Cholecystectomy is the medical term for the removal of the gallbladder. The procedure is a safe operation with a very low complication rate. Both minimally invasive and open gallbladder removal are routine procedures. Cholecystectomy is the only satisfactory method for curing symptomatic gallstone disease.
The gallbladder is a thin-walled, pear-shaped organ with a capacity of around 30 - 50 ml. It is connected to the liver by connective tissue and is located on the underside of the liver in the right upper abdomen.
The gallbladder serves as a storage organ for the bile produced in the liver.
The liver cells form the bile, which flows together via tiny bile ducts to form ever larger bile ducts. Outside the liver, two large draining bile ducts finally merge to form thecommon hepatic duct.
When food is ingested, bile is emptied both from the liver (directly produced bile) and from the gallbladder. It flows into the common bile duct via thecystic duct, which departs from the gallbladder. After the union of the cystic duct and the common hepatic duct, the common bile duct is referred to as the hepatocholedochal duct (DHC).
This in turn joins with thepancreatic duct (pancreatic duct) and finally opens into theduodenum via a papilla with a valve function(papilla Vateri).
Immediately before it joins the duodenum, the bile duct has a ring muscle that contracts during rest. The resulting reflux causes the gallbladder to fill with bile via the gallbladder duct. Shortly after eating, the mouth of the bile duct(papilla Vateri) opens and the bile flows out.
Bile acids serve a number of important metabolic functions, above all the digestion of fats and the transportation of fat-soluble substances.
They are later almost completely reabsorbed in the small intestine, transported back to the liver via the bloodstream and made available for renewed excretion via the bile.
If the gallbladder is removed, the bile is still produced in the liver and drained into the small intestine via the common bile duct. The only thing missing is a reservoir of bile secretion, which is not noticeable during digestion as long as fats are not consumed in significant excess all at once.
Otherwise, the undigested fats could lead to diarrhea. Also, with our modern eating habits, where food is generally always available, the reservoir function of the gallbladder is no longer necessary.
Around 250 - 1000 ml of bile is produced every day. The bile is thickened and concentrated in the gallbladder. Due to the composition of the bile (e.g. water, salts, cholesterol, bilirubin), there may be an excess of one of the components. The resulting supersaturation causes the secretion to crystallize , leading to the formation of various types of gallstones (e.g. cholesterol stones, bilirubin stones, etc.).
At least 15 % of the total population are carriers of gallstones. Women suffer from gallstones more frequently than men. Risk factors for the development of gallstones, in addition to the female sex, are
and many more. The number of people affected increases with age. However, not all gallstone carriers necessarily have symptoms. Most gallstone carriers (around 75%) are symptom-free throughout their lives.
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However, if symptoms occur, such as seizure-like pain (colic), often after a large meal, or persistent pain in the upper abdomen, which can radiate to the back and right shoulder and is often accompanied by nausea or even vomiting, treatment is required to avoid serious complications of gallstone disease.
To do this, the gallbladder, which is the main source of the gallstones, must be surgically removed.
Gallstones can take on very different shapes and sizes, from a few millimetres to several centimetres.
Smaller concretions are more likely to cause complications, as they can pass through the bile ducts or obstruct them and cause colic. This can obstruct the outflow of bile into the intestine and lead to a backlog of bile secretions. This can lead to the appearance of pale stools and a dark coloration of the urine.
This can also lead to the bile pigment (bilirubin) leaking into the blood and causing jaundice (occlusive jaundice). This can also lead to inflammation of the bile ducts(cholangitis). This is often accompanied by fever and chills.
At the same time, the common duct of the gallbladder and pancreas can be obstructed by the gallstones and lead to inflammation of the pancreas (biliary pancreatitis) due to a backlog of digestive juices.
A long-lasting, chronic blockage of the bile flow can lead to damage to the liver cells, which then die and are replaced by scarred connective tissue (biliary form of liver cirrhosis).
The gallstones themselves can also damage the gallbladder wall and cause inflammation of the gallbladder(cholecystitis). A severely inflamed gallbladder can rupture (perforate), which can lead to the escape of bile secretions into the free abdominal cavity and cause life-threatening peritonitis (biliary peritonitis).
Chronic inflammation of the gallbladder can lead to scarring and thus shrinkage of the gallbladder (shrunken gallbladder). The same applies to the detection of a so-called porcelain gallbladder, which gets its name from the scarred remodeling of the tissue with calcium deposits caused by the chronic inflammation. Both forms tend to degenerate, which can lead to the development of gallbladder cancer.
The detection of particularly large gallstones with a diameter of more than 3 cm is also a reason to remove the gallbladder (cholecystectomy), even if the patient has no symptoms, as these can also increase the risk of developing gallbladder cancer.
The same applies to the detection of gallbladder polyps. The gallbladder should then also be removed, as it cannot be ruled out that a malignant tumor is behind this neoplasm.
Gallbladder inflammation rarely occurs after severe trauma or major surgery (stress gallbladder).
If a bladder inflammation is diagnosed, antibiotic treatment and a so-called early cholecystectomy, i.e. early surgical removal of the gallbladder within three days, are carried out first. If the symptoms subside, the operation can also be performed during the symptom-free interval and after the inflammation has subsided (after around four to eight weeks).
However, early removal of the gallbladder is associated with fewer complications overall, as the inflammation of the gallbladder can lead to changes in the gallbladder wall as well as adhesions and callosities, which could make the operation more difficult.
The detection of gallbladder empyema (accumulation of pus in the gallbladder) or gangrenous cholecystitis, with tissue destruction caused by the inflammation, requires immediate surgery, as there is a risk of perforation with the development of peritonitis.
