Gallbladder Surgery at the Sachsenhausen Clinic, Germany, Frankfurt

Gallbladder Surgery

A gallbladder is a pear-shaped hollow organ approximately between 8 and 10 cm long and from 4 to 5 cm wide located under the liver and partially merged with it. It stores bile that is produced by the liver cells. Most of this organ is in the small intestine. Between the intakes of food, the liver guides the produced bile through the bile duct system into the gallbladder. There it is devoid of water and salts and is in a concentration that is ten times higher.

Then the bile finally gets into the duodenum, where some of its components are combined with the split edible fats, forming the so-called micelles. These micelles, which are granules with various soluble components, make it possible for fats to be absorbed in the intestines.

In addition, the bile also acts as an important excretory liquid that does not contain any metabolized hormones. In the end part of the small intestine, the bile acid is removed from the intestine and transported back to the liver, where it is again used for the absorption of fats.

How Can One Identify Gallbladder Pain?

Discomfort resulting from gallbladder pain is often unclear. The following symptoms can occur with gallbladder problems:

  • Diffuse pain in the upper right abdomen, similar to stomach or intestinal complaints
  • General sense of malaise
  • Nausea
  • Fullness and/or meteorism

Episodic dull pain with spasms in the gallbladder area is called biliary colic. This is usually caused by the bile flow difficulties associated with gallstones.

Causes of Gallbladder Problems

“The bile is coming up!” is a popular phrase. But in fact, gallbladder problems are often caused by a decrease in bile flow. The reason, in addition to the difficulty in transporting the bile because of gallstones or gallbladder inflammation, is the so-called biliary dyskinesia.

Biliary Dyskinesia

This is a functionally induced disorder of gallbladder or biliary tract permeability, which leads to a decrease in biliary secretion, which leads to typical symptoms. This is not always caused by an organic disease such as gallbladder stones (cholelithiasis) or gallbladder inflammation (cholecystitis).

Muscle Dysfunction

In addition to the reduced function of the gallbladder or the bile ducts, the function of the sphincter of Oddie is often impaired. This is the muscle responsible for the proper mobility of the gallbladder and pancreatic ducts. As a result of this disorder, too little bile gets into the small intestine.

Decrease in Bile Production Caused by Liver Disease

The decrease in bile production is another potential cause of gallbladder problems. In this case, the liver cells are no longer able to produce enough bile and deliver it to the gallbladder.

This leads to problems in the digestion of fats, because bile acids in the bile fluid are used to digest fat in the small intestine.

Dietary Effects

Nutrition plays an important role as well. Irritants such as fatty food, beans, coffee, alcohol or cigarettes can have a negative effect on bile flow and contribute to the formation of gallstones in the gallbladder.

Therefore, changing your diet and giving up bad habits are often the first step in the event of complaints about bile for unknown reasons. In very rare cases, the cause of a blockage in the bile ducts may be a tumor.

Psychosomatic Problems with Bile

As in the case of the inflamed intestines, problems with the bile are often caused by stress or internal anxiety. This is due to the various functions of the autonomic nervous system which regulates our digestive system through the closely interconnected centers in the brain, as well as controls our emotions.

Diagnosing Gallbladder Problems

The symptoms of the functional discomfort of the bile-excretory ducts are very similar to those of gallstones: biliary colic can be associated with pain in the upper right abdomen, nausea, meteorism, bloating and loss of appetite.

When diagnosing problems with the gallbladder, it is necessary to consider diseases with similar symptoms, such as:

  • Cholecystitis (gallbladder inflammation)
  • Cholelithiasis
  • Stomach and duodenal problems
  • Pancreatitis
  • Heart attack
  • Pulmonary embolism
  • Reflux disease
  • Lactose intolerance
  • Metabolic disorders
  • Bacterial intestinal disorders
  • Pancreatic, esophageal or stomach cancer

If you have difficulty in diagnosing, you can use an ultrasound, contrast X-ray or CT scan. The best way to see any possible gallstones or gallbladder inflammation is to use ultrasonography.

The dysfunction of the sphincter of Oddie can be measured by manometry (physical pressure measurement) during colonoscopy. Another specific procedure is ERCP (endoscopic retrograde cholangiopancreatography, the visualization of biliary ducts on a contrast X-ray). Both methods are not safe and should be used only in emergency situations.

Treatment of Gallbladder Diseases

To alleviate acute symptoms, antispasmodic and analgesic medications are primarily used. Heat and resting state also help many patients: a hot-water bottle on the stomach and deep sleep provide relaxation and relieve spasms.

If the symptoms occur immediately after a meal, it is recommended to start a low-fat diet. In addition, stress-related bile problems can be partially overcome through the use of relaxation methods.

Complaints caused by extreme psychological stress cannot be cured with self-medication. If you suspect that such stress is the cause or concomitant cause of your complaints, you should consider a combination of medical and psychotherapy treatments.

