What is laparoscopic or "keyhole" surgery?
This surgery involves the insufflation of Carbon Dioxide into the abdominal cavity to create space into which keyholes, known correctly as ports, are inserted. These ports allow instruments, rather than the surgeon's hands, to enter the abdomen so as to minimise the size of the wounds and minimise pain. The surgeon is able to watch the procedure on a television monitor, thanks to a telescope passed via another port. Laparoscopic surgery necessitates complete relaxation and thus a general anaesthetic i.e. you are completely unconscious. Local anaesthetic is usually placed into the wounds for pain relief just before you awaken.
Preparation for surgery
As with any operation, you should endeavour to be in your best possible shape beforehand. Stopping smoking even for 1 week has measurable clinical benefits. If you are on the oral contraceptive pill, you should discuss this with your surgeon before surgery. You will be screened for MRSA "superbugs" at your pre-assessment and you will be instructed in advance about when to discontinue medication or diet and fluids. You may be advised to shower or bath with antiseptic soap, but you should not shave your abdomen - this will be done, where necessary, when you are asleep. Elasticated TED compression stockings will be provided to you to wear to reduce the chance of you getting clots in your deep leg veins. You may wear your own night attire. An anaesthetist will visit you before you come to theatre to ensure that you understand what is planned for getting you off to sleep and for pain relief afterwards. Your surgeon will visit too and discuss the operation and recovery, culminating in you signing a consent form. Most importantly, we want you to be fully informed, relaxed and content in the knowledge that you are in safe hands.
Once you are asleep, an antiseptic lotion is applied to your trunk. A 2-3cm incision is made near the umbilicus to enter the abdomen. Three further ports are inserted: one near the tip of the breast bone in your upper abdomen and two in the right middle area, these measuring 5-10mm. The operation entails disconnecting the gallbladder from its attachments to the bile tube, the blood supply and the liver substance. The surgeon will dissect internally until these attachments are noted, then apply titanium clips to the attaching structures and divide them. Once disconnected, the gallbladder is delivered out of the abdomen through one of the ports. If there has been some mildly excessive bleeding during the operation (which is acceptable), then a drain (or rubber tube) is placed via one of the ports to lie near the gallbladder site. This allows fluid to leave the abdomen by gravity or by suction. The wounds are then closed, by deeper permanent sutures in the muscle layer, and by dissolvable sutures in the skin layer.
Keyhole surgery is nonetheless surgery and it too involves cutting. You must therefore have realistic expectations of your recovery. Typically, patients will be home in less than 24 hours from admission. Discharge from hospital requires all of the following criteria to be met:
1. You must have fully recovered from the anaesthetic
2. You must have been up out of bed and completed a short walk
3. You must have been able to eat and drink successfully
4. You must have support at home from a sensible adult
5. You must have your pain under control with oral medication
6. You must have normal vital signs (temperature, pulse, Blood Pressure)
What should you expect?
Pain: A degree of pain from an operation is inevitable. Towards the end of your operation you will have local anaesthetic injected into the keyholes. This should last for up to 4 hours. The anaesthetist will often administer intravenous morphine-type medication which will be in your system when you come round. Once you are able to eat and drink you can have more oral medication: until then you will need intravenous pain relief through a drip. Powerful pain killers are available to you, but nurses and doctors cannot second-guess whether you are in pain or not. There are no points for bravery, so ask if you need it! Common sense and professional behaviour mandate that we cannot give you pain relief that is unreasonable or disproportionate to your needs. Over the first 24 hours you may experience pain in your shoulders or between your shoulder blades. This pain is caused by the distension of your tummy by the carbon dioxide during the surgery. You will find it painful to cough, sneeze or laugh. The nurses will explain how you can minimise this pain. Over the next 2-3 days you will need to rest up at home. Although you can get up to use the toilet or get to and from your rooms, we suggest that you generally stay off your feet. Over the ensuing days, your pain should gradually subside. We anticipate that you will need to take regular painkillers for a week and then use these as and when required for a further 1-2 weeks. Except for heavy coughing and sneezing, you should be pain free by 3 weeks.
