the

GALLSTONES - A Guide for Patients, Part 1

hello if you're facing surgery for gall

stones or your gall bladder this DVD is

for you in it we're going to describe

why ''tis were recommending surgery what

the surgery involves the potential

pitfalls and complications and what your

recovery will be like

these are some of the gall stones that

I've collected from my patients over the

last few weeks what you'll see is that

they range in size from the very small

to the really quite substantial what

you'd be interested perhaps to know

though is that the amount of trouble

that patients get is not determined on

the number or the size or the shape and

in fact the patient who had these stones

here had almost as much pain if not more

than the person who had this single

stone so here's a case where size

doesn't really matter about one in four

patients over the age of 70 will develop

gall stones though thankfully not all of

them will actually have symptoms well

despite the difference all of the stones

arise in the same way so here's a quick

biology lesson I'd like you to meet my

model Dave

so bio is produced by the liver here

shown in brown and bile passes out of

the liver down this duct here in fact it

goes behind the stomach in pink here but

for the purposes of this demonstration

passes in front and opens out into the

intestines just about here now there's a

small offshoot coming off from the bile

duct that goes into this gall bladder

which is about the size of half a lemon

and when you eat a fatty meal there's a

routine stimulus that causes this

gallbladder to squeeze and the bile

comes down it's little duct into the

bile duct and down into the intestines

where it's ready to digest and absorb

the fat that you've just eaten bile is a

slightly sticky yellowish green fluid

and for some reason and we don't know

why in some people and not in others

little crystals can grow in this pool of

sticky fluid within the gallbladder and

over years these crystals can grow and

actually form stones now the problem is

as you remember when the gallbladder

squeezes what can happen if you've got

stones is that those stones can block

the outlet of the gall bladder such that

it's squeezing against an obstruction

and that's what causes the acute pain

that we call biliary colic after a

patient has had a lot

of attacks of billary colleague the

gallbladder wall becomes thickened and

inflamed and the whole organ really

ceases to work properly and that's

another reason that we need to consider

recommending an operation

what else can cause gallbladder trouble

well stones in the gallbladder produced

pain that's bad enough but there are

other things too little polyps can grow

in the wall of the gallbladder and that

can cause pain a scan of gallbladder

that just doesn't function very well and

doesn't squeeze very well if patients

get symptoms that sound like it's coming

from their gallbladder and they have

these problems we often recommend a

cholecystectomy as well but I think we

can be less confident in these patients

that it's actually going to cure the

problem there's also gallbladder cancer

but that really is an extremely rare

problem our gall stones found well we

use the same tests that they use for

women who are pregnant it's called an

ultrasound

it's totally non-invasive totally

painless and hopefully the

ultrasonographer will be able to find

something like this some stones

ultrasound is is accurate in about 90%

of cases there are a small number of

patients where gall stones aren't found

the first time and a second scan needs

to be done if the doctors convinced that

there are gall stones but they're not

shown on the first scan in Jeremy's case

here the gall bladder was clear and no

stones were found

what are the treatment options patients

can and sometimes do decide to live with

their gall stones trying to avoid the

foods that would set off an attack but

accepting that every now and then

despite that they may still get one we

don't push people into surgery but in

truth most do II like to have an

operation because at the end of the day

they just don't know when the next

attack might otherwise come in the past

doctors have tried shattering stones and

dissolving them and whilst it may have

worked reasonably it left behind the

gallbladder which could then form more

stones later there are some homeopathic

remedies which can sometimes be

successful in alleviating gall stones

but again the gallbladder is left behind

surgery is really the only permanent

solution

why remove the whole gallbladder and not

just take the stones away well it is

easier to remove the whole bag and take

the bits out and if we did leave a

little tiny fragment behind of course it

would then grow into a stone again

anyway try removing the pits from a

lemon without damaging it if we really

needed a gallbladder to live a normal

life it wouldn't be possible to remove

it but you can live perfectly happily

without a gallbladder and eat a normal

diet including fat well that of course

begs the question why do we have a

gallbladder in the first place

I don't know you'd need to ask the

manufacturer but suffice it to say that

whilst the gallbladder does have a

function it's a function that we can

learn to live quite happily without

when gallstones blocked the outlet of

the gallbladder that causes enough

problem in itself but when the gall

stems go out of the gallbladder on the

new verses we would say that can cause

other problems a stone can pass out of

the gallbladder into the bile duct now

if we're lucky that stone will pass on

into the intestine without too much

trouble but as it does so it can cause

some pressure on the tube draining the

pancreas the pancreas here shown in grey

if that does happen then the pancreas

can become inflamed as a result of the

pressure of the stone passing through

and this produces a rare condition which

can nonetheless be quite serious called

pancreatitis

if the gallstone comes out of the gall

bladder down the bile duct and gets

stuck and causes a blockage then clearly

none of the bile produced by the liver

can get into the intestines and that

leads to jaundice yellow jaundice

welcome to the day surgery unit this is

where you're going to come first of all

you'll meet a receptionist that will

sign you in and then ultimately you'll

be checked into one of the rooms like

