Gallbladder Removal

Patient Education Partners in Your Surgical Care American College of Surgeons Division of Education Cholecystectomy Surgical Removal of the Gallbladder

LaparoscopicLaparoscopic versus versus Open Open Cholecystectomy Cholecystectomy LLaparoscopicaparoscopic Cholecystectomy Cholecystectomy OpenOpen Cholecystectomy Cholecystectomy Patient Education This educational information is to help you be better informed about your operation and empower you with the skills and knowledge needed to actively participate in your care.

Keeping You Informed Treatment Options Expectations Information that will help you further understand your operation. Surgery Before your operation— Evaluation usually Education is provided on: Laparoscopic cholecystectomy—The includes blood work, an gallbladder is removed with instruments abdominal ultrasound, Cholecystectomy Overview...... 1 placed into 4 small slits in the abdomen. and an evaluation by your Condition, Symptoms, Tests...... 2 Open cholecystectomy—The gallbladder surgeon and anesthesia Treatment Options...... 3 is removed through an incision on the provider to review your right side under the rib cage. health history and Risks and Possible Complications...... 4 medications and to discuss Preparation and Expectations...... 5 Nonsurgical pain control options. Your Recovery and Discharge...... 6  Stone retrieval The day of your operation— Pain Control...... 7 For gallstones without symptoms You will not eat or drink for at least 4 hours Glossary/References...... 8  Watchful waiting before the operation.  Increased exercise Most often you will take  Diet changes your normal medication with a sip of water. The Condition Benefits and Risks Your recovery—If you Cholecystectomy is the surgical Benefits and Risk have no complications, removal of the gallbladder. The you are often discharged operation is done to remove Gallbladder removal will relieve pain, treat home the same day after gallstones or to remove an infected infection, and in most cases stop gallstones from a laparoscopic procedure or inflamed gallbladder. coming back. The risks of not having surgery and in 2 to 3 days after are the possibility of worsening symptoms, an open procedure. Call Common symptoms infection, or bursting of the gallbladder. your surgeon if you are in  Sharp pain in the upper Possible complications include bleeding, severe pain, have stomach center or right abdomen bile duct injury, fever, liver injury, cramping, a high fever or chills, your skin turns  Low fever infection, numbness, raised scars, hernia yellow, or there is odor  Nausea and feeling bloated at the incision, anesthesia complications, puncture of the intestine, and death. and increased drainage from your incision.

This first page is an overview. For more detailed information, review the entire document.

American College of Surgeons • 633 N. Saint Cl air St. • Chicago, IL 60611 • www.facs.org Laparoscopic versus Open Cholecystectomy Laparoscopic Cholecystectomy Open Cholecystectomy

Cholecystectomy The Condition, Signs and Symptoms, and Diagnostic Tests

Common hepatic duct Common bile duct Keeping You Cystic duct Informed Pancreas Most people with gallstones Liver do not have symptoms. Pancreatic duct Eighty percent of people with gallstones go 20 years or Gallbladder Small intestine longer without symptoms.1,2

