Artlabeling Activity the Anatomy of the Gallbladder and Bile Ducts

Gallbladder and Bile Duct Surgery

i) Background

The gallbladder is a pocket-sized pear shaped organ that lies in the upper right part of the abdomen just underneath the liver and close to the diaphragm and rib cage. It acts as a reservoir for bile which is a digestive juice made by the liver and excreted down the bile duct which is a narrow tube coming out of the liver. The gallbladder is continued to the bile duct past a tube called the cystic duct. Bile enters and leaves the gallbladder via this connecting tube. The bile duct runs down to the bowel where it enters the duodenum. The valve where the bile duct meets the duodenum is called the ampulla (ampulla of Vater) information technology is also known as the sphincter of Oddi.

When yous have a meal the sight and smell of food causes a complex chain of events to outset which control release of bile into the duodenum from the gallbladder and bile duct via the ampulla. Food, particularly fatty food, inbound the gut is a further strong stimulus for release of bile, which continues to be released until nutrient and digestive juices attain the next part of the bowel.

If yous do non accept a gallbladder (e.m. following surgery) it makes very piffling difference to this procedure since bile is stored in the bile duct instead of the gallbladder. A normal gallbladder holds but around 25-40ml of bile. An boilerplate person makes 500-800ml of bile per day.

2) Gallstones

Gallstones are extremely common, every bit many as twenty per cent of the UK population may go them during their life time. Most people with gallstones get no symptoms and need no treatment.

Gallstones are usually made from cholesterol or bile pigments, both of which are normal constituents of bile. They may develop for several reasons, either because of an excess of ane or other elective in the bile or because the gallbladder is not emptying properly thus allowing sediment to form or because there are aberrant proteins in the bile triggering precipitation of cholesterol or pigment stones.

Most stones are just a few millimetres across although occasionally they may attain 4-5cm

iii) Common symptoms

When gallstones kickoff to crusade problems they unremarkably give some of the following symptoms.

Pain , this is commonly felt under the ribs on the correct manus side of the abdomen (tummy), it may be felt across the whole of the upper abdomen in some patients. It may concluding minutes or hours. Information technology can be very severe, it is usually a precipitous, cramping or aching pain that cannot easily be relieved except by potent medication. Women ofttimes compare it to labour pains. It is often chosen biliary colic by doctors. The pain may travel into the back or shoulder. It is usually worse after eating fat foods.

Bloating / indigestion, uncomfortable distension of the belly after fatty meals

Jaundice , yellow pigmentation of the skin and eyes, often accompanied by very night urine and stake bowel motions . This is unremarkably caused by passing a stone.

Itching / fever / rigors . Patients with stones in the bile duct oftentimes get itchy skin, a loftier temperature and episodes of shaking / tremor (rigors). Anyone with these symptoms should seek urgent medical advice.

4) Laparoscopic (keyhole) surgery

Most patients with symptomatic gallstones are advised to have the gallbladder removed. This can normally exist done as a keyhole operation involving four small holes in the wall of the abdomen (tummy), through which a camera and various operating instruments are introduced. In full general this is a relatively condom operation that takes between twenty and xc minutes depending on the complexity of the case and the caste of inflammation around the gallbladder. In patients in whom we doubtable there may be stones in the bile duct we accept pictures of the duct either with a laparoscopic ultrasound probe placed directly on the bile duct, or by injecting dye into the bile duct and taking X-rays (operative cholangiogram ).

Most patients get home on either the same 24-hour interval as the operation or the next day.

