Partners in Your Surgical Care
DIvISIOn Of EDuCATIOn
Surgical Removal of the Gallbladder
Laparoscopic versus Open Cholecystectomy
Laparoscopic versus Open Cholecystectomy
Laparoscopic Cholecystectomy Open Cholecystectomy
This educational information is
to help you be better informed
about your operation and
empower you with the skills and
knowledge needed to actively
participate in your care.
Informed Treatment Options Expectations
Information that will help you
further understand your operation. Surgery Before your operation—
Education is provided on: Laparoscopic cholecystectomy—The includes blood work, an
gallbladder is removed with instruments abdominal ultrasound,
Cholecystectomy Overview ............. 1 placed into 4 small slits in the abdomen. and an evaluation by your
Condition, Symptoms, Tests ............ 2 Open cholecystectomy—The gallbladder surgeon and anesthesia
Treatment Options ......................... 3 is removed through an incision on the provider to review your
right side under the rib cage. health history and
Risks and Possible Complications ..... 4 medications and to discuss
Preparation and Expectations ......... 5 Nonsurgical pain control options.
Your Recovery and Discharge ........... 6 Stone retrieval The day of your operation—
You will not eat or drink
Pain Control.................................. 7 For gallstones without symptoms
for at least 4 hours
Glossary/References....................... 8 Watchful waiting before the operation.
Increased exercise Most often you will take
Diet changes your normal medication
with a sip of water.
The Condition Benefits and Risks Your recovery—If you
Cholecystectomy is the surgical have no complications,
Benefits and Risk
removal of the gallbladder. The you are often discharged
operation is done to remove Gallbladder removal will relieve pain, treat home the same day after
gallstones or to remove an infected infection, and in most cases stop gallstones from a laparoscopic procedure
or inflamed gallbladder. coming back. The risks of not having surgery and in 2 to 3 days after
are the possibility of worsening symptoms, an open procedure. Call
Common symptoms infection, or bursting of the gallbladder. your surgeon if you are in
Sharp pain in the upper Possible complications include bleeding, severe pain, have stomach
center or right abdomen bile duct injury, fever, liver injury, cramping, a high fever
infection, numbness, raised scars, hernia or chills, your skin turns
at the incision, anesthesia complications, yellow, or there is odor
Nausea and feeling bloated and increased drainage
puncture of the intestine, and death.
from your incision.
This first page is an overview. For more detailed information, review the entire document.
A mE R IC A n COl l EGE Of S uR GEO n S • 633 n. S A In T C l A IR S T. • C hIC AG O, Il 6 0 611 • w w w.fac s.org 1
The Condition, Signs and
Symptoms, and Diagnostic Tests
Common hepatic duct
Keeping You Cystic duct
Common bile duct
most people with gallstones Pancreas
do not have symptoms. Pancreatic duct
Eighty percent of people with
gallstones go 20 years or Gallbladder
longer without symptoms.1,2
Gallstones are more Gallbladder
common in people who:
are native American
have a family history
of gallstones The Condition Symptoms
are overweight The Gallbladder The most common
eat a lot of sugar symptoms of cholecystitis are:
The gallbladder is a small pear-shaped
are pregnant organ under the liver. Sharp pain
do not exercise regularly in right Upper
The liver makes about 3 to 5 cups of
lose weight rapidly abdomen
bile every day. Bile is stored in the
use estrogen to manage Low fever
gallbladder, and when food is eaten,
menopause3,4 especially fatty foods, the gallbladder Nausea and Right Left
Gallbladder pain or biliary squeezes bile out through the cystic duct bloating
colic is usually temporary. It and into the small intestine. Jaundice Lower
starts in the middle or right (yellowing
side of the abdomen and can Gallstones of the skin) may occur if gallstones
last from 30 minutes to 24 The medical term for gallstone are in the common bile duct
hours. The pain may occur formation is cholelithiasis. A gallstone
in the common bile duct is called
after eating a fatty meal.
