Gallbladder stones are a common and frequent disease, and the danger of stones lies in their chronic irritation of the gallbladder, obstruction of the cystic duct, secondary bile duct stones, biliary pancreatitis, gallbladder cancer and a series of other complications. Cholecystectomy has been used to treat gallbladder stones for more than 100 years, but today, most scholars still believe that “gallbladder stones, everything is done”. The gallbladder resection has evolved from traditional open cholecystectomy to Laparoscopic Cholecystectomy (LC), which has been performed for more than 20 years and has the advantages of less trauma, less pain, faster recovery, minimal scarring after wound healing, and positive curative effect. As surgeons continue to accumulate experience, improve technical level, and gradually improve and update related equipment and instruments, its surgical indications are gradually expanding, with less and less side injuries, and it has become the “gold standard” for the treatment of benign diseases such as gallbladder stones.
LC is one of the characteristic techniques of our department, which has reached the level of skillfulness and is basically free of side-injuries and complications. We welcome all gallbladder stone patients to come for surgery and believe we can give you a satisfactory result.
Knowledge of LC.
I. Gallbladder stones that must be operated (indications)
1. Gallbladder stones with symptoms.
2.Gallbladder stones with comorbidities: even if there is no symptom, but with diabetes and cardiopulmonary dysfunction disease, surgery should be performed in the stable period.
3.Gallbladder stones with complications: combined with acute and chronic cholecystitis, common bile duct stones, biliary pancreatitis and other complications, suitable for laparoscopic surgery.
4. Gallbladder stones with increased chance of gallbladder cancer: age > 60 years, huge stones (diameter > 2cm), ceramic gallbladder, etc.
II. Absolute contraindications.
1.With severe cardiopulmonary insufficiency and unable to tolerate anesthesia, pneumoperitoneum and surgery.
2.With coagulation dysfunction.
3.Acute cholecystitis with serious complications, such as: gallbladder gangrene, perforation.
4.With acute severe cholangitis or acute gallstone pancreatitis.
5.Gallbladder cancer or suspected gallbladder cancer.
6.Chronic atrophic cholecystitis, gallbladder volume <4.5cm×1.5cm, wall thickness >0.5cm (measured by ultrasound).
7.Severe cirrhosis with portal hypertension.
8.Patients with middle or late pregnancy.
9, with abdominal infection, peritonitis.
10, with diaphragmatic hernia.
III. Relative contraindications.
1.Acute attack of calculous cholecystitis.
2.Chronic atrophic calculous cholecystitis.
3, common bile duct stones and obstructive jaundice.
4.Mirizzi syndrome, gallbladder neck stone impaction.
5, History of previous upper abdominal surgery.
6, Morbid obesity.
7, Extra-abdominal hernia.
These relative contraindications have gradually become indications for LC as we have gained sufficient experience.
IV. Indications for intermediate open surgery.
In the process of performing laparoscopic cholecystectomy, if the following conditions are found, the continued use of laparoscopic cholecystectomy is likely to produce complications such as bile duct injury, and should be transferred to open surgery according to the specific situation.
1, unclear anatomy of the gallbladder triangle: intraoperatively, it is found that the common bile duct, cystic duct and common hepatic duct at the gallbladder triangle have adhesions that are difficult to separate and the anatomical structure is difficult to distinguish and
2, the opening of the cystic duct is too high close to the hepatoportal, and it is difficult to separate the cystic duct.
3, the cystic duct is too short <3mm, too thick (diameter >5mm) and cannot be clamped.
4, the cystic duct is parallel to the common hepatic duct or common bile duct
5, extrahepatic biliary tract and gallbladder artery variation making it difficult to identify the relationship between the cystic duct and common bile duct or easily causing fatal hemorrhage.
6, intraoperative injury to the common bile duct: bile duct injury, electrical burns to the bile duct wall.
7. Intraoperative damage to the blood vessels that have been found to cause active bleeding
8, adjacent organ injuries: stomach, duodenum, colon and other organ injuries.