5) Bile duct stones

Bile duct stones can crusade severe symptoms and trigger some quite dangerous illnesses such as pancreatitis (inflammation of the pancreas) and cholangitis (bile duct infection / inflammation). We always remove bile duct stones (unless they are very tiny), in that location are several ways of dealing with them.

a) Laparoscopic bile duct exploration this is a keyhole technique used to remove stones from within the bile duct by passing baskets and other instruments into the bile duct and fishing the stones out nether 10-ray guidance. It is mainly suitable for cases where the bile duct is dilated and there are only a few small-scale or medium sized stones lying in it. Information technology tin exist a technically very difficult procedure and it is only successful in around 60% of cases. However in experienced easily information technology is a low chance process virtually every bit safe as ordinary keyhole gallbladder surgery.

b) Open bile duct exploration this is used for cases where the stones in the duct are big, impacted or cannot be removed by other methods. Information technology is an open operation involving a xv-25cm incision in the top correct manus side of the belly beneath the rib cage to let access to the bile duct. Most patients stay in hospital for effectually a calendar week afterwards the surgery and take viii-12 weeks to return to full normal activities. In complicated or recurrent bile duct stones the operation may include a drainage procedure replumbing the bile duct to improve the flow of bile into the bowel and preclude stones reforming. This is major surgery and carries an increased risk of postoperative complications when compared with keyhole surgery, still it is extremely effective.

c) ERCP and sphincterotomy this is an endoscopic technique where a flexible telescope is passed via the mouth into the duodenum and used to extract stones from the lower end of the bile duct past cutting open the muscular valve (sphincterotomy) at the ampulla (see diagram of beefcake above) and passing baskets and balloons up the duct from below. It is a relatively safe procedure just it still has risks including pancreatitis, haemorrhage, duodenal perforation and cholangitis. The mortality for this procedure is generally quoted equally being betwixt 1:250 and 1:500 beyond the UK..

d) PTC this involves passing needles and tubes through the wall of the abdomen to gain access to the bile ducts in the liver. It is rarely used for retrieving gallstones, usually in patients non fit for surgery in whom ERCP has failed.

6) Common questions earlier gallbladder surgery

My symptoms have eased off , do I still demand the operation? In one case gallstones have started to cause symptoms the bug tend to proceed coming back time after time, unremarkably getting more and more than frequent. Thus in general we recommend operating on patients who have had any typical biliary symptoms and have stones on ultrasound.

Should I be on a low fatty diet? This usually improves symptoms in the curt term but information technology will not make stones resolve.

Is it safer to have open surgery? In general the overall risks of laparoscopic and open surgery are both depression. Laparoscopic (keyhole) surgery allows a much faster return abode and return to full physical activeness / work. The disadvantage of keyhole surgery is that information technology is associated with higher levels of injury to the common bile duct (encounter anatomy diagram), which is a very serious complication, the nationally accepted figure for bile duct injury is approximately 1:150 cases. All of the surgeons on this website are specified biliary experts each removing between fifty and i hundred and twenty gallbladders per year. Equally a group our incidence of pocket-sized bile duct injury is 1:400 and major bile duct injury ane:800 over the concluding 2 years, the mortality from the surgery is approximately 1:yard cases. The disadvantages of open surgery are higher levels of post operative hurting, longer hospital stay and increased risk of serious cardiac and respiratory complications such as eye attacks / chest infections / pneumonia / deep vein thrombosis and pulmonary embolus (blood clots on the lung), the mortality from open up surgery is effectually ane:200.

What is a cholangiogram? This is an X-ray of the bile ducts washed during the operation to exclude stones in the bile duct. We usually practice one if you lot accept been jaundiced, had pancreatitis or your scans or blood tests suggest at that place may be a rock stuck in the chief bile duct.

How long volition I stay in infirmary? If you are reasonably fit and not overweight then we should be able to do this equally a 24-hour interval case where yous spend only 6-viii hours or and so in hospital. If you are less fit then you will need to stay at least ane dark in hospital. For open surgery the standard length of stay is 5-10 days depending on your fitness and the magnitude of the operation.

Tin can you dissolve the stones? There are treatments that tin can dissolve stones to some extent, still you require lifelong drug handling and the medications are not effective for the majority of stones. These treatments are only used equally a terminal resort for patients not fit for surgery in the UK.

