Gallbladder and Biliary Surgery

Gallbladder Surgery

Removing the gallbladder (cholecystectomy) is a common procedure in our community and is mostly performed for symptoms arising from the gallbladder due to gallstones. Occasionally the gallbladder is removed as it is no longer functioning properly (Gallbladder Dysfunction) or there is concern regarding a polyp or potential malignancy.

Laparoscopic Cholecystectomy

This is the removal of the gallbladder via keyhole surgery and is performed under a general anaesthetic. This procedure involves a small incision (around 10mm) around the navel (umbilicus) and three 5mm incisions under the right side of the rib cage. The gallbladder is dissected off the liver and surrounding structures and then removed in a small bag via the umbilical port. An X-Ray (cholangiogram) of the bile duct is also normally performed during the operation to ensure there are no abnormalities with or stones inside the bile duct. The bile duct is the main drainage tube from the liver. This procedure normally takes around 45 minutes and you are in hospital for one night following the operation. Very occasionally the procedure is unable to be safely performed with keyhole surgery and a larger incision needs to be made in the upper abdomen. Patients normally take around 1-2 weeks off prior to returning to work however many work from home during this time. Light exercise can normally commence in 1-2 weeks however it takes around 4 weeks to get back into strenuous exercise.

Open cholecystectomy

This procedure is performed via a larger incision in the upper abdomen, usually under the right side of the rib cage or in the midline. It may be necessary to perform an open operation if the keyhole technique is unable to be safely performed due to previous scarring or severe gallbladder inflammation. For some conditions eg. Suspected gallbladder cancer, an open procedure may be recommended by your surgeon. In general, an open procedure will take longer to recover from and has an increased risk of wound complications such as infection or post operative hernia.

Biliary Surgery

Biliary surgery refers to surgery of the gallbladder and/or the bile duct. Surgery of the bile duct is normally performed for malignancy, stricture (narrowing) or gallstones that are unable to be removed via less invasive procedures. Often the bile duct needs to be re-joined to the bowel in order for the liver to drain properly. Your surgeon will discuss with you the exact type of biliary surgery they are proposing and the reasons for doing so.

Complications of Gallbladder Surgery

All surgery carries risks and gallbladder surgery is no different. Although laparoscopic cholecystectomy is generally very safe some of the complications that may occur include a leakage of bile following the procedure (around 1:300 risk), damage to other organs such as the small bowel, wound infection or a hernia at the port sites. Other general operative risks include clots in the legs (Deep Vein Thrombosis/DVT) or lungs (Pulmonary Embolism/PE), chest infection or severe reaction to the anaesthetic agents. All care is taken to avoid these complications using certain medications and stockings however they may still occur.

Read more detailed information on cholecystectomy

Liver Surgery

Surgery is performed on the liver for a variety of both benign (non cancerous) and malignant (cancerous) conditions. Liver surgery varies from removing a very small portion of the liver to removing up to around 70 – 75% of the liver. Enough liver needs to be left behind to ensure the liver is still able to perform its role. The liver is divided into a left and right half, both of which have four segments. The liver has a dual blood supply from the hepatic artery and portal vein. The liver drains via three main hepatic veins. The liver also produces and drains bile via the common hepatic duct.

The liver has many functions which include the conversion of sugar into energy, the elimination of waste products, the production of bile which helps to break down fats, the production of clotting factors and the metabolism and elimination of certain medications.

Various techniques are employed to dissect through and remove liver tissue and minimise operative risks. Liver resection can be broadly classified into the following categories:-

  1. Subsegmental resection – the lesion is removed with a small amount of normal liver tissue surrounding it (a ‘margin’)
  2. Segmental resection – a segment of the liver containing the tumour is removed to ensure an adequate margin is obtained
  3. Hemi-hepatectomy – One half of the liver is removed. This is normally done for larger tumours or multiple tumours in one half of the liver.
  4. Extended Hepatectomy – This involves removing one half of the liver and part of the liver on the opposite side. This is done when the tumour approaches the opposite side of the liver so part of the opposite side needs to be removed to ensure the whole tumour is fully excised.

Liver surgery may be performed via the open or laparoscopic (keyhole) technique. As with other abdominal operations, the benefits of laparoscopic surgery are smaller incisions, less post operative pain and a quicker return to activity. Often a larger incision is still required to remove the specimen however this can be placed lower in the abdomen and results in less post operative pain.

