Your gallbladder is a pear-shaped organ under your liver. It stores bile, a fluid made by your liver to digest fat. As your stomach and intestines digest food, your gallbladder releases bile through a tube called the common bile duct. The duct connects your gallbladder and liver to your small intestine.

Your gallbladder is most likely to give you trouble if something blocks the flow of bile through the bile ducts. That is usually a gallstone. Gallstones form when substances in bile harden. Gallstone attacks usually happen after you eat. Signs of a gallstone attack may include nausea, vomiting, or pain in the abdomen, back, or just under the right arm.

Gallstones are most common among older adults, women, overweight people, Native Americans and Mexican Americans.

Gallstones are often found during imaging tests for other health conditions. If you do not have symptoms, you usually do not need treatment. The most common treatment is removal of the gallbladder. Fortunately, you can live without a gallbladder. Bile has other ways to reach your small intestine.

Gallstones are hard, pebble-like pieces of material, usually made of cholesterol or bilirubin, that form in your gallbladder. Gallstones can range in size from a grain of sand to a golf ball. The gallbladder can make one large gallstone, hundreds of tiny stones, or both small and large stones.

When gallstones block the bile ducts of your biliary tract, the gallstones can cause sudden pain in your upper right abdomen. This pain is called a gallbladder attack, or biliary colic. If your symptoms continue and they’re left untreated, gallstones can cause serious complications.

However, most gallstones don’t cause blockages and are painless, also called “silent” gallstones. Silent gallstones usually don’t need medical treatment.

Types of gallstones

The two main types of gallstones are

• cholesterol stones
• pigment stones

Cholesterol stones are usually yellow-green in color and are made of mostly hardened cholesterol. In some countries, cholesterol stones make up about 75 percent of gallstones.

Pigment stones are dark in color and are made of bilirubin. Some people have a mix of both kinds of stones.

Gallstones are very common, affecting 10 to 15 percent of the U.S. population, which is almost 25 million people. About a quarter of the nearly 1 million people diagnosed with gallstones each year will need to be treated, usually with surgery.

Your biliary tract, which is made up of your gallbladder and bile ducts, helps with digestion by releasing bile.

The gallbladder is a small, pear-shaped organ that stores bile and is located in your upper right abdomen, below your liver.

The bile ducts of your biliary tract include the hepatic ducts, common bile duct, and cystic duct. Bile ducts also carry waste and digestive juices from the liver and pancreas to the duodenum.

Your liver produces bile, which is mostly made of cholesterol, bile salts, and bilirubin. Your gallbladder stores the bile until it’s needed. When you eat, your body signals your gallbladder to empty bile into your duodenum to mix with food. The bile ducts carry the bile from your gallbladder to the duodenum.

Most of us give little thought to the gallbladder, a pear-sized organ that sits just under the liver and next to the pancreas. The gallbladder may not seem to do all that much. But if this small organ malfunctions, it can cause serious problems. Gallbladder disorders rank among the most common and costly of all digestive system diseases. By some estimates, up to 20 million Americans may have gallstones, the most common type of gallbladder disorder.

The gallbladder stores bile, a thick liquid that’s produced by the liver to help us digest fat. When we eat, the gallbladder’s thin, muscular lining squeezes bile into the small intestine through the main bile duct. The more fat we eat, the more bile the gallbladder injects into the digestive tract.

Bile has a delicate chemical balance. It’s full of soluble cholesterol produced by the liver. This is a different type of cholesterol than the kind related to cardiovascular disease. If the chemical balance of bile gets slightly off, the cholesterol can crystalize and stick to the wall of the gallbladder. Over time, these crystals can combine and form gallstones.

Gallstones can range from the size of a grain of sand to that of a golf ball. When the gallbladder injects bile into the small intestine, the main bile duct can become blocked by these crystalline stones. That may cause pressure, pain, and nausea, especially after meals. Gallstones can cause sudden pain in the upper right abdomen, called a gallbladder attack (or biliary colic). In most cases, though, people with gallstones don’t realize they have them.

The causes of gallstones are unclear, but you’re more likely to have gallstone problems if you have too much body fat, especially around your waist, or if you’re losing weight very quickly. Women, people over age 40, people with a family history of gallstones, American Indians, and Mexican Americans are also at increased risk for gallstones.

“For the average person with an average case, the simplest way to diagnose a gallstone is by an ultrasound,” says Dr. Dana Andersen, an NIH expert in digestive diseases.

If left untreated, a blocked main bile duct and gallbladder can become infected and lead to a life-threatening situation. Gallbladder removal, called a cholecystectomy, is the most common way to treat gallstones. The gallbladder isn’t an essential organ, which means you can live normally without it.

Gallbladder removal can be done with a laparoscope, a thin, lighted tube that shows what’s inside your abdomen. The surgeon makes small cuts in your abdomen to insert the surgical tools and take out the gallbladder. The surgery is done while you are under general anesthesia, asleep and pain-free. Most people go home on the same day or the next.

Researchers have long investigated medications that can prevent gallstones from forming, but these therapies are currently used only in special situations.