choledocholithiasis. Gallstones in the
Acute cholecystitis pain
lasts longer than 6 hours, ducts can block the flow of bile and cause
swelling of the gallbladder.
and there is abdominal
History and Physical
tenderness and fever. Cholecystitis is inflammation of the
Pain on the right side of gallbladder, which can happen suddenly Tests (see glossary)
the abdomen can also (acute) or over a longer period of time Abdominal ultrasound
be from ulcers, liver (chronic).
problems, and heart pain. This is the most common test to check
Perforated gallbladder is a condition when for gallstones. You may be asked not
Standard treatment the gallbladder bursts or leaks, which
of acute cholecystitis to eat for 8 hours before the test.
happens only in rare cases but can be
is intravenous fluids, life threatening. Blood tests
antibiotics, pain medication,
and cholecystectomy.5 Cholecystectomy is the surgical removal Complete blood count
of the gallbladder. The most common Liver function tests
reason for a cholecystectomy is to remove Coagulation profile
gallstones that cause biliary colic (acute
pain in the abdomen caused by spasm or HIDA scan, cholescintigraphy
blockage of the cystic or bile duct). Endoscopic retrograde cholangiogram
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The site is stapled or sutured
Surgical Treatment closed, and a small drain may be
An operation is the recommended placed going from the inside to the Keeping You
treatment for gallbladder pain from
gallstones, and it is the only treatment
outside of the abdomen. The drain is
usually removed in the hospital. The
for acute cholecystitis. procedure takes about 1 to 2 hours. Conversion rates from a
laparoscopic to an open
technique are less than 1%
Laparoscopic versus Open Cholecystectomy
Laparoscopic versus Open Cholecystectomy
Laparoscopic Cholecystectomy Open Cholecystectomy
Open Cholecystectomy Procedure Options for young healthy people.
Procedures may be done to remove The need to convert from
gallstones from the common bile duct. a laparoscopic to an open
Laparoscopic transcystic common bile procedure can increase
duct stone extraction is performed significantly if you are over
with insertion of instruments into 65 years, are male, have a
the abdomen similar to laparoscopic history of acute cholecystitis,
cholecystectomy. The bile duct is past abdominal operations,
entered, and stones are removed high fever, high bilirubin,
directly or with a wire basket. repeated gallbladder
attacks, and diseases that
Endoscopic retrograde cholangio- limit your activity.5
Laparoscopic Cholecystectomy pancreatography is done by inserting
This technique is the most common for an endoscope into your mouth and
simple cholecystectomy. The surgeon continuing to pass it through your
will make 4 small slits in the abdomen. stomach and then into the common
bile duct. Gallstones are removed
Questions you should ask
A port (nozzle) is inserted into one of
the slits, and carbon dioxide gas inflates directly or with a balloon or basket. What type of procedure
the abdomen. This process allows the is right for me and why?
Complication rates range from 0
surgeon to see the gallbladder more to 9.1 per 1,000 procedures.6 How much experience
easily. A laparoscope is inserted through do you have with
another port. It looks like a telescope this procedure?
with a light and video camera on the nonsurgical Treatment Has the procedure been
end so the surgeon can see inside the done often at this center?
abdomen. Surgical instruments are Do you know the
placed into the other small openings If gallstones are seen on your ultrasound approximate cost of
and used to remove the gallbladder. but you do not have symptoms, the procedure?
watchful waiting is recommended.1,2
The surgeon removes the gallbladder
through the incision. The carbon Gallstones only, without cholecystitis
dioxide comes out through the small
slits and then the sites are closed with Increase your exercise. Exercising
sutures, metal clips called staples, or 2 to 3 hours a week reduces
steri-strips. Your surgeon may start the risk of gallstones.7,8
with a laparoscopic technique and Eat more fruit and vegetables,
need to change to an open technique. and eat less foods high in sugars
and carbohydrates like donuts,
The procedure takes about 1 to 2 hours. pastry, and white bread.
