SAGES Gallbladder CBD

8/7/2019 SAGES Gallbladder CBD

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Gallbladder and Bile Duct Surgery(Cholecystectomy and Common DuctExploration)

A simple guide to help answer yourquestions


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What is a gallbladder?

The gallbladder isthe organ in thebody which isresponsible for

concentrating andstoring bile. Itsits just under theliver in the upperright side of the

abdomen (belly).


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What is bile?

Bile is a digestive juice that is made by

the liver. It is responsible for helpingthe body to digest fats and the fatty

foods in our diet. Normally, bile isgolden in color. Our body makes about - 1 quart of bile each day.


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What are the bile ducts?

Since bile is used in the digestiveprocess, it must be taken from the liver

where it is made to the intestine(bowel) where it is used. The tubes orpipes in the body which deliver the bilefrom the liver to the small intestines arecalled bile ducts. They are the size of a

small straw or pencil. The bile ductslink the liver to the gallbladder as well,so that some of the bile which is made

can be stored for future use.


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This is a diagram showing the relationship

between the liver, gallbladder, bile duct,stomach and small intestine

Small Intestine (Duodenum)

Bile Duct


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The area around the gallbladder and bile

ducts is very complicated

The bile ducts are further categorized

(named) for their relationship to theliver. The pancreas and the pancreaticduct (the tube that drains the

pancreatic juices) are in very closeproximity and association to the bileducts and the small intestine. Lookclosely at the next slide to betterunderstand how these relate to each

other.


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Gallbladder, Pancreas andGallbladder, Pancreas and

their ductstheir ducts

(Where the bile and pancreatic

juices enter the small

intestine)

Beginning of the

small intestine

Muscle which controls emptying of the

stomach into the small intestine


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What is a gallstone?

A gallstone occurs whenthe bodys chemistrygets out of balance.

The bile gets too thickin the gallbladder, andcrystallizes (forms) intostones. These can be

single or many, and canvary greatly in size.The size is generallydetermined by the

amount of time that thestones have beenpresent. To the eye,gallstones mayresemble gravel, peas,or even olives.


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Gallstones in the gallbladder


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Who gets gallstones?

Certain factors seem to be more commonin people who develop gallstones

Overweight

Women more than men especially

those with more than one child

People over the age of forty

People who have gained or lost a largeamount of weight in a relatively short

period of time


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Who gets gallstones?

Certain ethnic races/nationalities

Native Americans Inuit

Northern Europeans People with certain other illnesses

Sickle cell anemia

Hemolytic anemia

Inflammatory bowel disease


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What symptoms do gallstones cause?

Many people have no symptoms (up to50%)

Those who do may notice the followingafter eating a meal which contains fat

Crampy pain in the upper right or middlepart of the belly. This pain usually radiatesto the shoulder blade.

Nausea or vomiting

Bloating or gassiness


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What symptoms do gallstones cause?

In more severe cases, fever, chills, a yellowtint to the whites of the eyes or dark colored

urine may be present. Occasionally sludge or very thick bile can

cause these symptoms even if there are nogallstones in the gallbladder.

These symptoms should prompt a visit either toyour doctor or in severe cases to theemergency room.


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How are gallstones detected or diagnosed?

The most accurate (>90%) way is withan ultrasound exam (radiology test

which uses sound waves). Other tests such as a CAT scan may

detect gallstones, but are not as likelyas an ultrasound to see the gallstones ifthey are there.

Rarely (15%), gallstones can be seenon an ordinary X-Ray of the abdomen(belly).


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Ultrasound showing 2 large gallstones

within the gallbladder. Notice how theycreate a shadow below.

Arrows pointing

to 2 gallstones

inside of thegallbladder

Dotted arrows

pointing to the

wall of the

gallbladder


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Ultrasound showing thick sludge within the

gallbladder

Liver

Gallbladder


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Gallstones seen on an ordinary X-Ray of the

abdomen (belly)


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How are gallstones treated if they are

found? Standard treatment is to remove the

gallbladder along with the stones insurgery.

In patients who are too old or sick toundergo surgery, an attempt atdissolving them with medications or

pulverizing them with ultrasound wavesmay be tried.


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How are gallstones treated if they are

found?