It’s uncommon for the gallbladder to cause problems other than gallstones. Gallbladder cancer is often difficult to treat, as it’s usually diagnosed at an advanced stage. But such cancers are relatively rare.

While the gallbladder may not be the star of the digestive system, it still plays an important role. Treat it well by maintaining a healthy diet and getting regular exercise, and the little bag of bile should do its job. Don’t ignore pain or symptoms, and see your doctor if you’re in discomfort, especially after eating.

Symptoms of a Gallstone Attack

Talk with your doctor if you have:

• severe pain in the upper-right side of the abdomen that starts suddenly and lasts from 30 minutes to many hours.
• pain under the right shoulder or in the right shoulder blade.
• indigestion after eating foods high in fat or protein, including desserts and fried foods.

Seek help right away if you have these signs of a serious attack:

• abdominal pain that lasts more than 5 hours.
• nausea and vomiting.
• fever or chills.
• yellowish color of the skin or the whites of the eyes.
• dark urine or light-colored stools.

Certain groups of people have a higher risk of developing gallstones than others.

• Women are more likely to develop gallstones than men. Women who have extra estrogen in their body due to pregnancy, hormone replacement therapy, or birth control pills may be more likely to produce gallstones.
• Older people are more likely to develop gallstones. As you age, the chance that you’ll develop gallstones becomes higher.
• People with a family history of gallstones have a higher risk.
• American Indians have genes that raise the amount of cholesterol in their bile, and have the highest rate of gallstones in the United States.
• Mexican Americans are also at higher risk of developing gallstones.

People with certain health conditions

You are more likely to develop gallstones if you have one of the following health conditions:

• cirrhosis, a condition in which your liver slowly breaks down and stops working due to chronic, or long-lasting, injury
• infections in the bile ducts, which can also be a complication of gallstones
• hemolytic anemias, conditions in which red blood cells are continuously broken down, such as sickle cell anemia
• some intestinal diseases that affect normal absorption of nutrients, such as Crohn’s disease
• high triglyceride levels
• low HDL cholesterol
• metabolic syndrome, which can also raise the risk of gallstone complications
• diabetes and insulin resistance

People with diet- and weight-related health concerns

You are more likely to develop gallstones if you

• have obesity, especially if you are a woman
• have had fast weight loss, like from weight-loss surgery
• have been on a diet high in calories and refined carbohydrates and low in fiber

Being overweight or having obesity may make you more likely to develop gallstones, especially if you are a woman. Researchers have found that people who have obesity may have higher levels of cholesterol in their bile, which can cause gallstones. People who have obesity may also have large gallbladders that do not work well. Some studies have shown that people who carry large amounts of fat around their waist may be more likely to develop gallstones than those who carry fat around their hips and thighs.

Losing weight very quickly may raise your chances of forming gallstones, however. Talk with your health care professional about how to lose weight safely.

When you don’t eat for a long period of time or you lose weight quickly, your liver releases extra cholesterol into the bile. Fast weight loss can also prevent the gallbladder from emptying properly. Weight-loss surgery may lead to fast weight loss and higher risk of gallstones.

Your chances of developing gallstones may depend on the type of weight-loss treatment you choose. Diets or surgeries that cause fast weight loss may be more likely to lead to gallstone problems than diets or surgeries that lead to slower weight loss. If you have silent gallstones, you may also be more likely to develop gallstone symptoms.

Several factors may raise your chances of having problems with gallstones after weight-loss surgery or a very low-calorie diet. These factors include

• gallstones that you had before your weight-loss surgery or before you went on a very low-calorie diet, especially if the stones caused symptoms
• a large amount of extra weight before you have weight-loss surgery or go on a very low-calorie diet
• very quick weight loss after the surgery or a very low-calorie diet

If you are starting a very low-calorie diet or having weight-loss surgery, talk with your doctor about how to lower your chances of developing gallstones. The medicine ursodiol can help prevent gallstones in people who lose weight rapidly through very low-calorie diets or weight-loss surgery.

Weight cycling, or losing and regaining weight repeatedly, may also lead to gallstones. The more weight you lose and regain during a cycle, the greater your chances of developing gallstones.

Stay away from "crash diets" that promise to help you drop the pounds quickly. Aim for losing weight at a slower pace and keeping it off over time.

Gallstones may form if bile contains too much cholesterol, too much bilirubin, or not enough bile salts. Researchers do not fully understand why these changes in bile occur. Gallstones also may form if the gallbladder does not empty completely or often enough. Certain people are more likely to have gallstones than others because of their risk factors for gallstones, including obesity and certain kinds of dieting.

If gallstones block your bile ducts, bile could build up in your gallbladder, causing a gallbladder attack, sometimes called biliary colic. Gallbladder attacks usually cause pain in your upper right abdomen, sometimes lasting several hours. Gallbladder attacks often follow heavy meals and usually occur in the evening or during the night. If you’ve had one gallbladder attack, more attacks will likely follow.

Gallbladder attacks usually stop when gallstones move and no longer block the bile ducts. However, if any of your bile ducts stay blocked for more than a few hours, you may develop gallstone complications. Gallstones that do not block your bile ducts do not cause symptoms.

