Gallstones Removal | Gallbladder Surgery Singapore

Biliary colic treatment gallstone surgery gallbladder removal

How do you know if you have gallstones?

By Dr. Lee Ser Yee

Gallstones are the most common result of gallbladder disease and one of the most common causes of upper abdominal pain.

The treatment of gallbladder disease will depend on the situation – whether it is asymptomatic, symptomatic or complicated.

Most patients experience no symptoms even if they have gallstones (asymptomatic). In this group, gallstones are usually diagnosed during health screenings or tests for other health conditions e.g. blood tests or ultrasound scan.

Some patients may feel some of these symptoms, especially after a fatty meal

Abdominal Pain
- sharp, squeezing in nature, on and off, waxes and wanes (Biliary Colic)
- around the central/right upper abdomen, sometimes going to the right shoulder or back

Indigestion and frequent burping
Nausea & Vomiting
Yellowing of eyes and skin (Jaundice), clay- coloured stools, tea coloured urine
Bloating and abdominal discomfort
Fever, chills and rigors

Occasionally, the first attack of a gallstone will result in a complication with any prior warning symptoms. This will depend on where the gallstone blocks and gets stuck.

When the gallstone/s block the outlet of the gallbladder, the gallbladder can swell and get infected.
In severe cases, the gallbladder can burst (perforated) or start to die due to lack of blood supply (gangrenous)

When the gallstone/s drop out of the gallbladder, it can get stuck along the tube leading to the small intestine, this will cause the bile flow to be obstructed. The build up of bile in the body will lead to jaundice which results in yellowing of the eyes and skin. Prolonged jaundice can lead to an impairment of liver function.

If a gallstone gets stuck along the tube leading to the small intestine, this will cause the bile flow to be obstructed. Like any blocked pipe, the fluid, in this case, bile, cannot flow and bacteria within will overgrow and spread into the blood stream resulting in a potentially severe infection (Sepsis)

When the gallstone/s migrate and block the common channel where the pancreatic juices and the bile meet just before it drains into the small intestine, it can block the pancreas and cause it to swell and cause inflammation of the pancreas, this may lead to more serious damage to other organs. (Systemic inflammatory Response Syndrome, SIRS)

Some may result in chronic infections e.g. chronic cholecystitis or pancreatitis

How are gallstones confirmed?

A scan is necessary to confirm gallstones. Most commonly, an ultrasound is performed. Stones may also be detected on CT scan or MRI of the abdomen. In addition, blood tests may be done to rule out any obstruction of the bile ducts and infection.

What is the treatment for gallstones?

Surgery is not necessary in most people if they have no symptoms as the risk of the surgery is higher than the risk of developing symptoms and complications from the gallstones.

However, once gallstones become symptomatic or develops complications, there is a tendency to recur and can become worse, then surgery may be recommended.

Surgery to remove the gallbladder is the gold standard treatment for gallstones. Surgery to remove just the gallstones and leave the gallbladder intact is not recommended as it does not treat the underlying diseased gallbladder.

Laparoscopic cholecystectomy

A “keyhole” removal of the gallbladder also known as laparoscopic cholecystectomy is the procedure of choice for removal of the gallbladder.

In about 3-5% of patients undergoing the laparoscopic procedure, there may be a need to convert to the open procedure due to circumstances encountered during the surgery. Such decisions are made during surgery for patient safety and is not considered a complication.

The surgery is performed under general anaesthesia through 3-4 small cuts (0.5 -1cm incisions) in the abdomen. The gallbladder is detached from the liver and clips are applied to the artery that supplies the gallbladder and the duct that drains from it. The gallbladder is then removed in a bag through one of the incisions.

Cholangiogram and CBD Exploration

In some selected cases, when necessary, an X-ray, called a cholangiogram, may be performed during the operation to check for any stones in the bile duct or to visualize the anatomy of the bile duct. If there are stones in the bile duct, the liver surgeon may remove them during the surgery itself [common bile duct (CBD) exploration] or he may choose to have them removed later through an endoscopic procedure called ERCP, or he may convert to an open operation in order to remove all the stones during the operation.

Open cholecystectomy

This is a procedure where the gallbladder is removed through a longer incision(10-15cm) on the abdomen. This incision is usually oblique and placed below the ribs on the right side. This may be considered if the minimally invasive approaches are deemed not suitable.

Risks of gallstones surgery

This is a generally a safe operation with very low complication rates. The risks of surgery include risk of risks related to general anaesthesia, wound infection, bleeding and rarely blood clots in the legs or lungs. The risks specific to cholecystectomy include a small risk (less than 1%) of an injury to the bile duct, nearby organs and blood vessels, which may require further repair of the injury. Hernia may form at the incision sites, especially in obese patients that may require repair in the future.

Occasionally (< 5%), stones may drop into the bile duct during the surgery or it may be undiagnosed before the surgery, these may require subsequent procedures e.g. ERCP to treat.

In the event of conversion of the laparoscopic approach to an open procedure, the risks will remain the same as above with similar good outcomes. However, post-operative recovery and hospital stay may be slightly longer.

What to expect after gallstone surgery?

Although gallbladder removal is a major abdominal surgery, most patients go home on the same day or the day after the surgery. If the surgery was performed with an open procedure (larger cut), the patient may have to stay a few more days. Some pain, nausea and vomiting may occur but most are well controlled by medications.

Once discharged, most patients can perform light duties and most activities of daily living. Most of the patients can return to work within a week or two after the surgery after a follow-up review with the surgeon. Some patients may still feel some bloating and some may have loose stools after the surgery as the body gets used to the absence of the gallbladder. Most symptoms will usually resolve within a couple of weeks or months.

For more information, please consult your surgeon.

“Keyhole (laparoscopic) removal of the gallbladder together with the gallstones within is the safe, effective and the current gold standard treatment for the condition. It is a relatively common and straightforward procedure in trained hands and most patients can go home on the day itself with minimal pain and discomfort.”

Dr Lee Ser Yee

Senior Consultant Hepatopancreatobiliary Surgeon

MBBS, MMed (Surgery), MSc, FAMS, FRCSEd

Prior to private practice, Dr Lee Ser Yee was a founding member and Senior Consultant at the Department of Hepatopancreatobiliary (HPB) and Transplant Surgery at Singapore General Hospital (SGH). He served as the Director of the Laparoscopic programme and the Director of the Surgical Skills Training Program and the SingHealth Surgical Skills Centre.

He started his medical training at the National University of Singapore in 1996 and completed his training in General Surgery, HPB surgery and Liver Transplantation at SGH and National Cancer Centre, Singapore.

He also completed dual USA-fellowships in Advanced Laparoscopic HPB surgery and Liver Transplantation under Professor Daniel Cherqui at the New York Presbyterian Hospital-Weill Cornell Medical Center and a Complex Surgical Oncology clinical fellowship at Memorial Sloan Kettering Cancer Center in New York.