Liver surgery is a technically demanding operation with many potential complications. General risks include blood clots in the legs (DVT) or lungs (PE), a severe reaction to the anaesthetic and post operative pneumonia (lung infection). Post operative bleeding, wound infections & a post operative incisional hernia can also occur. Complications specific to liver surgery include a leakage of bile from the liver or liver failure although this is rare and normally only seen when large portions of the liver are being removed.

Read more detailed information on liver surgery

Pancreatic Surgery

The pancreas is an organ located deep in the abdominal cavity, the function of which is to produce both endocrine (eg. insulin) and exocrine (eg. Amylase and lipase) substances. These substances help to control the blood sugar level and digest food. On occasion part of the pancreas needs to be removed and there are four main procedures that can be performed to achieve this. In general these procedures are performed via open surgery however some of these procedures may be performed via laparoscopic (keyhole) or robotic surgery.

Whipple procedure

This is also known as a pancreaticoduodenectomy and is named after Dr Allen Whipple who helped pioneer this surgery. During this procedure the head of the pancreas, the duodenum, part of the stomach and small bowel as well as the gall bladder and bile duct are removed. The remaining bile duct, pancreas and stomach are then reconnected to allow for appropriate drainage of the pancreas and liver.

Distal pancreatectomy

In this procedure the last part of the pancreas is removed +/- the spleen. This is normally performed for tumours or cysts in the body or tail of the pancreas. The spleen is also removed if there is concern the tumour may be malignant and appropriate clearance is required.

Central pancreatectomy

In general this procedure is performed for lesions that are thought to be at very low potential for invasive malignancy. The benefit of this procedure is that more pancreatic tissue is retained to help with blood sugar control and digestion. The potential down side of this procedure is that it tends to have a higher complication rate when compared with a distal pancreatectomy.

Total pancreatectomy

This procedure is rarely performed however on occasions when a tumour extends across a large area of the pancreas the whole organ may need to be removed. During the procedure the entire pancreas, gallbladder, common bile duct, spleen and parts of the stomach and small bowel are removed. The bile duct and stomach are then reconnected to allow for drainage of the liver and stomach. As the whole pancreas is removed the patient is reliant on insulin to control their blood sugar and enzyme supplements (Creon) to help digest food.

Complications of pancreatic surgery

Pancreatic surgery is technically demanding and the complication rates are higher than many other abdominal operations. Potential complications include bleeding, wound and lung infections and clots in the legs (DVT) or lungs (PE). As multiple anastomoses (joins between the pancreas, bile duct and bowel) are required this increases the complexity of the surgery. Even with excellent surgical technique these joins may leak and this can cause problems in the post operative period. The most significant of these leaks is a leak of fluid from the pancreas and this is known as a pancreatic fistula. Delayed gastric emptying may also occur following surgery. Your surgeon will discuss with you in more detail the potential complications of pancreatic surgery.

As the pancreas produces insulin and digestive enzymes patients will often be required to take diabetic medication and/or enzyme supplements following pancreatic surgery.

Read more detailed information on pancreatic surgery

Hiatus Hernia Surgery

Most hiatus hernia surgery is performed laparoscopically (keyhole surgery) and involves returning the contents of the hiatus hernia to the abdominal cavity and then repairing the hernia itself.

The Procedure

The procedure is performed under a general anaesthetic. Five small incisions are made to act as the keyholes down which the surgeon places instruments to retract the liver and perform the surgery.

A hiatus hernia usually contains some or all of the stomach, and occasionally other organs such as the liver or colon. The stomach (or other organs) that have slipped through the hernia, are sitting above the diaphragm in the chest, and they are then pulled back down along with the sac, or lining of the hernia itself.

Once the organs are back where they belong the hiatus is repaired by stitching the muscles that surround it together with a series of surgical sutures. Sometimes a piece of mesh is used to reinforce this repair and allow an appropriate amount of scar tissue to form to strengthen the hiatus itself.

After the hernia is repaired a fundoplication, or gastric wrap, is performed (see Fundoplication – Anti-Reflux Surgery topic). This is because people with hiatus hernias tend to have reflux, which may persist following repair of the hernia, unless the fundoplication component to the operation is undertaken. It is a routine part of a hiatus hernia repair.

Recovery

You will usually stay in hospital for 1-2 days after your surgery. Sometimes there is a little chest pain in the first couple of days, but most people don’t need much pain relief by the time that they go home.

