Saturday, May 28, 2016

Day of the Gallbladders


It looked like it was going to be a good day. I wasn’t on call, I would be off the weekend and all I had scheduled for the day was four elective cases, all laparoscopic cholecystectomies.
How could the day be any better?
The surgeon’s prayer popped into my head:

“Lord, please protect me from the interesting cases and don’t let me screw up today.”

Cholecystectomy is the most common operation that is performed in the United States. Gallbladder disease occurs as a consequence of diet, hormonal changes, genetics and physiologic changes involving the rest of the body. It seems that everything affects the gallbladder. Gaining weight, losing weight, pregnancy, illness, stress and probably a whole bunch of other things cause the gallbladder to form stones, stop functioning or become inflamed. Whenever the gallbladder starts to behave badly one can rest assured that a friendly general surgeon is nearby to address the problem.
It was six thirty in the morning, the dogs were fed and I was scheduled to start in an hour.
Maybe I can get rounds done before I surgery.
It was a rare day. I only had patients at one hospital, the same venue where the cases were scheduled. I arrived at six fifty five and greeted my first patient in Day surgery.
Maria was forty, about five foot one and weighed in at two hundred sixty pounds. She had multiple gallstones and had suffered through repeated episodes of right upper quadrant abdominal pain. She had gone to the ER once, but otherwise had endured multiple nights of suffering.
“I just get up and walk around or sit in the chair until the pain goes away, usually after a couple of hours. I take some Motrin, which helps a little.”
Textbook case. All Four F’s: Female, Fertile, Forty and ‘Rotund’.
I went to the hospital computer and checked on each of my in house patients, their vital signs, lab results and such. I only had five patients to see. Everyone looked good in the computer.
I guess I need to see each one in person.
I ran up to the third floor, the post surgical unit. I saw Bill and Irma and Lucille, each post op from laparotomies and each was doing well. Notes and orders were written (the good old days, before computerized everything) and then I ran down to the OR to start Maria’s surgery.
She was just going to sleep when I walked into OR five. I went out to wash my hands while she was being prepped.
“Draperies please,” I asked.
The tech handed me a towel and I began to drape Maria.
All the proper tools were passed off and connected and surgery commenced.
I infiltrated some long acting local anesthetic in Maria’s belly button area, made a small incision, elevated her abdominal wall and tried to pass the Veress needle. This needle is what I commonly use to insufflate the abdomen, that is blow it up with carbon dioxide gas. Only the needle wouldn’t pass. I put it in up the hilt, but no go.
She doesn’t look to be that large. But, women tend to have their adipose tissue in the abdominal wall, I guess Maria has a bit more than I thought.
“I need a longer Veress needle.”
In about a minute the circulator returned with the 150 cm needle which I was able to pass into the abdomen without difficulty.
I hope that’s the only glitch for the day.
And Maria’s case went off without a hitch. Inside her abdomen there wasn’t much fat. Each structure stood out. The gallbladder was hanging off the liver, the common bile duct was easily seen, and the cystic artery nearly jumped out at me. It was spread, spread, clip, clip, clip, cut, clip, clip, clip, clip, cut, then snip, snip, snip, snoop and in five minutes the gallbladder was in a pouch, pulled out through the epigastric wound and on the back table. Ten minutes later the final band aids were laid over the last of Maria’s wounds as she began to wake up. Thirty five minutes after she had gone to sleep she was in the Recovery Room.
I should have time to see my other two hospital patients.
I saw Joe and Juana on the fourth floor. Neither had a problem which would require surgery. I stopped to say “hello, how are you, you should be going home soon and then went back to the OR to operate on Michael.
Michael had been having pain for years, always in the upper abdomen, radiating to his back, occurring almost every day. He had gone through endoscopies, CT Scans, MRI’s, ultrasounds and more endoscopies. Finally, he found a GI specialist who ordered a HIDA Scan. This is an anatomic and functional test of the gallbladder. In Michael’s case the HIDA revealed his gallbladder only emptied 4% when stimulated and, maybe more important, his symptoms were reproduced, exactly. I told his there was an 85-90% chance his pain would be relieved by surgery.
He was being wheeled into the OR as I finished my rounds.
Should be straightforward. No stones, chronic symptoms, overall in excellent health.
Never make such assumptions.
Michael’s surgery started off simple enough. The gallbladder was partially intrahepatic, but that just means a little more dissection until the gallbladder is free. I began in the usual way, incising the thin layer of peritoneum over the neck of the gallbladder and dissecting this peritoneum and the some surrounding fat away from the wall of the gallbladder. I lmost always start on the inferio lateral aspect of the gallbladder, where I should be safely away from the common bile duct.