this there you're going to meet the

anesthetist you'll meet the surgeon and

your sign a consent form and a consent

forms a confusing document and we want

to be absolutely clear with you that

there's anything you don't understand

you must ask consent form looks

something like this and on it you'll

notice that there are some sections

talking about complications

now that is difficult because at the

very time we're trying to instill

confidence in you

we're also going to be having to mention

the things that could go wrong but you

need to understand that our interest is

in making sure that you really

understand both that you're having an

operation and the things that might

possibly go wrong with it we won't

mention everything but we will mention

the commentaries so when you arrive in

the ward you'll be shown to somewhere

like this this is a single room that may

be a bay with four beds in it and this

is where the nurse will come and check

all your details we'll go over

everything with you before going off to

surgery it's also the same room where

the aneesa's will come and visit you and

the surgeon to sign the consent form we

need to just warn you there going to be

lots of times only going to be asked the

same questions but bear with us this is

just part of our checking process to

ensure everything is as safe as it

possibly can be so this is the

anaesthetic room and you'll walk through

into this and lie down on the trolley in

this room will be the anesthetist an

anaesthetic assistant and maybe one or

two other people will go home some other

checks again the same ones as before

just for security sake and then you'll

be put to sleep by the anesthetist and

then we'll go through these doors here

into the operating theatre itself the

next stage is the operating theatre

where the operation will actually be

done of course you'll be asleep at this

point but I'm very grateful to

Margaret's use a patient of mine who had

this operation done a few weeks ago

who's come along to help us today

now before 1990 we used to do this

operation through or at least a six

eight inch scar across the top of the

tummy here and the trouble with that was

that was it was a good operation it

meant the patient was in hospital for

nearly a week and would take probably

six weeks to get over it nowadays with

keyhole surgery using the sort of stack

that you can see behind me it's possible

to do the same operation exactly the

same operation but through four little

holes as you can see on Margaret's tummy

here one below the belly and three in a

little line underneath the right ribs

here we can do this because of keyhole

surgery keyhole surgeries is done using

a camera like this attached to a long

telescope and that's what the surgeon

looks at the image of on the screen here

behind me the whole operation can take

anything from thirty minutes to two

hours depending on the difficulty that

the surgeon encounters you need to know

that in about 2 to 5 percent of cases

the surgeon won't be able to complete

the surgery laparoscopically and have to

make an old-fashioned cut but in 95% of

cases you'll be going back to the ward

where you came and the nurses will be

preparing you for going home they'll

start your drinking then ultimately

eating they'll make sure you're

comfortable and got painkillers and look

at the instructions about the dressings

though there won't be any sutures to

remove and so hopefully after a few

hours you'll be prepared to go home

what sort of things can go wrong well

clearly we can't mention every single

possible thing that could go wrong cuz

some of them are really very rare but I

do want to touch on one or two things

that might and please remember that if

there's anything else you want to ask

you're free to do so

so the common things that could happen

bleeding

significant bleeding after laparoscopic

cholecystectomy is really very uncommon

it might possibly need another operation

to stop it but that is very unusual if

the surgeon thinks there's a little bit

more bleeding than normal what he may do

is put a little plastic tube inside the

body coming out through one of the holes

in the skin and that - once it's done

its work will be removed after a few

hours a little bit of minor bleeding

from the wound itself is quite common

and usually just managed by changing the

dressing and bathing the wound infection

is a risk of almost every operation we

will give you an antibiotic before the

operation starts and the worst that

you'll probably get is perhaps a little

bit of tackiness around the bottom of

the tummy bottom wound that can simply

be managed with bathing and dressings

conversion to an old-fashioned open

operation in about two to five percent

of cases it won't be possible for the

surgeon to complete the operation

laparoscopically and they'll have to

convert to an old-fashioned open

operation that's because the fingers of

his hand are a lot more flexible than

the rigid instruments that he's using at

keyhole surgery

another reason for conversion might be

for instance if there's any excess

bleeding bile duct stones stones or

fragments of stones that are passed out

of the gallbladder into the bile duct

will of course need to be dealt with

before your treatment is complete now

now sometimes surgeons will suspect that

there are bile duct stones on the basis

of the fact you've been jaundice or your

blood tests are abnormal and in those

circumstances he or she will probably do

an x-ray during the operation to prove

or disprove it sometimes however it's

possible that the bile duct stones won't

reveal themselves until sometime

after the operation is done and that

might be on the basis that you don't get

better in the way that they're expecting

it to but we deal with bile duct stones

with a procedure a separate procedure

called an ERCP and I'll talk about this

later on leakage of bile it's very rare

but sometimes there's a little leak of

bile from the bed of the liver where the

gall bladder was and if that does happen

it's occasionally necessary for the

surgeon to do another little keyhole

operation to put a drain in to take it

away but it's very rare inadvertent

damage to other structures it's

incredibly rare but sometimes important

structures like the bile duct can get

damaged at laparoscopic surgery we need

to mention it but I do want to reassure

you that that kind of incident is

extremely rare