Silent gallstones

Most people with gallstones do not have symptoms. Gallstones that do not cause symptoms are called silent gallstones. Silent gallstones don’t stop your gallbladder, liver, or pancreas from working, so they do not need treatment.

See a doctor right away if you are having these symptoms during or after a gallbladder attack:

• pain in your abdomen lasting several hours
• nausea and vomiting
• fever—even a low-grade fever—or chills
• yellowish color of your skin or whites of your eyes, called jaundice
• tea-colored urine and light-colored stools

These symptoms may be signs of a serious infection or inflammation of the gallbladder, liver, or pancreas. Gallstone symptoms may be similar to symptoms of other conditions, such as appendicitis, ulcers, pancreatitis, and gastroesophageal reflux disease, all of which should be treated by a doctor as soon as possible.

Gallstone complications can occur if your bile ducts stay blocked. Left untreated, blockages of the bile ducts or pancreatic duct can be fatal.

Doctors use your medical history, a physical exam, and lab and imaging tests to diagnose gallstones.

A health care professional will ask you about your symptoms. He or she will ask if you have a history of health conditions or health concerns that make you more likely to get gallstones. The health care professional also may ask if you have a family history of gallstones and what you typically eat. During a physical exam, the health care professional examines your body and checks for pain in your abdomen.

Health care professionals may use lab or imaging tests to diagnose gallstones.

Lab tests

A health care professional may take a blood sample from you and send the sample to a lab to test. The blood test can show signs of infection or inflammation of the bile ducts, gallbladder, pancreas, or liver.

Imaging tests

Health care professionals use imaging tests to find gallstones. A technician performs these tests in your doctor’s office, an outpatient center, or a hospital. A radiologist reads and reports on the images. You usually don’t need anesthesia or a medicine to keep you calm for most of these tests. However, a doctor may give you anesthesia or a medicine to keep you calm for endoscopic retrograde cholangiopancreatography (ERCP).

Ultrasound. Ultrasound is the best imaging test for finding gallstones. Ultrasound uses a device called a transducer, which bounces safe, painless sound waves off your organs to create an image or picture of their structure. If you have gallstones, they will be seen in the image. Sometimes, health care professionals find silent gallstones when you don’t have any symptoms.

Computed tomography (CT) scan. CT scans use a combination of x-rays and computer technology to create images of your pancreas, gallbladder, and bile ducts. CT scans can show gallstones, or complications such as infection and blockage of the gallbladder or bile ducts. However, CT scans also can miss gallstones that you may have.

Magnetic resonance imaging (MRI). MRI machines use radio waves and magnets to produce detailed images of your organs and soft tissues without x-rays. MRIs can show gallstones in the ducts of the biliary tract.

Cholescintigraphy. Cholescintigraphy—also called a hydroxyl iminodiacetic acid scan, HIDA scan, or hepatobiliary scan—uses a safe radioactive material to produce pictures of your biliary tract. You’ll lie on a table while a health care professional injects a small amount of the radioactive material into a vein in your arm. The health care professional may also inject a substance that causes your gallbladder to squeeze. A special camera takes pictures of the radioactive material as it moves through your biliary tract. Doctors use cholescintigraphy to diagnose abnormal contractions of your gallbladder or a blockage in the bile ducts.

Endoscopic retrograde cholangiopancreatography (ERCP). ERCP combines upper gastroendoscopy and x-rays to treat problems of your bile and pancreatic ducts. ERCP helps the health care professional locate the affected bile duct and the gallstones. This test is more invasive—or involves more instruments inside your body—than other tests. Doctors use it selectively, usually to remove a gallstone that is stuck in the common bile duct.

Complications of gallstones can include

• inflammation of the gallbladder
• severe damage to or infection of the gallbladder, bile ducts, or liver
• gallstone pancreatitis, which is inflammation of the pancreas due to a gallstone blockage

Many people do not have symptoms of gallstones until they have complications.

If left untreated, gallstones can be deadly. Treatment for gallstones usually involves gallstone surgery.

If your gallstones are not causing symptoms, you probably don’t need treatment. However, if you are having a gallbladder attack or other symptoms, contact your doctor. Although your symptoms may go away, they may appear again and you may need treatment. Your doctor may refer to you a gastroenterologist or surgeon for treatment.

The usual treatment for gallstones is surgery to remove the gallbladder. Doctors sometimes can use nonsurgical treatments to treat cholesterol stones, but pigment stones usually require surgery.

Surgery

Surgery to remove the gallbladder, called cholecystectomy, is one of the most common operations performed on adults in the United States. The gallbladder is not an essential organ, which means you can live normally without a gallbladder.

A health care professional will usually give you general anesthesia for surgery. Once the surgeon removes your gallbladder, bile flows out of your liver through the hepatic duct and common bile duct and directly into the duodenum, instead of being stored in the gallbladder.

Surgeons perform two types of cholecystectomy:

Laparoscopic cholecystectomy. Almost all surgeons perform cholecystectomies with laparoscopy. Surgeons perform many laparoscopic cholecystectomies on an outpatient basis, meaning you may be able to go home the same day. You will probably be able to return to normal physical activity in about a week.