The intermediate open abdomen is to avoid unnecessary side injuries and protect the patient’s life, not a failure of surgery, but the normal completion of surgery.
V. Complications and management, efficacy evaluation
Since LC was carried out in our department, complications have been rare and the efficacy has been good. For detailed information about LC complications and efficacy evaluation, please refer to the article “Introduction to laparoscopic cholecystectomy” on this website.
Explanation of patients’ doubts
1. Is it “no more guts” after cholecystectomy?
Individual patients are full of fear of cholecystectomy and think that they are “gutless” after cholecystectomy. In fact, this is a misconception. The intrahepatic bile duct starts from the intrahepatic capillary bile duct, and goes to the bile ducts, lobular bile ducts, hepatic segmental ducts, hepatic lobular ducts, left and right hepatic ducts, while the extrahepatic bile ducts include the common hepatic duct, gallbladder, cystic duct and common bile duct, in which the cystic duct and common hepatic duct merge to form the common bile duct. The gallbladder is only a storage organ of the biliary system, which plays a role in storing and concentrating the bile secreted by the liver. After eating, the gallbladder contracts, the duodenal Oddi sphincter relaxes, and the gallbladder bile is removed and enters the duodenum through the common bile duct, where it acts as an emulsifying fat in the intestine and facilitates the digestion of fat by digestive enzymes. That is, the gallbladder plays the role of storing and concentrating liver bile, and the concentrated bile discharged into the duodenum plays the role of emulsifying fat to facilitate its digestion. In the early stages of cholecystectomy, some patients may have a transient effect on fat digestion due to the low concentration of bile and may experience steatorrhea after eating a high-fat diet. However, as time goes by, the common bile duct will gradually expand and replace the gallbladder’s function of storing and concentrating bile, and the bile’s function of emulsifying fat will be gradually restored, and the intestinal fat digestion will return to normal in about half a year, and fatty diarrhea will no longer occur. Therefore, cholecystectomy is not “no more bile”, the patient’s biliary system still exists and performs its own function, only one organ of the biliary system is removed to store and concentrate bile, and this function will be compensated by the common bile duct within six months, which does not affect the function of the biliary system itself.
2.What are the risks to human body after cholecystectomy?
As mentioned above, bile is secreted by the liver, and the gallbladder is the organ for storing and concentrating bile, and the function of bile is to promote fat emulsification and facilitate the digestion and absorption of fat. After gallbladder removal, hepatic bile still enters the duodenum through the lower end of the common bile duct to help digestion and absorption of fat, but the bile is thinner than the original one (if the gallbladder still has some concentration function before surgery), and some patients may have steatorrhea after eating a high-fat diet. However, in about six months, the compensatory expansion of the common bile duct will gradually replace the gallbladder’s function of storing and concentrating bile, and the digestion and absorption of fat will gradually return to the preoperative level. If the patient’s gallbladder was already non-functional before surgery, suggesting that the common bile duct has long since replaced the gallbladder, this steatorrhea will not occur.
Except for the possibility of steatorrhea mentioned above, cholecystectomy has almost no adverse effects on patients unless they have other diseases in combination.
3.Is there an increased risk of colon cancer after gallbladder removal?
Some patients have heard that the risk of colon cancer is increased after gallbladder removal. In fact, this knowledge is not confirmed by scientific evidence. It is indeed believed that cholecystectomy is a possible risk factor for colon cancer, but clinical evidence of its relevance is lacking and the mechanism is unclear, which may be related to bile with pro-stone formation properties. Gallstone disease elevates the risk of colon cancer to a similar extent as cholecystectomy, which supports the pro-stone forming bile acid exposure theory. Therefore, I believe that gallbladder stone patients have an increased risk of colon cancer due to the effect of lithogenic bile acids, whereas cholecystectomy itself is not intrinsically linked to the development of colon cancer. I caution patients with gallbladder stones not to give up elective cholecystectomy because of the claim that gallbladder resection increases the risk of colon cancer, after all, it is an objective fact that cholecystectomy can eliminate patients’ symptoms and complications of gallbladder stones after more than 100 years of practice.
