This site is designed to help educate you about the anatomy of the gallbladder, the indications and alternatives to gallbadder surgery, possible complications, and what to expect in the peri-operative period.
To better help determine your individual risk, the American College of Surgeons has a free online risk assessment tool American College of Surgeons Online Risk Assessment Tool During our workup process, we have done our best to identify and optimize any medically correctable conditions to reduce your risk of complications from your gallbladder surgery.    At the end of today’s visit, you will be asked to sign an operative consent form.  We expect that you do not sign until you understand these risks, have asked all questions, and wish to proceed with this procedure.  Remember, typically, this is an elective procedure.  There are medical alternatives to surgery, and you should not proceed unless you are doing so deliberately based upon your own decision making and careful research.

We will attempt to perform gallbladder surgery through a laparoscopic approach.  Our goal is to accomplish this in the safest a most minimally invasive procedure as possible.  Most cases will be done through standard laparoscopic techniques highlighted by the video where there is multiple small incision.  If conditions are right, we will consider using a reduced number of small incisions.  To accomplish this, we occasionally employ the use of specialized equipment, which may include but not be limited to have: magnets for retraction,  robotics, and single incision platforms.

In rare cases, an open incision could be required.  This typically involves an incision from the breast bone carried down to near or below the belly button or can follow along the border of the rib cage.  When an open incision is required in patients struggling with weight, there is an increased risk of hernia and infection in the wound.

At the time of your operation, we will first assess the overall condition of your abdomen.  If deemed medically necessary, we may need additional procedures to prevent further complications.  The most common include:

1. Lysis of Adhesions – Meaning to break up scar tissue. The associated risks include but are not limited to  unrecognized injury to the bowel
2. Abdominal wall hernia repair
3. Placement of a drain: In certain circumstances, your surgeon may elect to leave a temporary plastic tube – a drain behind. The drain is to collect infection, blood, or bile. May serve as an early warning for bile leakage. If there is no abnormality, it will typically be removed before discharge from the hospital.
4. Cholangiogram – an X-ray test where a dye is injected into the ducts or tubes around the gallbladder to help identify anatomy and look for gallstones within the ducts. Occasionally, due to the inability to correctly identify the anatomy, the gallbladder may only be partially removed or a drainage catheter placed in the gallbladder. Both of these scenarios could require more completion surgery at a later date. Under infrequent circumstances, the surgeon may determine that the procedure should be aborted altogether. This is most often due to massive scarring from previous surgeries, or the intra-operative diagnosis of medical problems such as severe liver disease or tumors.

The consent form we use is standardized for the health system and includes several generic bullet points that will not be covered in this video.  However, we expect that you carefully read these and ask any questions before signing the consent form.

Your restrictions postoperatively will include: not lifting anything heavier than a milk jug for the first three weeks after surgery. Not taking a shower in the first 48 hours to allow the glue that we used to close the incisions to dry properly. You will not want you to drive until you’re off pain medicine because that’s like drinking and driving and that your pains in a good enough control that you can do all the functions required of driving (like being able to move quick enough to slam on the brakes or turn and look in your blind spot quickly). For most people, this is about a week to 2 weeks.

The gallbladder is a small part of your body about the size of an egg that sits in the right upper side of our abdomen under our liver. To understand the gallbladder you need to know a little about the liver, the largest organ in our body. The liver has many functions, but one is to produce a liquid substance called bile. The bile produced by the liver flows out of the liver down through tubes or plumbing known as biliary ducts into the first portion of the small intestine. In the small intestine, the bile mixes with food emptying from the stomach to help the body absorb nutrients from the food we have eaten.

When not eating, a muscle at the end of the plumbing squeezes causing bile to back up and fill a storage sac called the gallbladder. When we eat food, our stomachs make a hormone or signal which tells our gallbladder to squeeze the bile down into biliary ducts dumping the bile into the small intestine so it can mix with the food.

Due to diet, genetics, and a host of other factors many have stones or sludge form in their bile. The stones commonly form from a chemical imbalance in regions where the bile sits still or is stagnant like bile storage sac, the gallbladder. They can range dramatically in size from that of course sand to golfball size. Having gallstones doesn’t necessarily mean you will have problems. In fact, approximately 25% of people have gallstones and don’t know it. This is referred to as asymptomatic cholelithiasis. In most cases, no treatment is needed for asymptomatic gallstones other than alerting your health care team to the presence of the gallstones.