What is Cholecystectomy?

Cholecystectomy is a surgical removal of the gallbladder. The surgery is performed almost 200,000 times a year in Germany and is currently carried out mainly by making a small incision in the abdominal wall (minimally invasive, laparoscopic cholecystectomy). There are cases, however, when an open surgical procedure (traditional cholecystectomy) is still required.

Cholecystectomy is mainly performed in case of gallbladder inflammation (cholecystitis), especially in the presence of complications. The procedure usually gives good results and significantly improves the patients’ quality of life. Other diseases that require gallbladder removal are:

  • Gallbladder perforation (e.g. in case of an accident)
  • Connecting passages between the biliary tract and the gastrointestinal tract (the so-called biliodigestive fistulas)
  • Large stones in bile ducts that cause bile stasis (cholestasis) and cannot be removed otherwise
  • Gallbladder or bile duct tumors
  • Asymptomatic cholecystitis (which does not cause any discomfort) is not in itself a cause for gallbladder removal

In fact, gallbladder removal can be accomplished in two ways – a traditional open surgical cholecystectomy and minimally invasive laparoscopic cholecystectomy.

Traditional Cholecystectomy

With traditional cholecystectomy, the operating area is usually exposed under general anesthesia by making an incision below the right ribs. The supply artery and the branching bile duct are then tied up, cut and the gallbladder is removed. Wound drainage is usually not required. The use of antibiotics before the operation reduces the risk of infection. Thrombosis prevention (e.g. heparin) may be required, but it is not prescribed by default. Most patients can leave the hospital three to five days after that.

Laparoscopic Cholecystectomy

The gold standard in the treatment of gallbladder inflammation today is laparoscopic cholecystectomy. The gallbladder is minimally invasively removed by means of what is known as a “keyhole operation”. The basic principle of all laparoscopic operations is the insertion of three long instruments and a flexible camera through small incisions into the abdominal cavity. The instruments can be manipulated from the outside while the camera sends the image to the monitor in real time.

The abdominal cavity is expanded by injecting carbon dioxide, which provides better visibility and mobility for operating doctors (the so-called pneumoperitoneum). In this way, they can use visually controlled instruments to remove the gallbladder and then transport it through one of the incisions outside.

The advantages of laparoscopic gallbladder surgery over traditional procedures are, in particular, the reduction of pain after surgery, the minimization of scars and therefore a better aesthetic result, as well as a shorter stay in the hospital. Complications are the same with both procedures.

Laparoscopic removal of the gallbladder should not be performed in the following cases:

  • a gallbladder tumor is suspected, as the risk of tumor cell inoculation in the abdominal cavity is too great (e.g. due to accidental perforation of the gallbladder);
  • in the case of a serious cardiovascular disease, as the air injected increases the pressure in the abdomen and thus makes it difficult for the blood to return to the heart;
  • in patients with coagulation disorders because effective hemostasis is much more problematic when performing laparoscopic cholecystectomy than when performing open surgery;
  • in pregnant women (especially in the last trimester of pregnancy), as the placement of instruments and gas can be challenging;
  • in patients who have already had surgery on the abdomen and may therefore have abdominal adhesions.

Sometimes, during laparoscopic surgery, it is necessary to switch to the traditional open surgery. This may be required, for instance, if, during laparoscopic surgery, the instruments appear to pose an excessive risk of damaging adjacent organs or tissues (in about 9% of cases).

Cholecystectomy is a relatively safe procedure, but complications cannot be completely ruled out as with any surgery. They include bleeding, infection or damage to adjacent organs, which is extremely rare. The risk of death as a result of such an intervention is extremely low (less than 0.1% of cases).

In general, a special diet is not necessary after cholecystectomy. However, since the bile required for fat digestion is still produced in the liver, but can no longer be accumulated in the gallbladder and delivered in large quantities to the intestines, after the gallbladder has been removed, fatty foods should be avoided. Otherwise, you will suffer from severe diarrhea.

You can drink transparent liquids immediately after the removal of the gallbladder. You can eat normally starting from the first day after surgery. To avoid diarrhea, you need to be mindful of different things in the long term:

Reducing fat content in foods: especially in the early stages immediately after cholecystectomy, it makes sense to consider a diet with reduced fat content. If possible, patients should not consume more than three grams of fat per serving.

Increasing fiber content: grain crops such as wheat and barley contain a lot of fiber and have a positive effect on the bowel movement. However, the amount of fibers should increase slowly over several weeks, otherwise they can lead to unpleasant abdominal distension and spasms.

Increasing the amount of food you eat during the day while reducing servings – this helps the gastrointestinal tract to make better use of nutrients.

Reducing the amount of food that can cause diarrhea, such as coffee, dairy products, fatty or very sweet foods.

Prof., Dr. med. Plamen Staikov

Prof., Dr. med. Plamen Staikov

Medical Director, Head physician

Holger Bahn

Holger Bahn

Senior physician

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