Gallstones are more Gallbladder common in people who:  are Native American  have a family history of gallstones The Condition Symptoms  are overweight The Gallbladder The most common  eat a lot of sugar symptoms of cholecystitis are: The gallbladder is a small pear-shaped   are pregnant organ under the liver. Sharp pain  do not exercise regularly in right Upper The liver makes about 3 to 5 cups of Right Left  lose weight rapidly abdomen bile every day. Bile is stored in the   Low fever use estrogen to manage gallbladder, and when food is eaten, 3,4  menopause especially fatty foods, the gallbladder Nausea and Right Left Gallbladder pain or biliary squeezes bile out through the cystic duct bloating  colic is usually temporary. It and into the small intestine. Jaundice Lower starts in the middle or right (yellowing side of the abdomen and can Gallstones of the skin) may occur if gallstones last from 30 minutes to 24 The medical term for gallstone are in the common bile duct hours. The pain may occur formation is cholelithiasis. A gallstone after eating a fatty meal. in the common bile duct is called Common  Acute cholecystitis pain choledocholithiasis. Gallstones in the lasts longer than 6 hours, ducts can block the flow of bile and cause Diagnostic Tests swelling of the gallbladder. and there is abdominal History and Physical tenderness and fever. Cholecystitis is inflammation of the  Pain on the right side of gallbladder, which can happen suddenly Tests (see glossary) the abdomen can also (acute) or over a longer period of time Abdominal ultrasound be from ulcers, liver (chronic). problems, and heart pain. This is the most common test to check Perforated gallbladder is a condition when Standard treatment for gallstones. You may be asked not the gallbladder bursts or leaks, which to eat for 8 hours before the test. of acute cholecystitis happens only in rare cases but can be is intravenous fluids, life threatening. Blood tests antibiotics, pain medication,  and cholecystectomy.5 Cholecystectomy is the surgical removal Complete blood count of the gallbladder. The most common  Liver function tests reason for a cholecystectomy is to remove  Coagulation profile gallstones that cause biliary colic (acute pain in the abdomen caused by spasm or HIDA scan, cholescintigraphy blockage of the cystic or bile duct). Endoscopic retrograde cholangiogram Magnetic resonance cholangiopancreatography

American College of Surgeons • 633 N. Saint Cl air St. • Chicago, IL 60611 • www.facs.org American College of Surgeons • 633 N. Saint Cl air St. • Chicago, IL 60611 • www.facs.org Cholecystectomy Surgical and Nonsurgical Treatment

The site is stapled or sutured Surgical Treatment closed, and a small drain may be An operation is the recommended placed going from the inside to the Keeping You treatment for gallbladder pain from outside of the abdomen. The drain is Informed gallstones, and it is the only treatment usually removed in the hospital. The for acute cholecystitis. procedure takes about 1 to 2 hours. Conversion rates from a laparoscopic to an open technique are less than 1% LaparoscopicLaparoscopic versus versus Open Open Cholecystectomy Cholecystectomy LLaparoscopicaparoscopic Cholecystectomy Cholecystectomy OpenOpen Cholecystectomy Cholecystectomy Procedure Options for young healthy people. Procedures may be done to remove  The need to convert from gallstones from the common bile duct. a laparoscopic to an open Laparoscopic transcystic common bile procedure can increase duct stone extraction is performed significantly if you are over with insertion of instruments into 65 years, are male, have a the abdomen similar to laparoscopic history of acute cholecystitis, cholecystectomy. The bile duct is past abdominal operations, entered, and stones are removed high fever, high bilirubin, directly or with a wire basket. repeated gallbladder attacks, and diseases that Endoscopic retrograde cholangio- limit your activity.5 Laparoscopic Cholecystectomy pancreatography is done by inserting This technique is the most common for an endoscope into your mouth and simple cholecystectomy. The surgeon continuing to pass it through your will make 4 small slits in the abdomen. stomach and then into the common Questions you should ask A port (nozzle) is inserted into one of bile duct. Gallstones are removed  the slits, and carbon dioxide gas inflates directly or with a balloon or basket. What type of procedure is right for me and why? the abdomen. This process allows the Complication rates range from 0  surgeon to see the gallbladder more to 9.1 per 1,000 procedures.6 How much experience easily. A laparoscope is inserted through do you have with another port. It looks like a telescope this procedure? with a light and video camera on the Nonsurgical Treatment  Has the procedure been end so the surgeon can see inside the Watchful waiting done often at this center? abdomen. Surgical instruments are  Do you know the placed into the other small openings If gallstones are seen on your ultrasound approximate cost of and used to remove the gallbladder. but you do not have symptoms, the procedure? watchful waiting is recommended.1,2 The surgeon removes the gallbladder through the incision. The carbon Gallstones only, without cholecystitis dioxide comes out through the small  slits and then the sites are closed with Increase your exercise. Exercising 2 to 3 hours a week reduces sutures, metal clips called staples, or 7,8 steri-strips. Your surgeon may start the risk of gallstones.  with a laparoscopic technique and Eat more fruit and vegetables, need to change to an open technique. and eat less foods high in sugars and carbohydrates like donuts, The procedure takes about 1 to 2 hours. pastry, and white bread. Open Cholecystectomy  Alternative medicine options are available.9 The surgeon makes an incision approximately 6 inches long in the upper right side of the abdomen and cuts through the fat and muscle to the gallbladder. The gallbladder is removed, and any ducts are clamped off.