Most problems people develop with their gallbladder come on after eating because the gallbladder is stimulated to push bile down to mix with the food. The stones within the gallbladder being squeezed with the liquid bile into the plumbing between the liver and the small intestine clogging up the system. The stones can temporarily block the outflow of the gallbladder. When this occurs the gallbladder tries to squeeze hard to push the stone through causing pain.

When a gallstone is blocking the emptying of the gallbladder one of three scenarios tend to occur. In the first scenario, the gallbladder squeezes hard trying to overcome blockage from the stone, causing pain. After a few minutes, the gallbladder tires and eases off its painful squeeze letting the stone fall back into the gallbladder relieving the blockage. causing colicky pain which comes and goes. This is known as symptomatic cholelithiasis, the most common cause of gallbladder issues. It is the leading indication for elective surgery to remove the gallbladder.

In the second scenario, the stone blocking the emptying of the gallbladder becomes permanently stuck causing the crampy pain to turn constant and lead to inflammation of the gallbladder. This is referred to as acute cholecystitis, and typically this condition leads to urgent removal of the gallbladder.

Additionally, the stone can be propelled by the squeezing of the gallbladder down into the main tube or duct between the liver and small intestine known as the common bile duct. If that occurs it can block the bile flow between the liver and small intestine causing a yellow discoloration (most notable in the whites of the eyes initially) called jaundice. If untreated an infection can develop up in the liver called cholangitis.

Finally, the stone can pass all the way down to just before it enters the small intestine. In this region, the stones can block not only the drainage of the bile from the liver but also block the plumbing from the pancreas. This can lead to inflammation of the pancreas called gallstone pancreatitis, which can vary wildly in severity from a single episode of pain to a chronic deadly condition.

The prospect of surgery can be scary. Surgeons use studies of other patient’s past gallbladder experience to understand the risks and benefits of treatment options. Surgery is recommended only when the risk of not doing surgery outweighs the risk of doing surgery. As discussed in the last section most patients present fairly early in the progression of their gallbladder issues. However, if left unmanaged gallbladder disease can get very severe. Typically surgery is recommended to remove the gallbladder when stones intermittently start to block the flow of bile out of the gallbladder or from the liver with enough severity to cause pain what we call symptomatic cholelithiasis. At this degree of gallbladder symptoms the risks of surgery for average risk patients has been shown to be lower than complications associated with non-operative management.

Since pain may occur only occasionally some are surprised when surgery is recommended and interested in non-surgical alternatives. While there are non-surgical alternatives they are typically reserved for those who particularly high risk due to age and other severe health conditions.

Non-Surgical Options include:

1. Oral medications (ursodiol or chenodiol) to dissolve gallstones. These can be effective for small gallstones but typically take a significant period of time to work. It’s common if you stop taking the medication for the stones to come back. Many require dosages high enough to be effective that have a side effect of diarrhea.

2. Shock wave to break up the stones. Not commonly performed anymore. Stone fragments can still get stuck in the biliary ducts and create problems

3. Needle injection of a chemical called methyl tertiary butyl ether (MTBE) into the gallbladder to dissolve stones. Very limited experience with this technique across the United States. The chemical itself is historically an additive to gasoline, requires a well-ventilated area for administration, and experienced team or harm can come to patient and team.

4. Endoscopic Drainage of biliary ducts. It requires an endoscopy or tube run-down through the mouth to the opening of the biliary ducts into the small intestine. A muscle at the end of the plumbing is cut to better allow stones to pass.

5. Transmural drainage or cholecystoenterostomy – Requires an endoscopy or tube run-down through the mouth into the stomach or intestine and using ultrasound a needle or stent is placed into the gallbladder to drain it.

6. Percutaneous Cholecystostomy – Using advanced imaging like Cat Scanners a drainage tube is poked into the gallbladder and left in place draining bile out fo the body. Typically required surgical removal of the gallbladder later.

