Not every gallbladder is the same operation

“I have gallstones. Surgery is much the same wherever I have it, isn't it?” It is a question I hear often enough from patients arriving with a screening report in hand, and there is something in it. Removing the gallbladder is one of the operations a general surgeon does most.

What is not true is that every one of them is the same operation. A gallbladder that holds stones and has never been inflamed, and a gallbladder that has been inflamed repeatedly until it is stuck fast to what is around it, are two different situations from the moment the abdomen is opened. The same named procedure can differ widely in difficulty and in how it has to be approached.

What makes one gallbladder harder than another#

To take a gallbladder out safely, the cystic duct and the cystic artery have to be identified with certainty and dealt with. The difficulty is that the anatomy around them is not the same in everyone. The position of the ducts and vessels and the way they branch vary between people, and where inflammation is severe the tissue swells and adheres until the boundaries that would normally be visible are not.

Misjudge a structure there and the bile duct or a neighbouring vessel can be injured. Bile duct injury in particular can lead to a complication serious enough to require further procedures or another operation. That is why an operation this common still turns on taking the time, during it, to confirm what each structure is.

Does a gallstone without symptoms need an operation?#

Finding a gallstone incidentally on a health checkup does not mean it has to come out. Stones causing no pain and no cholecystitis can usually be watched. There are cases in which pre-emptive surgery is considered on the basis of the size of the stone, the state of the gallbladder and other conditions the patient has, so the judgement is an individual one.

It is different once a stone is causing repeated pain in the right upper abdomen, or has produced a complication — cholecystitis, cholangitis, pancreatitis. At that point the questions become whether the gallbladder needs to come out and when it is appropriate to do it.

What repeated inflammation leaves behind#

Repeated attacks of cholecystitis can make the operation harder. Inflammation that flares and settles, over and over, thickens the wall of the gallbladder and binds it to the tissue around it until the original boundaries are indistinct. Where it has been severe, the duodenum or the colon next to the gallbladder can be adherent firmly enough that separating them safely becomes part of the operation.

What matters in that situation is not getting the gallbladder out at any cost, but operating while the structures are being confirmed. Before the cystic duct and cystic artery are divided, the surrounding tissue has to be dissected far enough to make clear what each structure actually is.

If they cannot be told apart safely, another route can be taken. Converting to a subtotal cholecystectomy, which leaves part of the gallbladder behind, or to open surgery where that is what the situation calls for — changing the approach to match the patient and what is found during the operation. Recognising a dangerous situation and moving to a safer method is a better judgement than holding to the plan the operation started with.

Is an operation with fewer holes a better one?#

Fewer incisions in the abdomen does not necessarily mean a better gallbladder operation. Single-incision laparoscopic surgery, done through one opening, has the advantage of a smaller scar, but which method to use has to be decided from the degree of inflammation and adhesion and the state of the patient.

Where the gallbladder is badly inflamed and the surrounding structures are hard to distinguish, securing an adequate view and confirming the ducts and vessels safely comes before the size of the scar.

• A meta-analysis of 48 randomised trials, 2,838 patients having single-incision surgery against 2,956 having conventional multiport surgery, found single-incision associated with 2.51 times the risk of incisional hernia (95 percent confidence interval 1.23 to 5.12) and an operation about 15 minutes longer, with complications otherwise equivalent.
• A network meta-analysis of 96 randomised trials and 11,083 patients found no significant difference between minimally invasive techniques in bile duct injury, bile leak, intra-abdominal infection or conversion to open surgery.

So if an operation is coming, rather than comparing how many holes will be made, it is better to establish first how difficult your own gallbladder is likely to be. If you have been told that cholecystitis has recurred or that the inflammation is severe, the things worth looking at together are whether a high-difficulty gallbladder can be handled, whether the approach can be changed appropriately according to what is found during the operation, and whether the treatment that would be needed afterwards can be carried on if a problem arises.

In the end what matters in gallbladder surgery is not making the smallest wound. It is finishing the operation safely, by the method that suits the state of the gallbladder.