Wounds: You will have 4 small wounds on your abdomen that will be covered in dressings that are adherent and waterproof. The wounds are small (two are 5mm and two are 10mm) and closed with dissolvable stitches beneath the skin. It is occasionally necessary to make the wounds a little bigger to extract the gallbladder e.g. where the gallbladder contains large or multiple stones. One in 50 patients wakes up with what we call a Kocher's incision wound: this is a generous 10-15cm oblique cut just below your right ribcage which is needed to perform "open" surgery. By this we mean that we have had to open you up the old-fashioned way to get our hands into the abdomen to perform the surgery. This is only done because we have encountered unexpected difficulty during the keyhole surgery and because to continue with the keyhole method is futile or unsafe. The keyhole wounds will typically be a bit bruised afterwards, especially the one in your upper abdomen. Before you go home we will discuss wound care with you. As a general rule of thumb, the wounds should remain covered for 72 hours. Thereafter, if the wound is not weeping and thus staining your clothing, you can remove the dressing and let the wound "breathe". You can shower with your dressings on during the first 3 days - if the dressings come loose there will be spare dressings to apply. After 72 hours you can shower or bath without dressings but don't have a long soak during the first 2 weeks. All wounds are tender to the touch at first. Be careful to avoid bumping them. All wounds initially look a little weepy and may develop a crust: clean it with cotton wool if it is wet, but try to avoid the temptation to pick at your scab. All scars look pink for about 6 months, but they transform to white scars that blend more cosmetically with your skin tone at one year. They may also shrink partially with time and thereby become even more cosmetically attractive.
Mobility: You will be surprised just how many movements involve tensing or using your abdominal muscles. You will naturally adopt a stooped posture both when sitting or being upright, as this reduces the pulling open of the wound edges. Remember that your wounds are not just in the skin, but in the muscles too. You will discover that simple movements like changing position in bed, arising from a chair, lowering yourself into a car etc. are surprisingly uncomfortable and restrictive in the first week. I suggest that you take 48 hours "off" and put your feet up. However, you must keep your legs and feet moving even when not upright, or else you may get blood clots (DVT, deep vein thrombosis) which can be fatal. After a couple of days, try to take a few small walks each day, e.g. down the lane, around the block. If you feel comfortable doing this, and you wish to exercise more, do so - you won't very likely do yourself harm unless you slip or fall. Because of your wounds, you will tend to stoop: try to remind yourself to straighten up at regular intervals. Stretch your trunk (and your wounds) by twisting slowly to your left and to your right,slowly, until you feel the wound begin to hurt a bit. Hold it in that position for 20 seconds and then relax again. The same tip can be applied to flexing sideways or extending. Just think of that old advice: "shoulders back, chest out, chin up"! If you wish to increase your activity levels by actually exercising, I suggest a power walk or static exercise bicycle cycle or swimming (if your wounds are healing well) from 2 weeks onwards. Do not lift weights, run or cycle on open roads for 4 weeks.
Driving: You may not drive in the 24 hours after your surgery. Check your car insurance policy to see what, if any, restrictions are placed in your contract as regards driving after surgery. Most policies say either 1 week, 2 weeks, or on the advice of your surgeon. There is no medical evidence to show that driving a normal vehicle in normal circumstances will injure keyhole wounds. It thus relies on common sense - you decide when to drive. It is very important to consider the legal responsibilities of taking control of a vehicle: you must be able to take all reasonable actions expected of a driver in all circumstances i.e. your wounds (or any other consequence of your surgery and anaesthetic) are not a valid reason for failing to drive in a "normal" way. For example, you must be able to slam on the brakes, wrench the steering wheel and swerve to avoid a child that has run across your path.
WHAT ARE THE RISKS OF THIS SURGERY?
All surgery carries with it some element of risk and these risks are part and parcel of surgery: without risk, nothing can be gained. Remember that you would not be going through this surgery if it was more likely to cause harm to you than your gallstones can cause. Remember too that very few patients suffer complications and the majority of operations and recoveries are uneventful. Some of the risks described below are serious, but these are pretty rare. The majority of complications are a nuisance rather than a serious health problem. No list can be complete, but the most frequently noted complications are:
- Bleeding: All cutting surgery causes some bleeding, but it is called a complication when bleeding occurs that warrants an unplanned return to the operating theatre to stem the bleeding, or when bleeding is so heavy that a blood transfusion is required. If your bleeding has resulted in substantial blood loss, you might need blood transfusions or iron supplementation.