Open cholecystectomy. A surgeon performs an open cholecystectomy when your gallbladder is severely inflamed, infected, or scarred from other operations. Your doctor may perform a cholecystectomy if problems occur during a laparoscopic cholecystectomy. After the surgery, you may need to stay in the hospital for up to a week. You will probably be able to return to normal physical activity after about a month.

A small number of people have softer and more frequent stools after gallbladder removal, because bile now flows into your duodenum more often. Changes in bowel habits are usually temporary; however, discuss them with your doctor.

All surgeries come with a possible risk of complications; however, gallbladder surgery complications are very rare. The most common complication is injury to the bile ducts, which can cause infection. You may need one or more additional operations to repair the bile ducts.

Nonsurgical treatments

Doctors use nonsurgical treatments for gallstones only in special situations, like if you have cholesterol stones and you have a serious medical condition that prevents surgery. Even with treatment, gallstones can return. Therefore, you may have to be regularly treated for gallstones for a very long time, or even for the rest of your life.

A doctor may use the following types of nonsurgical treatments to remove or break up cholesterol gallstones:

Endoscopic retrograde cholangiopancreatography (ERCP). Sometimes doctors use ERCP to remove a gallstone that is stuck in the common bile duct.

Oral dissolution therapy. Ursodiol (Actigall) and chenodiol (Chenix) are medicines that contain bile acids that can break up gallstones. These medicines work best to break up small cholesterol stones. You may need months or years of treatment to break up all stones.

Shock wave lithotripsy. A doctor can use shock wave lithotripsy to blast gallstones into small pieces. Doctors use this procedure only rarely, and sometimes along with ursodiol.

Introduction

Laparoscopic cholecystectomy is a minimally invasive surgical procedure for removal of a diseased gallbladder. This technique essentially has replaced the open technique for routine cholecystectomies since the early 1990s. At this time, laparoscopic cholecystectomy is indicated for the treatment of cholecystitis (acute/chronic), symptomatic cholelithiasis, biliary dyskinesia, acalculous cholecystitis, gallstone pancreatitis, and gallbladder masses/polyps]. These indications are the same for an open cholecystectomy. Cases of gallbladder cancers are usually best treated with open cholecystectomy. Approximately 20 million people in the United States have gallstones. Of these people, there are approximately 300,000 cholecystectomies performed annually. Ten percent to 15% of the population has asymptomatic gallstones. Of these, 20% are symptomatic (biliary colic). Of the 20% who are symptomatic approximately 1% to 4% will manifest complications (acute cholecystitis, gallstone pancreatitis, choledocholithiasis, gallstone ileus)[. The incidence of gallstones increases with an increase in age, with females more likely to form gallstones than males. Age 50 to 65 approximately 20% of women and 5% of men have gallstones. Overall, 75% of gallstones are composed of cholesterol, and the other 25% are pigmented. Despite the composition of gallstones the clinical signs and symptoms are the same.

Anatomy and Physiology

The gallbladder lives on the inferior aspect of the liver bed, more specifically under liver segments 4b and 5. The gallbladder can be up to 10 cm in length and physiologically can hold up to 50 cc of fluid (bile). A line from the gallbladder to the inferior vena cava separates the liver into right and left lobes. There are four anatomical sections to the gallbladder: fundus, body, infundibulum, and neck. There is great variation in the biliary ductal anatomy. The cystic duct most commonly arises from the common bile duct and inserts at the neck of the gallbladder. The branch point of the cystic duct from the common bile duct marks the beginning of the common hepatic duct superiorly. The blood supply to the gallbladder is from the cystic artery which originates approximately 90% of the time from the right hepatic artery. Again, there is great variation in the course and origin of the cystic artery. The hepatocystic triangle (triangle of Calot) is a surgical anatomical landmark created by the cystic duct laterally, the common hepatic duct medially, and the liver edge superiorly. This triangle is of surgical importance because this is the location for the most common path of the cystic artery to the gallbladder. There sentinel lymph node of the gallbladder resides within the hepatocystic triangle, also known as Lund's node (and erroneously referred to as the node of Calot).

Indications

• Cholecystitis (Acute/Chronic)
• Symptomatic cholelithiasis
• Biliary dyskinesia- hypofucntion or hyperfunction
• Acalculous cholecystitis
• Gallstone pancreatitis
• Gallbladder masses/polyps

Contraindications

• Inability to tolerate pneumoperitoneum or general anesthesia
• Uncorrectable coagulopathy
• Metastatic disease

Please note that although gallbladder cancer was once a contraindication to a laparoscopic cholecystectomy, the current literature supports laparoscopic intervention

Equipment

• Two laparoscopic monitors
• One laparoscope (5/10 mm, 0/30 degrees) including camera cord and light source
• Carbon dioxide source and tubing for insufflation
• 5 mm to 12mm trocars (average three 5 mm working trocars and one 10 mm to 12 mm trocar)
• Laparoscopic instruments: Atraumatic graspers, Maryland grasper, clip applier, electrocautery (e.g., hook, spatula), and a retrieval bag
• Scalpel (11/15 blade), forceps, needle driver, and absorbable sutures
• Major open tray, for possible conversion

Personnel

• Operating surgeon (patient's left)
• Surgical assist (patient's right)
• Scrub tech/nurse (patient's left)

Preparation

The patient should be medically optimized preoperatively.

