Gallbladder Disease – Treatment and Surgical Options with daVinci® Single-Site

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Gallbladder

The gallbladder is located below your liver in the right upper abdomen. The liver produces the bile, a fluid that helps digest fat. The gallbladder then stores the bile, and releases it to the intestine when needed to help with digestion.

Sometimes the gallbladder may need to be removed for various reasons, but rest assured that we can actually live without the gallbladder because the bile can reach our intestine in other ways.

Where is it?

Located under your liver in the right upper abdomen

  • The bile duct connects it to the liver and small intestine

What does it do?

Stores & releases bile fluid to help digest fat

  • Our liver makes the bile
  • Our stomach and intestine digest food

We can live without the gallbladder

  • The bile can reach your small intestine in other ways
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Gallbladder Disease

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Types of Gallbladder Disease

  • Gallstones
  • Gallbladder inflammation (Cholecystitis)
  • Stones in the duct (Choledocholithiasis)
  • Gallbladder dysfunction

Gallstones

Gallstones are a stone-like substance. They can be as small as a grain of sand or as big as a golf ball.

The bile contains water, cholesterol, fats, bile salt, proteins, and bilirubin. If the bile contains too much of some of these components, it can harden into gallstones. There are different types of gallstones. The cholesterol gallstones are the most common in the U.S., accounting for about 80% of gallstones. They are mostly hardened cholesterol, and the color is usually yellow-green. Another type is called bilirubin stones or pigment stones. They are usually small and dark.

The stones can be inside of the gallbladder or sometimes they can move into the ducts that connects it to other organs. These may cause inflammation that could be painful, and if any of the bile ducts are blocked for a long time, severe damage or infection could happen in the gallbladder, liver or pancreas. If left untreated, the condition can be fatal.

  • Stone-like substance
  • Can be as small as a grain of sand or as big as a golf ball
  • Formed from cholesterol and/or pigment in the gallbladder

*In the U.S., almost 80% of gallstones are cholesterol stones.

Healthy Gallbladder Gallbladder with Gallstones
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How Common is Gallstone Disease?

How many people will be newly diagnosed with gallstone disease?

a)200,000

b)500,000

c)1 million

d)2 million

Answer: C. In the U.S., almost 1 million new cases are diagnosed each year.

  • Very common
  • Affects 10-15% of people in the U.S. (over 25 million)
  • Women ages 20 – 60 are 3 times more likely to develop gallstones than men
  • Gallstones are the most common cause for ER and hospital admissions for severe abdominal pain.

Risk Factors: What Increases the Chance of Having Gallstones?

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  • Female gender
  • Family history of gallstones
  • Over 40 years old
  • Obesity or being overweight
  • Rapid weight loss or “crash diets”
  • Sedentary (inactive) lifestyle
  • Liver disease
  • Certain medications (e.g. birth control pills or cholesterol lowering drugs)
  • Certain ethnicity (e.g. Native Americans, Mexican Americans)

Symptoms of Gallstones

Many people with gallstones do not have any symptoms and may not require treatment.

Typical symptoms are …

  • Severe steady pain in the upper abdomen or right side
  • Pain between the shoulder blades or in the right shoulder

An “attack” can last 15 minutes or hours

See a doctor immediately if you have …

  • Pain lasting for hours
  • Nausea or vomiting
  • Fever (even low-grade)
  • Chills
  • Yellowing of skin or eyes
  • Clay-color stool
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Tests & Diagnosis

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When you see a doctor, your description of symptoms is often the first clue to your doctor to figure out what might be happening with you.  So, try to give a thorough description, even if the pain or bothersome symptoms happened weeks or months ago.

Your doctor will perform a physical exam, and if he/she suspects gallstones, he/she may order a few tests to confirm.

  • A routine blood test is a helpful start to look for signs of infection, blockage, pancreatitis, or jaundice
  • Abdominal ultrasound is commonly used to see if you have gallstones; however, it may not be enough if a stone has passed out of the gallbladder into the bile duct
  • A HIDA scan can help to see how well the gallbladder contracts or if the bile ducts are blocked
  • CT scans can also be used but it is not as accurate as an abdominal ultrasound

MRI and EUS are both quite accurate in finding stones in the bile duct. ERCP can be used to locate and sometimes remove stones in the bile ducts. The doctor inserts an endoscope (a long, flexible, lighted tube with a camera) down your throat, through the stomach and into the small intestine. The doctor injects an x-ray dye to help better see the bile ducts and find gallstones. If the stones can be removed safely, they are captured in a tiny basket and removed with the endoscope.

Surgical & Non-Surgical Options

If your gallstones are small and if you don’t have acute cholecystitis, it might be possible to dissolve or break them up in order to naturally pass them out of your body, or to remove them using ERCP.

