Laparoscopic Bile Duct Exploration
Laparoscopic cholecystectomy is a keyhole operation to remove the gallbladder. It is one of the most common operations performed. It involves using a small camera and surgical instruments that are inserted through small cuts (incisions) in your abdomen.
The gallbladder is a small, pear-shaped pouch that sits under the liver in the right upper part of your abdomen (tummy). It stores bile that is produced by the liver. When you eat fatty foods, a non-diseased gallbladder contracts and squirts the bile down the bile duct into the intestine to help with food digestion.
The following are the indications for a cholecystectomy (removal of the gallbladder):
1. Symptoms from gallstones are by far the most common indication. Bile is made of several chemicals (cholesterol, bile salts and waste products) that are sensitive to hormonal changes in the body as well as changes in our weight (weight gain and weight loss). When the balance of these hormonal changes is disturbed, such as what might occur with pregnancies, menstrual cycle, the use of contraceptive pills etc., the balance between these chemicals is disrupted resulting in the precipitation of crystals that clump together forming stones. That’s why women are more likely to develop gallstones than men (the chances are 9 women to 1 man). Gallstones are common and cholecystectomy is usually reserved to people who develop pain or complications from gallstones.
2. Rarely, however, polyps might develop in the gallbladder and warrant a cholecystectomy. This is particularly if the polyps are causing symptoms, are multiple, 1cm in size or larger or if they are enlarging. Otherwise, a follow up ultrasound, perhaps once a year, might be all that is needed to keep an eye on those polyps.
3. The gallbladder might rarely become diseased and acutely inflamed (called “cholecystitis”) in the absence of gallstones (called “acalculous cholecystitis”) and require a cholecystectomy.
Most gallstones cause no symptoms and are incidentally detected on an ultrasound scan or other form of imaging of the abdomen during the course of investigations for other conditions (and consequently do not require surgery). However, in a small proportion of patients the gallstones can cause abdominal pain usually in the right upper abdomen called “biliary colic”.
The pain can also be felt in the middle of the chest and sometimes becomes confused with a heart attack. It is not uncommon that some patients end up having extensive heart tests before gallstones are discovered. The pain could rarely be present in the left upper abdomen only. Most people will describe the pain as of sudden onset, severe, colicy in nature, precipitated by food, especially fatty foods, may be felt like a band gripping across the upper abdomen and may well radiate into the back.
It tends to last for few minutes to few hours at a time and often resolves all of a sudden and its own. Attacks of pain of lesser severity are also common. Sometimes the pain might last longer and go on for few days; this is often suggestive of a complication of gallstones such as acute cholecystitis, mucocele of the gallbladder, or pancreatitis (see below). Nausea and vomiting as well as palpitation (the heart beating fast) and sweating are also common symptoms that are associated with abdominal pain.
An ultrasound of abdomen is the standard test for detecting gallstones, and in that regard is much more likely to pick these up than a CT scan. However, an ultrasound of abdomen is operator-dependent and if it is negative in the presence of a strong clinical suspicion of gallstones, consideration should be given to a repeat ultrasound of abdomen by a more experienced radiologist or radiographer. Rarely stones may not be detected on an ordinary ultrasound and can only be shown on an endoscopic ultrasound (EUS) which involves the use of special camera with a scanner at the tip of it that is then passed through the mouth into the stomach under sedation and comes very close to the gallbladder inside the abdomen to detect finer stones.
Complications of gallstones are not uncommon. The most common complications may include:
1. Acute cholecystitis:
This is the most common complication of gallstones and represents an acute inflammation of the gallbladder that is often caused by a stone obstructing the gallbladder. This is characterised by a rather constant, and often severe, pain in the right upper abdomen, fever, nausea and vomiting. Most surgeons would manage this with antibiotics, and possibly an ultrasound-guided drainage of the gallbladder, until the inflammation settles down and then arrange a laparoscopic cholecystectomy 3 months later as the surgery tends to be easier to perform then and much more likely to be completed by keyhole surgery without needing to convert to an open operation with a large incision. However, my preference is to perform a laparoscopic cholecystectomy urgently in this setting as there is a 20% (1-in-5 patients) chance that the acute inflammation will not settle and then a potentially more difficult emergency cholecystectomy might become necessary and there is a 20% chance that the gallbladder will flare up again within the 3 months while one is awaiting a laparoscopic cholecystectomy. The concerns that most surgeons have about an urgent cholecystectomy while the gallbladder is inflamed are that the surgery is likely to be much more difficult and therefore might need to be converted to open surgery as well as the associated risks of bleeding and injury to the main bile duct (a potentially serious complication). However, Professor Ammori has a large experience with laparoscopic cholecystectomy for acute cholecystitis and none of these required conversion to open surgery or sustained a bile duct injury. Failure to treat acute cholecystitis promptly and adequately could result in sepsis and peritonitis, which are serious and potentially life threatening complications.