Your surgeon will do everything possible to minimize risks, but cholecystectomy, like all operations, has risks.

The Risk What Happens Keeping You Informed Infection Infections occur in less than 1 per 1,000 Your health care team should wash their patients who have laparoscopic procedures.5,6,13,14 hands before examining you. Antibiotics are given right before the operation.5

Common bile Injury to the bile duct is reported in 1 per 1,000 Your surgeon and nurse will watch for jaundice, duct injury patients for open cholecystectomy and in 1 to 5 fever, and abnormal blood tests.5 Further per 1,000 for laparoscopic cholecystectomy.5,6,14 testing or surgery may be needed.

Bleeding Bleeding is rare. If you have chronic Your surgeon will check a coagulation profile to biliary disease, your liver may not monitor for bleeding problems. A blood transfusion form clotting factors.5,6,13 usually is not required for cholecystectomy.

Bile leakage Bile leakage after surgery is very rare. Your surgeon will check for fever, monitor labs, and may need to perform other tests such as sonography or endoscopic retrograde cholangiopancreatography (ERCP).

Retained common A gallstone may pass after surgery Your surgeon will check blood tests bile duct stone and block the bile from draining.5 for your liver function.

Pneumonia General anesthesia, lack of deep breathing Deep breathing exercises can help expand your and movement are possible causes. lungs and prevent complications after surgery.10

Heart problems Heart problems are rare. Cardiac arrhythmias Your surgeon may have you see a heart specialist were reported in about 5 per 1,000 patients before your operation. Your anesthesia provider is and heart attack in 1 per 1,000.6,13 always prepared in advanced cardiac life support.

Kidney problems Kidney or urinary problems have been reported Your surgeon may give you extra fluids before your in 5 per 1,000 patients. Dehydration and operation.5 Let your nurse know when you urinate. liver problems can increase this risk.6,13

Deep vein No movement during surgery can lead to Your surgeon or nurse will place support or thrombosis blood clots forming in the legs. In rare compression (squeezing) stockings on your legs (blood clots) cases the clot can travel to the lungs. and may give you blood thinning medication. Your job is to get up and walk after surgery.

Premature labor Fetal loss is reported as 40 per 1,000 patients These risks increase with peritonitis and fetal loss for uncomplicated cholecystectomy and as high (infection of the abdominal cavity). as 600 per 1,000 when pancreatitis is present. The risk of preterm labor also increases.11,12

Injury to the Instrument insertion and use during laparoscopic The surgeon will use extreme care and continuously intestines or technique can injure the intestines. watch for any bleeding or bowel contents during the abdominal organs procedure. Patients who are obese or who have a history of past abdominal operations or adhesions make it more difficult to move and manipulate instruments.5

Death Death is extremely rare in healthy people Your entire surgical team will review for possible and is reported as 0 to 1 per 1,000 complications and be prepared to decrease all risks. patients. The risk of death increases with gangrene, a burst gallbladder or severe diseases that limit your activity.1,6

