Cholecystectomy

Common Symptoms

The most common symptoms of cholecystitis are¹:

Sharp pain in the right upper abdomen
Low fever
Nausea and bloating
Jaundice (yellowing of the skin) may occur if gallstones are in the common bile duct.

Treatment Options

Surgical Procedure²

Laparoscopic cholecystectomy—The gallbladder is removed with instruments placed into small incisions in the abdomen.

Open cholecystectomy—The gallbladder is removed through an incision on the right side under the ribcage.

Nonsurgical Procedure—Stone removal by endoscopy

For Gallstones without Symptoms—Watchful waiting for all patients,³Increased exercise

Benefits and Risks of the Operation

Benefits—Gallbladder removal will relieve pain, treat infection, and, in most cases, stop gallstones from coming back.

Possible risks include—Bile leak, bile duct injury, bleeding, infection of the abdominal cavity (peritonitis), fever, liver injury, infection, numbness, raised scars, hernia at the incision, anesthesia complications, puncture of the intestine, and death.⁴

Risks of not having an operation—The possibility of continued pain, worsening symptoms, infection or bursting of the gallbladder, serious illness, and possibly death.⁵

Expectations

Before your operation— Evaluation usually includes blood work, a urinalysis, and an abdominal ultrasound. Your surgeon and anesthesia provider will discuss your health history, home medications, and
pain control options.

The day of your operation— You will not eat for 4 hours but may drink clear liquids up to 2 hours before the operation. Most often, you will take your normal medication with a sip of water. You will need someone to drive you home.

Your recovery— If you do not have complications, you usually will go home the same day after a laparoscopic procedure or in 1 to 2 days after an open procedure.⁵

Call your surgeon if you have severe pain, stomach cramping, chills, a high fever (over 101°F or 38.3°C), odor or increased drainage from your incision, your skin turns yellow, no bowel movements for three days, or vomiting and the inability to keep fluids down.

Cholecystitis in Children

In children, inflammation of the gallbladder can be caused by gallstones. This is called acute (sudden) calculous (with gallstones) cholecystitis (ACC). ACC is most common in children with intestinal diseases and sickle cell disease.⁷ Children with sickle cell disease should have an ultrasound screening for gallstones.⁸ A more frequent type of cholecystitis in children is acute acalculous (without gallstones) cholecystitis (AAC). Children with cholecystitis who have pain, fever, nausea or jaundice (yellow skin) may be treated with IV fluids, antibiotics and non-opioid pain medication in the hospital. Cholecystectomy may be recommended for children with painful gallstones. The procedure is most often done laparoscopically through small incisions in the belly button or abdomen.

The Condition

The Gallbladder

The gallbladder is a small pear-shaped organ under the liver. The liver makes 3 to 5 cups of bile every day which is stored in the gallbladder. The gallbladder sends bile to the small intestine through ducts to help digest fats in food.¹

Gallstones

Gallstones are hardened digestive fluid that can form in your gallbladder. Gallstones can leave the gallbladder and block the flow of bile through the ducts and cause pain and swelling of the gallbladder (Cholecystitis).

The Procedure

Laparoscopic Cholecystectomy

This technique is the most common for cholecystectomy.² The surgeon will make several small incisions in the abdomen. Ports (hollow tubes) are inserted into the abdomen, through the openings. Surgical tools and a lighted camera are placed into the ports. The abdomen is inflated with carbon dioxide gas to make it easier to see the internal organs. The gallbladder is removed, and the port openings are closed with sutures, surgical clips, or glue.

Open Cholecystectomy

The surgeon makes an incision approximately 6 inches long in the upper right side of the abdomen and cuts through the fat and muscle to reach the gallbladder. The gallbladder is removed, and the cystic duct is clamped off. The site is stapled or sutured closed. A small drain may be placed going from the inside to the outside of the abdomen. The drain is usually removed in the hospital. Your surgeon may start with a laparoscopic technique and need to change (convert) to an open laparotomy technique.

The procedure takes about 1 to 2 hours.

Conversion rates from laparoscopic to open for elective surgery in healthy patients is 7.5%.⁹
The chance of conversion increases up to 30% if you are over 50 years old, are male, and have acute cholecystitis; have had past abdominal operations; or have high fever, high bilirubin, repeated gallbladder attacks, or conditions that limit your activity.^{9, 10}

Nonsurgical Treatment

Gallstones affect about 1 in 7. Eighty percent of adults with gallstones are not bothered by them and many go 20 years without symptoms.¹¹ Current guidelines recommend watchful waiting until they cause symptoms.³

If you have gallstones without pain, exercise at least 2-3 times each week to reduce your risk of cholecystitis. Eat more fruits and vegetable and less sugar, carbohydrates and fats.

Common Tests

History and Physical Exam⁶

Your health care provider will ask you about your pain and any stomach problems.