4. Do asymptomatic gallbladder stones require surgery?
Asymptomatic gallbladder stones can be observed in most cases, but prophylactic cholecystectomy is needed in the following cases.
(1) Gallbladder stones with comorbidities: as mentioned above, those with combined diabetes and cardiopulmonary dysfunctional diseases should be operated during the stabilization period.
(2) Asymptomatic gallbladder stones that cause an increased chance of gallbladder cancer: age > 60 years, huge stones (diameter > 2 cm), ceramic gallbladder, etc.
(3) Patients who require early surgery. It has been observed that most patients with asymptomatic gallbladder stones are transformed into symptomatic gallbladder stones after 5-10 years, and serious complications may occur during this transformation process, therefore, it is advocated that preventive cholecystectomy should be actively performed for gallbladder stones, regardless of whether they are symptomatic or not.
5. Is “gallbladder stone retrieval” feasible?
What is the purpose of gallbladder stone extraction? As the name suggests, the purpose of gallstone extraction is to protect the function of the gallbladder, that is, to maintain the original function of the gallbladder. In theory, there are indications for biliary lithotripsy, but in practice such indications are almost non-existent. The ideal condition for gallstone extraction is at least good gallbladder function and no lesions in the gallbladder wall, otherwise gallstone extraction itself loses its meaning. How many patients have such conditions?
Moreover, the gallbladder stone extraction itself cannot eliminate the “hotbed” of stone recurrence – the diseased gallbladder, and the stone is easy to recur after stone extraction, and it can cause adhesions around the gallbladder after stone extraction, which increases the difficulty of re-operation.
Therefore, I do not advocate biliary stone extraction for gallbladder stones. Of course, this is only my opinion, I hereby declare!
6.Can gallbladder stones be cured by non-surgical methods?
Pure cholesterol stones can be dissolved by applying bile acid preparations such as ursodeoxycholic acid and goose deoxycholic acid, but it takes six months to two years to take them, but long-term use of such drugs may lead to liver function damage, which many patients cannot adhere to. Patients with pure cholesterol stones are more common in the West, but gallbladder stones in China are rarely pure cholesterol stones, but mostly cholesterol-based stones with high calcium content, which are difficult to dissolve in in vitro lithotripsy experiments, therefore, lithotripsy therapy is not effective for most gallbladder stones in China. I do not advocate lithotripsy treatment for gallbladder stones in China, especially those in Guangdong.
However, the lower end of the bile duct is very narrow and it is difficult for stones to pass through it. However, the number of gallbladder stones with this condition is almost negligible, and we cannot exclude the influence of individual differences and biliary tract lesions, and the lower end of the bile duct is not necessarily 3.0mm when it is opened; once the stone is embedded in the lower end of the cystic duct or common bile duct during stone removal, it will cause severe biliary colic, acute cholecystitis, biliary pancreatitis, acute cholangitis and other complications, which may be life-threatening in serious cases. Therefore, lithotripsy for gallbladder stones has actually been discarded by the medical profession long ago.
As for lithotripsy, it is one of the conventional treatment methods for urinary stones. The pathogenesis and composition of gallbladder stones and kidney stones are different, and the anatomy of the bile duct and urethra are also very different. Theoretical and practical evidence shows that lithotripsy is suitable for some urinary stones, but not for gallbladder stones.
In conclusion, lithotripsy, lithotripsy and lithotripsy are not suitable for the treatment of gallbladder stones. The so-called non-surgical treatment can only achieve the effect of reducing the inflammation of gallbladder and eliminating the pain, which is usually called “anti-inflammatory and biliary” treatment, which cannot fundamentally eliminate the stones and their long-term harm.