Preparing What You Can Expect Keeping You for Your Operation A bracelet with your name and identification number will be placed on Informed Tell your surgeon about other medical your wrist. Your wristband should be An effective way to do deep problems that you have. Bring a list checked by all health care team members breathing is to breathe deeply of all of the medications that you are before providing any procedures or and hold for 3 to 5 seconds. taking, and show that list to your giving you medication. If you have Take 5 to 10 deep breaths every surgeon and anesthesia provider. any allergies, an allergy bracelet hour while you are awake. should also be placed on your wrist. Young children can do deep Most often you will take your morning breathing by blowing bubbles. medication with a sip of water. If you An intravenous line (IV) will be started are taking blood thinners (Plavix, to give your fluids and medication. The coumadin, aspirin), your surgeon medication will make you feel sleepy. may ask you to stop taking these. A tube will be placed down your throat to Home Preparation help you breathe during the operation. Questions you should ask You can often go home the same Your surgeon will perform your operation  What medications day after a laparoscopic procedure. and then close your incisions. If you have should I stop taking Your hospital stay will be longer (2 an open operation, a drain may be placed before my operation? to 3 days) for an open procedure. from the inside of your incision out your  When should I stop abdomen. taking them? Anesthesia After your operation, you will be moved  Should I take any You will meet with your anesthesia to a recovery room. medicines on the day provider before the operation. Let of my operation? Preventing Pneumonia him or her know if you have allergies,  What are the risks, neurologic disease (epilepsy or stroke), Movement and deep breathing after problems, and side effects heart disease, stomach problems, lung your operation can help prevent fluid of general anesthesia? disease (asthma, emphysema), endocrine 10 in your lungs and pneumonia.  Do I need antibiotics disease (diabetes, thyroid conditions), Preventing blood clots before surgery? loose teeth, or if you smoke, abuse alcohol  or drugs, or take any herbs or vitamins. What will you do to When you have surgery, you are at risk prevent blood clots? of getting blood clots because of not  If hair has to be removed The Day moving during anesthesia. The longer on my abdomen, how and more complicated your surgery, the will it be done? of Your Operation greater the risk. Your doctor will know  your risk for blood clots, and steps will be Did you wash your hands? Don’t eat or drink taken to prevent them. This may include Not eating or drinking for at least 4 blood thinning medication and support hours before the operation reduces your or compression (squeezing) stockings. risk of complications from anesthesia. Preventing Infection What to bring  The risk of infection can be  Insurance card and identification lowered if antibiotics are given  Advance directive (see terms) right before surgery and hair is removed at the surgical site  List of medicines with clippers versus shaving.  Personal items such as  All health care providers should wash eyeglasses and dentures their hands before examining you.  Loose-fitting comfortable clothes  Leave jewelry and valuables at home

 A small amount of drainage from Your Recovery the incision is normal. If the and Discharge drainage is thick and yellow or the site is red, you may have an Thinking Clearly infection so call your surgeon. The anesthesia may cause you to feel  If you have a drain in one of different for 2 or 3 days. Do not drive, your incisions, it will be taken drink alcohol, or make any big decisions out when the drainage stops. for at least 2 days.  Surgical staples, will be removed Avoid driving x during your first office visit. Nutrition  Steri-strips will fall off in 7 to  When you wake up, you will be 10 days or they will be removed able to drink small amounts of during your first office visit. liquid. If you are not nauseous, you  Avoid wearing tight or rough clothing. can begin eating regular foods. It may rub your incisions and  Continue to drink lots of fluids, make it harder for them to heal. usually about 8 to 10 glasses per day.  Protect the new skin, especially Activity from the sun. The sun can burn and cause darker scarring.  You will be helped getting  Your scar will heal in about 4 to out of bed and walking. 6 weeks and will become softer  Slowly increase your activity. and continue to fade over the next  Do not lift or participate in strenuous year. Keep the wound site out Steri-strips will fall off or activity for 3–5 days for laporoscopic of the sun or use sunscreen. they will be removed during and 10–14 days for open procedure.  Sensation around your incision will your first office visit  Avoid driving until your pain is return in a few weeks or months. under control without narcotics. Bowel Movements  You can have sex when you feel ready, usually after your sutures  After intestinal surgery, you may or staples are removed. have loose watery stools for several  It is normal to feel tired. You may need days. If watery diarrhea lasts longer more sleep than usual. than 3 days, contact your surgeon.  Pain medication (narcotics) can Work cause constipation. Increase the You can go back to work when you feel fiber in your diet with high-fiber well enough. Discuss the timing with foods if you are constipated. Your your surgeon. surgeon may also give you a prescription for a stool softener. Wound Care High-Fiber Foods  Always wash your hands before and Wash your hands before and after touching near your incision site. Food high in fiber include beans, after touching near your  bran cereals and whole grain breads, incision site Do not soak in a bathtub until your stitches, steri-strips, or staples are peas, dried fruit (figs, apricots, and removed. You may take a shower dates), raspberries, blackberries, after the second postoperative strawberries, sweet corn, broccoli, day unless you are told not to. baked potatoes with skin, plums, pears, apples, greens, and nuts.  Follow your surgeon’s instructions on when to change your bandages.

