GALLBLADDER

The gallbladder is an outpouching of the extrahepatic biliary system and is used for storing and concentrating bile, which is produced by the liver and recycled in the small intestine.  Bile is used in the emulsification and absorption of dietary fats and is usually free of bacteria.  The gallbladder is connected to the bile duct system via the cystic duct and a two-way valve, called the spiral valve of Heister.

The gallbladder is an outpouching of the extrahepatic biliary system and is used for storing and concentrating bile, which is produced by the liver and recycled in the small intestine.  Bile is used in the emulsification and absorption of dietary fats and is usually free of bacteria.  The gallbladder is connected to the bile duct system via the cystic duct and a two-way valve, called the spiral valve of Heister.

Gallstones (cholelithiasis) are found in 10-20% of adults, with higher frequency in women, obesity and older age.  Heredity and pregnancy are also risk factors.  In the US, gallstones are a mixed composition of cholesterol and lesser contributions from calcium and bilirubin (pigment).  Gallstones can change in size over time (getting bigger and smaller).  Gallstones are often found incidentally on ultrasound or CT scan.  Further evaluation includes blood tests to look at liver function and rarely biliary scintigraphy (HIDA scan).

The majority of those with gallstones never have symptoms; only 1-2% per year of patients with cholelithiasis will develop symptoms that require surgery.  Except in special circumstances (ie transplant, bariatric and hemolytic patients), asymptomatic gallstones are observed, with gall bladder removal (cholecystectomy) recommended only for those who develop symptoms or complications.   Gallbladder cancer is rare but is more common in those patients with a calcified (porcelain) gallbladder.  For this reason, it is also recommended that porcelain gallbladders found incidentally should be removed.

Symptomatic cholelithiasis often presents as constant right upper or mid-upper abdominal pain (biliary colic), often triggered by eating fatty foods and caused by contraction of the gallbladder while bile flow is temporarily blocked by a gallstone.  These episodes resolve spontaneously within a few hours but may recur with increasing frequency and severity.  Acute cholecystitis is an inflammation of the gallbladder caused by sustained blockage of the cystic duct with subsequent changes in the bile and gallbladder.  This can occur with or (less commonly) even without gallstones.  During an episode of cholecystitis, the gallbladder becomes swollen and its wall becomes thickened.  Secondary bacterial infection of bile can sometimes occur.  Pain is prolonged, often worse with touching the abdomen and may be associated with nausea, vomiting, loss of appetite and sometimes fever.  Still, many episodes of cholecystitis can resolve on their own.  Cholecystitis occurs most commonly in women between the ages of 30-70 years old.

Potential serious complications of cholelithiasis and choledocholithiasis (gallstones in the bile duct outside of the gallbladder) are pancreatitis, cholangitis and gallstone ileus.  Treatment depends on the exact nature of the problem and may involve open surgery to evaluate and relieve any intestinal blockage or may be able to be accomplished endoscopically (endoscopic retrograde cholangiopancreatography, ERCP, with sphincterotomy) or percutaneously (percutaneous transhepatic biliary drainage, PTBD).  Patients who develop pancreatitis or cholangitis should have cholecystectomy once the acute illness has resolved.

Cholecystectomy may be done electively or urgently (within 48 hours of symptom onset) and either laparoscopically or open.  The majority of gallbladder operations are done laparoscopically and electively under general anesthesia.  In emergent situations when the patient is too sick for surgery, a tube may be inserted into the gallbladder through the skin (cholecystostomy) by the interventional radiologist to decompress the gallbladder and facilitate resolution of gallbladder inflammation.  Intraoperatively, an Xray of the biliary system (cholangiogram) may be done to help clarify bile duct anatomy and evaluate for choledocholithiasis.

The benefits of laparoscopic or robotic surgery are shorter hospital stay and recovery time (ie. full activity in 7-10 days).  However, open cholecystectomy may be indicated in certain situations and usually involves an incision just under the right rib cage.  Complications of cholecystectomy (either open or laparoscopic/robotic) occur infrequently (<5%).  These include bile leak, retained stone, various GI symptoms (ie. diarrhea, bloating, heartburn) and postcholecystectomy syndrome (unexplained recurring pain, presumed to involve papillary fibrosis and/or biliary dyskinesia).

Another treatment option for gallstones is oral dissolution medication (ie chenodeoxycholic acid) to dissolve the gallstones.  However, oral medications are useful only for small gallstones, and therapy can take up to a year or longer with recurrence common within five years if the medication is discontinued.

HERNIAS

aHernia operations are among the most common operations performed by general surgeons.

Hernias are defined as abdominal contents protruding through the abdominal wall.  They generally occur as a result of a weakening or stretching of the muscle and its tendinous tissue covering, called fascia.

They can occur in many areas of the abdominal wall, particularly where these fascial fibers separate or cross.  Hernias may be soft and reducible (they can be pushed back inside), or rarely they may be hard and stuck out (incarcerated).  When associated with pain, nausea or vomiting, a hernia can be an emergency.

Hernias may be present at birth or may develop with age or after an operation.  In adults, they are often associated with obesity, chronic coughing, or frequent straining.  Diagnosis can be by physical examination alone, or with the assistance of imaging studies such as ultrasound or CT scan.  Sometimes hernias may be diagnosed incidentally on an imaging study done for an unrelated reason.

bInguinal and femoral hernias both occur in the groin and can usually be distinguished on physical examination.  Men are the most common recipients of inguinal hernia repairs, while femoral hernia surgery is much more common in women. Hernia repair has been performed for more than two centuries.  In modern times, it can be done either open or laparoscopically.  Most involve the use of mesh, a prosthetic material intended to reinforce the patient’s native, weakened tissue.  Most inguinal hernia repairs are performed on an out-patient basis.

The most common complications of inguinal hernia repair are seroma, hematoma, wound infection, urinary tract dysfunction, testicular atrophy, recurrence and chronic pain.  Most of these are self-limited and do not require repeat surgery.

Ventral hernia is a general term used to describe abdominal wall defects.  These include hernias in the umbilical (belly button) area or in the epigastric region, just above the umbilicus. Umbilical hernias are 3x more common in females than males.  In children, up to 20% of newborns may have an umbilical hernia, the majority of which close on their own by 4 years of age if the hernia is small.    Obesity, pregnancy, ascites and certain medications are known risk factors.

cAnother type of ventral hernia is an incisional hernia, which occurs in the same area where there was prior surgery.  These appear like a bulge under a scar in the abdominal area. Postoperative hernias may occur in up to 4% of patients but increase in incidence if wound infection occurs and may still develop up to 5 years after surgery (although half develop within 6-12 months).  Diagnosis can be difficult if the bulge is not obvious and may require CT scan or ultrasound to see it.  Repair is typically open, as opposed to laparoscopic, due to the risk of recurrence and mesh is almost always used to reinforce the repair. All hernias are repaired in the operating room, but often small ones do not require a general anesthesia.

Recovery after hernia repair is variable, depending on the size and location of the hernia.