Preoperative antibiotics should be given within 30 minutes of incision per protocol.

An aseptic surgical field is created from just above the bilateral costal margins to the pubic tubercle and laterally to the right and left flanks. The sterile surgical field should allow for the possibility of an open procedure if needed.

Technique or Treatment

After induction of anesthesia and intubation, the laparoscopic cholecystectomy may begin.

First, insufflation of the abdomen is achieved to 15 mmHg using carbon dioxide. Next, four small incisions are made in the abdomen for trocar placement (supraumbilical x1, subxiphoid x1, and right subcostal x2). Utilizing a camera (laparoscope) and long instruments the gallbladder is retracted over the liver. This allows for exposure of the proposed region of the hepatocystic triangle. Careful dissection is carried out to achieve the critical view of safety. This view is defined as (1) clearance of fibrous and fatty tissue from the hepatocystic triangle, (2) the presence of only two tubular structures entering into the base of the gallbladder, and (3) the separation of the lower third of the gallbladder from the liver to visualize the cystic plate. Once this view is adequately achieved, the operating surgeon can proceed with confidence that he/she has isolated the cystic duct and cystic artery. Both structures are carefully clipped and transected. Electrocautery or harmonic scalpel is then used to separate the gallbladder from the liver bed completely. Hemostasis should be achieved after the abdomen is allowed to deflate to 8 mmHg for 2 minutes. This technique is employed to avoid missing potential venous bleeding that can be tamponaded by elevated intra-abdominal pressure (15 mmHg). The gallbladder is removed from the abdomen in a specimen pouch. All trocars should be removed under direct visualization. Closure of port sites is surgeon specific; this author recommends fascial closure of trocar sites greater than 5 mm to avoid incisional hernias in the postoperative period.

Complications

Common complications include but are not limited to bleeding, infection, and damage to the surrounding structure. Bleeding is a common complication as the liver is a very vascular organ. Experienced surgeons must be knowledgeable about anatomical anomalies of arteries to prevent potential significant blood loss. The most severe complication is an iatrogenic injury of the common bile/hepatic duct. Injury to either of these structures may require a further surgical procedure to divert the flow of bile into the intestines. This procedure usually requires a specially trained hepatobiliary surgeon.

Lastly, although not a complication, conversion to an open procedure has become a rare event as the experience of surgeons has increased over the years. Conversion to an open procedure creates a larger abdominal incision, causes significant pain control issues postoperatively, and leads to a cosmetically displeasing scar. Please note that conversion to an open procedure should not be viewed as a complication but as a well-educated decision made by an experienced surgeon to care for the patient[9] safely.

Bile leaks might complicate the procedure and present with vague abdominal pain fever, with or without the characteristic features of direct hyperbilirubinemia. The complicated patients usually present within the first week following the surgery. Management should be initiated with diagnostic ultrasonography and or abdominal CT scan. In the case of retained choledocholithiasis, biliary sphincterotomy is mandatory. High-grade leaks should be managed with sphincterotomy and stenting. A HIDA scan evaluating bile leaks is recommended in equivocal findings on CT or ultrasonography.

Clinical Significance

The etiology of gallbladder disease is associated with a poorly functioning gallbladder and superconcentrated bile. Normally, the gallbladder empties its contents in response to physiologic changes associated with digestion (cholecystokinin, vagal input from antral distension, migrating myoelectric complex). High concentrations of cholesterol within the gallbladder is a known cause for precipitation of cholesterol gallstones. Pigmented stones precipitate typically from hemolytic diseases (black stones) or from infection (brown stones) where bacterial enzymes break down bilirubin into an insoluble content. Stasis within the gallbladder or bile ducts increases the likelihood of stone formation. Gallbladder disease is exemplified by obstruction of the cystic duct. Patients may experience acute obstruction of the cystic duct by stones, or occasionally, in most critically ill patients, there is acute acalculous cholecystitis, where there is no mechanical obstruction but a functional obstruction. This obstruction, mechanical or not, in conjunction with attempted bile excretion for digestion will cause acute inflammation of the gallbladder.

A classic finding for gallbladder disease is right upper quadrant or epigastric abdominal pain. The pain typically has an onset 30 minutes to two hours after consumption of fatty foods. The pain can last from one to two hours, up to more than 24 hours. Pain lasting more than 24 hours is associated with a secondary infection known as acute cholecystitis. Pain radiates from the right upper quadrant to the right flank, and occasionally to the right shoulder due to sympathetic innervation. Associated symptoms include but are not limited to nausea, vomit (bilious), fever, chills, and diarrhea. Less specific symptoms may be experienced like indigestion, GERD-like symptoms, PUD symptoms, and dyspepsia. Earlier in the disease process pain will be intermittent and associated with oral intake of fatty foods. As the process progresses, pain may become more frequent and occur regardless of oral intake.

