Laparoscopic cholecystectomy

Laparoscopic cholecystectomy is a surgical procedure in which the gallbladder is removed through small incisions in the abdomen. It is mainly carried out when gallstones cause biliary pain, inflammation or other complications.

What is a laparoscopic cholecystectomy?

The gallbladder is a small organ situated beneath the liver which stores some of the bile produced by the liver and releases it into the intestine during digestion. Stones (cholelithiasis) —also known as gallstones— can form inside it from various substances present in the bile.

When these stones cause illness, a cholecystectomy involves more than just removing the stones: the entire gallbladder is removed. Leaving a gallbladder that has already formed stones in place would allow new ones to develop and the episodes to recur.

The laparoscopic approach allows the operation to be carried out using a camera and various instruments inserted through small incisions. The difficulty of the procedure may vary depending on the degree of inflammation, the anatomy of the area and whether the patient has undergone previous abdominal surgery.

After the gallbladder has been removed, the liver continues to produce bile. The difference is that the bile flows more continuously into the intestine rather than being temporarily stored in the gallbladder.

When surgery may be recommended

One of the most common indications is biliary colic, an intense, continuous pain that is usually felt in the upper abdomen or beneath the right ribs and may radiate towards the back or shoulder.

When these episodes recur or significantly affect daily life, removal of the gallbladder may be considered. Surgery also becomes particularly important when gallstones cause inflammation or complications in the bile ducts or the pancreas.

The relationship between the symptoms and gallbladder disease must be assessed before surgery. Symptoms such as bloating, heartburn, indigestion or isolated episodes of nausea may have other causes and do not necessarily improve following a cholecystectomy.

Cholecystitis and other complications of gallstones

Acute cholecystitis occurs when the gallbladder’s outlet remains blocked and inflammation develops. The pain usually lasts longer than that experienced during biliary colic and may be accompanied by fever, abdominal tenderness and abnormal test results.

Where the patient’s clinical condition permits, laparoscopic cholecystectomy may be performed at an early stage during the same hospital stay. Prior to this, the severity of the inflammation, the patient’s general condition and any factors that might affect the safety of the procedure are assessed.

Stones may also pass out of the gallbladder and travel into the common bile duct, the main duct that carries bile to the intestine. This condition, known as choledocholithiasis, can lead to jaundice, biliary tract infection or pancreatitis.

Following biliary pancreatitis, gallbladder surgery may form part of the strategy aimed at preventing further episodes once the patient’s clinical condition allows the procedure to be carried out.

How the gallbladder and bile ducts are assessed before surgery

The assessment begins with a medical history and a physical examination. The aim is to determine whether the characteristics of the pain are consistent with a biliary disorder and to check for signs of inflammation, obstruction of the ducts or pancreatic involvement.

An abdominal ultrasound scan is usually the first imaging test. It allows stones to be identified, the gallbladder wall to be assessed and the bile ducts to be checked for dilation.

Laboratory tests can assess bilirubin, liver enzymes, inflammatory markers, blood cells and coagulation. The results of these tests, together with the ultrasound scan and the symptoms, help to determine whether the common bile duct also needs to be investigated.

When gallstones in the common bile duct are suspected

Where there is evidence to suggest stones in the biliary tract, tests such as magnetic resonance imaging (MRI) of the bile ducts, endoscopic ultrasound or, in certain situations, cholangiography during surgery itself may be used.

ERCP — endoscopic retrograde cholangiopancreatography — allows access to the bile ducts from the intestine via an endoscope and enables stones to be removed when there is a clinical indication.

ERCP and cholecystectomy serve different purposes. The former enables the treatment of stones lodged in the bile ducts; the surgery removes the gallbladder, which may otherwise continue to act as a source of new stones.

Not everyone needs these additional tests or procedures. The scope of the investigation is determined by the likelihood of stones being present outside the gallbladder.

Preparing for surgery

Before the operation, the test results, any associated medical conditions, allergies and regular medication are reviewed. The anaesthetic assessment allows the necessary conditions for performing the surgery under general anaesthesia to be evaluated.

Anticoagulant and antiplatelet treatments, as well as certain diabetes medications, may require specific planning. Any changes must be made in accordance with the instructions of the medical team responsible and not on your own initiative.

Instructions regarding fasting and which medicines may be taken on the day of the operation depend on the anaesthetic protocol and the individual’s circumstances.