An x-ray test may be performed on the first or second post-operative day to ensure the repair is working and that you can swallow fluids without an issue. You will go onto a fluid diet initially. Your diet will gradually increase from fluids, to puree, soft foods and eventually normal food, over a period of a few weeks.

After keyhole surgery your stitches are usually dissolving and there are some small dressings that are removed in the first week or so.

Follow Up

Your surgeon will see you in the office several weeks after your surgery. At this time your diet will be progressed meaning you will be able to eat more normal food and your surgeon will ask you questions about your symptoms. Usually by this time you can swallow as normal and your reflux symptoms have resolved.


Fundoplication – Anti-Reflux Surgery

A fundoplication is performed for people with proven gastro-oesophageal reflux that can’t be managed with medication alone. It is also performed as part of a hiatus hernia repair. It is usually performed laparoscopically (keyhole surgery).

The Procedure

The procedure is performed under a General Anaesthetic. Five small incisions are made to act as the keyholes down which the surgeon places instruments to retract the liver and perform the surgery. Often, the first thing that the surgeon does is repair a hiatus hernia if one is present ((see Hiatus Hernia Repair topic))[#].

To perform a fundoplication, the surgeon disconnects the upper part of the stomach (the fundus) from the surrounding tissues to ensure that it is mobile enough to wrap around the junction between the oesophagus (food pipe) and the stomach. Sometimes this involves controlling and ligating through some of the small blood vessels that run from the fundus towards the spleen.

Once the fundus is able to move freely, it is wrapped around the junction of the oesophagus and stomach and stitched in place there with surgical sutures. It can be wrapped around the front (anterior fundoplication) or the back (posterior fundoplication) and can be wrapped around partially or completely. You surgeon can discuss these finer points with you. In essence, a greater degree of wrap will provide a tighter space for food to pass down and gastric acid to pass up and is therefore more effective, but at greater risk of causing swallowing difficulty. Your surgeon will be able to gauge how tight to make your wrap to get the balance as close to perfect as possible.

Recovery

You will stay in hospital for 1-2 days after your surgery. Sometimes there is a little chest pain in the first couple of days, but most people don’t need much pain relief by the time they go home a few days after surgery.

Your diet will gradually increase from fluids, to puree, soft foods and eventually normal food, over a period of a few weeks. After keyhole surgery your stitches are usually dissolving and there are some small dressings that are removed in the first week or so.

Follow Up

Your surgeon will see you in the office several weeks after your surgery. At this time your diet will be progressed meaning you will be able to eat more normal food and your surgeon will ask you questions about your symptoms. Usually by this time you can swallow as normal and your reflux has completely gone.


Gastrectomy

A gastrectomy is performed for the surgical management of gastric (stomach) cancer. It involves the removal of the tumour with the stomach itself ensuring that the entire cancer is removed, along with removal of the lymph nodes that would typically be the first place that cancer would spread.

The Procedure

The procedure is performed under a General Anaesthetic and is often performed laparoscopically (keyhole), although open surgery is sometimes best to ensure safe removal of the tumour. First the surgeon will check that there is no spread of cancer outside of the stomach and nodes that are being removed. Assuming that this is all ok, the surgeon will proceed to perform the gastrectomy.

The stomach is freed up from all of the blood vessels that deliver blood to it. These arteries need to be carefully controlled by the surgeon to prevent bleeding. The stomach is then disconnected from the first part of the small bowel (duodenum) and from the oesophagus (food pipe). If the tumour is in the bottom part of the stomach, a distal gastrectomy is performed meaning that a short segment of stomach will be left behind at the top. If the tumour is a higher up, a total gastrectomy will be performed, meaning that the entire stomach is removed, and the oesophagus is left in place. Once the stomach is completely disconnected it can be removed.

The lymph nodes are taken out with the stomach. These are found in all of the fatty tissue that surrounds the stomach and the blood vessels that supply it.

The stomach and all of the lymph nodes are sent to the pathologist to be examined under a microscope to provide further information about the tumour.

After removal of the stomach, the small bowel needs to be joined onto the remaining upper part of the stomach (partial gastrectomy) or onto the oesophagus (total gastrectomy) so that food can make it all the way through.

Recovery

Following a gastrectomy you will go to the High Dependency Unit (HDU) in the post operative period for close monitoring. Pain will usually be controlled with a self-controlled button (Patient Controlled Analgesia or PCA) to allow comfortable mobility. You will be mobilised early, especially after keyhole surgery. Often it may be necessary to use a nasogastric tube - a tube passing down your nose to your stomach passed at surgery - which keeps the join deflated. There may be a surgical drain coming through the abdominal wall. You will also usually have a catheter in your bladder. You will remain in hospital until you are eating adequately and mobilising comfortably.

