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Single Hole Surgery -
Scarless Surgery
You thought that a Surgery, even keyhole,
always produces a scar. Not any
more!
Gall Bladder
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What is Gall Bladder?
The gallbladder is a small
organ located high on the right side of the abdomen
(tummy) under the
liver. In adults, the gall blabber measures
approximately 8 cm in length and 4 cm in diameter when
fully distended. It is divided into three sections: fundus,
body, and neck. The neck tapers and connects to the
biliary tree via the
cystic duct, which then
joins the
common hepatic duct to
become the
common bile duct.
What is Gall
Bladder’s function?
The adult human gallbladder
stores about 50-75 millilitres of
bile which is released
into the small intestine when
food containing fat
enters the small intestine from the stomach. This bile
along with the bile released directly from the liver helps
in digestion of fat present in the food.
 What
are Gall Bladder Stones or Gall stones? How are they
formed?
Gall stones are small, hard stones which can sometimes
develop in the gall bladder . There are two types of
gallstones: cholesterol stones and pigment stones. Eighty
percent of gallstones are cholesterol stones. The size of
gallstones varies from a grain of salt to golf-ball size.
A person can develop a single stone or several stones.
When gallstones are present in the gallbladder itself, it
is called cholelithiasis. When gallstones are present in
the bile ducts, it is called choledocholithiasis.
Gallstones form when bile stored in the gallbladder
hardens into stone-like material. Too much cholesterol,
bile salts, or bilirubin (bile pigment) can cause
gallstones. Slow emptying of the gallbladder can also
contribute to the formation of gallstones.
What are the risk factors for developing Gall Stones?
Female sex, obesity, pregnancy, fatty foods, Crohn's
disease, terminal ileal resection, gastric surgery,
hereditary spherocytosis, sickle cell disease, and
thalassemia are all associated with an increased risk for
developing gallstones. Only first-degree relatives of
patients with gallstones and obesity (defined as body mass
index >30 kg/m2) have been identified as strong
risk factors for development of symptomatic gallstone
disease
What are the symptoms
of Gall stones?
To begin with, most gallstones do not cause symptoms.
However, when gallstones become larger, or when they begin
obstructing the neck of gall bladder, symptoms or
"attacks" begin to occur. Attacks of gallstones typically
occur after a fatty meal and at night. The following are
the most common symptoms of gallstones. However, each
individual may experience symptoms differently. Symptoms
may include, but are not limited to, the following:
·
pain that comes and goes in the abdomen (usually lasting
less than 6 hours)
·
nausea and/or vomiting
·
abdominal bloating
·
intolerance of fatty foods
·
belching or gas, and indigestion
Uncomplicated Gall stones usually don’t
cause jaundice, fever or longer lasting pain (more than 24
hours). These symptoms appear only after complications of
gall stones set in.
The symptoms of gallstones may resemble
other medical conditions or problems.
What are
complications of Gall stones?
Gall stones can cause a plenty of
complications which can be quite dangerous. This is one of
the major reason that the Gall stones be removed as soon
as they become symptomatic. Some of the major
complications are-
1.
Acute Cholecystitis-
If stones become lodged in the
cystic duct/neck of the gall bladder and block the flow of
bile, they can cause cholecystitis, an inflammation of the
gallbladder. This causes severe pain in right upper side
of tummy ( lasting usually longer than 24 hours), nausea,
vomiting and fever. The patient usually requires admission
in the hospital for giving intravenous fluids (glucose),
analgesics (pain killers), and antibiotics. This gives
rest to the gall bladder and leads to recovery with in a
couple of days. The diagnosis is done with the help of
Ultrasound. Ultrasound shows the presence of
thickening of the gallbladder wall (>4 mm),
pericholecystic fluid (fluid around the gall bladder),
gallbladder distention, impacted stone, and a sonographic
Murphy's sign (focal tenderness directly over the
gallbladder).
Complications
of Acute Cholecystitis- Pyocele (Gall bladder
full of pus), Gangrene & Perforation of Gall bladder (
It’s a serious condition generally requiring emergency
surgery)
Implications
of Acute Cholecystitis- It makes the surgery
challenging due to adhesions and increased friability of
tissues leading to a higher chances of conversion to
conventional laparoscopy and open surgery.
2.
Migration of stone to
CBD (Common Bile Duct)- This condition is
also called Choledocholithiasis. CBD
is the main tube/duct which carries bile from liver to the
intestine. The bile stored in the gall bladder is also
drained into the CBD. When the stone passes from the gall
bladder into the CBD, it can block the main flow
of bile and can cause jaundice, lightening of the stools,
and darkening of the urine. If not treated quickly, it can
also lead to fever, pain and shock. Stone in CBD can also
block the opening of Pancreatic duct in the CBD leading to
Pancreatitis.
Common bile duct stones may be silent
and are often discovered incidentally. About 1% to 2% of
patients with normal liver function tests managed with
laparoscopic cholecystectomy for gallstones present with a
retained stone in the CBD after cholecystectomy.