Complete a thorough history and physical examination, including abdominal examination, and specifically check for a “Murphy’s Sign.”

• Murphy’s sign: deep palpation in the right upper quadrant while the patient inspires deeply. A positive test is when the patient abruptly stops their inspiration secondary to pain.
• Labs: Complete Blood Count (CBC) with differential (leukocytosis), Liver function panel (Elevated total bilirubin, alkaline phosphatase, and possible transaminitis), Amylase/Lipase (Elevation can indicate gallstone pancreatitis).
• Imaging:

1. Abdominal ultrasound of the right upper quadrant will identify the presence of gallstones/sludge/polyps/masses, thickness of the gallbladder wall (normal limits less than 3 mm), width of common bile duct (normal limits less than 6 mm, however, 1 mm may be added per decade of life after 50 years of age or in pregnant women), and the presence/absence of pericholecystic fluid
2. Magnetic resonance cholangiopancreatography (MRCP): MRI imaging study for noninvasive visualization of biliary and pancreatic ducts
3. Endoscopic Retrograde Cholangiopancreatography (ERCP): an invasive endoscopic procedure is utilizing x-rays and dye to visualize biliary and pancreatic ducts. The advantage of ERCP is that it is both diagnostic and therapeutic. However, this is an invasive procedure and comes with procedural risks
4. Hepatobiliary Iminodiacetic Acid (HIDA) Scan: imaging study to visualize liver, gallbladder, and bile ducts. A radioactive tracer is injected into the vein, attaches with bile substrates, and is processed by the liver. A nuclear scanner then tracks the flow of the tracer through the liver, into the bile ducts, gallbladder, and into the duodenum. The addition of cholecystokinin, CCK, in the absence of gallstones is useful to diagnose acalculous cholecystitis. A measured ejection fraction of less than 35% is usually indicative of a poorly functioning gallbladder. Reproduction of symptoms with administration of cholecystokinin also has been shown to predict the resolution of symptoms after cholecystectomy. Cholecystokinin should not be administered in the presence of gallstones as this may provoke passage of the stones into the common bile duct.

Enhancing Healthcare Team Outcomes

When patients present to the emergency department physician, primary care provider and nurse practitioner with gallstones, they should be educated about the options of treatment. While laparoscopic cholecystectomy is now the standard of care, patients should be informed about the possibility of conversion to an open procedure. The risk of injury to the bile duct is always a possibility depending on the experience of the surgeon. For those patients who are asymptomatic, it is important to recommend a healthy low-fat diet, maintenance of low body weight and regular exercise.

Introduction

Gallbladder disease is one of the most common procedures done in the United States with more than 1.2 million cholecystectomies done annually. Before 1991, an open technique was the standard procedure for cholecystectomy. This usually included performing an intraoperative cholangiogram, and patients usually had a 2 to 6-day postoperative in-house stay. With the advent of laparoscopic surgery and laparoscopic cholecystectomy in the late 1980s, the gold standard for cholecystectomy has changed to a laparoscopic approach. This method showed a 30% increase in the overall performance of elective cholecystectomies. Today, 92% of all cholecystectomies are done laparoscopically, although open cholecystectomies remain more common in many less affluent settings. With the advent of laparoscopic cholecystectomies in the 1990s, common bile duct (CBD) injuries increased by three to ten times. The injury rate dropped to 0.3% but has remained the same despite better training, preventative maneuvers, and equipment. Laparoscopic CBD injuries are typically more complex. There are several indications to perform open cholecystectomies, and this procedure remains an important part of training for the general surgery resident.

Anatomy and Physiology

The anatomy of the biliary tree remains one of the most variant areas of the body. The gallbladder is a pear-shaped organ affixed to the undersurface of segments IVB and V of the liver. It has no capsule. There is a slight outpouching of the distal gallbladder called Hartman's pouch, which tapers distally to the cystic duct, which contains Valves of Heister. The cystic duct joins the bile duct at the confluence of the common hepatic (proximal) and common bile (distal) ducts. The common bile duct empties into the duodenum at the Ampulla Vater. The sphincter of Oddi controls the flow of bile into the duodenum. The proximal common hepatic duct branches into the left and right hepatic radicals in the liver. These radicals eventually branch into smaller intrahepatic ducts. There may be small ducts that traverse directly into the gallbladder from the gallbladder bed of the liver, called the ducts of Luschka, that may result in postoperative bile leaks if not identified and addressed at the time of surgery].

The blood supply to the gallbladder is from the cystic artery, which usually branches from the right hepatic artery, which branches from the common hepatic artery. There is no formal venous structure associated with the gallbladder. A commonly used landmark is the triangle of Calot. There are two definitions of this anatomical landmark. The original description uses the cystic duct, the cystic artery, and the liver. The more commonly used description of Calot's triangle is the cystic duct, the common hepatic duct, and the undersurface of the liver. The latter description helps identify the cystic artery that lies within the triangle beneath the lymph node of Calot. The portal vein lies just below the common bile duct. The surgeon must always be aware of the high incidence of the diversity of this area of the body, and there, in fact, is no such thing as standard biliary anatomy. There are many anatomical variances such as choledochal cysts, fusiform gallbladders, accessory ducts, intrahepatic gallbladders, and duplications.

