Indications:

(i)  Symptomatic gallstones - Pain, nausea and vomiting from gallstones   (gallstones that do not cause any symptoms can be monitored - only 15-25% develop symptoms after 10-15 years of follow up).  

(ii) Complications from gallstones - infection, pancreatitis, jaundice. The risk is 2-3 % a year once patients develop biliary pain. But once a complication occurs, the risk of further complications is 30% a year. 

(iii) Polyps more than 10mm/suspicion of cancer of gallbladder(eg porcelain gallbladder)

(iv) Acalculous cholecystitis - when gallbladder is gangrenous, emphysematous or perforated

Procedure

General anaesthesia. Intravenous antibiotics also given to reduce risk of infection - usually Cephazolin IV.  Compression stockings to legs(this can also be put on before the surgery)

Local anaesthetic injections to port sites. 

4 small cuts on abdomen - to allow placement of a 12mm port, 10mm port and two 5mm ports.

Carbon dioxide gas insufflation to lift abdominal wall up for view. Telescope with an angled 30 degree viewing camera inserted via umbilical port site. 

Dissection to free gallbaldder from liver and identify  cystic duct & cystic artery clearly in Calot's triangle (this move is to avoid damaging the bile duct)

Metal clips to gallbladder(cystic) artery and cystic duct.

X-ray of bile duct performed after dye is injected via a cholangiogram cathether in the cystic duct to exclude stones in bile duct(Operative cholangiogram)

The cystic duct is then clipped and cut. The gallbladder is then detached from the liver. The gallbladder is then placed in an endoscopic plastic bag.

Drain tube may be used at end of case.

The gallbladder is removed from the incision near the belly button in the endoscopic plastic bag(this bag prevents spillage of stones and contamination of the skin)

Wounds are closed with dissolvable 3/0 Vicryl sutures, Steristrips & Tegaderm dressings

Operating time - usually around 45min. Longer if patients have a thicker fatty layer or the gallbladder is badly inflammed. Dr Cheah's operating time in nearly a 1000 cases range from 30min (in a thin patient with noninflammed gallbladder) to nearly 3 hours(in a severely inflammed gallbladder with lots of adhesions and gallbladder cancer)

POSTOP

After the operation, you will wake up in recovery.  The nurse will ask you to frequently cough and take deep breaths as well as to move your legs while in bed.

Once back in the ward, you should ask the nurse to allow you first sit out of bed and then accompany you when you first walk.

If in pain, you can ask for pain killers - but note : Morphine, Endone and other opioids can cause nausea and constipation 

The drain tube(if used) is removed the following day if there is no bile leak.

Discharge usually on the next day if able to mobilize comfortably and tolerate food. 

The Tegaderm dressings can be changed the next day if soaked. Leave the Tegaderm dressing(plastic dressing with a white pad) on for 2 weeks, Steristrips(white tapes under the Tegaderm) for 3 weeks. The Tegaderm dressings are waterproof and patients can shower with the dressings on. If the dressings start to come off earlier - they can be removed earlier. It is best to leave the white tapes under the plastic dressings on for as long as possible (up to 3 weeks) - if they have to be removed - carefully pinch the wound together as you remove it so as not to open up the sutured wound. The wounds can then be dressed with simple BandAids (changed when wet)

In terms of returning to work - patients can usually have one week off work. Some patients start light duties straight away working from home from Day 3 postop - working shorter hours initially and gradually increasing the hours worked.  Patient doing heavy manual labour can get back to usual duties usually around 4 weeks. 

One should be careful getting out of bed to avoid straining the wounds and avoid repetitive bending of the abdomen. One can lift as much as one can easily do with one's arm. Avoid swimming until the wound is fully healed - usually in 1-2 weeks. 

Risks

Stone in bile duct - may need exploration of bile duct during operation or further surgery(ERCP)

Bile leak (1 in 200)/bile duct injury(1 in 230 statistically) - may need further operation to insert a drain for the former and major operation to repair the bile duct for the later. 