2. Obstructive Jaundice:
This refers to a yellowish discolouration of the skin and the whites of the eyes). It is often caused by at least one or multiple stones passing from the gallbladder into the main bile duct and causing obstruction to the flow of bile. One’s bowel motions often become rather pale and clay-coloured, the urine becomes dark and tea-coloured and the skin becomes itchy. This is often associated with abdominal pain (biliary colic). The presence of a bile duct stone can be confirmed on a scan (called MRCP) but these are occasionally seen on a simple ultrasound scan of the abdomen. The stone might pass spontaneously, but most likely these will need to be removed either by a camera procedure that is passed into the stomach under sedation during (called ERCP), or during surgery to explore the bile duct and remove the gallbladder. Although most surgeons prefer ERCP to clear the duct before proceeding at a later date to a laparoscopic cholecystectomy, my own preference in fit patients is to perform a laparoscopic cholecystectomy and explore the bile duct to clear it at the same time. This is technically more challenging to the surgeon and requires additional specialist expertise, but there is evidence to suggest that the risk of such an operation are lower than the added risks of an ERCP followed by a laparoscopic cholecystectomy. An ERCP carries a 3% risk of causing acute pancreatitis (inflammation of the pancreas as the pancreatic duct and the bile duct open at the same point into the intestine and the pancreas can become irritated by the ERCP procedure), bleeding or perforation of the duodenum (intestine), albeit rare, as well as the potential for failing to access the bile duct or failing too clear the bile duct by one procedure that then requires repeated ERCPs.
3. Acute pancreatitis:
This is acute inflammation of the pancreas gland that sits behind the stomach and produces insulin to help regulate the levels of our blood sugar. The duct of the pancreas gland joins the main bile duct (called common bile duct) at the same point into the intestine, just beyond the stomach, and drains its digestive juices into the intestine. A gallstone passing down the bile duct may temporarily block the pancreatic duct resulting in acute pancreatitis; this is more likely to be caused by smaller than larger stones. Acute pancreatitis is an infrequent complication of gallstones and is characterised by a constant central abdominal pain around the belly button that is often severe and associated with fever, nausea and vomiting. Although it is commonly mild and resolves within few days, acute pancreatitis can be quite severe in 3-out of-10 patients (30%) who then end up with further complications.
4. Mucocele of the gallbladder:
This is caused usually by a large gallstone that blocks the gallbladder and prevents its secretion (mucus) from draining down the bile duct into the intestine. The gallbladder fills up and distends with mucus causing a constant dull ache under the right lower ribcage. Unlike acute cholecystitis, there is no infection here and no symptoms of fever or sepsis.
The complications of laparoscopic anti-reflux surgery are considerably less than with open anti-reflux surgery. However complications may occur as with any operation. Complications during operation may include anaesthetic complications, bleeding, injury to the oesophagus, stomach or very rarely the spleen. Complications may occur after the operation such as woundIf gallstones are found incidentally on a scan and are not causing symptoms, they can be left alone and no surgery is needed. Otherwise, a laparoscopic cholecystectomy is recommended as once the gallstones cause symptoms (usually pain), they will go on to cause further attacks of biliary colic and/or complications. If someone is unfit for surgery, it is possible to attempt to dissolve the stones with drugs; however, the chance of success is very small indeed, the medications will need t be taken for quite some time and up to a year. Moreover, these medications are not without their side effects, and once discontinued the stones re-form fairly quickly. If the gallbladder, for example, is opened and the gallstones are removed without removing the gallbladder, the stones will undoubtedly re-form and recur.
Although gallstones that are not causing symptoms are usually left untreated, there is some argument for recommending laparoscopic cholecystectomy in young women (who are likely to run into problems with gallstones in the future especially during pregnancies) and in those with diabetes or those who are on immune suppressing drugs (as they are at risk of developing more severe forms of acute cholecystitis due to their suppressed immunity). infection, although this is very rare, and chest infection.
If the surgeon experiences difficulties in removing the gallbladder by keyhole surgery, such as bleeding, severe adhesions from previous inflammation or confusion about the exact anatomy, then conversion to an open operation while you are asleep (under general anaesthesia) may become necessary. This involves a large incision in your abdomen, and is a more invasive operation than keyhole surgery that requires a longer stay in hospital and it takes longer to recover.
Professor Ammori has converted only one amongst more than 1000 patients on whom he performed a laparoscopic cholecystectomy (less than 0.1%). It is extremely rare that a surgeon might decide to abandon the operation altogether if the abdomen is hostile and the surgery, even if done by open technique, is deemed too risky.
A cholecystectomy will have no adverse effects on you or your body functions, and this is the case in the large majority of patients. Rarely, however, someone might experience loose frequent stools during the initial few weeks or months after surgery that usually resolves without a need for medications. This is attributed to an element of bile salt malabsorption. If certain foods do trigger symptoms, you may wish to avoid them in the future.