Open Cholecystectomy Alternative medicine options
The surgeon makes an incision
approximately 6 inches long in the
upper right side of the abdomen and
cuts through the fat and muscle to the
gallbladder. The gallbladder is removed,
and any ducts are clamped off.
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Risks of This Procedure
Your surgeon will do everything possible to minimize risks,
but cholecystectomy, like all operations, has risks.
The Risk What Happens Keeping You Informed
Infection Infections occur in less than 1 per 1,000 Your health care team should wash their
patients who have laparoscopic procedures.5,6,13,14 hands before examining you. Antibiotics
are given right before the operation.5
Common bile Injury to the bile duct is reported in 1 per 1,000 Your surgeon and nurse will watch for jaundice,
duct injury patients for open cholecystectomy and in 1 to 5 fever, and abnormal blood tests.5 further
per 1,000 for laparoscopic cholecystectomy.5,6,14 testing or surgery may be needed.
Bleeding Bleeding is rare. If you have chronic Your surgeon will check a coagulation profile to
biliary disease, your liver may not monitor for bleeding problems. A blood transfusion
form clotting factors.5,6,13 usually is not required for cholecystectomy.
Bile leakage Bile leakage after surgery is very rare. Your surgeon will check for fever, monitor labs, and
may need to perform other tests such as sonography or
endoscopic retrograde cholangiopancreatography (ERCP).
Retained common A gallstone may pass after surgery Your surgeon will check blood tests
bile duct stone and block the bile from draining.5 for your liver function.
Pneumonia General anesthesia, lack of deep breathing Deep breathing exercises can help expand your
and movement are possible causes. lungs and prevent complications after surgery.10
Heart problems heart problems are rare. Cardiac arrhythmias Your surgeon may have you see a heart specialist
were reported in about 5 per 1,000 patients before your operation. Your anesthesia provider is
and heart attack in 1 per 1,000.6,13 always prepared in advanced cardiac life support.
Kidney problems Kidney or urinary problems have been reported Your surgeon may give you extra fluids before your
in 5 per 1,000 patients. Dehydration and operation.5 let your nurse know when you urinate.
liver problems can increase this risk.6,13
Deep vein no movement during surgery can lead to Your surgeon or nurse will place support or
thrombosis blood clots forming in the legs. In rare compression (squeezing) stockings on your legs
(blood clots) cases the clot can travel to the lungs. and may give you blood thinning medication.
Your job is to get up and walk after surgery.
Premature labor fetal loss is reported as 40 per 1,000 patients These risks increase with peritonitis
and fetal loss for uncomplicated cholecystectomy and as high (infection of the abdominal cavity).
as 600 per 1,000 when pancreatitis is present.
The risk of preterm labor also increases.11,12
Injury to the Instrument insertion and use during laparoscopic The surgeon will use extreme care and continuously
intestines or technique can injure the intestines. watch for any bleeding or bowel contents during the
abdominal organs procedure. Patients who are obese or who have a history
of past abdominal operations or adhesions make it
more difficult to move and manipulate instruments.5
Death Death is extremely rare in healthy people Your entire surgical team will review for possible
and is reported as 0 to 1 per 1,000 complications and be prepared to decrease all risks.
patients. The risk of death increases with
gangrene, a burst gallbladder or severe
diseases that limit your activity.1,6
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Preparation for Your Operation
Preparing What You Can Expect Keeping You
for Your Operation A bracelet with your name and
identification number will be placed on Informed
Tell your surgeon about other medical your wrist. Your wristband should be An effective way to do deep
problems that you have. Bring a list checked by all health care team members breathing is to breathe deeply
of all of the medications that you are before providing any procedures or and hold for 3 to 5 seconds.
taking, and show that list to your giving you medication. If you have Take 5 to 10 deep breaths every
surgeon and anesthesia provider. any allergies, an allergy bracelet hour while you are awake.
should also be placed on your wrist. Young children can do deep
Most often you will take your morning
An intravenous line (IV) will be started breathing by blowing bubbles.
medication with a sip of water. If you
are taking blood thinners (Plavix, to give your fluids and medication. The
coumadin, aspirin), your surgeon medication will make you feel sleepy.
may ask you to stop taking these.