Can you break the stones with lasers / ultrasound etc? Actress corporeal shock moving ridge lithotripsy (ESWL) is a well recognised technique for breaking up kidney stones which are usually hard and chalky and shatter well. Unfortunately gallstones are soft and oftentimes fatty so they do not shatter well, plus if they do interruption upward rather than passing or dissolving you lot are unremarkably left with lots of modest stones rather than a few large ones. This may cause more than rather than fewer symptoms. This is another last resort treatment that is nearly never used in the UK.

Practice I need my gallbladder? No, its only function is to store bile. If yous develop gallstones it is probably not emptying properly already and is therefore largely redundant. At that place are other mechanisms which control the production, release and storage of bile and these fully compensate for the loss of the gallbladder.

Tin you simply take the stones out? Yes nosotros could but this would exist a pointless exercise equally you would just make new stones in the gallbladder and need more than treatment.

7) Common questions after surgery

How long exercise I need off work? For keyhole surgery you will need a couple of weeks off unless your job is a very heavy manual task (eastward.thou. labourer / hod carrier / nurse / farmer) when y'all are amend brash to take 3-4 weeks off in total. If you have open surgery then for an office job you lot will need around four to half-dozen weeks off work and for a heavy transmission job 2-3 months.

When can I drive? For whatever operation the fundamental question is tin can you safely control the car and practise an emergency end? For keyhole surgery most people are comfortable enough to achieve this 7-10 days after surgery. For open surgery it is more like iv-6 weeks.

When can I play sport again? The same answer applies as for return to piece of work, relatively gentle sports (swimming / jogging) can be resumed a fortnight afterwards keyhole surgery if you feel comfortable, but very physical or contact sports (east.m. circuit training / weight training / rugby / martial arts) should be left for a month or so. Later open surgery gentle sporting action can be resumed after 4-6 weeks and more than strenuous concrete exertion after 8-12 weeks.

I accept a red patch around one of the wounds, is this ok? It is common to get a picayune bruising and redness around the port sites (laparoscopic wounds) on your stomach, most often the port closest to your omphalus is affected. If this extends for more an inch (two.5cm) on either side of the wound, or if it discharges pus or is very hot and bloated information technology should be reviewed either past your exercise nurse, GP, or a member of the surgical team every bit yous may be developing a wound infection.

I have had more pain and my urine has gone dark, is this right? About i person in v gets a like pain to their gallstone hurting within the get-go few weeks of surgery, this usually passes chop-chop and does not crave further investigation or activity. It probably represents passing a few tiny pieces of rock droppings that take been dislodged during surgery. Withal very occasionally (one or 2 cases per 100) a larger fragment of stone has been dislodged and this may become stuck in the lower bile duct and crusade severe symptoms and dark urine and fifty-fifty jaundice. If you become jaundiced after gallbladder surgery you must see your doctor at one time and be referred dorsum to your surgeon or another surgeon familiar with your case the same day.

I take been sent home with a T-Tube coming out of my tummy what is this? If we surgically explore the bile duct to remove stones from it we usually leave a T shaped condom drainage tube in the bile duct equally a temporary safety valve whilst information technology is healing up over again. One end of this comes out of the wall of the abdomen and drains some of your bile into a purse. The tube is usually left in for 2-vi weeks depending on the nature of the surgery. Information technology can easily be removed in clinic when everything has safely healed within.

8) Bile duct Reconstruction.

This major surgery is usually performed to correct injuries to the bile duct which are most unremarkably caused during surgery for gallstones. If y'all have a bile duct injury it is best to have information technology dealt with by a specialist hepatobiliary surgeon with a specific involvement in this work. In Southampton two surgeons bargain with the majority of these problems from the surrounding region .

9) Malignant diseases of the gallbladder and bile ducts.

Gallbladder cancers and bile duct cancers are rare in the UK. They are cholangiocarcinomas and are best considered either with primary liver cancers (come across Liver surgery page) if they arise in the gallbladder or upper bile ducts shut to the liver. Tumours in the lower bile duct behave like pancreatic cancers and should be considered with them (encounter Pancreatic surgery page ).

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Source: http://www.allps.co.uk/gallbladder-surgery.php

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