Pain Pain Control The amount of pain is different for each Everyone reacts to pain in a different Keeping You person. Some people need only 2 to 3 way. A scale from 0 to 10 is often doses of pain control medication, while used to measure pain. At a “0,” you Informed others use narcotics for a full week. do not feel any pain. A “10” is the Extreme pain puts extra stress worst pain you have ever felt. on your body at a time when Home Medications your body needs to focus on The medicine you need after Common Medicines to Control Pain healing. Do not wait until your your operation is usually Narcotics or opioids are used for severe pain has reached a level “10” related to pain control. pain. Some side effects of narcotics or is unbearable before telling are sleepiness; lowered blood pressure, your doctor or nurse. It is much When to Contact heart rate, and breathing rate; easier to control pain before it skin rash and itching; constipation; becomes severe. Your Surgeon nausea; and difficulty urinating. Some examples of narcotics include morphine, If you have: oxycodone, and hydromorphone.  Pain that will not go away Medications are available to control  Pain that gets worse many of the side effects of narcotics.  A fever of more than 101°F (38.3ºC) Non-narcotic Pain Medication  Vomiting  Most nonopioid pain medications Swelling, redness, bleeding, are nonsteroidal anti-inflammatory or bad-smelling drainage drugs (NSAIDs). They are used to from your wound site treat mild pain or combined with a  Strong abdominal pain narcotic to treat severe pain. They  Jaundice or yellow skin also can reduce inflammation. Some  No bowel movement or unable side effects of NSAIDs are stomach Splinting your stomach to pass gas for 3 days upset, bleeding in the stomach or  Watery diarrhea lasting intestines, and fluid retention. These longer than 3 days side effects usually are not seen with short-term use. Examples of NSAIDs include ibuprofen and naproxen. Other Instructions: Non-medicine Pain Control Distraction helps you focus on other activities instead of your pain. Music, games, and other engaging activities are especially helpful with children in mild pain. Guided imagery Splinting your stomach by placing a Follow-up Appointments pillow over your abdomen with firm pressure before coughing or movement Who Date Phone can help reduce the pain.

Guided imagery helps you direct and control your emotions. Close your eyes and gently inhale and exhale. Picture yourself in the center of somewhere beau- tiful. Feel the beauty surrounding you and your emotions coming back to your control. You should feel calmer.