A tube will be placed down your throat to
Home Preparation help you breathe during the operation. Questions you should ask
You can often go home the same Your surgeon will perform your operation What medications
day after a laparoscopic procedure. and then close your incisions. If you have should I stop taking
Your hospital stay will be longer (2 an open operation, a drain may be placed before my operation?
to 3 days) for an open procedure. from the inside of your incision out your When should I stop
abdomen. taking them?
After your operation, you will be moved Should I take any
You will meet with your anesthesia to a recovery room. medicines on the day
provider before the operation. Let of my operation?
him or her know if you have allergies, Preventing Pneumonia What are the risks,
neurologic disease (epilepsy or stroke), Movement and deep breathing after problems, and side effects
heart disease, stomach problems, lung your operation can help prevent fluid of general anesthesia?
disease (asthma, emphysema), endocrine in your lungs and pneumonia.10 Do I need antibiotics
disease (diabetes, thyroid conditions),
loose teeth, or if you smoke, abuse alcohol Preventing blood clots
or drugs, or take any herbs or vitamins. What will you do to
When you have surgery, you are at risk prevent blood clots?
of getting blood clots because of not If hair has to be removed
The Day moving during anesthesia. The longer
and more complicated your surgery, the
on my abdomen, how
will it be done?
of Your Operation greater the risk. Your doctor will know
Did you wash your hands?
your risk for blood clots, and steps will be
Don’t eat or drink taken to prevent them. This may include
Not eating or drinking for at least 4 blood thinning medication and support
hours before the operation reduces your or compression (squeezing) stockings.
risk of complications from anesthesia.
What to bring The risk of infection can be
Insurance card and identification lowered if antibiotics are given
Advance directive (see terms) right before surgery and hair
is removed at the surgical site
List of medicines
with clippers versus shaving.
Personal items such as
All health care providers should wash
eyeglasses and dentures
their hands before examining you.
Loose-fitting comfortable clothes
Leave jewelry and valuables at home
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Your Recovery and Discharge
A small amount of drainage from
the incision is normal. If the
and Discharge drainage is thick and yellow or
the site is red, you may have an
Thinking Clearly infection so call your surgeon.
The anesthesia may cause you to feel If you have a drain in one of
different for 2 or 3 days. Do not drive, your incisions, it will be taken
drink alcohol, or make any big decisions out when the drainage stops.
for at least 2 days. Surgical staples, will be removed
during your first office visit.
Steri-strips will fall off in 7 to
When you wake up, you will be 10 days or they will be removed
able to drink small amounts of during your first office visit.
liquid. If you are not nauseous, you Avoid wearing tight or rough clothing.
can begin eating regular foods. It may rub your incisions and
Continue to drink lots of fluids, make it harder for them to heal.
usually about 8 to 10 glasses per day. Protect the new skin, especially
from the sun. The sun can burn
Activity and cause darker scarring.
You will be helped getting Your scar will heal in about 4 to
out of bed and walking. 6 weeks and will become softer
Slowly increase your activity. and continue to fade over the next
Do not lift or participate in strenuous year. Keep the wound site out
Steri-strips will fall off or of the sun or use sunscreen.
activity for 3–5 days for laporoscopic
they will be removed during
and 10–14 days for open procedure. Sensation around your incision will
your first office visit
Avoid driving until your pain is return in a few weeks or months.
under control without narcotics.
You can have sex when you feel
ready, usually after your sutures After intestinal surgery, you may
or staples are removed. have loose watery stools for several
It is normal to feel tired. You may need days. If watery diarrhea lasts longer
more sleep than usual. than 3 days, contact your surgeon.