Sometimes, some of the gallstones get out

of the gallbladder and make their waydown the bile duct into the intestine. Aslong as these stones do not get caught in

the bile duct this is not a problem. Ifthese stones do get caught in one of thebile ducts, this can cause a very severeinfection or severe inflammation of thepancreas. This will be discussed later in

this presentation.


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A CAT Scan showing an enlarged and inflamed infectedgallbladder. This is what can happen if a stone blocks the

drainage duct to the gallbladder

Gallbladder with an infection

shown by arrows


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How is the gallbladder removed?

There are 2 major techniques to remove thegallbladder and stones:

1. Open involves making

a large incision (6 15

inches) just under the rib-

cage on the right side so

that the surgeon can placehis hands inside the body

to remove the gallbladder


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How is the gallbladder removed?

2. Laparoscopic several small incisions( inch) aremade through which atelescope connected to

a TV camera and smallinstruments are placedto perform the surgery.

The surgeon watcheson a TV monitor whileperforming the

surgery.

Small incisions (circled)


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Can I live without my gallbladder?

The gallbladder is where bile is stored until itis needed to help with the digestion of fatty

foods. Bile is made in the liver If the gallbladder is removed, the bile goes

directly into the intestine

The gallbladder is not a necessary organ andtherefore there arent any problems

associated with removing it(SIMPLY PUT YES, WITHOUT ANY PROBLEM!)


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These diagrams illustrate where the most commonlocations for the incisions for gallbladder surgery are

made and what each one is used for.

Telescope

and Camera

Grasping andDissecting

Instruments

Lap Assoc

of SF


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Laparoscopic Cholecystectomy (removal

of the gallbladder and stones)

The image that isobtained by the telescopeis enlarged and projectedon a TV screen


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Laparoscopic Cholecystectomy (removal of

the gallbladder and stones)

This picture shows how the

laparoscopic operation isperformed. The camerathat is connected to thetelescope which is inside of

the abdomen (belly)projects the picture ontothe large TV. The surgeonthen uses this picture in

combination with smallinstruments to remove thegallbladder


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Instruments used during a laparoscopic gallbladder surgery. The sizedepends on your symptoms and the surgeons preference. These are

placed through the abdominal (belly) wall and enable the surgeon tooperate through small incisions.


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A close-up view of the smallest of these instruments which allows anincision so small that you can barely see it. The smaller the incision,

the less pain that the patient feels after the operation.


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When very small instruments are used for surgery, thescars left after surgery are very difficult to see and cause

very little pain.


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Yellow cholesterol gallstones removed beforethe gallbladder became infected

ll d f fl d d f d


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Gallstones inside of an inflamed and infectedgallbladder

Ad t f L i


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Advantages of Laparoscopic

Cholecystectomy

Less scaring Less pain

Quicker recovery

Shorter hospitalization Faster return to work

Fewer problems with the incisions

P ibl li ti f llbl dd


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Possible complications of gallbladder

surgery Injury to the bile duct

Injury to the intestine of one of theadjacent organs

Narrowing of the bile duct

Bleeding

Infection

Hernia

Leakage of bile into the abdominal

cavity

P ibl li ti f llbl dd


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Possible complications of gallbladder

surgery

Spillage of stones into the abdominal

cavity Missing stones in the bile duct

Bowel obstruction (blockage) from scartissue

Blood clot in the veins of the leg or inthe lung

Wh t h h ll t l th


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What happens when gallstones leave the

gallbladder and get into the bile duct?

This makes the problem of

gallstones much morecomplicated for yourdoctor and can increase

the severity of symptomsthat the patientexperiences. Thesestones can either partiallyor completely block theflow of bile from the liverinto the intestine

LaparoscopicAssociates of SF

Wh t h h ll t l th


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What happens when gallstones leave the

gallbladder and get into the bile duct?If the flow of bile is blocked, the

potential for a serious and severeinfection known as Cholangitis(infection of the bile ducts) is very high.

This problem can be life-threateningand should be treated immediately.

Symptoms include: shaking chills, highfever, severe abdominal pain, nausea,vomiting, and jaundice (turning yellow).

How do we know if a patient has stones in


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their bile ducts? Most of the time, patients will have

symptoms that will alert the doctor tothis this may include dark coloredurine, light colored stool (feces), or a

yellow tint in the whites of their eyes Sometimes, patients will not havesymptoms. Most doctors will perform

lab tests to help them identify patientswho have stones in their bile duct buthave no symptoms



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their bile ducts?Surgeons can alsoperform special tests atthe same time thegallbladder is removedto detect these stones.