Glossary of Terms For More Information Abdominal ultrasound This test uses sound For more information, please go to the American waves to determine the location of deep College of Surgeons Patient Education Web site at structures in the body. A hand roller is placed on www.facs.org/patienteducation/. top of clear gel and rolled across the abdomen. The information provided in this brochure is chosen from recent Advance directives Documents signed by clinical research. The research listed below does not represent a competent person giving direction to all of the information that is available about your operation. health care providers about treatment 1. Society for Surgery of the Alimentary Tract. Treatment choices. They give you the chance to tell of gallstones and gallbladder disease. (2003) your feelings about health care decisions. 2. National Institutes of Health. Gallstones and laparscopic Adhesions A fibrous band or scar cholecystectomy. NIH Consensus Statement (1992)12:1–28 tissue that causes internal organs 3. Nakeeb A, Cumuzzie AG, Martin L, et al. Gallstone: genetics to adhere or stick together. versus environment. Annals of Surgery (2002)235:842–849 4. Weinsier RL, Wilson LJ, Lee J. Medically safe rate of weight loss Bilirubin A blood test used to determine for the treatment of obesity: a guideline based on risk of gallstone liver and gallbladder dysfunction. formation. American Journal of Medicine (1995)98:115–117 Complete blood count (CBC) A blood test 5. Souba W, Fink M, Jurkovich G, et al. ACS Surgery: that measures red blood cells (RBCs) Principles and Practice. New York, NY: WebMD, 2004 and white blood cells (WBCs). WBCs 6. Petelin J. Laparoscopic common bile duct exploration. increase with inflammation. The normal Surgical Endoscopy (2003)17: 1705–1715 range for WBCs is 8,000 to 12,000. 7. Leitzmann MF, Giovannucci EL, Rimm EB, et al. The relation of physical activity to risk for symptomatic gallstone disease Endoscopic retrograde cholangiogram An in men. Annals of Internal Medicine (1998)128:417–425 endoscope with a camera on the end is 8. Leitzmann MF, Rimm EB, Willet WC, et al. Recreational passed through your mouth, stomach, physical activity and the risk of cholecystectomy in women. and intestines into the bile duct to New England Journal of Medicine (1999)341:777–784 check for and remove gallstones. 9. Moga MM. Alternative treatment of gallbladder disease. Medical Hypothesis (2003)60:143–147 HIDA (hepatobiliary iminodiacetic acid scan) 10. Overend TJ, Anderson CM, Lucy SD, et al. The effect of A scan that images the liver, gallbladder, incentive spirometry on post-operative complications. Chest and bile ducts following injection of (2001)120:971–978 radiolabeled dye into the veins. 11. Graham G, Baxi L, Tharakan T. Laparoscopic cholecystectomy Hernia A bulge through an abnormal during pregnancy: a case series and review of the literature. opening in the abdominal wall. Obstetrics and Gynecology Survival (1998)53:566–574 12. Al-Fozan H, Tulandi T. Safety and risks of laparoscopy in pregnancy. Magnetic resonance cholangiopancreatography Current Opinion in Obstetrics and Gynecology (2002)14:375–379 A scan that uses powerful magnets and 13. Khaitan L, Apelgren K, Hunter L, et al. A report on the Society radio waves to show pictures of the body. of American Gastrointestinal Endoscopic Surgeons (SAGES) outcome intiative. Surgical Endoscopy (2003)17:365–370 14. Giger UF, Michel JM, Opitz I, et al. Risk factors for perioperative complications in patients undergoing laparoscopic cholecystectomy: This information is published to educate you about your specific surgical procedure. It is not intended to take the analysis of 22,953 consecutive cases from the Swiss Association place of a discussion with a qualified surgeon who is familiar of Laparoscopic and Thoracoscopic Surgery database. Journal with your situation. It is important to remember that each of the American College of Surgeons (2006)203:723–728 individual is different, and the reasons and outcomes of any operation depend on the patient’s individual condition. Reviewed by: Patricia L. Turner, MD, FACS The American College of Surgeons (ACS) is a scientific and Mark Malangoni, MD, FACS educational organization that is dedicated to the ethical and competent practice of surgery. It was founded to raise the standards of surgical practice and to improve the quality of care for the surgical patient. The ACS has endeavored to present information for prospective surgical patients based on current scientific information; there is no warranty on We are grateful to Ethicon Endo-Surgery for their support the timeliness, accuracy, or usefulness of this content. in printing this document.

American College of Surgeons • 633 N. Saint Cl air St. • Chicago, IL 60611 • www.facs.org