Spillage of stones out of gallbladder - the gallbladder can be torn when it is retracted during the surgery

Need for open surgery(1 in 20) - especially if acutely inflammed

Bleeding and wound haematoma. The risks are higher in an emergency operation for an inflammed gallbladder. (a recent study of 1744 patients undergoing elective cholecystectomies in 7 Melbourne teaching hospitals from Jan 2018 to June 2019 showed that significant bleeding complications occurred in 42 patients (2.4%) of which half were major events. 5 patients needed further surgery and 9 needed blood transfusion. One patient died from bleeding.  This risk was increased by giving blood thinning injections to prevent DVT & PE during the operation. 4 patients out of the 1744 developed DVT and 1 developed PE despite being given blood thinning injections)  

Injury to bowel(the gallbladder normally rests on part of the small bowel - duodenum) , blood vessels(eg portal vein, hepatic artery, vena cava) , liver and other organs(stomach or small bowel stuck under the umbilical port site from previous peritonitis/surgery/abdominal trauma), adhesions

Wound infection, scar or keloid, hernia at port site( especially the umbilical wound if a big gallbladder packed with stones has to be removed from the wound)

Gas embolus

Heart attack, stroke, anaesthetic reactions, chest infections, blood clots in legs(deep venous thrombosis - DVT) and lungs(pulmonary embolism  - PE), death

Postop abdominal distension, gas pain in shoulder, loose bowel action/diarrhoea(in 5- 10% of patients especially after a fatty meal; most cases improve after a few months. Some patients say that cholecystectomy helps with their constipation). Persisting symptoms despite surgery.

Not being able to remove all the gallbladder - the neck of the gallbladder may be too inflammed or stuck (especially in cases of gallbladder cancer and xanthogranulomatous cholecystitis) (Dr Cheah has had a couple of cases of each of these in nearly 1000 cholecystectomies)

Cholecystectomy is also associated with increased risks of bowel cancer particularly on the right side. One should do faecal occult blood screening 2 yearly after the gallbladder surgery - if this is positive, please see Dr Cheah again for a colonoscopy. 

Alternatives

Percutaneous Cholecystostomy - usually in patients who are too sick for the whole surgery to remove the gallbladder. A drain is left in the gallbladder. After 1-2 weeks, a tract forms. This is gently dilated and the gallstones in the gallbladder is removed with a wire basket. 

Extracorporeal Shock Wave Lithotripsy - shattering the gallstones smaller but this may cause more symptoms/complications as the smaller stones are passed down the bile duct and risks getting stuck causing jaundice and acute pancreatitis.  Hence ESWL is not as helpful for gallstones as it is for kidney stones

Oral dissolution therapy - Chenodoxycholic acid & Ursodeoxycholic acid(urosodiol, 600mg daily). The former is no longer used due to many side effects.  The latter is expensive. Very slow - reduces size of a non-calcified gallstone by 1mm a month.  Does not work for calcified stones. Need functioning gallbladder and cystic duct to be open. Mechanism of action - dissolves gallstones by dissolving cholesterol from the surface  of the gallstone. When the cholesterol portion of gallstones that have limited amounts of calcium salts dissolve, the remainder of the stone disintegrates into sand that is expelled over time by a functioning gallbladder. But this can cause risks of gallstones falling out of gallbladder and causing acute pancreatitis & jaundice. This medication can also help gallbladder emptying. Ursodeoxycholic acid brands available in Australia include Urososan, Ursofalk(500 mg tablet) , Ursodox GH, APO-urodeoxycholic acid and Urso. Urso comes from the Latin word ursus which means bear. This was originally obtained from farmed bile bears but is now synthetically produced. 

Other methods :

Statins - may reduce risks of forming cholesterol gallstones.

Exetimibe - this inhibits absorption of cholesterol from the small intestine.  

Monoterpenes - Rowachol. May help dissolve gallstones. 

Topical contact dissolution - Historically, a small catheter was inserted into the gallbladder and a solvent such as methyl ether and later ethyl proprionate(a food additive) was injected in. Takes hours to do. 

With all these methods, there is a risk of long term gallstone recurrence.

Other surgical techniques :

Mini laparoscopy - using thinner laparoscopic instruments. But the umbilical incision still has to be large enough to take out the gallbladder with the gallstones in it

Single incision laparoscopy(SIS) - putting all the ports in the umbilical site. Longer incision in one area. Makes the operation longer. Can be robot assisted as well - but longer time to do.

Natural orifice transluminal endoscopic surgery(NOTES) : Through the vaginal or stomach so as not to leave scars on the stomach. Higher risks and longer operation. 

Robot assisted cholecystectomy - the set up time under general anaesthesia  would be roughly the time of a normal straightforward cholecystectomy

Operative Cholangiogram - X-ray of the bile duct with contrast