What is cholecystectomy (Gallbladder Removal)?
Cholecystectomy is a well-known surgery since the 19th century. Surgeons back then figured out that gallbladder conditions may not be relieved by simple traditional medications therefore they innovated surgical procedures to excise the gallbladder. In July 1882 the first open cholecystectomy was performed by a German surgeon called dr. Carl Langenbuch and it was a breakthrough in medicine. After the invention of laparoscopy, dr. Erich Mühe was the first surgeon to perform a laparoscopic cholecystectomy in 1985.
Statistics of cholecystectomy
Although cholecystectomy is a major surgery , it is frequently performed and has significant results. Physicians recommend cholecystectomy for almost 80% of patients with gall stones because of its high success rate. Statistics have shown that the success rate of open cholecystectomy is 83% while laparoscopic cholecystectomy is 98%.
Physicians consider cholecystectomy the definitive treatment for many gallbladder conditions such as recurrent gallstones. it is estimated that more than 700.000 gallbladder removal surgeries are performed every year in the US. The mortality rate of cholecystectomy is barely noticeable as it is found to be less than 0.3%.
Patients who are indicated to get their gallbladder removed ask whether their life quality or expectancy will be affected after the surgery, in fact, patients after cholecystectomy usually have a healthier lifestyle and longer life span.
» Now, let’s discuss Types, Contraindications, Indications, Preparations, Recovery and Complications of cholecystectomy
Are there types of cholecystectomy surgeries?
Patients indicated to remove their gallbladder usually get informed with the surgery and how it will go. There are two types of procedures surgeons do to remove the gallbladder. Both types are almost equal in results and have barely noticeable differences in complications. These operations are called open cholecystectomy and laparoscopic cholecystectomy.
Open cholecystectomy was the operation of choice in the 20th century until 1990 when laparoscopic cholecystectomy took its place. Open cholecystectomy involves making an incision of about 10 cm below the right costal margin (the lowermost ribs) or just next to the midline. Then the surgeon separates the muscle layer and fascia till he has access to the gall bladder. Then retraction is applied to the gallbladder allowing the surgeon to dissect its duct and cauterize its supplying artery.
This operation takes approximately an hour and the patient could be discharged after 3 – 4 days. Patients feel no pain during the surgery because they get general anesthesia, they might have some sort of discomfort after it though. Open cholecystectomy is said to have a zero% mortality rate and it is still performed nowadays yet the majority of patients prefer not to have the 10 cm abdominal scar.
Laparoscopic cholecystectomy (LC) is now considered the gold standard for patients indicated to get their gallbladder removed. It is estimated that more than 80% of the performed gall bladder removal surgeries every year are laparoscopic. LC is significantly successful with almost neglectable complications. However, its mortality rate is less than 0.5% and its morbidity rate is about 5%.
The technique of laparoscopic cholecystectomy includes making 3 or 4 holes in which the surgeon inserts his tools and a laparoscope to visualize the viscera. Scaring after laparoscopic cholecystectomy is minimal and less than open cholecystectomy. Operation time of laparoscopic cholecystectomy is longer than open cholecystectomy and it is about 80 minutes ± 4. Laparoscopic cholecystectomy has a shorter hospitalization period as patients who underwent LC can leave the hospital after just 1-2 days.
Indications of cholecystectomy
Can anyone remove his gallbladder? Patients elected to remove their gall bladder should need to get their gallbladder removed otherwise the surgery won’t be useful. Indications of both open cholecystectomy and LC are the same and they are subjected to the surgeon’s decision which is mostly based on the recurrence and severity of the condition. These indications include:
- Symptomatic gallstone which is called cholelithiasis is the most common indication for cholecystectomy. Asymptomatic gallstone is not considered an indication for surgery because it may be resolved on its own or by medications. It is still controversial whether gallstones causing mild symptoms should be removed surgically or not. However, surgeons believe that if the gallstone is more than 2.5 cm in diameter, the gall bladder should be removed. Gallstones isn’t a fatal condition but it may result in secondary bacterial infections which could be serious, moreover, the gallstones recurrence rate is high especially in women.
- Cholecystitis is inflammation of the gall bladder. Acute and chronic cholecystitis are indications for gall bladder removal. Cholecystitis could occur due to multiple causes. gall stones and bile duct obstructions are the most reported causes of cholecystitis.
- Gallbladder tumors or liver tumor invaded gallbladder are both indications for cholecystectomy. Although malignancies don’t often rise from the gallbladder, the liver is a common site for metastasis. Most gallbladder tumors are benign but they may turn malignant anytime, therefore, doctors don’t prefer to risk it but they recommend cholecystectomy. Gallstones are reported to be a major risk factor for gallbladder tumors.
- Biliary dyskinesia is a functional disorder in which the motility of the gall bladder is impaired leading to stagnation of bile in it. Biliary dyskinesia is considered a rare condition but still an indication for cholecystectomy. it is commonly presented with a typical gall bladder pain that may radiate to the right shoulder. The exact cause of biliary dyskinesia is still unclear but doctors assume it is neurological or dopamine-related.