Follow Up

Your surgeon will see you in the office around one month following your surgery. By this time, you should feel well on the road to complete recovery. There may be a need for further cancer treatment with chemotherapy depending on whether cancer was the reason for your gastrectomy and what the pathologist has found.

This appointment is an opportunity to further discuss your pathology results and how you are progressing since you left hospital.


Oesophagectomy

An oesophagectomy is performed to remove a tumour of the oesophagus or the junction between the oesophagus and stomach, along with the lymph nodes to which this cancer tends to spread first.

The Procedure

The procedure is performed under general anaesthetic and usually performed using an open technique. This is done via an incision down the middle or across the top of the abdomen and a separate incision on the right side of the chest. Often keyhole surgery is used for a portion of this surgery.

First the surgeon will ensure the tumour has not spread outside of the oesophagus and nodes that are being removed. Assuming that this is all ok, the surgeon will proceed to perform the oesophagectomy.

The stomach is freed up from most of the blood vessels that enter it to allow it to freely move up towards the chest. It is then narrowed down using a series of surgical stapling devices into a long tube that can replace the oesophagus once it is removed. The upper part of the stomach near the tumour is removed along with the lymph nodes that are nearby to ensure that the whole cancer is removed.

The tumour is usually close to the point here the oesophagus passes from the chest, through the diaphragm into the abdomen and this area is freed up from the diaphragm to allow it to come free. A pyloromyotomy or pyloroplasty is performed. This is where the muscle that controls the outflow from the stomach into the small bowel is disrupted to make sure food can pass freely through. A plastic surgical drain is placed and brought out through the skin and the abdomen is closed.

The team then carefully reposition the patient to perform a thoracotomy (operation on the chest). An incision is made below the right shoulder blade and between the ribs to access the oesophagus. The lung is deliberately collapsed by the anaesthetist and the oesophagus is found in the chest cavity. The oesophagus is removed along with all of its lymph nodes and the stomach is dragged up into the chest to join onto the part of the upper stomach which has been left behind. One or two plastic drains are placed in the chest and brought out between the ribs before the lung is reinflated and the wound closed with surgical sutures.

In some instances, the surgeon needs to remove more of the oesophagus and so the stomach is actually brought all the way through the chest up to the neck, where an additional incision is made to join onto the oesophagus up in the neck area.

Recovery

Following an oesophagectomy the patient is admitted to the intensive care unit (ICU) afterwards. You will wake up with a tube coming out of your nose which keeps the join deflated. There may be a surgical drain coming through the abdominal wall and there may also be a feeding tube coming through the abdominal wall. There will also be a drain coming out of your chest. You will also have a catheter in your bladder. You may have a central venous cannula going into one of the main veins in your neck.'

Your diet is restricted for the first week or so to allow the join to heal safely. Over the next week, the various drainage tubes will gradually be removed, and you will make your way from ICU to the normal ward.

After about a week there is usually a contrast x-ray test to confirm that the join is not leaking, and that fluid passes through normally. After this, you will be gradually allowed to drink fluids, then purees and soft foods in a progressive fashion.

Most people spend around 10 – 14 days in hospital and go home once all of the drains have been removed and you are eating or at least drinking normally.

Follow Up

Your surgeon will see you in the office around one month following your surgery. By this time, you should feel well on the road to complete recovery. There may be a need for further cancer treatment with chemotherapy depending on whether cancer was the reason for your oesophagectomy and what the pathologist has found.

This appointment is an opportunity to further discuss your pathology results and how you are progressing since you left hospital.


Abdominal Wall Hernia Surgery

Abdominal wall hernias are common and involve the protrusion of the abdominal contents through a defect in the abdominal wall. These hernias are often located around the navel or in the midline above the navel. The hernia may also occur at the site of a previous operation, this is known as an incisional hernia. There are many different ways to repair these hernias, this includes a laparoscopic (keyhole) approach, open approach or a combination of the two. Surgical mesh is often used to reinforce the hernia and reduce the risk of recurrence. Your surgeon will discuss with you the advantages and potential drawbacks of the various forms of hernia repairs and suggest an approach that is best for your individual situation.