Additional Tests (see Glossary)
Blood tests, including complete blood count
Liver function tests
Coagulation profile
Abdominal ultrasound is the most common study for gallbladder disease. You may be asked not to eat for 8 hours before the test.
Hepatobiliary iminodiacetic acid scan (HIDA scan)
Endoscopic retrograde cholangiopancreatography (ERCP)
Magnetic resonance cholangiopancreatography (MRCP)

Gallstones are more common in people who:⁴

Are Native American
Have a family history of gallstones
Are overweight
Have sickle cell disease
Are pregnant
Lose weight rapidly
Use estrogen to manage menopause

Risks	Percent for Average Patient	Keeping You Informed
Pneumonia: Infection in the lungs	Open 1.7% Laparoscopic 0.2%	You can decrease your risk by rinsing with antiseptic mouthwash the morning of your operation (to decrease mouth bacteria), quitting smoking before your operation, and getting up often to walk post-operatively.
Heart complication: Heart attack or sudden stopping of the heart	Open 0.9% Laparoscopic 0.1%	Problems with your heart or lungs can be affected by general anesthesia. Your anesthesia provider will take your history and suggest the best option for you.
Wound infection	Open 7.0% Laparoscopic 1.0%	Antibiotics are not routinely given except for high-risk patients. You should wash your abdomen with an antimicrobial soap such as dial the night before the operation.
Urinary tract infection: Infection of the bladder or kidneys	Open 0.8% Laparoscopic 0.4%	A Foley catheter may be placed placed during surgery to drain the urine. Let your surgical team know if you have trouble urinating after the tube is removed—this is more common in older men or if an epidural is used for pain.
Blood clot: A blood clot in the legs can travel to the lung	Open 1.0% Laparoscopic 1.0%	Longer surgery and bed rest increase the risk. Walking 5 times/day and wearing support stockings reduce the risk.
Renal (kidney) failure: Kidneys no longer function in making urine and/or cleaning the blood of toxins	Open 0.9% Laparoscopic 0.1%	Pre-existing renal problems, Type 1 diabetes, being over 65 years old, and other medications may increase the risk.
Return to surgery	Open 2.7% Laparoscopic 0.6%	Bile leakage or a retained stone may cause a return to surgery or require additional endoscopy or radiology procedures. Your surgical team is prepared to reduce all risks of return to surgery.¹
Death	Open 0.8% Laparoscopic 0.1%	Your surgical team will review for possible complications and be prepared to decrease all risks.
Discharge to nursing or rehabilitation facility	Open 7.6% Laparoscopic 0.7%	Pre-existing health conditions can increase this risk.
*Bile Duct Injury/Leakage¹²**	Open 1/1,000 patients	Injury can happen between 1 week to 6 months after the operation from fever, pain, jaundice, or bile leakage from the incision. Further testing and surgery may be needed.¹²
*Retained common bile duct stone¹**	Open 1.8%	A gallstone may pass after surgery and block the bile from draining. The stone should be removed because of an increased risk of biliary obstruction or inflammation of the pancreas or bile duct.¹
Pregnancy Complications, premature labor and fetal loss*	Fetal loss 4% (uncomplicated removal) up to 60% if pancreatitis	Most pregnant women with gallstones will have no symptoms during pregnancy. If you have biliary disease or pancreatitis, gallbladder removal will be offered to reduce maternal complications.¹³

1% means that 1 of 100 people will have this complication
*Results from the last 10 years of literature

The ACS Surgical Risk Calculator estimates the risk of an unfavorable outcome. Data is from a large number of patients who had a surgical procedure similar to this one. If you are healthy with no health problems, your risks may be below average. If you smoke, are obese, or have other health conditions, then your risk may be higher. This information is not intended to replace the advice of a doctor or health care provider. To check your risks, go to the ACS Risk Calculator at http://riskcalculator.facs.org.

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Glossary

Abdominal ultrasound: A handheld transducer, or probe, is used to project and receive sound waves to determine the location of deep structures in the body. A gel is wiped onto the patient’s skin so that the sound waves are not distorted as they cross through the skin.

Advance directives: Documents signed by a competent person giving direction to health care providers about treatment choices. They give you the chance to tell your feelings about health care decisions.

Adhesions: A fibrous band or scar that causes internal organs to adhere or stick together.

Bile: A fluid produced by the liver and stored in the gallbladder which helps in the digestion of fats.

Biliary colic: Sudden pain in the abdomen caused by spasm or blockage of the cystic or bile duct lasting for more than 30 minutes.

Bilirubin: A yellow breakdown product of the red blood cells. High levels may indicate diseases of the liver or gall bladder.

Complete blood count (CBC): A CBC measures your red blood cells (RBCs) and white blood cells (WBCs). WBCs increase with inflammation. The normal range for WBCs is 5,000 to 10,000.

Endoscopic retrograde cholangiopancreatography (ERCP): A tube with a light and a camera on the end is passed through your mouth, stomach, and intestines to check for conditions of the bile ducts and main pancreatic duct and to remove gallstones.