For most patients who experience symptoms from gallbladder disease, surgery to remove the gallbladder is often recommended. This is called “cholecystectomy” or “chole” in short. A general surgeon will perform this surgery in one of 3 ways: robotic-assisted laparoscopic chole, traditional laparoscopic chole and open chole.  Of these three approaches, open chole is the most invasive surgical option and not as commonly used.

Patients generally do well after surgery and have limited difficulty with digesting food.  Remember, we can live without the gallbladder because the bile can reach the intestine through other ways.

gallbladder gallstones
Surgical Non-Surgical
What does it do?
  • Surgery to remove the gallbladder
  • Dissolves stones without removing the gallbladder
Options
  • Robotic-Assisted Laparoscopic Cholecystectomy
  • Traditional Laparoscopic Cholecystectomy
  • Open Cholecystectomy
  • Oral medication (to dissolve small cholesterol stones)
Who can have it?
  • Patients with symptomatic  gallbladder disease
  • Patients with small stones, mild symptoms, without acute cholecystitis

Types of Cholecystectomy

Open Cholecystectomy

Traditional Laparoscopic

Cholecystectomy

Robotic-Assisted Laparoscopic

Cholecystectomy

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A Long Incision

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Multiple Small Incisions

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A Single Small Incision

Open surgery is very invasive and no longer commonly performed for gallbladder removal in the U.S.. In open surgery, the surgeon makes a long incision, about 5 to 8 inches, across the abdomen. This allows doctors to see and touch your organs as they operate. Open surgery may be necessary if the gallbladder is severely inflamed or infected.

Laparoscopic chole is used more often. In fact, more than 90% of all gallbladder removals in the U.S. are now done laparoscopically. There are 2 ways to perform laparoscopic chole today:

  • One is the traditional way – where the surgeon uses manual instruments to perform the surgery
  • The other is with robotic assistance – where the surgeon controls a robotic surgery system

The surgeon can perform both laparoscopic surgeries through several small incisions in the abdomen or just one small incision in the bellybutton.  Let’s talk about the two laparoscopic approaches in more details.

Traditional Laparoscopic Cholecystectomy

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  • The surgeon makes 4 small incisions in the abdomen
  • Compared to open surgery, may result in:1
    • Less pain after the surgery
    • Quicker recovery
    • Better cosmetic results
  • Sometimes this can be done with a single incision, although technically challenging

This picture shows a traditional laparoscopic chole. The surgeon makes 4 small incisions in the patient’s abdomen. A tiny video camera called a laparoscope is inserted through one of these incisions, along with several other instruments. As you can see in this picture, the surgeons manipulate these instruments manually while looking at a TV screen that shows what the tiny camera captures inside the patient’s body. At the end of the operation, the gallbladder is pulled out through the incision in the bellybutton.  One thing to note: during any laparoscopic chole, there is a small chance that the surgeon will have to change to an open surgery if he/she discovers that the gallbladder is too severely inflamed or encounters other complications.

Because the abdominal muscles are not cut, the patient may feel less pain after surgery, have a faster recovery and smaller scars with laparoscopic chole compared to open chole. The patient can usually leave the hospital the same or next day and return to normal activities within a few days after laparoscopic surgery.

Some surgeons can perform the traditional laparoscopic chole with one incision in the bellybutton, inserting all instruments through that one incision.

da Vinci® Single-Site® Surgery:
Robotic-Assisted Laparoscopic Surgery

  • Minimally invasive surgery with one small incision in the bellybutton
  • The surgeon controls every move of the instruments, performing highly precise cuts and repairs
  • The surgeon has a 3D-HD immersive view with up to 10x zoom
  • The robotic system helps to reduce tremor and can scale big movements down to very small movements

In the last decade, we have made great advancements in surgery.  One of the most noticeable advancements is robotic-assisted minimally invasive surgery using the da Vinci Surgical System. For gallbladder removal, it can be performed with one small incision in the bellybutton.

As shown in this picture, the surgeon is in full control of the da Vinci System while seated at the surgeon console. The patient is on an operating table nearby. Small instruments are attached to the robotic arms. The middle instrument is the laparoscope – a lighted camera that gives the surgeon a 3D-HD view with up to 10x magnification inside the patient during the entire operation.

Other instruments are specially designed to be curved, so that they can all be inserted through the same incision in the bellybutton. There is an Intuitive® Motion feature. Surgeon’s hand movements are replicated and scaled down to smaller movements, while hand tremors are reduced. This allows for the cuts and repairs to be done very precisely.

