Sample Consultation for Gallstones

The following hypothetical consultation about gallbladder surgery is presented for purposes of general information. If you think you have a similar condition, please see your primary care doctor to discuss your individual case and the exams and treatments that are best for you.

Background
More than 25 million people in the United States have gallstone disease. Gallstones are most common in overweight adults between the ages of 35 and 55, and affect more women than men. Each year there are approximately one million new cases of gallstone disease, and treatment becomes necessary in about one out of every two cases. The most common treatment is surgical removal of the gallbladder, or cholecystectomy. In our example, the patient is a 42-year-old woman whose primary care doctor has referred her to discuss surgery.

Consultation

Doctor: Hello. How are you?

Patient: I’m fine, thank you.

Doctor: How can I help you today?

Patient: I’m here to talk with you about having surgery on my gallbladder. I’ve had problems lately and my primary care doctor says it’s time to operate.

Doctor: I see. Please tell me about how all this started, and what symptoms you’ve been having.

Patient: During the past month, I’ve had two episodes of very severe pain in the upper right part of my abdomen. The first time I tolerated it and it passed. The second time, I went to my primary care doctor and he ordered an ultrasound. The ultrasound showed gallstones.

Doctor: I have the ultrasound report here. Do you understand why your doctor has referred you to me to discuss surgery at this point?

Patient: He tells me that there is a risk of serious problems, but I’m not sure I understand exactly what that means.

Doctor: Well, as you may know, the gallbladder is connected to the liver and to the small intestine. The liver manufactures bile and sends it to the gallbladder, which stores it until you need it. When you eat, particularly when you eat heavy, fatty or greasy foods, the gallbladder squeezes bile out into the small intestine to help with digestion. For reasons that are complex, stones sometimes form in the gallbladder. A stone can become trapped in a duct and prevent the gallbladder from emptying, and then you have an attack of pain. The gallbladder can also become infected, a condition we call cholecystitis, and that causes pain as well.

Patient: It certainly is painful.

Doctor: Have you had indigestion as well?

Patient: Bad indigestion.

Doctor: And have you experienced any nausea with it?

Patient: Some.

Doctor: Bloating?

Patient: Yes.

Doctor: And these problems started about a month ago?

Patient: That’s right.

Doctor: Do you have any other health problems? High blood pressure? Diabetes? High cholesterol or lipids?

Patient: No.

Doctor: All right. I’d like to examine you now, and then we’ll talk about the surgery.

The doctor examines the patient, noting that she is moderately overweight. She has no pain currently.

Doctor: Although it certainly sounds like you were hurting with your prior attacks, there are usually no long-lasting problems from any one attack of what we call “colic.” Thankfully, I don’t find any abnormalities on your physical examination today. I’ve reviewed your ultrasound report, and, all things considered, I would recommend that your gallbladder comes out.

Patient: What would happen if I didn’t have the surgery?

Doctor: A little while ago you asked what we mean by “serious problems.” When there are gallstones, there is the risk that stones will become trapped in a duct, either the ducts connecting to the liver or the duct connecting to the small intestine. In either case, this causes episodes of pain, as you’ve already experienced. If a stone blocks the common bile duct, which is the main duct connecting the gallbladder and liver to the intestines, then bile cannot flow get out of the liver. This situation can be very serious. You would possibly develop jaundice, and it’s usually necessary to operate immediately if that happens.

Patient: What is the surgical procedure?

Doctor: We remove your gallbladder laparoscopically.

Patient: Is that standard now, to do the surgery laparoscopically?

Doctor: Yes, in most situations. Over 90 percent of gallbladder removal surgeries are done laparoscopically now.

Patient: What are the advantages of doing it that way?

Doctor: Laparoscopic gallbladder surgery is a minimally invasive operation. Unlike the open operations that were used previously, laparoscopic gallbladder removal does not involve making a big cut in the abdominal muscles, so there is generally less pain and quicker healing.

Patient: And the scars are smaller?

Doctor: Yes. We will make four very small incisions. We insert an endoscope through one incision, and instruments through the others to remove the gallbladder. Now, one of the things we do here is a routine cholangiogram right there in the operating room.