- Infection: Infection in keyhole wounds is far less likely than in larger incisions. The same applies for getting "chesty" or suffering post-operative pneumonia. Wound infections in our hospital after keyhole and open cholecystectomy are vanishingly rare. You will be given prophylactic antibiotics whilst the operation is underway anyway. Very occasionally your gallbladder already contains infected bile or even pus, in which case additional antibiotics are given. Very rarely, such bile spills and creates a little puddle of infected fluid called a "collection" where the gallbladder used to be. This might need drainage by a local anaesthetic procedure or even a return to the operating theatre. Resistant bacteria like MRSA causing wound infections are virtually unheard of in our hospital.
- Wound healing: Some wounds stubbornly refuse to completely heal and gape open when the sutures dissolve. Others may only weaken much later in your life and this gives rise to a hernia called an incisional hernia. This is very rare after keyhole surgery. A wound might conversely even heal too well and cause a thickened, unsightly scar called a hypertrophic scar. This is more likely if your previous scars have done the same. These may need to be treated by a dermatologist or you might choose to see a plastic surgeon about having the scar revised. Most wounds heal eventually without pain, but a very small number of cases of persisting or chronic pain occur. These patients may need to take pain killers indefinitely or see a pain specialist.
- Adhesions: these are best described as internal scar tissue. They form as an unfortunate consequence of natural healing, but in some individuals the process is excessive, leaving behind scars that connect the organs of your abdomen to one another or to your abdominal wall. They are unavoidable and unpredictable, but also less likely after keyhole surgery. They are thought to be one of the reasons that some people have chronic pain after surgery. If you are very unlucky, adhesions might result in you being hospitalised in the years ahead with an intestinal blockage caused by your intestines getting tangled in an adhesion.
- Blood clots: Known as DVT (deep vein thrombosis), these rarely occur in day case surgery. Prophylactic measures will be taken to mitigate against these coming to pass such as elasticated stockings, compression inflation devices, blood thinning medication, early mobilisation. They can lead to varicose veins and they can even be fatal if they should float to the lungs. Your risks are extremely small, but certain people have greater risk factors than others, something we identify at your pre-assessment visit. I suggest that you wear your elasticated stockings for at least 4 weeks.
- Open surgery: There is a 1:50 chance approximately that we cannot complete your surgery using the keyhole technique. This is usually due to unexpected difficulties encountered during your operation. In such circumstances, a larger incision is made beneath your lower right ribcage.
- Bile leak: There is a 1:100 risk approximately that some bile leaks from the surface of the liver, from a bile tube or from an unrecognised accessory bile tube. Being caustic, bile irritates and causes pain, so we might have to intervene to stabilise the situation. This usually takes the form of a local anaesthetic drainage procedure, but in a small number of cases a camera procedure (called ERCP) might be necessary, or even further surgery.
- Bile Duct Injury: The gallbladder is attached to the bile system via a single tube. Recognising it is usually very easy, but if you have an unusual natural anatomical arrangement, this can mislead the surgeon. More commonly, the error is made because the anatomy of your bile system has been substantially disturbed by inflammation or previous illness or previous surgery. Should the wrong part of the bile system be disturbed, serious problems can follow. These certainly will need some form of intervention (e.g. ERCP, drainage, another look inside) but if the type of disturbance is critical then major surgical procedures to try to salvage the situation would be necessary. Across the United Kingdom, through all types of hospitals and through all manner of surgeons (including the inexperienced novice and the trainee) this complication happens in approximately 1:350 gallbladder operations, or about one third of 1 percent.
GETTING IN TOUCH IF YOU NEED HELP
You will be given clear instructions on how to quickly summons help whilst on the ward. If you should need to stay overnight, a Resident Medical Officer (RMO) is resident in the hospital to attend to you in the first instance. This doctor is able to deal with many emergency situations, as are the well qualified resident nursing staff. If necessary, Mr Bradford will be called both for advice and to attend - he is on-call for you at all times until you are discharged and he can be at your bedside within just a few minutes in an emergency.
Once at home you have access to medical advice in several ways:
1. Call the hospital to speak to the nurse on duty and/or the RMO
2. Call your local GP surgery (during hours)
3. Call the Out of Hours GP service (after hours)
4. Call the emergency services (999) or attend your nearest A&E services
As a general rule, unless it is an emergency rather call the hospital in the first instance for advice on who is best placed to attend to your needs. We have a low threshold for having a quick look ourselves if we are concerned that a complication might have arisen: usually it is a false alarm. If either your GP or the hospital staff feel that Mr Bradford needs to be contacted about you, they will track him down. In the event that your problem has arisen some days later, and Mr Bradford is away, you might have to default to the NHS services for assistance.