Contraindications
Patients may be contraindicated to have cholecystectomy for multiple reasons which are evaluated by their surgeon. Cholecystectomy is postponed in case of temporary contraindications whereas patients with permanent contraindications are switched to a line of treatment other than surgery. Contraindications are divided into absolute contraindication (mustn’t be done regardless of any indications) and relative contraindications (non-favorable unless its benefits overshadow its risks)
Absolute contraindications include uncontrolled coagulopathy. Coagulopathy is a medical disorder in which a patient’s blood can’t stop bleeding on its own by making clots properly. Patients with uncontrolled coagulopathy tend to bleed profusely, therefore they would be at a life-threatening risk if they underwent open cholecystectomy. Intolerance for general anesthesia is also considered an absolute contraindication for surgery.
Relative contraindications are subjected to surgeons’ evaluation and assessment. It is critically important to avoid putting a patient’s life in danger, so doctors carefully examine patients before surgeries especially those with relative contraindications. Acute cholecystitis is the most common relative contraindication for cholecystectomy. Surgeons prefer to wait until the inflammation subsides by medications before doing the surgery to avoid gallbladder rupture. Terminal gall bladder tumor that has spread to the surrounding organs is a relative contraindication for cholecystectomy because there would be no use of surgeries or medications other than palliative treatment. A gallbladder abscess is considered as a relative contraindication for cholecystectomy as it may cause empyema and sepsis so it should first be treated with antibiotics or drained.
Preparations prior to surgery
Patients should give a full detailed history of their chronic diseases and medications before scheduling the operation date because unmanaged drug intake may lead to an unexpected outcome. Patients taking blood thinners such as aspirin, clopidogrel, heparin, and warfarin should be referred to a specialist to adjust their doses before cholecystectomy to avoid undesired bleeding.
Surgeons give patients some instructions to do before the surgery. Patients should have empty bowels during the surgery so they are asked not to eat for about a day before surgery. Usually, there is no restriction over drinking waters as patients are asked to get hydrated well before the surgery. beverages and soft drinks aren’t recommended before surgery. Patients are requested to take a shower the day before the surgery.
Immunocompromised patients as diabetics and old patients may be indicated to get prophylactic antibiotics to avoid infection that their immunity can’t fight on their own. Post-surgical infection isn’t a common complication of surgeries nowadays due to the high level of sanitation of the operation room so prophylactic antibiotics are optional, if so it should be a single dose an hour before surgery.
Complications of cholecystectomy
Although cholecystectomy is believed to be a safe procedure, patients may be to some extent at risk for intra-operative and post-operative complications. The incidence of complication of cholecystectomy is approximately 3.2% and most of it is postoperative. A recent study has found that the probability to have intraoperative complications is equal for open cholecystectomy and laparoscopic cholecystectomy.
Vascular and visceral injuries represent the majority of the intra-operative complications of cholecystectomy. Bile duct injury is an intraoperative complication that needs immediate reconstruction by a specialist. Internal hemorrhage may also occur during surgery, it is rare but may be life-threatening. Intestinal injury mostly doesn’t occur. Like any major surgery, an unexpected response to anesthesia is an intra-operative complication.
Pyrexia is reported to be the most common postoperative complication of cholecystectomy. Post-operative complications also include infection, bile leakage, and deep venous thrombosis (DVT). Unfortunately, these complications are as serious as intra-operatives. Patients should be hospitalized and their vitals should be monitored for a day at least to avoid developing complications.
Recovery and post-operative instructions
Recovery from cholecystectomy takes up to 40 days then patients could resume their daily activities. It is believed that patients should follow simple instructions after cholecystectomy to guarantee the best outcome out of the surgery and to avoid complications. They ought to keep the surgical wound as dry and clean as possible. Regular follow-up visits to a gastroenterologist are recommended for a week or two after surgery to assess the results of the surgery.
patients must rest for a day after the operation then frequent non-vigorous exercising is preferred to improve blood circulation and to boost immunity. Straining should be avoided especially for patients who underwent open cholecystectomy.
a diet plan should be set by a dietitian for patients who had a cholecystectomy, it usually consists of fat-free foods to avoid steatorrhea. Patients are also asked to cut down on spicy and fried foods. Smoking, as well as drinking alcohol, must be stopped abruptly. Proper hydration is an essential process for wound healing and the vitality of organs. Make sure to inform your doctor if you feel any unexpected symptoms.
Fees of cholecystectomy
Cholecystectomy surgery fees vary within a reasonable range according to many variables. Unlike other surgeries, the main factor affecting its cost isn’t the type of operation but insurance. For patients who don’t have health insurance, gallbladder removal may be a bit expensive as laparoscopic cholecystectomy cost more than 10,000 US dollars while open cholecystectomy costs about 9,500 US dollars. Fees of surgeons doing cholecystectomy range from 2000 to 4000 dollars.
Hospital fees including operating room and hospitalization represent the greatest portion of the costs and it is estimated to be about 37%. Anesthesia cost approximately 11% of the total surgery fees. Cholecystectomy costs in US more than in many countries so Some US citizens prefer to have the operation abroad, in Mexico for instance. It is found that costs of cholecystectomy could be reduced by 80% if performed in Mexico. Egypt is also believed to provide excellent medical services including laparoscopic cholecystectomy for 1000 ±200 US dollars.