Inguinal (Groin) Hernia Surgery

A groin hernia is a common condition that may affect an area in the inguinal or femoral region. As with other hernias there are many different ways of repairing an inguinal hernia. The two main operative approaches are using laparoscopic (keyhole) or open surgery. A mesh is nearly always used as this significantly decreases the chance of the hernia coming back (recurrence). Patients often stay overnight in hospital after groin hernia surgery however it is possible to go home on the same day in selected cases. As a general rule, a laparoscopic hernia repair is associated with less post operative pain and a quicker return to work. Another advantage of the laparoscopic technique is that you can repair both sides (bilateral repair) through the same incisions. Some groin hernias may not be suitable for laparoscopic repair however and your surgeon will discuss with you the best option in your situation.

Specific complications of hernia repairs include local discomfort, infection, damage to nerves and blood vessels, bruising and urinary retention. There is also a very small chance of the hernia coming back in the longer term. Other general operative risks are also present and these include complications such as clots in the legs (DVT) or a severe reaction to the general anaesthetic.


Bariatric Surgery

Also known as weight loss or metabolic surgery, bariatric surgery is a proven treatment approach for the management of excess weight, obesity and diabetes. The goal is for patients to lose most of their excess weight, treat associated illnesses such as diabetes or high blood pressure and experience a healthier and improved lifestyle. Bariatric surgery includes a variety of different surgical procedures, generally performed laparoscopically (key-hole surgery) which all work in slightly different ways to help improve and enhance weight loss. Bariatric procedures can generally be categorised as “restrictive”, “malabsorptive” or a combination of both. Deciding which procedure is right for you can be challenging, and your surgeon will explain all of your options and offer a recommendation that is tailored to your needs, your weight and your previous history.

The most common procedures in Australia are the Laparoscopic sleeve Gastrectomy, Laparoscopic adjustable Gastric Band and Laparoscopic Gastric Bypass. There are also other procedures available for patients with particular needs.

Laparoscopic Sleeve Gastrectomy

A large part of the stomach is removed with a surgical stapling device using keyhole surgery (laparoscopy) to change the shape of the stomach from being a bag into a long narrow sleeve. In doing so, the patient feels full very quickly and so their portion sizes are vastly reduced. Patients also generally report feeling much less hungry with a decreased appetite due to a reduction in the hunger hormone ghrelin. It is a reliable and well tolerated procedure.

Laparoscopic Adjustable Gastric Band

A plastic ring is inserted using keyhole surgery (laparoscopy) around the upper part of the stomach. This ring is lined with a small balloon which can be inflated and deflated using a tiny needle passed into a reservoir implanted under the skin on the abdomen. When inflated, the balloon restricts the flow of food through the stomach, resulting in feeling full more quickly during and after meals. Portion sizes are thereby reduced. This procedure is reversible with repeat surgery and if necessary can be converted to other procedures such as a sleeve gastrectomy or gastric bypass.

Laparoscopic Gastric Bypass

Using keyhole surgery (laparoscopy) the stomach is stapled across leaving a small stomach “pouch” for food to go into. The small intestine is then attached to this new smaller stomach resulting in less feelings of hunger, feeling full more rapidly and the absorption of less of the available energy in the diet. This procedure has both restrictive and malabsorptive elements. Two main types exist, called the roux-en-y gastric bypass and the omega loop (sometimes referred to as the ‘mini’ gastric bypass).

Read more detailed information on bariatric surgery

Endoscopic Procedures

Gastroscopy

A gastroscopy (or endoscopy) is a procedure that examines the oesophagus, stomach and first part of the small bowel (duodenum). The procedure involves a camera being inserted through the mouth and down the oesophagus (gullet). The procedure normally takes around 10 minutes and is done under sedation. No bowel prep is required however you will need to fast for 6 hours prior to the procedure.

Colonoscopy

A colonoscopy is a camera examination of the colon that is usually performed to look for lesions in the bowel such as polyps or bowel cancer. It can also be used to assess for inflammation in the bowel or look for causes of rectal bleeding. A colonoscopy requires bowel preparation prior to the procedure and clear fluids orally the day prior to the procedure. The colonoscopy is performed under sedation and normally takes around 20-30 minutes.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

An ERCP is similar to a gastroscopy however uses a slightly different scope with the camera on the side rather than on the end of the scope. This allows for a better view of the ampulla which is where the bile duct and pancreatic duct drain into the small bowel. An ERCP is normally performed in order to remove stones from the bile duct or unblock the bile duct by the placement of a stent. No bowel preparation is required however you do need to fast for six hours prior to the procedure.

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