.
Edema from an incarcerated hernia can get so severe that the blood supply to the intestine is cut off as it swells inside the fixed ring of the hole in the muscle. This acts like a tourniquet and leads to intestinal necrosis (the intestine tissue dies) which can perforate. This can be life-threatening. Avoiding strangulation is the main reason to repair inguinal hernias.
Direct, indirect and femoral. These are the three potential spaces that can herniate in the groin.
Indirect inguinal hernias are present at birth. When children have an inguinal hernia repair at a young age, this is for an indirect inguinal hernia. The indirect inguinal hernia sac is a remnant of a process called testicular migration. As a male fetus develops before birth, the testicles migrate from just beneath the kidneys to the scrotal sac. The purpose of this migration is that sperm cannot survive at body temperature. The testicles drag the abdominal cavity lining with them (processus vaginalis) and this defect is supposed to close once migration is complete. An inguinal hernia sac results from incomplete closure of the inguinal canal after migration. The embryologic medical term for this is called “patent processus vaginalis”. Even though indirect inguinal hernias are present at birth, if the hernia defect is small, the intestines won’t herniate and it could take many years to cause symptoms. Over time, as we increase intra-abdominal pressure with lifting, coughing and straining, the small hernia gradually dilates until the intestines enter the inguinal canal through the hernia sac and the patient will notice a bulge and/or discomfort in the groin. Indirect inguinal hernias are the most common hernia type in men and women.
Direct inguinal hernias are acquired from tearing of the abdominal wall fascial and muscle due to heavy lifting or repetitive straining. Chronic coughing can contribute to direct inguinal hernia formation due to the repetitive strain on the inguinal muscles.
Femoral hernias occur when the intestines try to follow the blood vessels (femoral artery and vein) from the groin into the leg. Whereas femoral hernias are more common in women than men, indirect inguinal hernias are still the most common inguinal hernia in women.
Indirect inguinal hernias are present at birth but the hole in the muscle grows larger over time so lifting can cause them to have symptoms at a younger age. Direct inguinal hernias are due to heavy lifting or chronic straining and wear and tear of the abdominal wall. Femoral hernias are a weakness in the femoral canal that can develop over time.
Yes, but they are much less common than in men. Femoral hernias are more common in women but the most common inguinal hernia in women is indirect.
The main reason to surgically repair inguinal hernias is to avoid complications from herniation of the intestine such as incarceration and strangulation, as well as manage the pain and discomfort that hernias can cause.
Mesh is used commonly in inguinal hernia repairs to reduce the chance for recurrence. The invention of mesh has drastically reduced the risk for recurrence. It has been used to reinforce hernia repairs for over 40 years. As the mesh heals, scar tissue embeds in the weave of the mesh which results in a repair that is stronger than our native tissue. With proper technique, mesh can be used without causing chronic pain. Non-mesh repairs can be done but they have a higher recurrence rate. There are improper techniques that can cause chronic pain after mesh repairs but this is mostly avoidable with proper techniques.
Open inguinal hernia repairs will heal to about 80% of maximum strength at 4 weeks. This is the reason to avoid lifting over 15 pounds for 4 to 6 weeks. Many people return to light duty work such as desk work after one week or less. For laparoscopic repairs, recreational lifting can start at 2 weeks post operatively, awkward heavy lifting can start after 4-6 weeks, with no restrictions on walking or lifting up to 15 pounds immediately after surgery.
It takes about six weeks for an inguinal hernia repair to reach maximum strength. Heavy lifting or overdoing it can cause the hernia repair to rip apart and cause a sudden recurrence or heal weaker and then recur later.
Laparoscopic surgery is done through several small incisions instead of one larger incision. The benefits of laparoscopic repair include, small scars, less pain, quicker recovery and the mesh is placed on the inside of the muscle which is a stronger repair and covers all 3 potential hernia spaces (direct, indirect and femoral). Bilateral repair (fixing both left and right sides) can be done through the same 3 small incisions. An open repair would require two larger groin incisions to fix both sides at the same operation and has a higher chance of causing chronic groin pain, though this is a rare event. Open repairs can be safer in a patient that needs to avoid general anesthesia or a patient is on certain blood thinners or blood thinners that cannot be stopped safely before and after surgery.
The two main ways to reduce recurrence after inguinal hernia repair is to avoid lifting over 15 pounds for 4- 6 weeks and to use mesh in the repair. Once the mesh scars in, the repair is stronger than our own tissue.
Many things can mimic an inguinal hernia. An experienced surgeon is invaluable to determine if a patient’s symptoms are due to a hernia that needs repair. Surgeons evaluate many patients with groin pain or bulge and find there is no hernia that needs surgical repair. Muscle, fascia and tendon inflammation or tears from overuse can mimic the symptoms of a hernia. Enlarged lymph nodes, skin cysts or benign fatty tumors can cause a bulge in the groin that mimics an inguinal hernia. An evaluation from an experienced hernia surgeon can determine if your symptoms are due to a hernia that needs surgical repair or something else that may need additional evaluation.
The biggest thing to worry about is strangulation where the herniated intestines swell to the point of cutting off the blood supply. This causes the intestines to die and rupture which can be life threatening. Several studies have been done where men with proven inguinal hernias are randomized to surgical repair versus no surgery. Typically, within two years most of the men in the non-surgical group crossover and have the hernia repaired due to increasing symptoms. It is also better to repair hernias when they are small instead of waiting for the muscle defect to be so large and chronically inflamed that you increase potential complications from surgery.
The bottom line is, if you are healthy and an inguinal hernia is impacting your lifestyle, you should get it repaired.