Pain medication (narcotics) can
Work cause constipation. Increase the
You can go back to work when you feel fiber in your diet with high-fiber
well enough. Discuss the timing with foods if you are constipated. Your
your surgeon. surgeon may also give you a
prescription for a stool softener.
Always wash your hands before and
Wash your hands before and Food high in fiber include beans,
after touching near your incision site.
after touching near your bran cereals and whole grain breads,
incision site Do not soak in a bathtub until your
stitches, steri-strips, or staples are peas, dried fruit (figs, apricots, and
removed. You may take a shower dates), raspberries, blackberries,
after the second postoperative strawberries, sweet corn, broccoli,
day unless you are told not to. baked potatoes with skin, plums,
pears, apples, greens, and nuts.
Follow your surgeon’s instructions
on when to change your bandages.
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Pain Pain Control
The amount of pain is different for each Everyone reacts to pain in a different Keeping You
person. Some people need only 2 to 3 way. A scale from 0 to 10 is often
doses of pain control medication, while used to measure pain. At a “0,” you
others use narcotics for a full week. do not feel any pain. A “10” is the Extreme pain puts extra stress
Home Medications worst pain you have ever felt. on your body at a time when
your body needs to focus on
The medicine you need after Common Medicines to Control Pain healing. Do not wait until your
your operation is usually Narcotics or opioids are used for severe pain has reached a level “10”
related to pain control. pain. Some side effects of narcotics or is unbearable before telling
are sleepiness; lowered blood pressure, your doctor or nurse. It is much
easier to control pain before it
When to Contact heart rate, and breathing rate;
skin rash and itching; constipation; becomes severe.
Your Surgeon nausea; and difficulty urinating. Some
examples of narcotics include morphine,
If you have:
oxycodone, and hydromorphone.
Pain that will not go away Medications are available to control
Pain that gets worse many of the side effects of narcotics.
A fever of more than 101°F (38.3ºC) Non-narcotic Pain Medication
Most nonopioid pain medications
Swelling, redness, bleeding, are nonsteroidal anti-inflammatory
or bad-smelling drainage drugs (NSAIDs). They are used to
from your wound site treat mild pain or combined with a
Strong abdominal pain narcotic to treat severe pain. They
Jaundice or yellow skin also can reduce inflammation. Some
No bowel movement or unable side effects of NSAIDs are stomach Splinting your stomach
to pass gas for 3 days upset, bleeding in the stomach or
Watery diarrhea lasting intestines, and fluid retention. These
longer than 3 days side effects usually are not seen with
short-term use. Examples of NSAIDs
include ibuprofen and naproxen.
Non-medicine Pain Control
Distraction helps you focus on other
activities instead of your pain. Music,
games, and other engaging activities are
especially helpful with children in mild
Splinting your stomach by placing a
Follow-up Appointments pillow over your abdomen with firm
pressure before coughing or movement
Who Date Phone can help reduce the pain.
Guided imagery helps you direct and
control your emotions. Close your eyes
and gently inhale and exhale. Picture
yourself in the center of somewhere beau-
tiful. Feel the beauty surrounding you
and your emotions coming back to your
control. You should feel calmer.
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Glossary of Terms
and for More Information
Glossary of Terms for more Information
Abdominal ultrasound This test uses sound for more information, please go to the American
waves to determine the location of deep College of Surgeons Patient Education Web site at
structures in the body. A hand roller is placed on www.facs.org/patienteducation/.
top of clear gel and rolled across the abdomen.