3.
Gallstone Pancreatitis
– As mentioned above, stone in the CBD can block the
opening of Pancreatic duct in the CBD leading to
Pancreatitis. In Pancreatitis, the patient experiences
severe pain in the upper tummy, nausea, vomiting, fever,
electrolyte imbalance (disturbances in calcium, potassium
and sodium levels), pleural effusion ( Fluid accumulation
around the lungs) and even life threatening shock (drop in
blood pressures). Diagnosis is usually confirmed by CECT
(Contrast enhanced CT scan). An ERCP with sphincterotomy
and stone extraction ( An endoscope is put through the
mouth, lower end of CBD is dilated and slightly cut and
the stone in the CBD is taken out) is the initial
treatment and may relieve the pancreatitis. Once the
pancreatitis has subsided, the gallbladder should be
removed during the same admission. If the pancreatitis is
self-limited, the stone has likely passed. For these
patients, cholecystectomy is indicated as soon as
possible.
4.
Intestinal Obstruction-
Passage of a gallstone into the small intestine can lead
to a mechanical intestinal obstruction, also known as
gallstone ileus. Most (75%) of these fistulas develop
between the gallbladder and duodenum (proximal part of the
small intestine), occur in elderly people, and account for
1% of all small bowel obstructions. Gallstone ileus may
account for as many as 25% of cases of intestinal
obstruction in patients older than 70 years who have no
previous surgery or hernias on physical exam. The patient
has complaints of nausea, vomiting, and abdominal pain
5.
Fistula between Intestine and
Gall Bladder- Also known as Biliary-enteric fistula, it usually
follow an episode of acute cholecystitis with gangrene and
perforation of the gallbladder wall into the adjacent
intestine or from pressure necrosis from an impacted
gallstone.
Can the patient have
symptoms similar to that of Gall stone Disease without
having stones in the Gall Bladder?
Yes, its possible. This condition is called Biliary
Dyskinesia. If gallstones are not indicated from the test
and your symptoms are still not explained, further tests
may include a gallbladder emptying. The gallbladder
emptying test (CCK-Tc-HIDA
scan)
is an outpatient test involving an injection into your arm
of a substance which will cause your gallbladder to fill
with bile quickly. While this is happening, you will lay
very still while a radiologist watches by x-ray the speed
in which your gallbladder fills. Then you will be injected
with another fluid that will cause your gallbladder to
spasm violently and empty its contents rapidly. This
causes intense, though brief nausea, which should last
approximately 5 minutes and end suddenly. By observing the
speed your gallbladder empties itself, your doctor will be
able to tell whether or not it may be diseased.
An ejection fraction less than 35% at 20 minutes is
considered abnormal. These patients have functional
abnormality of gall bladder and surgery (gall bladder
removal) may be indicated in these patients.
What is the treatment
of Gall Bladder stones?
The standard treatment of Gall stones is removal of Gall
bladder surgically.
The surgery to remove the gallbladder is called a
cholecystectomy ("Ko-lee-sist-eck-toe-mee").
Is there any effect
of Gall Bladder removal on the body? (What's the effect of
Gall Bladder removal on the body?)
The liver produces about 750-1100 millilitres of bile
every day. The function of the adult human gallbladder
is to store about 50-75 millilitres of
bile (produced in the
liver) and release
into the small intestine when
food containing fat
enters the small intestine from the stomach. This bile
along with the bile released directly from the liver helps
in digestion of fat present in the food. The Gall
bladder releases only about 15-20% of the total bile
produced by the liver, the rest being released directly by
the Liver in the intestine.
When the stones develop in the Gall bladder, the capacity
of Gall Bladder is markedly reduced due to inflammation
and the stones. At the same time, in many patients with
gall stones, the function of Gall Bladder to contract and
release bile is also deranged (becomes faulty). So,
practically in majority of patients with Gall stones, the
Gall Bladder is not serving any purpose. Therefore its
removal doesn't has any negative effect on the body.
Secondly, even after removal of the Gall Bladder, the
Liver produce the same amount of bile as it used to
produce before its removal. So, the common ducts draining
bile (Common Hepatic Duct & Common Bile Duct) dilates to
accommodate the flow of bile.
Can Gall Bladder
Stones be totally 'silent' (not causing any symptoms) ?
Yes, in some patients the Gall stones can be totally
silent causing no symptoms at all. In these patients, the
stones in the Gall Bladder are accidentally detected when
an Ultrasound is done for some other reason.
Does asymptomatic
'silent' Gall stones need to be removed?
Gall stones not causing any symptoms, may or may not be
removed. The medical scientific literature is equivocal
(either way) about it. However, there are few conditions
when Gall bladder in even asymptomatic Gall stones should
be removed. These are
1. Diabetes Mellitus
2. Stone size more than 2 cms (It increases the risk of
Gall Bladder Cancer)
3. Polyp in the Gall bladder. (It increases the risk of
Gall Bladder Cancer)
4. Porcelain Gall Bladder- (It increases the risk of Gall
Bladder Cancer many fold)
5. Regions where Gall Bladder Cancer is very common (
Endemic zones)- As Gall stones increases the risk of
developing Gall Bladder Cancer, in regions where Gall
bladder cancer is very common like North India, even
asymptomatic stones should be treated by Gall bladder
removal.