How a laparoscopic cholecystectomy is performed

The procedure is carried out under general anaesthesia. The abdomen is inflated with carbon dioxide to create a working space, and a camera and surgical instruments are inserted through small incisions.

The surgeon gradually separates the gallbladder from the surrounding tissues and locates the structures connecting it to the bile duct and the vascular system. Before severing these structures, it is essential to check precisely which structures are being dealt with.

The so-called ‘critical safety view’ is a surgical strategy designed to correctly identify the cystic duct and the cystic artery before sealing or cutting them. Its purpose is to reduce the risk of confusing these structures with other bile ducts.

Once the anatomy has been reliably identified, the gallbladder is separated from the liver and removed through one of the small incisions. At the end of the procedure, the surgical field is examined and a decision is made as to whether a drain is required; this is not routinely necessary in all operations.

The duration of the procedure depends on the degree of inflammation, the anatomy, the patient’s surgical history and any difficulties that may arise during the procedure.

How surgery is adapted when the anatomy is complex

Severe inflammation, adhesions or certain anatomical variations can make it difficult to identify the bile ducts with certainty. In these circumstances, the priority is to avoid injury to the biliary tract, even if this means modifying the initially planned strategy.

The surgeon may use imaging during the operation, change the approach to the gallbladder, or perform a subtotal cholecystectomy. This technique involves removing most of the gallbladder whilst preserving the area where dissection might be unsafe.

In other situations, it may be necessary to convert the laparoscopic procedure to open surgery via a larger abdominal incision. This decision provides a different route of access when inflammation, bleeding or anatomical factors mean that continuing with laparoscopy is not the safest option.

A subtotal cholecystectomy may subsequently require specific follow-up due to the possibility of bile leakage, residual stones or other problems related to the preserved gallbladder tissue.

Benefits and outcomes of cholecystectomy

When the indication is well established, cholecystectomy removes the gallbladder, where stones form, and reduces the likelihood of further attacks of colic, inflammation and other complications arising from this organ.

The benefit is usually particularly clear when there are episodes of pain with typical biliary characteristics or when cholecystitis or another stone-related complication has already occurred.

However, the operation does not guarantee that digestive discomfort arising from other causes will disappear. Heartburn, bloating, a feeling of heavy digestion or certain types of nausea may persist after a technically successful operation if they were not related to the gallbladder.

The laparoscopic approach allows the surgery to be performed via smaller incisions than those required for open surgery. The actual recovery time depends, however, on the degree of inflammation, the complexity of the procedure and the individual’s response.

Risks and potential complications depending on the complexity of the surgery

Laparoscopic cholecystectomy is a surgical procedure and may be associated with complications. The type and likelihood of complications occurring depend on factors such as the degree of inflammation, anatomy, associated medical conditions, previous abdominal surgery and the actual complexity encountered during the operation.

Possible general complications include bleeding, infection, thrombosis, respiratory problems and those related to anaesthesia.

One particularly significant complication is injury to the bile ducts. This may involve a leak of bile from small ducts or a more serious injury to the main bile ducts.

When a bile leak or injury occurs, it may lead to pain, fever, bile accumulation, jaundice or infection. Treatment depends on the type and extent of the injury and may require endoscopy, image-guided procedures or specialised surgery.

Blood vessels, the bowel, the liver or other nearby structures may also be injured. Furthermore, after the operation, stones that were already present in the common bile duct but had not been previously detected may become apparent.

The extent of the risk cannot be expressed by a single estimate valid for everyone. An elective cholecystectomy without significant inflammation and surgery performed on a severely inflamed gallbladder represent different clinical scenarios.

Recovery and diet following gallbladder removal

Following the operation, you may experience pain at the incision sites, a feeling of abdominal distension and discomfort in the shoulder related to the gas used during the laparoscopy. The severity and duration of these symptoms vary depending on the type of surgery and the individual’s response.

Tolerance to liquids and food is assessed gradually. Some people may be discharged after a relatively short period of observation, whilst others may need to remain in hospital due to inflammation, associated medical conditions or the complexity of the procedure.

During the first few days, smaller meals with a moderate amount of fat may be better tolerated. Subsequently, the diet is gradually expanded according to tolerance.