The chance of dying or mortality with gallbladder surgery is low and ranges from 0.1% to 0.8%. Each patient comes with their own unique medical conditions which could increase a patient’s operative risk. If the gallbladder is removed electively then certain steps may be taken to reduce a patient’s operative risk. Examples of risk reduction strategies include but are not limited to: using a medical specialist to help better control or understand medical conditions like heart disease or diabetes, stopping certain medications which increase risk, quitting smoking, increase its physical activity, and weight loss. You should discuss risk reduction strategies with your doctor to ensure you are fully optimized for surgery.

The gallbladder lies under the liver.  Certain medical conditions can make the liver very large making surgery difficult.

Several body parts like the liver, small intestine, pancreas, colon, and stomach are a few of the intra-abdominal organs that lie near the gallbladder. They could be damaged at the time of your operation possibly necessitating repair, partial removal, or another surgery.

While removing the gallbladder it must be lifted and moved around to properly identify the anatomy. In the process of moving the gallbladder, it can be injured resulting in spillage of bile and stones. This spillage even with washed and removed can occasionally result in infection requiring further medical or surgical treatment. While every effort is made to remove any spilled gallstones it’s not always possible to find and remove them all. In rare cases, these remaining stones can lead to complications such as infections down the line.

During removal of the gallbladder surgeons carefully remove or dissect any surrounding fatty tissue to reveal the specific blood vessels and ducts draining the gallbladder. Once identified, these structures are clipped shut to prevent leakage. They are then cut freeing the gallbladder, so it can be removed. The body of the gallbladder is also attached to the liver and must be carefully detached.

Between 0.6 and 5% of the time, patients will leak bile after surgery. The most common sites of a leak include:

1. Small sites on the liver called Ducts of Luschka.

2. The small duct is known as the cystic duct connecting the gallbladder to the plumbing between the liver and the small intestine.

If a bile leak occurs, its typically not discovered until after surgery where a tube or catheter may need to be placed through the skin to drain the bile collection.

Another special test known as an ERCP is often required to diagnose and manage this leak.  To perform an ERCP an endoscope, while sedated, is brought down through the mouth to the region where the ducts enter the intestine to examine this region.

Patients with previous stomach surgery, such as commonly performed weight loss surgeries may require more surgery to access the GI tract in the regions shown by the red circles to allow access to the bile duct with the ERCP test

While the pictures of the gallbladder anatomy appear somewhat simplistic, in reality, this portion of the body can vary from person to person making proper identification of the structures challenging. Surgeons attempt to use standardized surgical techniques known as obtaining the critical view of safety to aid in the proper identification of the anatomy. To help identify the anatomy, your surgeon can inject dye (known as cholangiogram or fluorescence imaging) into the gallbladder or ducts assisting visualization of the structures. Even when all of these techniques to properly identify structures are used, the anatomy can be misidentified leading to the wrong structure being clipped, cut, burnt, narrowed, or damaged in some way. Most commonly the injury occurs to some portion of the tubing between the liver and the intestine known as a biliary injury. This occurs between 1/200 and 1/300 cases. The surgeon may not recognize that a bile duct injury occurred at the time of surgery requiring further testing and more surgery to repair. If a bile duct injury is recognized at the time, the surgeon may attempt to repair it using a variety of techniques including:

1. placing a tube or stent into the bile duct

2. Suturing the bile duct

3. Re-connecting it to the intestine

The surgeon may decide to delay the repair of the bile duct to a future date. The surgeon may also call for assistance by another surgeon to repair the bile duct. Tests may need to be performed postoperatively to determine if a bile leak or bile duct injury has occurred. Repair of a bile duct injury usually requires a large, open incision.

When a dye is injected into the ducts as described above approximately 1-2% of the time patients can have an allergic reaction. The allergic reaction may be minor (such as hives, itching, or redness), or maybe severe and life-threatening with low blood pressure, swelling of the throat, and airways requiring emergency treatment including assistance with breathing.

In addition to biliary injuries its possible to damage, clip, cut the nearby arteries and veins which can lead to bleeding or injury to the organs supplied blood these arteries and veins.