What are the ways to
remove Gall Bladder?
The Gall
bladder can traditionally be removed by two methods- Open
& Laparoscopic (Keyhole). Now Single Hole Laparoscopic
Surgery (Single Incision Laparoscopic Surgery- SILS or
Scarless Surgery) has revolutionized the way, the Gall
Bladder surgery is done.
What is Open Gall
Bladder Surgery? How it is done?
In traditional Open surgery, the gallbladder is
removed through a 10-15 cms long incision (cut) in
the tummy. The cut is
made just below the ribs on the right side and goes to
just below your waist. This is called an open
cholecystectomy.
The Open surgery involves a sizable incision in the
upper right abdomen which may take several weeks
recovery and cause considerable discomfort and several
days of hospitalization. Since the cut is larger, the
risk of wound infection is also higher. The long scar
leads to cosmetically poor scar. Because of these
reasons, Laparoscopic (keyhole) Cholecystectomy has
replaced open surgery as the procedure of choice in
the last 15 years.
However, even today, Open Surgery is indicated in the
following conditions:-
1.
Poor lung or Heart function
2. Suspected gall bladder cancer
3.
Cirrhosis and portal hypertension
4.
Pregnancy- Third trimester (6th-9th
month)
What is
Laparoscopic Cholecystectomy (Gall Bladder Surgery) ?
About 20 years back, a better way to remove the
gallbladder called laparoscopic ( "lap-are-oh-skop-ick")
cholecystectomy was started. In this surgery, a
laparoscope (a small, thin tube with a camera on the tip
of it that is used to see the inside of your body) is used
to remove the gallbladder. Several small incisions (cuts)
are made rather than one large incision. In USA, about
500,000 to 700,000 cholecystectomies are performed
per year.
How is Laparoscope
used to remove the gallbladder?
The laparoscope is put into your body through a tiny cut
made just below your navel. Your doctor can then see your
gallbladder on a TV screen and do the surgery with thin
long instruments inserted in 3 other small cuts made
in the right upper part of your abdomen. Your gallbladder
is then taken out through one of the incisions.
What are the benefits
of Laparoscopic Cholecystectomy?
With laparoscopic cholecystectomy, one may return to work
more quickly, have less pain after surgery, have a shorter
hospital stay, and have a shorter recovery time. Unlike
open surgery, laparoscopic surgery to remove the
gallbladder can be done without cutting the muscles of
your abdomen. The incision is also much smaller and the
scars are much less noticeable than those made by open
cholecystectomy.
So the
advantages of Laparoscopic surgery over Open surgery are
1. Less pain
2. Early
discharge from the hospital
3. Early return to work
4. Less risk
of wound infection
5. Lesser
risk of hernia formation as no muscle is cut
6. Better
cosmetic result (as there is no big scar, only multiple
small scars)
What are
contraindications of Laparoscopic Cholecystectomy?
Contraindications to laparoscopic cholecystectomy
include coagulopathy (inability of blood to clot or
bleeding to stop timely), severe chronic obstructive
pulmonary disease, end-stage liver disease, and congestive
heart failure.
Can Laparoscopic
procedure need to be converted to Open surgery? If yes,
why and how often?
Yes, the laparoscopic surgery may need to converted to
Open surgery at times. The reasons for this could be
inability to clearly identify all of the anatomic
structures, uncontrolled bleeding, acute cholecystitis
(leading to adhesions, swelling and friability of
tissues), previous surgery in the region leading to
scarring and adhesions or damage to a vital
organ/structure. The conversion rate for elective
laparoscopic cholecystectomy should be around 5%, whereas
the conversion rate in the setting of acute cholecystitis
may be as high as 30%. Conversion to an open procedure is
not a failure, and the possibility should be discussed
with the patient preoperatively.
What is Single
Incision Laparoscopic Surgery (SILS) or Single Hole
Surgery or Scarless
Surgery?
In SILS, the complete surgery is done through a single
small puncture/hole/incision of about 1.5 to 2.5 cms.
This small cut is made inside the navel (umbilicus)
in such a way that the scar is practically invisible
after the operation, making it a scarless surgery.
SILS has revolutionized the field of laparoscopic
surgery as the latter did about 20 years back.
What are
advantages of SILS or Single Hole Surgery operation?
SILS has number of distinct advantages,
1. Wonderful cosmesis- The cosmetic result is
fantastic as there is no visible scar after the
operation. It is very good for ladies who are quite
careful about cosmesis.
2. Less pain- As the number of cuts are less.
3. Early recovery
4. Early return to work
5. Less chances of Infection as there is only one
small cut.
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