It is not usually necessary to follow a special diet permanently simply because you do not have a gallbladder. The liver continues to produce bile, which flows directly into the intestine; therefore, most people gradually adapt to this new form of bile flow.

For a while, you may experience looser stools, a sudden urge to go to the toilet, bloating or a reduced tolerance to certain foods. If diarrhoea persists, it may be necessary to assess whether there is a problem related to bile acids and to consider specific treatment.

A return to work, exercise and other activities should be gradual. The timing depends on the clinical course, the nature of the operation and the level of physical exertion required for each activity.

Alternatives to cholecystectomy

The approach depends on the symptoms, any complications present and the patient’s general health.

When gallstones are discovered incidentally and have not caused any symptoms or complications, a ‘watch-and-wait’ approach may be adopted. Medicines capable of dissolving certain types of gallstones have very limited indications and do not constitute a general alternative to surgery in symptomatic biliary disease.

In people with acute cholecystitis who are temporarily unable to undergo surgery safely, initial treatment may include antibiotics and, in certain situations, drainage of the gallbladder to control the infection and allow for a subsequent reassessment.

ERCP is a therapeutic alternative for stones located in the bile ducts, but it does not remove the gallbladder and therefore plays a different role in treatment.

Signs requiring medical assessment

Following the procedure, you should contact the healthcare team if you experience a fever, progressively worsening abdominal pain, persistent vomiting, severe bloating or significant changes to the wounds, such as increasing redness or discharge.

The appearance of a yellowish tinge to the skin or eyes, very dark urine or abnormally pale stools may indicate a problem with bile flow and requires assessment.

Severe or worsening abdominal pain, breathing difficulties, loss of consciousness, significant bleeding, rapid deterioration in general health, or a combination of fever and jaundice require urgent medical attention.

Specialists involved

The clinical pathway for a patient requiring a cholecystectomy begins with confirming that the symptoms or complications originate from the gallbladder and assessing whether there are also gallstones or abnormalities in the bile ducts.

At the Publio Cordón Memorial Hospital, the General and Digestive Surgery department is directly responsible for the surgical assessment and for performing the cholecystectomy. The department forms part of the hospital’s Metabolic Centre and carries out abdominal surgery using both conventional and minimally invasive techniques.

Where there is a suspicion of stones in the common bile duct, biliary pancreatitis or other disorders of the ducts, the Department of General and Digestive Surgery may be involved in the investigation and treatment of the biliary tract. Within this speciality, the Biliopancreatic Unit focuses specifically on disorders of the biliary tract and the pancreas and has expertise in advanced endoscopic techniques.

The Radiology Unit can provide ultrasound, CT scans, MRI and other techniques when it is necessary to characterise a complication or to further investigate the abdominal and biliary anatomy. The unit has specific expertise in thoracoabdominal radiology and works in coordination with the clinical and surgical specialities.

In selected cases, Interventional Radiology may be involved through image-guided procedures, for example when drainage is required in a patient who is initially unable to undergo surgery. The hospital offers Interventional Radiology as part of its range of services.

Anaesthetology and Resuscitation carries out the perioperative assessment and maintains anaesthetic and physiological control during the operation. Its involvement extends from the pre-operative preparation through to the period immediately following surgery.

Not everyone needs to go through all these stages. The team adapts its approach depending on whether there is only gallbladder disease, whether the bile duct is also affected, the severity of the inflammation, and the needs that arise before, during or after surgery.

Medical information for general guidance

This information sheet aims to help you understand what a laparoscopic cholecystectomy involves, when it may be recommended, how the gallbladder and bile ducts are examined, how the operation is carried out, and what changes may occur during recovery. It also explains why the surgical technique can be adapted in cases of inflammation or complex anatomy.

At the Publio Cordón Memorial Hospital, we believe it is important for medical information to be accurate, understandable and useful in guiding each person through their care journey. Our specialists devote part of their work to explaining conditions, tests and treatment options in an accessible way, helping patients and their families to better understand each stage and to participate with greater confidence in decisions about their health. This commitment to knowledge and public outreach is also part of our commitment to .

The information contained in this fact sheet describes the general principles of laparoscopic cholecystectomy. The indication for surgery and the surgical approach must be tailored to each individual, taking into account their symptoms, the presence of inflammation or complications, any potential involvement of the bile duct, their anatomy, associated conditions and their specific clinical circumstances.