Gallbladder: The gallbladder is a small pear-shaped organ under the liver. The liver makes 3 to 5 cups of bile every day which is stored in the gallbladder.

Gallstones (Cholelithiasis): Hardened deposits of digestive fluid that can form in your gallbladder.

Gallstone Pancreatitis: Gallstones can move to and block the common bile duct, the pancreatic duct or both.

Hepatobiliary iminodiacetic acid scan or gallbladder scintigraphy (HIDA): A scan that shows images of the liver, gallbladder, and bile ducts following injection of a dye into the veins.

Intraoperative cholangiogram: During surgery to remove the gallbladder (cholecystectomy), a small tube called a catheter is inserted into the cystic duct, which drains bile from the gallbladder to check for remaining gallstones.

Magnetic resonance cholangiopancreatography (MRCP): A medical imaging technique that uses magnetic resonance imaging to visualize the biliary and pancreatic ducts.

DISCLAIMER

The American College of Surgeons (ACS) is a scientific and educational association of surgeons that was founded in 1913 to improve the quality of care for the surgical patient by setting high standards for surgical education and practice. The ACS endeavors to provide procedure education for prospective patients and those who educate them. It is not intended to take the place of a discussion with a qualified surgeon who is familiar with your situation. The ACS makes every effort to provide information that is accurate and timely, but makes no guarantee in this regard.

Reviewed and updated: 2009, 2013, 2015, and 2022 by:
Patricia Lynne Turner, MD, FACS
Kathleen Heneghan, PhD, MSN, RN, FAACE Mark Malangoni, MD, FACS
Nancy Strand, MPH, RN
Nicholas J. Zyromski, MD, FACS
Stephen Richard Thomas Evans, MD, FACS Dan Eisenberg, MD, MS, FACS, FASMBS
Kyle Vincent, MD, FACS

References

The information provided in this brochure is chosen from recent articles based on relevant clinical research or trends. The research listed below does not represent all of the information that is available about your procedure. Ask your doctor if he or she recommends that you read any additional research.

Gallstones. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestivediseases/gallstones?dkrd=hispt0204. Accessed July 1, 2021.
Laparoscopic Cholecystectomy (Gallbladder Removal) https://my.clevelandclinic.org/health/treatments/7017-laparoscopiccholecystectomy-gallbladder-removal. Accessed July 13, 2021.
Ibrahim M, Sarvepalli S, Morris-Stiff G, Rizk M, et al. Gallstones: Watch and wait, or intervene? Cleve Clin J Med. 2018 Apr; (4):323-331. doi: 10.3949/ccjm.85a.17035. PMID: 29634468.
Gallstones. https://www.mayoclinic.org/diseases-conditions/gallstones/symptoms-causes/syc-20354214 Accessed July 27,
2021
American College of Surgeons. ACS Risk Calculator. http://riskcalculator.facs.org. Last accessed August 2021.
Diagnosis of Gallstones; How do Doctor’s Diagnose Gallstones? https://www.niddk.nih.gov/health-information/digestivediseases/gallstones/diagnosis. accessed July 27, 2021
Inah GB, Ekanem EE. Sonographic Diagnosis and Clinical Correlates of Gallbladder Stones in Patients with Sickle Cell Disease in
Calabar, Nigeria. Open Access Maced J Med Sci. 2019;7(1):68-72. Published 2019 Jan 12. doi:10.3889/oamjms.2019.015
Poddighe D, Sazonov V. Acute acalculous cholecystitis in children. World J Gastroenterol 2018; 24(43): 4870-4879 Available
from: URL: http://www.wjgnet.com/1007-9327/full/v24/i43/4870.htm DOI: ]http://dx.doi.org/10.3748/wjg.v24.i43.4870
Sugrue, M., Coccolini, F., Bucholc, M. et al. Intra-operative gallbladder scoring predicts conversion of laparoscopic to open
cholecystectomy: a WSES prospective collaborative study. World J Emerg Surg 14, 12 (2019). https://doi.org/10.1186/s13017-
019-0230-9 ]
Loozen C. S., van Santvoor H. C., van Geloven A. A. W., et al. Perioperative antibiotic prophylaxis in the treatment of acute
cholecystitis (PEANUTS II trial): study protocol for a randomized controlled trial. Trials. 2017;18(1):p.390. doi: 10.1186/s13063-
017-2142-x.]
Tanaja J, Lopez RA, Meer JM. Cholelithiasis. [Updated 2020 Dec 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470440/
Pandit N, Yadav TN, Awal L, et al. Current Scenario of Postcholecystectomy Bile Leak and Bile Duct Injury at a Tertiary Care
Referral Centre of Nepal Minimally Invasive Surgery, 2020, 4382307 - April 2020 https://doi.org/10.1155/2020/4382307
Chiappetta P, Napoli E, Canullan C, et al. Minimally invasive management of acute biliary tract disease during pregnancy. HPB Surg. 2009;2009:829020. doi: 10.1155/2009/829020. Epub 2009 Jul 12.