The most common testis an X-ray called aCholangiogram.Special dye is injected

into the bile duct andstones will appear assmall bubbles withinthe duct.

Bile

Duct



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their bile ducts?

Another test is an ultrasound exam atthe time of surgery. A small probe isplaced directly on the bile duct todetect stones.

How are patients treated who have stones


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How are patients treated who have stones

in their bile ducts?There are 3 ways to treat patients

who have stones in their bile duct:

1. Laparoscopic bile duct exploration andstone removal

2. Open bile duct exploration and stone

removal

3. Endoscopic stone extraction (ERCP)

Laparoscopic Bile Duct Exploration


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The surgeon uses small baskets and

flexible scopes to remove the stone atthe same time that the gallbladder isremoved. They may also use a

Lithotripter which is an instrument thatpulverizes the stone into dust so that

you body can pass it. This is donethrough the same small incisions whichare used to remove the gallbladder.



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ADVANTAGES

Only one procedureneeded (gallbladderand stones in theduct removed at thesame time)

DISADVANTAGES

Requires thesurgeon to havespecial training

Can be a technicallydifficult surgery



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X-ray showingstone in duct

Stone

Basket beingused to remove

stone

Flexible scope andbasket being used

to remove stone

Open Bile Duct Exploration


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Occasionally (5-10% of the time), thestones cannot be removed using a

laparoscopic approach (or your doctorhas not been trained in this technique),and it is necessary to revert to an open

operation. In this instance, a largerincision is made (just like in the opengallbladder removal) and your surgeonuses the same techniques as describedin the previous slides to remove the

stones.



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ADVANTAGES

Only one procedureneeded (gallbladder andstones in the ductremoved at the sametime)

Technically, less difficultthan a laparoscopic

procedure

DISADVANTAGES

Large incision, andtherefore more pain alonger hospital stay,and much more time tofully recover

Much more complicatedsurgery than just

removing thegallbladder

ERCP (endoscopic retrograde


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cholangiopancreatography)

A procedure performed with a flexible,lighted telescope which allows thedoctor to take X-rays of the bile ducts

and remove stones from the bile ductsthrough the small intestine.



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cholangiopancreatography)Since the opening of the bile duct is in

the small intestine, this scope can beplaced through the mouth, downthrough the stomach, and into the

intestine where the duct is located. Theduct can then be opened (a procedure

known as sphincterotomy) so that thestones that are in the bile duct can beremoved.



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cholangiopancreatography)

These pictures illustrate how the

flexible scope is able to removestones from the duct. Cathetersand instruments can be fedthrough the scope enabling the

doctor to inject dye into the duct,enlarge the opening of the duct(with special devices that cut withelectrical current) to allow passage

of the stones, and even to place aballoon catheter up into the duct toassist with removal of the stones.

ERCP showing the presence of gallstones


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g p gin the main bile duct

Stones in

the Bile

Duct

Flexible

scopewhich is

in the

small

intestine

ERCP


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with sphincterotomy and stone extraction

This shows the process of finding the end

of the bile duct and opening it to removetrapped stones

Openingof the

bile ductinto theintestine

Greatly enlarged

opening aftersphincterotomyto allow passage

of stones



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( p g

cholangiopancreatography)ADVANTAGES

Does not requiregeneral anesthesiaand admission to

the hospital is notrequired

DISADVANTAGES

Requires anadditional procedurebefore or after the

gallbladder isremoved

If the stones cannotbe removed, anadditional operationmay be necessary

Possible complications of ERCP


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Possible complications of ERCP

Pancreatitis

Injury to the bile duct

Failure to remove all of the stones inthe bile duct

Bleeding

Perforation of the intestinal tract

Infection

Which is method of stone removal is best


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for me??

Your doctor will decide taking intoconsideration how severe your conditionis, how healthy you are, and the

individual skill and training of thedoctors involved in your care.

If you would like more information on this


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If you would like more information on this

topic, or to find surgeons in your area whomay be experience in laparoscopicsurgery.

Contact your physician or go to the SAGESwebsite for more help

www.SAGES.org

THANK YOU

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