Gallstones and Gallbladder Disease
Gallstones (cholelithiasis) affect approximately 10-15% of adults and are the most common reason for upper GI surgery. Cholesterol gallstones (80%) and pigment stones form within the gallbladder and can cause significant symptoms and complications.
Clinical presentations requiring surgery:
Biliary colic: Episodic severe right upper quadrant/epigastric pain after fatty meals - caused by temporary stone impaction in the cystic duct. Episodes typically last 30 minutes to several hours. Laparoscopic cholecystectomy is recommended after first symptomatic episode in low-surgical-risk patients.
Acute cholecystitis: Stone impaction without relief - inflammation of gallbladder wall - fever, persistent RUQ pain, Murphy’s sign positive, elevated WCC and CRP. Early laparoscopic cholecystectomy (within 72 hours) versus interval after 6 weeks - both are acceptable; early is now preferred by most guidelines.
Choledocholithiasis (CBD stones): Gallstones migrating into the common bile duct - causes obstructive jaundice, abnormal LFTs, potential ascending cholangitis (Charcot’s triad: jaundice + fever + RUQ pain). ERCP (endoscopic retrograde cholangiopancreatography) clears CBD stones, followed by laparoscopic cholecystectomy.
Gallstone pancreatitis: Stone transiently obstructing the pancreatic duct - elevated serum amylase/lipase; moderate to severe abdominal pain. Cholecystectomy within the same hospital admission (mild pancreatitis) or within 6-8 weeks (moderate-severe) is essential to prevent recurrence.
Gallbladder polyps: Polyps ?10 mm (or ?6 mm with risk factors) - cholecystectomy due to malignant potential.
Investigations before surgery:
- Abdominal ultrasound (first-line): demonstrates gallstones; wall thickness; CBD diameter
- LFTs, amylase: assess biliary obstruction and pancreatic involvement
- MRCP (MRI cholangiopancreatography): non-invasive CBD assessment if ultrasound/LFTs suggest CBD stones - negative MRCP avoids pre-op ERCP
- Intraoperative cholangiogram (IOC): performed at time of cholecystectomy if CBD not fully cleared
The Surgical Procedure
Standard 4-port laparoscopic cholecystectomy: Under general anaesthesia; CO- pneumoperitoneum; 10 mm umbilical port (camera), 5 mm epigastric port (retraction), and two 5 mm right subcostal working ports. The gallbladder is dissected out of the liver bed using a hook diathermy/energy device. Critical View of Safety (CVS) - both cystic duct and cystic artery clearly identified as entering the gallbladder - before division. Clips applied to cystic duct and artery; gallbladder excised and extracted via umbilical port in a retrieval bag.
3-port (single-incision modifications): Experienced surgeons may perform with 3 ports for simple, non-inflamed gallbladders - reduced port site pain, better cosmesis.
Intraoperative cholangiogram (IOC): If the CBD requires assessment intraoperatively (unexplained CBD dilatation, intraoperative bile duct injury concern, or protocol-based): contrast dye injected via cystic duct with fluoroscopic imaging. If CBD stones found: laparoscopic CBD exploration or post-operative ERCP.
Conversion to open (<5%): Occasionally required for severe inflammation, anatomical variant, inadvertent bile duct injury, or bleeding. Experienced upper GI surgery teams have conversion rates <5% for elective cases.
ERCP (Endoscopic Retrograde Cholangiopancreatography): If choledocholithiasis confirmed (MRCP positive), ERCP is performed before cholecystectomy: endoscope passed to ampulla of Vater; sphincterotomy made; balloon/basket stone extraction from CBD. Success >90%. Same admission as cholecystectomy (ERCP Day 1; cholecystectomy Day 2) is possible in planned cases.
Acute cholecystitis (emergency or semi-urgent): Partner hospitals accept urgent referrals for acute biliary disease requiring early cholecystectomy - typically operable within 24-48 hours of assessment.
Recovery and Costs
Typical recovery:
- Hospital: Day case (4-6 hours) or 1 night
- Hotel: 3-5 nights recommended before flying
- Pain: mild incisional discomfort; shoulder-tip pain from residual CO- for 1-2 days
- Diet: light diet for 24 hours; resume normal diet from Day 2
- Driving: 5-7 days
- Return to desk work: 5-7 days; manual work: 2-3 weeks
- Flying: 5-7 days post-op (no intraperitoneal gas concerns)
- Laparoscopic port sites: small dressings; removed at Day 5-7
- Pathology: gallbladder sent for histology; results in 5-7 days (important to exclude gallbladder cancer in rare cases)
Diet after cholecystectomy: The gallbladder’s concentration function is removed. Most patients tolerate normal diet within days. A small proportion (10-15%) have loose stools initially (bile acid-related) - usually resolves within 4-8 weeks. High-fat meals may cause loose stools in the first few months - gradually tolerated.
Cost comparison:
| Procedure | Turkey | UK Private |
|---|---|---|
| Laparoscopic cholecystectomy (elective) | -2,500-4,000 | -5,000-8,000 |
| With pre-op MRCP | +-400-600 | +-800-1,200 |
| ERCP + cholecystectomy | -4,000-6,000 | -8,000-14,000 |
All-inclusive: surgeon, anaesthetist, hospital, histopathology, and BB Global Health coordination.