Gallstone disease is one of the most common diseases in hepatobiliary surgery, summarizing several issues of most concern to patients in clinical practice, and share with you. Due to the limited tools at hand, let’s just look at the sketch! Gallbladder stones, to open or not to open? Young patients, with small stones and no symptoms, can be suspended without surgery, pay attention to diet and regular follow-up review; patients with symptoms of right upper abdominal pain and discomfort, especially those with recurrent attacks, are in principle recommended to have surgery; elderly patients with many underlying diseases, even if asymptomatic, are recommended to have surgery as early as possible, because once the risk of acute attack is great; those with suspected risk of malignancy such as gallbladder atrophy found on physical examination, should have surgery as early as possible. When is the appropriate time for surgery? It is generally recommended to operate when there is no pain, and for acute attacks, it is more appropriate to operate 1-2 months after the inflammation is controlled, because at that time the gallbladder is not inflamed and edematous, and the operation is simple, with quick recovery and few complications. If conservative treatment is not effective, emergency surgery is required, but the risk is much greater. Minimally invasive, or open? I would just like to say that one is a delicate operation under a high-definition magnified view many times, and the other is a deep small incision to pull out by hand. There is no doubt that laparoscopic cholecystectomy has been the international gold standard for decades. Of course, those who have difficulty operating laparoscopically still need open surgery as a supplement, and the incision must not be small at that time. Trust the doctor, not the lady in the next village. How is cholecystectomy done? Is it minimally invasive and clean? The procedure of cholecystectomy is exactly the same for minimally invasive and open surgery. The difference is that minimally invasive has a small puncture opening in the abdominal wall, and we will remove the gallbladder in a retrieval bag. Sometimes, because of too many stones and too large, or because of gallbladder edema, we will cut up the specimen for easy removal, but the gallbladder is removed to make sure it is intact, not piece by piece, and there will be no residue. Can I have my gallbladder preserved? How is a biliary lithotomy done? Imaging tests such as ultrasound or MRI clearly identify single or few stones, and intraoperative choledochoscopy or cholecystoscopy must clearly identify the absence of residual stones or sediment; otherwise, stone recurrence is the biggest pain after biliary preservation. What is the difference between bile duct stones and gallbladder stones? Please see the title picture, the location of growth is different and some of the etiology is different. Some of the bile duct stones are gallbladder stones that fall into the bile duct through the gallbladder duct, called secondary bile duct stones, while primary bile duct stones have a higher recurrence rate. Common bile duct stones may cause bile duct obstruction and affect liver function, etc. In principle, surgery is recommended for all of them. Why is it necessary to put a drainage tube for bile duct stone surgery? Because the bile duct is the only way for the bile secreted by the liver to enter the intestine, bile duct stones cannot be simply removed like gallbladder stones. When the bile duct is incised to remove the stone and then sutured, the healing process may cause biliary stricture because of the constriction of the incision, so we routinely leave a T-tube in the bile duct to prevent stricture and bile leakage. Currently, the T-tube is usually left in place for 2-3 months and is removed only after there are no strictures or stones remaining on the imaging. What is ERCP? There is an alternative treatment for common bile duct stones. The opening of the bile duct into the intestine is found via gastroduodenoscopy, and a retrograde tube is inserted to remove the stones from the bile duct. This is a better minimally invasive treatment because there is no need to incise the common bile duct and no drainage is left in place. We recommend that patients with gallbladder stones combined with bile duct stones can be treated in two steps, with ERCP first to remove the bile duct stones and then laparoscopic cholecystectomy to achieve the least trauma and fastest recovery. However, the relative cost is higher and ERCP does not guarantee 100% success. How will gallbladder removal affect my life? The physiological function of the gallbladder is to concentrate and store bile, so a low-fat diet is required for a short period of time after gallbladder removal, and generally the bile ducts will compensate for the expansion of the gallbladder in 2-3 months and play a part in the role of the gallbladder. Therefore, it is normal to find mild dilatation of bile ducts after cholecystectomy and there is no need to worry.