Fifteen percent to 20% of patients will have altered anatomy. One of the most dangerous situations is a short cystic duct with the accompanying short cystic artery. The common bile duct may be mistaken for the cystic duct and be at risk for transection. A short cystic artery may lead to injury or transection of the right hepatic artery. Ten percent to 15% of people have a replaced right hepatic artery with the origin from the superior mesenteric artery (SMA).

Indications

With the advent of laparoscopic cholecystectomies, the indications to perform an open cholecystectomy have decreased. The most common instance (2% to 10%) that an open cholecystectomy is performed is when converting from a laparoscopic to open cholecystectomy. This change is made for a variety of reasons. Any time there is a question of the anatomy, surgeons may change to an open technique. Extensive inflammation, adhesions, anatomical variances, bile duct injury, retained bile duct stones, and uncontrolled bleeding are all indications to convert to an open procedure. The need for a common bile duct exploration also can be a reason to convert to an open procedure, as laparoscopic bile duct exploration can be difficult. A planned open cholecystectomy may be performed in cases of cirrhosis, gallbladder cancer, extensive upper abdominal surgeries with adhesions, and other comorbid conditions (notably, diabetes melitis). Situations of critically ill patients also may necessitate the need for a planned open cholecystectomy, as an open procedure may be less stressful in critically ill patients, thereby avoiding the physiologic changes associated with a surgical pneumoperitoneum (e.g. decreased cardiac return and higher ventilation pressures).

Poor visualization and unclear anatomy are typically the reason to convert from laparoscopic to open procedure. Conversion to open cholecystectomy should not be viewed as a complication or a failure but just the opposite. It is showing good judgment to complete the operation in the safest manner possible.

Contraindications

There are no contraindications in performing an open cholecystectomy versus laparoscopic cholecystectomy. However, the preferred method is to complete the procedure using the laparoscopic technique as this can be done outpatient and reduces the recovery time from several weeks to about one week. General contradictions for any surgery, in general, apply to open cholecystectomy. Severe comorbid conditions such as shock, advanced cardiac and respiratory disease, anticoagulation, a recent neurologic event, and other life-threatening ailments are relative contraindications to laparotomy. Additionally, if there is a concern for possible gallbladder cancer, resection should not proceed until a thorough workup has been completed, including potential depth of invasion and metastases.

Equipment

Surgeons work in an appropriate operating room and use a general anesthetic. They use standard laparotomy equipment. Fluoroscopy and cholangiogram catheters need to be available in case an intraoperative cholangiogram is needed. A colonoscope and instrumentation to perform a possible common bile duct exploration should also be available. Bile duct baskets, graspers, and Fogarty catheters are also required to do extractions of common bile duct stones. An array of T- tubes are also required if performing bile duct exploration. Often cultures are also done in cases of acute cholecystitis or obvious infections.

Self-retaining retractors, such as a Bookwalter, may be of some benefit depending on the operative setting. If a cholangiogram is needed, either a flat plate x-ray or C arm fluoroscopy is helpful.

Personnel

An experienced surgeon who is comfortable performing open cholecystectomies is the most important person. In modern times, residents have less experience with open cholecystectomies than surgeons who trained before the 1990s. A capable anesthesiologist is needed to administer the appropriate general anesthesia. An experienced first assistant is also needed. This is usually a senior surgery resident. A scrub technician and circulating nurse round out the personnel needed to complete an open cholecystectomy. In cases where an intraoperative cholangiogram is indicated, a radiology technician with fluoroscopy is also needed.

Preparation

A thorough diagnostic workup needs to be completed to make the diagnosis of gallbladder disease. This workup includes a gallbladder ultrasound and possibly, an abdominal CT scan, Hida scan, and blood work. The decision to perform a scheduled open cholecystectomy needs to be made by the surgeon. A laparoscopic procedure can always be converted to an open procedure if needed. The surgeon must evaluate the risks versus the benefits before attempting a laparoscopic cholecystectomy. Patients must be hemodynamically stabilized and resuscitated if needed. Appropriate permits and information must be discussed with the patients, including all risks, benefits, and options. Standard pre-operative preparation, such as nothing by mouth, possible antibiotics, and deep vein thrombosis prophylaxis, must be instituted.

Part of the workup needs to include a thorough history and physical exam. Other specialties may be involved, such as gastroenterology or interventional radiology, to help in the workup and preparation in cases where preop endoscopic retrograde cholangiopancreatography or cholecystostomy tube is needed.