Some people might put weight on after surgery as they find that they can finally indulge in some of the foods that are rich in fat, and often carbohydrates, without experiencing abdominal pain.
The body will adapt with time, and if you have a scan of your abdomen some years after cholecystectomy, it might show that the common bile duct has dilated (to take on some of the bile storage function of the removed gallbladder).
Gallstones can form in the common bile duct years after a cholecystectomy in approximately 1-in-100 people. Caution with fatty foods is advised.
Most people have this surgery as a day-case procedure and leave the hospital on the same day after the operation. Some, however, will stay overnight. You can resume normal activity within two weeks, return to driving within 10-14 days, and return to strenuous activity and sports within 4 weeks of surgery. In the rare event that your surgery is converted to an open operation, your hospital stay will be longer (3-7 days) and your recovery will be slower. Professor Ammori has converted only one of more than 1000 patients to open surgery (conversion rate of less than 0.1%).
Laparoscopic cholecystectomy is generally a safe procedure with very low risk of complications. The most common complication is infection at the site of the incision, which might happen in around 1 in 15 patients. Bleeding is a rare complication after any operation and might require a return to theatre for re-laparoscopy. Deep vein thrombosis is also rare and we routinely prescribe elastic stockings and a heparin injection before surgery to thin the blood and reduce that risk, and routinely use special boots around your legs during surgery that inflate and deflate alternately to keep the blood in your legs moving.
A bile leak is a rare but relevant complication of a cholecystectomy and although it usually settles after insertion of a drain into the abdomen using an ultrasound scan, it may rarely be a consequence of a previously undetected stone in the bile duct or a bile duct injury. Bile duct injury can be a serious complication of a cholecystectomy and is reported to occur in 1-in-300 patients (0.3%). Professor Ammori has had no bile duct injury in over 1000 laparoscopic cholecystectomies. A previously undetected stone in the common bile duct after a cholecystectomy will require an ERCP (a camera procedure through the mouth) to remove that stone, or rarely a further laparoscopic operation.
If detected before your laparoscopic cholecystectomy, small bile duct stones of 3mm or less in diameter might pass spontaneously. Most stones however are larger than 3mm in diameter and will need to be removed either at an ERCP or during laparoscopic cholecystectomy whereby the bile duct is explored (opened).
Although most surgeons prefer ERCP to clear the duct before proceeding at a later date to a laparoscopic cholecystectomy, my own preference in fit patients is to perform a laparoscopic cholecystectomy and explore the bile duct to clear it at the same time. This is technically more challenging to the surgeon and requires additional specialist expertise, but there is evidence to suggest that the risk of such an operation are lower than the added risks of an ERCP followed by a laparoscopic cholecystectomy. An ERCP carries a 3% risk of causing acute pancreatitis (inflammation of the pancreas as the pancreatic duct and the bile duct open at the same point into the intestine and the pancreas can become irritated by the ERCP procedure), bleeding or perforation of the duodenum (intestine), albeit rare, as well as the potential for failing to access the bile duct or failing too clear the bile duct by one procedure that then requires repeated ERCPs.
The surgeon may suspect gallstones to be present in the bile duct during laparoscopic cholecystectomy if the common bile duct is found to be rather dilated, and this can be confirmed during the surgery with an X-ray in which a dye is injected into the bile duct and an image taken, called cholangiography. A laparoscopic ultrasound, if available, is an alterative option to detect stones in the bile duct during laparoscopic cholecystectomy. The management options for such bile duct stones are again either an ERCP (performed after surgery or during surgery if there is expertise available to do it there and then) or by laparoscopic exploration of the bile duct which is the choice Professor Ammori prefers for the reasons mentioned earlier.
Professor Ammori has a large expertise in advanced laparoscopic surgery as well as having been a specialist in surgery of the biliary tree, liver and pancreas. He has performed over 1000 laparoscopic cholecystomies with only a single conversion to open surgery in his early days as a Consultant and with no bile duct injuries.
He is able to deal with difficult gallbladders laparoscopically, thus offering the advantages of minimally invasive surgery to his patients including those of shorter hospital stay, rapid recovery and better cosmetic outcome. If you are suffering with acute cholecystitis, Professor Ammori prefers to offer you a laparoscopic cholecystectomy early rather than adopt the approach preferred by most surgeons of waiting for three months, during which the inflammation might not settle (1-in-5 patients) or might recur while waiting (1-in-5 patients). Should you happen to have a stone in the bile duct, professor Ammori has the rare expertise of being able to explore your bile duct laparoscopically at the same time as your cholecystectomy and clear the duct, and therefore resolve the problem at the same setting without having to take a chance on an ERCP at a later date.