Patient: Why is that important?

Doctor: When we do laparoscopic surgery, we operate through very small holes. The cholangiogram gives us an image of your bile ducts to tell us exactly how they are positioned, if there are stones where they shouldn’t be, and where all the ducts are located. We feel that this helps us operate more accurately, and reduces the risks of serious complications.

Patient: So the cholangiogram increases the safety of the surgery?

Doctor: That’s correct

Patient: What is the success rate of the surgery?

Doctor: For laparoscopic gallbladder surgery, the success rate is approximately 100 percent. That means that virtually all the time, we complete the operation. Sometimes, however, about 2 percent of the time, we need to make a bigger incision to complete the operation safely. That’s called a “conversion to open operation.” If we do that, it’s for your safety.

Patient: Is it an outpatient procedure?

Doctor: Yes and no -- it depends your definition of “an outpatient procedure.” Some patients go home the same day, and some stay overnight -- we call that a 23-hour admission, an outpatient procedure, for insurance purposes.

Patient: How long does the operation take?

Doctor: On average, a laparoscopic gallbladder surgery takes about an hour and a half.

Patient: What are the risks?

Doctor: First, there are risks to the anesthesia. You will have general anesthesia, and there is always the chance that you will have a reaction to the anesthesia or that you will have trouble breathing, but these risks are very rare.

Patient: Are there other risks?

Doctor: From the surgery itself, there is a risk of bleeding or infection, and the possibility of injury to the tissues around the gallbladder. We do everything we can to minimize those risks. You will be given intravenous antibiotics at the start of the operation, and on the low-risk chance that you get an infection after surgery, we will give you more antibiotics to treat it. And as I said before, sometimes we need to make an incision and perform the operation as an open procedure. If this happens you will be in the hospital for several days and will have a longer recovery.

Patient: How do I prepare for the surgery?

Doctor: In general, we instruct patients not to eat or drink anything after midnight before the surgery, but this, too, depends on scheduling issues and other factors, such as diabetes, which can influence the timing of a patient’s meals. You do not have diabetes, so we will not have to consider that when we give you your pre-surgery instructions. On the morning of the surgery, you can take your normal medicines with a small sip of water. You’ll come here to the hospital and you’ll need to have someone with you who will be able to drive you home after the procedure. We do the procedure in the operating room, under general anesthesia, and we keep you here afterward while you come out of the anesthesia, observing you and making sure that you are ready to go home.

Patient: How long does it take to recover from the surgery?

Doctor: For the first couple of days, you will be sore, and you will probably find physical exercise uncomfortable. You should be able to drive within a few days, as long as you’re not taking narcotic pain medicines. Generally, it takes patients four to six weeks to return completely to their normal activities.

Patient: How soon will I be able to go back to work?

Doctor: It depends on your occupation. Patients have gone back to work as soon as the next day. In general, patients take between two and six weeks off work to recover.

Patient: Will there be any restrictions on me after the surgery?

Doctor: We tell patients not to do any heavy lifting for six weeks.

Patient: What do you consider heavy lifting?

Doctor: Anything you cannot comfortably lift at arm’s length is too heavy, and of course anything that hurts is also too heavy.

Patient: Anything else?

Doctor: You may find you have problems with fatty foods causing bloating and diarrhea, so we recommend that you stick to a fat-free diet for several weeks. Then, if your normal diet contains fat, we advise you to work up to it slowly.

Patient: So no French fries

Doctor: No French fries.

Patient: All right.

Doctor: Do you have any other questions?

Patient: Just one. Why did I get gallstones, and some people never do?

Doctor: It’s hard to say, exactly, for any one person, but we do know that it usually has to do with how your body handles fats. It’s also related to age, and it’s more common in women because estrogen can promote the formation of gallstones. There’s also a link between being overweight and having gallstones.

Patient: I see. Well, I have them now, and I’d like to set up the surgery date and take care of this before it gets any worse. What is the next step?

Doctor: My assistant will schedule the operation for you and our nurses will give you some verbal and written instructions to help you prepare for the surgery.

Patient: Thank you.

Resources

Read more about Gastrointestinal Surgery and the Digestive Health Center at UC San Diego Health System.