During removal of the gallbladder, from simply manipulating the gallbladder a stone can be pushed (occurs between 4-40%[^1]of the time)[^2] down into the main tube or duct between the liver and small intestine known as the common bile duct. If that occurs it can block the bile flow between the liver and small intestine causing a yellow discoloration (most notable in the whites of the eyes initially) called jaundice. If untreated an infection can develop up in the liver called cholangitis.

In some instances, this stone can sit undetected for weeks to years. An MRI test or other type of X-ray may be required to look for these retained stones. If found, the previously described E-R-C-P test can typically be used to remove the stones. Rarely more surgery is required for removal.

[^1]: Jackson PG, Evans S. Biliary System. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Saunders Elsevier; 2012:chap 55.

[^2]: Jackson PG, Evans S. Biliary System. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Saunders Elsevier; 2012:chap 55.

Any elective or non-emergent surgical incision in an otherwise healthy patient has a small chance of getting an infection in the wound around 1%. Patients struggling with certain medical conditions (obesity, smoking, infection, etc.) are at a higher risk of developing infections in their wounds.  The small laparoscopic incision has a lower rate of infection than larger open incisions.

After surgery, a small amount of clear, pink, or thin yellow drainage from the incision is common and does not mean there is any infection.

Signs of infection include increased peri-incisional pain, redness around the incision, fever, and drainage of pus.

If these signs occur we will need to look at the wound either by way of an in-person visit or you can send us pictures through My Chart to determine a treatment strategy.  Occasionally an infected incision will open up and drain either spontaneously or by way of our surgical team.  Open incisions often require frequent packing with gauze or the use of a sponge attached to a suction device known as a wound vac in order to speed healing which in this scenario can take several weeks

Pain should normally resolve in a few days but could persist chronically in the abdomen.

Lying on the operating table for the 1-5 hour period of time it may take to perform your surgery can exacerbate nerve issues.  This can be permanent numbness related to the incision.

Another unintended consequence of surgery can be an exacerbation of back pain or pressure point pain.  During the night we lay for extended periods of time but we unconsciously shift our weight periodically throughout the night to avoid nerve pain.  While on the operating table you are completely motionless.  We tilt the table to a near-standing position during surgery to use gravity to hold organs out of the operative field.  Laying in this position can exacerbate these nerve issues like numbness, weakness, paralysis, or pain.  It will be very important in the operating room that you help use pad and position you appropriately prior to going to sleep in order to prevent nerve damage.

During gallbladder surgery patients are placed under general anesthesia which requires a breathing tube to be placed in the trachea or windpipe through the mouth after asleep.  During the procedure, the anesthesia team will control your body’s intake of oxygen through mechanical ventilation.  A common complication of ventilation is the collapse of small air spaces in the lungs knowns as atelectasis. If not treated in the post-op period pneumonia or infection in the lung can develop. The lungs can be expanded after surgery by walking and use of an incentive spirometer which will be provided if you stay in the hospital.

Uncommonly this could be so severe that you could need help breathing with a breathing machine or ventilator. A prolonged stay on a ventilator in the intensive care unit (ICU) may occur if a patient has severe pneumonias or after other significant complications. A temporary tracheostomy may be necessary.

Covid-19 infection at the time of elective surgery has been shown to increase chances or respiratory failure. Strict protocols are followed to reduce this risk factor but are not fool proof. Every reasonable measure should be taken to avoid Covid-19 infection in the peri-operative period.

An abdominal wall hernia is an opening in the tough layers of the abdominal wall where intra-abdominal contents such as bowel can protrude out and get stuck causing an obstruction or poor blood supply known as ischemia to that portion of the bowel.  This could result in emergency hernia surgery.  Abdominal wall hernias can develop after metabolic surgery at the site of our incisions.  After laparoscopic gallbladder surgery, this type of hernia occurs infrequently about 0.2% of the time.  However many patients will have pre-existing abdominal wall hernias that have been there since birth or after previous surgery.  To properly fix an abdominal wall hernia at the time of gallbladder surgery poses several potential issues.  Abdominal wall hernia is best fixed with the lowest recurrence in patients of normal weight by way of a permanent mesh that strengthens the abdominal wall.  These permanent pieces of mesh are prone to infection and when the gastrointestinal tract is being divided and re-connected increases the chance of their getting infected requiring surgical removal.  As a result, we often evaluate the likelihood of a blockage based upon the size, preoperative symptoms, and whether the opening is plugged by intra-abdominal fat at the time of your gallbladder surgery.  If the conditions are right we consider repair otherwise delay until the gastrointestinal tract is not being divided and you are otherwise properly prepared to risk reduce recurrence and mesh infection risk.