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da Vinci® Single-Site® Cholecystectomy

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With da Vinci® Single-Site® Cholecystectomy, potential benefits include:

  • Low rate of major complications
  • Low conversion rate to open surgery
  • Virtually scarless surgery
  • High patient satisfaction
  • Minimal Pain

After the incision heals, the scar is hidden inside the folds of the bellybutton and appears to be virtually scarless.  This picture here shows the bellybutton of an actual patient about 5 minutes after having a da Vinci Single-Site Cholecystectomy.

Please note: As with any surgery, these results cannot be guaranteed for everyone since surgery is unique to each patient and procedure.

Potential Risks of Gallbladder Surgery

As with any procedure, there are risks of receiving gallbladder surgery. Some potential risks of any cholecystectomy, including da Vinci Surgery are:

  • Bile leakage1,2,3
  • Bile duct stones/injury1,2,4
  • Pancreatitis (inflammation of the pancreas)1,2

What If I Can’t Have Single Incision Surgery?

Not all patients are candidates for single-incision surgery, including patients with:

  • Complex anatomy
  • Adhesions from prior surgery

However, these patients may be candidates for robotic-assisted da Vinci® Cholecystectomy with:

  • just a few small incisions
  • high-quality 3DHD visualization and added precision

Some patients may not be able to have single-incision surgery for gallbladder removal. However, robotic-assisted surgery with a few small incisions in the abdomen may be an option. Your doctor should discuss all treatment and surgical options with you to help you decide which is best for your situation.

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Insurance Coverage

  • Cholecystectomy is usually covered by health insurance
  • Ask your surgeon’s office and hospital for a cost estimate
    • Hospital/Facility fee
    • Physician fee
    • Anesthesia fee
  • Calculate your out-of-pocket costs
    • Review your co-pay, deductible balance or co-insurance amounts

Good to know:

  • The robotic-assisted and traditional laparoscopic surgery are reimbursed at the same rate by most insurance providers (e.g. Medicare, Anthem, CIGNA, United Healthcare)

Cholecystectomy is usually covered by health insurance. You can expect three separate bills – from the hospital, from your physicians, and from the anesthesiologist. You could call each office in advance to get a cost estimate and review your insurance coverage or call your insurance company to calculate what your out-of-pocket expenses might be.

If you are considering robotic-assisted surgery, it is good to know that it is reimbursed at the same rate as traditional laparoscopic surgery by most insurance providers, such as Medicare, Anthem, CIGNA, United Healthcare

Take Action

  • Know your personal risk factors
  • Pay attention to your symptoms
  • Talk to your doctor about all treatment and surgical options
  • Get a second opinion
  • Choose the option that’s right for YOU

Pay attention to your body, talk to your doctor, and get a second opinion when it comes to choosing a treatment or surgical procedure – and whatever you choose, make sure it’s right for you.

Important Information for Patients & Referring Physicians:

Surgical Risks

da Vinci® Surgery with Single-Site® Instruments and accessories is cleared for use in gallbladder removal, and for hysterectomy and ovary removal for benign conditions. Patients who bleed easily, have abnormal blood clotting, are pregnant or morbidly obese are not candidates for minimally invasive surgery, including da Vinci Surgery with Single-Site® Instruments. The safety and effectiveness of this device for use in the performance of general laparoscopic abdominal surgery procedures have not been established.

All surgery presents risk, including da Vinci Surgery. Results, including cosmetic results, may vary. Serious complications may occur in any surgery, up to and including death. Examples of serious and life-threatening complications, which may require hospitalization, include injury to tissues or organs, bleeding, infection, and internal scarring that can cause long-lasting dysfunction or pain. Temporary pain or nerve injury has been linked to the inverted position often used during abdominal and pelvic surgery. Patients should understand that risks of surgery include potential for human error and potential for equipment failure. Risks specific to minimally invasive surgery may include: a longer operative time, the need to convert the procedure to other surgical techniques, the need for additional or larger incision sites, a longer operation or longer time under anesthesia than your surgeon originally predicts. Converting to open surgery could mean a longer operative time, long time under anesthesia, and could lead to increased complications. Research suggests that there may be an increased risk of incision-site hernia with single-incision surgery. Patients who bleed easily, have abnormal blood clotting, are pregnant or morbidly obese are typically not candidates for minimally invasive surgery, including da Vinci Surgery. Other surgical approaches are available. Patients should review the risks of all surgical approaches and the risks of da Vinci procedures to decide if da Vinci Surgery is right for them. It is important to talk to your doctor about his/her surgical experience. For complete information on surgical risks, safety and indications for use, please refer to www.davincisurgery.com/safety.

More information about the da Vinci® System

If you have questions about the da Vinci® System or da Vinci® procedures, consult with a qualified surgeon. Surgeons experienced with the da Vinci® System can be found using the Surgeon Locator (http://www.davincisurgery.com/surgeon-locator/).

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