The information provided in this brochure is chosen from recent
Advance directives Documents signed by clinical research. The research listed below does not represent
a competent person giving direction to all of the information that is available about your operation.
health care providers about treatment 1. Society for Surgery of the Alimentary Tract. Treatment
choices. They give you the chance to tell of gallstones and gallbladder disease. (2003)
your feelings about health care decisions. 2. National Institutes of Health. Gallstones and laparscopic
Adhesions A fibrous band or scar cholecystectomy. NIH Consensus Statement (1992)12:1–28
tissue that causes internal organs 3. Nakeeb A, Cumuzzie AG, Martin L, et al. Gallstone: genetics
to adhere or stick together. versus environment. Annals of Surgery (2002)235:842–849
4. Weinsier RL, Wilson LJ, Lee J. Medically safe rate of weight loss
Bilirubin A blood test used to determine for the treatment of obesity: a guideline based on risk of gallstone
liver and gallbladder dysfunction. formation. American Journal of Medicine (1995)98:115–117
Complete blood count (CBC) A blood test 5. Souba W, Fink M, Jurkovich G, et al. ACS Surgery:
that measures red blood cells (RBCs) Principles and Practice. New York, NY: WebMD, 2004
and white blood cells (WBCs). WBCs 6. Petelin J. Laparoscopic common bile duct exploration.
increase with inflammation. The normal Surgical Endoscopy (2003)17: 1705–1715
range for WBCs is 8,000 to 12,000. 7. Leitzmann MF, Giovannucci EL, Rimm EB, et al. The relation
of physical activity to risk for symptomatic gallstone disease
Endoscopic retrograde cholangiogram An in men. Annals of Internal Medicine (1998)128:417–425
endoscope with a camera on the end is 8. Leitzmann MF, Rimm EB, Willet WC, et al. Recreational
passed through your mouth, stomach, physical activity and the risk of cholecystectomy in women.
and intestines into the bile duct to New England Journal of Medicine (1999)341:777–784
check for and remove gallstones. 9. Moga MM. Alternative treatment of gallbladder disease.
Medical Hypothesis (2003)60:143–147
HIDA (hepatobiliary iminodiacetic acid scan)
10. Overend TJ, Anderson CM, Lucy SD, et al. The effect of
A scan that images the liver, gallbladder, incentive spirometry on post-operative complications. Chest
and bile ducts following injection of (2001)120:971–978
radiolabeled dye into the veins. 11. Graham G, Baxi L, Tharakan T. Laparoscopic cholecystectomy
Hernia A bulge through an abnormal during pregnancy: a case series and review of the literature.
opening in the abdominal wall. Obstetrics and Gynecology Survival (1998)53:566–574
12. Al-Fozan H, Tulandi T. Safety and risks of laparoscopy in pregnancy.
Magnetic resonance cholangiopancreatography Current Opinion in Obstetrics and Gynecology (2002)14:375–379
A scan that uses powerful magnets and 13. Khaitan L, Apelgren K, Hunter L, et al. A report on the Society
radio waves to show pictures of the body. of American Gastrointestinal Endoscopic Surgeons (SAGES)
outcome intiative. Surgical Endoscopy (2003)17:365–370
14. Giger UF, Michel JM, Opitz I, et al. Risk factors for perioperative
complications in patients undergoing laparoscopic cholecystectomy:
This information is published to educate you about your
specific surgical procedure. It is not intended to take the analysis of 22,953 consecutive cases from the Swiss Association
place of a discussion with a qualified surgeon who is familiar of Laparoscopic and Thoracoscopic Surgery database. Journal
with your situation. It is important to remember that each of the American College of Surgeons (2006)203:723–728
individual is different, and the reasons and outcomes of any
operation depend on the patient’s individual condition. Reviewed by: Patricia L. Turner, MD, FACS
The American College of Surgeons (ACS) is a scientific and Mark Malangoni, MD, FACS
educational organization that is dedicated to the ethical and
competent practice of surgery. It was founded to raise the
standards of surgical practice and to improve the quality
of care for the surgical patient. The ACS has endeavored to
present information for prospective surgical patients based
on current scientific information; there is no warranty on We are grateful to Ethicon Endo-Surgery for their support
the timeliness, accuracy, or usefulness of this content. in printing this document.
8 A mE R IC A n COl l EGE Of S uR GEO n S • 633 n. S A In T C l A IR S T. • C hIC AG O, Il 6 0 611 • w w w.fac s.org