There is a small chance of heart attack or stroke in the peri-operative period which varies depending on age and risk factors (shown).    During our workup process, our team and you will work to reduce risk by optimizing these known risk factors if the urgency of your gallbladder permits.  Please alert our team if you feel any of these factors have not been adequately optimized at this time.

During surgery, electrical energy known as cautery is used to stop bleeding and cut tissue. Unintentional burn injuries can occur either on the skin or internally causing damage that could require more surgery to treat effectively.

During laparoscopic surgery, the abdominal cavity is filled with gas to provide room to be able to see the organs properly. Rarely during surgery, this gas pumped into the abdomen can fill small veins and travel back to the heart and lungs. This is known as gas embolism which can impede the normal flow of blood and oxygen to the body. In rare cases, a gas embolism can lead to low blood pressure, low oxygen levels, and death.

After surgery temporary kidney failure occurs rarely. Irreversible kidney failure has been reported.

In rare cases from simply laying on the operating room table damage can occur to the buttocks muscles causing them to break down in a process called Rhabdomyolysis.  The broken-down muscle can cause kidney failure and other electrolyte abnormalities.  It’s more common in patients with a BMI>50 who have a lengthy procedure typically greater than 4 hours.  If this becomes a concern intra-operatively your surgeon could make a decision to only drain or partially remove the gallbladder necessitating more surgery down the line.

Changes in bowel habits are common in the days and weeks after gallbladder surgery. Changes may include constipation, diarrhea, and excessive gas. Typically these symptoms are short-lived but rarely diarrhea can last for many years due to changes in the flow of bile. Some patients will require medications to manage the symptoms.

Most patients after general anesthesia and abdominal surgery develop some nausea that is short-lived.  Rarely patients will have nausea that can last several weeks to months.

Pulmonary embolism is a blood clot that forms in the legs, and elsewhere, and breaks off into the lungs.  In rare cases, these can cause death.

Given this risk, preventative measures will be initiated to decrease the risk of blood clots formation, these preventative measures include: the use of heparin (a medication that thins the blood), special foot and leg stockings, walking soon after surgery, and altering some medication use at home before and after surgery.  Completely eliminating the risks of DVT (clots) altogether is not medically possible.

The risks associated with the medications used to prevent blood clots can include excessive bleeding. Rarely, patients develop allergies to heparin, sometimes causing very severe reactions.

Any symptoms of leg swelling, chest pain or sudden shortness of breath should be immediately reported to the team or presentation to the emergency department

After any surgery people are at an increased risk for blood clots up to 90 days after surgery.  The greatest risk is in the first 30 days.  Post gallbladder surgery blood clots occur around 0.5% of the time.  Our team looks at your individual risk factors and determines a prevention strategy.  Every patient is instructed to take short walks each and every waking hour during the at-risk period which is up to 90 days after surgery.  At the pre-op appointment, some select higher-risk patients will be given a prescription for blood thinners to be used at home after surgery.  It’s our expectation that you get this prescription filled prior to surgery. If you have difficulty getting the prescription filled we expect to be notified before you have your procedure.  There will be some patients based upon risk factors that arise during your hospitalization who will be given a prescription for blood thinners to take at home.  If you are unable to get the prescription filled it’s our expectation that you alert the team immediately

Bleeding may occur unexpectedly in the operating room. Bleeding may also occur postoperatively in the days after the operation. Bleeding most commonly is inside the abdomen cavity and can be detected by lab tests. Some signs of bleeding include rapid heart rate, lightheadedness, fatigue. The incidence of bleeding in the surgical literature occurs about 1% of the time. A transfusion may be necessary in some circumstances. Re-operation to stop bleeding may be necessary.

With any abdominal surgery, you can form scar tissue that could block or obstruct the bowel.  This can cause severe pain and require additional medical and/or surgical treatment.