WHAT IS THE GALLBLADDER? The gallbladder is a small (2-3 inch), sac-like organ which sits at the undersurface of the liver and stores excess bile secreted by the liver before it passes into the intestinal system. Bile is a substance made by the liver that aids in the digestion of fats. The liver makes approximately 700-1200 cc of bile per day, approximately 30-60 cc are stored in the gallbladder at any given time. In response to a meal, particularly one that is high in fat, the gallbladder will contract and empty its’ contents into the duodenum where it will combine with fats from the recently ingested meal and help break down and absorb them.

WHAT ARE GALLSTONES AND HOW DO THEY FORM?
The bile that aids in the digestion of fats is composed primarily of bile salts, cholesterol and lecithin with water and several other chemical components also present. Under certain conditions, the cholesterol may precipitate and form gallstones; cholesterol gallstones comprise about 80% of gallstones, the other 20% are called pigment gallstones and are comprised primarily of bilirubin and calcium salts. Inherited body chemistry as well as gallbladder motility seem to be amongst the biggest culprits when it comes to the formation of gallstones. There is no known correlation between diet, cholesterol level, and the formation of gallstones. Other risk factors for gallstone formation include obesity, gender (females are more likely to form gallstones), rapid weight loss, certain ethnicities (Native Americans and Mexican-Americans are more likely to form gallstones), the use of estrogen therapy and age (more common after age 40).

WHAT ARE THE SYMPTOMS OF GALLSTONES?
The majority of people with gallstones have no symptoms. These patients have their gallstones diagnosed during the course of a normal medical workup or while undergoing tests for an unrelated problem. Except in certain circumstances (diabetes, patients at risk for complications, etc.), these patients need to have no specific therapy other than regular medical follow-up.

Patients with symptomatic cholelithiasis (symptoms from gallstones) may have a wide range of problems. Those with “classic” biliary colic may complain of postprandial (after eating) pain in the right upper abdomen that occurs 15-30 minutes after finishing a particularly fatty meal. This pain is often accompanied by nausea and vomiting and may radiate into the back. Complaints of bloating, reflux and cramping abdominal pain are common. Many patients do not present with “classic” symptoms but rather have an assortment of generalized abdominal complaints including pain, nausea, fever and bloating that start shortly after ingestion of a meal and end an hour to several hours after onset. These symptoms arise from the normal contraction of the gallbladder that occurs following ingestion of food; the gallstones that are present can wedge into the inflow area of the cystic duct and form a fixed obstruction in the manner of a ball-valve. When the gallbladder relaxes, the stone falls back and the bile is released—at that time the pain will stop. Studies have shown that once gallstones start causing problems, symptoms will not stop until either the gallbladder is removed or a serious complication occurs.

Symptomatic cholelithiasis can progress to serious complications if a gallstone becomes lodged in the opening to the cystic duct and causes obstruction, swelling and infection. This condition is called acute cholecystitis and usually requires hospitalization, antibiotics and urgent surgical removal of the gallbladder.

If gallstones progress beyond the cystic duct into the common bile duct the condition is known as choledocholithiasis. Gallstones which become stuck in the common bile duct can cause elevation of the bilirubin level in the blood, which can lead to jaundice (orange discoloration of the skin), may lead to an infection of the bile ducts and liver (cholangitis) or may progress into the pancreas and cause inflammation and infection of the pancreatic tissue (pancreatitis). These conditions are all life-threatening and usually require prolonged hospitalization, intravenous antibiotics and urgent surgical therapy.

TREATMENT OF GALLBLADDER DISEASE
Surgical removal of the gallbladder is the only effective, long-term treatment for symptomatic gallstones. Other treatment modalities such as removal of the gallstones, dietary modification, and chemical or ultrasonic dissolution of gallstones are ineffective, lengthy, expensive and prone to immediate recurrence when treatment ends. With removal of the gallbladder there is no location for bile to accumulate and cholesterol stones cannot form. The bile that would normally have been stored in the gallbladder goes directly to the intestine instead and aids in fat digestion. Removal of the gallbladder relieves symptoms from gallstones in greater than 90% of patients and has no serious long-term deleterious side effects. Laparoscopic cholecystectomy is the surgical removal of the gallbladder with the aid of a telescopic camera and long instruments. The procedure is performed through 4 small incisions and results in short hospitalization (usually done as an outpatient procedure), fast postoperative recovery and rapid return to work or preoperative activities.

Occasionally the laparoscopic approach must be converted to the open approach by making an incision that connects the upper 3 incisions. This usually happens when there is a high degree of inflammation present or when the anatomy of the gallbladder and bile ducts is aberrant and a closer look is required. This occurs in less than 1-4% of all operations and may increase hospitalization and recovery time.

RISKS AND RECOVERY
There is a small risk of postoperative bleeding or infection following all surgical procedures. Risks that are unique to laparoscopic cholecystectomy include injury to the common bile duct or other intra-abdominal structures, need for further procedures (ERCP) if there is a stone retained in the common bile duct, formation of hernias at incision sites and conversion to open operation. These complications occur very infrequently and can be discussed in greater detail at the time of the preoperative evaluation. Laparoscopic cholecystectomy is a safe, proven and effective treatment for gallstones. Patients generally have no dietary restrictions after surgery and have almost immediate relief of preoperative symptoms. Hospitalization is minimal and return to work and other activities is rapid.