Gallbladder surgery by laparoscopy

The gallbladder is 8-10 cm long and it is located on the lower surface of the liver. The gallbladder stores the gall, which is produced by the liver, and its volume is about 30 60 ml. During digestion, the gall is excreted through the bile ducts into the small intestines together with the pancreatic duct through the so-called papilla of Vater, which has a sphincter muscle, and it helps digestion and fat absorption (Figure 1). Multiple factors can lead to the formation of gallbladder stones, one of the main causes is a change in the composition of the gall, which leads to the precipitation of cholesterol.

In addition, it constitutes of calcium and bilirubin (gall dye). The pathology is often accompanied by bacterial infection, which leads to the acute or chronic inflammation of the gallbladder. Smaller stones or gallbladder sludge can be excreted from the gallbladder when it contracts and may cause obstruction. Large stones cannot get out, but they result in the total occlusion of the gallbladder; the gallbladder may grow to the size of 300 ml. In this case, if bacterial infection is not present, the gall will be absorbed, and a painless, tight gallbladder full of mucus will remain.

In many cases, gallstones do not cause complaints but the more time elapses, the higher is the probability that the gallstone carrying person becomes a patient with gallstones and complaints. Tissue abnormalities can develop in the liver after having asymptomatic gallstones for more than 5 years, and the prevalence of gallbladder cancer is probably more frequent too. According to the international aspects, surgery is recommended in all cases, so even in case of asymptomatic gallstones, in order to prevent severe complications.

Which are the main symptoms of the disease?

The most typical symptoms of gallstone disease:

• Bloating
• Feeling of discomfort under the right costal margin
• Gallbladder spams after eating, which typically radiate in the right chest and the shoulder Blade
• Disturbed digestion

Bacterial infection causes acute inflammation, which is a condition accompanied by intense pain, and very often, by fever. The gallbladder’s wall dies off, an abscess develops, which leads to peritonitis. In addition, liver abscess, bile fistulas, and icterus (jaundice) could develop.

The stones which are being excreted could cause bile duct occlusion. If this occurs further up, close to the gallbladder, gallstone complaints could develop. If it is located low, in front of the papilla of Vater, then not only that they could lead to the occlusion of the bile duct but also to the occlusion and the inflammation of the external canal of the pancreas. This may be accompanied by intense pain with a belt like pattern, weakness, malaise, vomiting, and fever.

What treatment options are available?

The surgical removal of the gallbladder is recommended by the professional guidelines. Conventionally, the intervention was performed from a small incision made under the right costal margin. About 30 years ago, the minimally invasive laparoscopic intervention became accepted. It has numerous advantages compared to the previous intervention:

• The duration of the surgery is shorter.
• Less burdensome.
• Less pain.
• Quicker recovery.
• The hospital stay reduced to 1-2 days.
• The probability of complications to develop during or following the surgery (abdominal incisional hernia, infection in the abdominal cavity, bleeding, wound healing disturbances) is reduced.

What happens to you in the operating room?

A short description of the intervention’s course:
An arched incision of about 10-15 mm will be made above the belly button and a special, the so called Veres needle will be inserted into the abdominal cavity through which the computer system creates an overpressure of 15 mm Hg by blowing carbon dioxide inside. Following this, a trocar with a10-mm diameter will be inserted in the needle’s place, in which the optics will be placed. We will take a look around the abdominal cavity with the camera, then an assisting trocar with a diameter of 10 mm will be inserted below the sternum with eye control, and another one under the right costal margin; if necessary, an additional 5 mm assisting trocar is placed below the latter. The assistant will help the surgeon to position the gallbladder through this. The surgeon will cleanse the gallbladder from the adhesions, prepares the bile duct (cystic duct) coming from the gallbladder and also the artery (cystic artery) that is going into the gallbladder. 2 + 1 clamps will be placed on both structures.

The structures will be cut with a scissor between the 2nd and the 3rd clamps and after preparation, the gallbladder is removed through the 10-mm operational trocar by putting it into the “endobag”. Rinsing and bleeding reduction are performed, if necessary. As closing, a thin, perforated drain made of silicone is left in the place of the gallbladder before removing one of the 5-mm trocars on the right side. If necessary, a stitch to the abdominal wall will be put in the wound under the sternum for the purpose of preventing a scar hernia, and then the wounds will be united by a skin suture.