If a malignant tumor of the gallbladder is suspected, the gallbladder is usually removed by open surgery, depending on the extent of the process. In the case of advanced tumors, the procedure must be extended to include the neighboring liver tissue, and the neighboring lymph nodes (ligamentous lymph nodes) should always be removed as well.
The sole removal or fragmentation of gallstones (e.g. extracorporeal shock wave lithotripsy, ESWL) while preserving the organ is not satisfactory according to the current state of medicine. In addition, the stones would soon form again and make a new operation necessary. Dissolving gallstones with medication (litholysis) does not bring lasting success either. Sufficient results and a cure for gallstone disease are not possible without removing the gallbladder.
More than 190,000 cholecystectomies are performed in Germany every year. In over 90 % of cases today, the gallbladder can be surgically removed laparoscopically through laparoscopy(keyhole or minimally invasive surgery).
In minimally invasive gallbladder removal, carbon dioxide is first injected into the abdominal cavity via a blunt cannula under general anesthesia. The gas causes the abdominal wall to rise slightly, creating sufficient visibility and space in the abdominal cavity for the operation.
An optical system and the surgical instruments are then inserted into the abdominal cavity via valve sleeves that are usually 3 - 10 mm in diameter. The images recorded by the camera are enlarged and displayed on a monitor in the operating room.
The skin incisions through which the sheaths are inserted into the abdominal cavity are correspondingly small. Four incisions are usually made (above the navel and centrally and laterally in the right upper abdomen), whereby the access in the navel area usually has to be widened to around 2 cm after the gallbladder has been removed from the liver bed in order to be able to retrieve the gallbladder, especially as it carries stones.
Under certain conditions and in order to enable even less scarring during surgery, the gallbladder can also be removed via three accesses (above the navel and in the right and left lower abdomen) or a single, larger access above the navel (so-called single-port technique).
The gallbladder duct must be severed together with the accompanying artery(A. cystica) before the gallbladder is removed from the liver bed. This is done after clamping the vessels with metal clips or mostly absorbable plastic clips, which dissolve after a few weeks. Only then can the gallbladder be peeled out of the liver bed and removed together with the stones it contains.
Before the skin is closed, the gas previously released into the abdominal cavity is drained again. Any remaining small amounts of carbon dioxide are broken down by the body.
The cholecystectomy usually takes about 30 - 60 minutes. The patient is allowed to get up and drink fluids on the same day. This is usually followed by a rapid diet and the patient is discharged from hospital after around two to four days.
In an open (conventional) cholecystectomy, the abdominal cavity is opened through an incision in the right upper abdomen or in the median (in the middle between the breastbone and navel). As a rule, an incision at least 8 - 10 cm long is made along the edge of the right costal arch. The length of the incision usually depends on the patient's constitution and the conditions in the abdominal cavity.
The gallbladder duct and the vessels supplying the gallbladder are closed and removed and then the gallbladder and its contents are detached from the liver bed under direct vision. Finally, the abdominal wall is closed again.
If there are no complications, the patient remains in hospital for around four to seven days.
Gallbladder removal is a safe operation with a very low complication rate, and both minimally invasive and open cholecystectomy are routine procedures.
Complications of a planned cholecystectomy depend largely on factors such as the patient's concomitant diseases and complications of the gallstone disease. Emergency cholecystectomies have a higher risk and a higher complication rate.
In addition to general surgical risks such as
Injuries to the bile ducts or neighboring organ structures are extremely rare. Even then, a repeat operation is only necessary in some cases and in the case of major injuries, e.g. to the common bile duct.
A bile blockage can be caused by stones remaining in the bile ducts. If stones are detected in the bile ducts before or after the operation, they can usually be removed as part of an endoscopic procedure(ERCP = endoscopic retrograde cholangiopancreatography). In addition to visualizing the bile ducts and the pancreatic duct with X-ray contrast medium, ERCP enables therapeutic procedures to be performed, such as the removal of trapped gallstones in the bile ducts, but not stones from the gallbladder.
In any case, when informing a patient before performing laparoscopic removal of the gallbladder, it must be pointed out that it may always be necessary to switch to an open procedure during the operation in the interests of the patient.
If, for example, unforeseen circumstances such as
the gallbladder can be removed through a larger abdominal incision with less risk for the patient.
Sore muscles in the upper abdomen and shoulders for a few days after the procedure are possible due to nerve irritation caused by the gas released into the abdominal cavity during the operation.
Laparoscopic removal of the gallbladder has major advantages over open cholecystectomy, i.e. in comparison to gallbladder removal via an abdominal incision:
In addition to the elimination of a large wound, a major advantage of laparoscopic cholecystectomy is that fine, miniaturized instruments are used for on-site dissection, which can significantly reduce the trauma caused by surgical dissection. The surgical trauma is therefore limited to the affected body region and a wide opening of the abdominal cavity is avoided.
For the patient, this results in a significant reduction in overall stress and, as a result, a much faster recovery. Patients who have undergone laparoscopic surgery generally leave hospital earlier and are able to return to work more quickly.
Follow-up care is only necessary if symptoms recur.
It is not necessary to avoid certain foods or to follow a special diet. Normal, unrestricted physical activity is usually possible again after about 14 days.
Surgery makes it possible to cure symptomatic gallstone disease. There are no satisfactory alternative methods available. Surgery is the treatment of choice.
Cholecystectomy is a safe operation with a very low complication rate.
Life without a gallbladder is completely unimpaired and the quality of life is higher than having to live with a diseased gallbladder and recurring symptoms.
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