Technique or Treatment

Once the patient is appropriately anesthetized and prepped, a right subcostal (Kocher) incision or upper midline incision is made. Adequate exposure is gained by using packs and retractors. It is important to obtain good visualization of the gallbladder, triangle of Calot, and bile ducts. Care must be taken to avoid liver injury from the retractors. Once the surgeon has adequately identified all of the structures of the porta hepatis, the gallbladder is grasped with clamps and manipulated to facilitate the best visualization. The decision is made to remove the gallbladder from the top-down or classically from the triangle of Calot up. The cystic duct is first identified and divided between hemoclips, as is the cystic artery. Definitive identification of these structures is crucial. The gallbladder then can be removed from the gallbladder bed of the liver using either electrocautery or a harmonic scalpel. Inspection of the gallbladder bed is done to identify and address any bleeding or bile leaks from the duct of Luschka. Operative cholangiogram or common bile duct exploration is dependent on factors associated with common bile duct stones such as elevated bilirubin and dilated common bile duct (over 8 mm) The abdomen is then closed in a standard multilayer fashion.

There are times where the gallbladder is tense and distended from inflammation that may need to be drained with a decompression needle prior to starting the case. As in laparoscopy, the technique is based on surgeon experience and comfort. With either procedure, the surgeon should strive to gain an excellent critical view of safety before clipping or cutting. Some cases may present with a great deal of inflammation, or Hartmann's pouch is so fibrotic that "bailout" maneuvers are needed; these may consist of a cholecystostomy tube, partial cholecystectomy, or at times of necrosis leaving the back wall Closed suction drains can be placed at the discretion of the surgeon.

Complications

When the procedure is done using an open technique, the implication is that it is not a typical cholecystectomy situation. Therefore, the complication rate associated is higher than a routine laparoscopic cholecystectomy (16% versus 9% in a recent study). Because the incision is larger than that required for laparoscopic surgery, there is a higher incidence of hernia formation, wound infection, and hematoma. Open surgery is usually more painful than a laparoscopic procedure. Bile leaks and bile duct injury, as well as retained bile duct stones, are all complications associated with this surgery.

There is typically an increased direct and indirect cost associated. This is usually a reflection of the additional time the patient spends in the hospital. Also, the complication rate is higher and may result in issues requiring additional procedures and/or medication, especially if a bile duct injury occurred during the operation. The longer recovery time may keep people out of work for an extended period.

Clinical Significance

Although the gold standard for gallbladder surgery is a laparoscopic cholecystectomy, it is imperative that surgeons are also comfortable doing open cholecystectomies. Certain conditions mandate a planned open technique as the initial surgery. However, in laparoscopic cases, the surgeon must be prepared to convert to the open technique during an operation.

There is no substitute for experience and using appropriate clinical judgment in tough cases. Preparation is key, and asking for help when the situation arises should not be forgotten or looked down upon. There is no substitute for safety. Residents should never pass up the chance to scrub an open chole. They are not very common anymore. The reason the case is open typically is preceded by some difficult issue that forces this technique.

Enhancing Healthcare Team Outcomes

The standard treatment of choice for gallbladder disease is laparoscopic cholecystectomy. Complete knowledge of all cholecystectomy techniques and indications is mandatory for a competent surgeon. Being able to convert from laparoscopic surgery to an open technique is part of the modern surgeon's arsenal. Indications from gallbladder cancer to poor visualization to indistinguishable anatomy are all reasons to convert cases to open. Preoperative preparation will also allow the experienced surgeon to prepare for the possibility of conversion to an open technique. These possibilities must also be thoroughly discussed with each patient, along with all possible risks and outcomes.

You can help prevent gallstones by

• adjusting your eating plan to include more foods high in fiber and healthy fats, fewer refined carbohydrates, and less sugar
• losing weight safely if you are overweight or have obesity
• maintaining a healthy weight through healthy eating and regular physical activity

You can lower your risk of gallstones by following a healthy eating plan and getting regular physical activity to help you reach and maintain a healthy weight.

Experts recommend the following to help prevent gallstones:

• Eat more foods that are high in fiber, such as
  • fruits, vegetables, beans, and peas.
  • whole grains, including brown rice, oats, and whole wheat bread.
• Eat fewer refined carbohydrates and less sugar.
• Eat healthy fats, like fish oil and olive oil, to help your gallbladder contract and empty on a regular basis.
• Avoid unhealthy fats, like those often found in desserts and fried foods.

Talk with your health care professional before you make any changes to your eating plan. Losing weight too quickly may cause health problems. Very low-calorie diets and weight-loss surgery can lead to rapid weight loss and raise your risk of gallstones.

Losing weight at a slow pace may make it less likely that you will develop gallstones. For people who are overweight or have obesity, experts recommend beginning with a weight loss of 5 to 10 percent of your starting weight over a period of 6 months. In addition, weight loss may bring you other benefits such as better mood, more energy, and positive self-image.

When making healthy food choices to help you lose weight, you can choose food that may also lower your chances of developing gallstones.

Regular physical activity, which will improve your overall health, may also lower your chances of developing gallstones. To improve health or prevent weight gain, aim for at least 150 minutes a week of moderate-intensity physical activity, like brisk walking or fast dancing. Adults also need muscle-strengthening activity, like lifting weights or doing push-ups, at least 2 days a week.

Talk with your doctor before you start an eating and physical activity plan to improve your health or maintain your weight loss.