As I began Michael’s dissection I saw a bluish structure just below the cystic duct and going towards the liver.
Not the right spot for the common bile duct or any bile duct. Be careful. Maybe it will be easier on the other side of the gallbladder.
I began dissecting on the medial aspect of the gallbladder.
It looks like there is another duct on this side. Maybe the gallbladder is lying between the right and left hepatic ducts? The structure in the middle looks like the cystic duct.
I started working higher on the gallbladder, away from any ducts, I hoped.
This is becoming far too much work. This was supposed to be my easy case.
As I dissected along the medial wall of the gallbladder I was able to identify a duct running along this part of the gallbladder and then going towards the liver. Luckily, I was able to separate this duct from the gallbladder.
That must be the left hepatic duct. At least Michael is not too chunky.
I retracted the gallbladder to the right and began teasing out the cystic duct.
Better check that duct like structure on the right side of the gallbladder.
It’s a good thing I did, because what I thought was all cystic duct turned out to be what I now presumed to be the right hepatic duct almost fused to the back wall of the gallbladder. I tried to separate these two structures. No luck. I did manage to find what I presumed was the cystic artery, very short and running along the medial aspect of the gallbladder, almost tethering the gallbladder between the two hepatic ducts.
Maybe take it from the top down, like the old days.
And so I began working on the fundus of the gallbladder. I pushed the liver up and retracted the gallbladder down and was able to separate the gallbladder until it was attached buy only the cystic duct, which was still fused to the right hepatic duct.
I’ll just take where it’s safe and leave the rest behind.
I used a stapling device to divide the gallbladder at its neck, being careful not to injure the bile ducts.
Finally it’s done. This was far too much work.
Michael woke up without a hitch, oblivious to the torture I had suffered. His operation which normally would have taken about thirty minutes had lasted over two hours.
Next was Michelle, twenty one, with pain for a week and a big stone impacted in the neck of the gallbladder. Michelle was typical of most patients with cholecystitis. That is she had persistent episodes of pain, and stones which either intermittently passed from the gallbladder through the bile duct, causing “biliary colic” or had big stones which would cause obstruction of the gallbladder with either acute symptoms of severe pain and tenderness, “acute cholecystitis” or paroxysmal pain, “chronic cholecystitis.”
Michael and Michelle, good name for a duo. And now we present “Michelle and Michael” the gallbladder singers.
My first glance at Michelle’s gallbladder revealed only that is was very distended. It wasn’t very inflamed and there was only a brief moment when it seemed like there might be some difficulty grasping it. There was a big stone filling the gallbladder neck, but I was able to retract the gallbladder to the right so that I could dissect the cystic artery and duct. Fifteen minutes later the gallbladder was in the endopouch.
But, it wouldn’t come out. The pouch was half in and half out of the abdomen, pulling it out through on of the larger trocar sites. I grabbed the gallbladder and tried to deliver it out of the pouch and abdomen. I was rewarded with a tiny piece of the gallbladder wall.
Keep at it. You always win in the end.
I tried to grab the stone with the ring Forceps, a clamp which has two rings which is ideally suited to grasping gallstones and pulling them out of the Endopouch. Michelle’s stone was big, really big. With one lucky swoop I managed to get the jaws of this clamp around the stone. I pulled it up towards the small opening in the abdominal wall. It was equivalent to trying to put a camel through the eye of a needle.
Maybe I can break the stone up.
I tried to close the jaws of the clamp and break the stone into pieces. There was a “snap” and then I was able to pull the clamp out, minus one of its jaws.
That is one tough stone.
I tried a different type of clamp. No luck.
After twenty minutes of pulling, prying and hoping I did what I needed to do.
“Knife please.”
I made the incision bigger, big enough to deliver this baby. I made it bigger and bigger until it was a mini laparotomy. Finally, I pulled pouch gallbladder and stone out of Michelle’s abdomen. T
The stone was five and a half centimeters in diameter, the size of a chicken egg. I took a break for a minute, shaking my hand to relieve a cramp and stretching my fingers after this ordeal. I closed Michelle in short order and got ready for Owen.
I’m not sure they pay me enough. Maybe Owen will treat me better.
I shouldn’t think such thoughts, surely I jinxed myself. Owen. Even now the name makes me shudder.
Owen was 78 years old and had typical complaints of RUQ abdominal pain. He had been having pain almost daily for 6 weeks. His ultrasound revealed, and I quote, “Multiple mobile stones,” and the gallbladder was not visualized on HIDA scan, which suggests cystic duct obstruction and certainly explained Owen’s frequent symptoms.
“Are you ready to get this over with?” I asked.
“Sure thing, Doc. I’m planning to play eighteen holes tomorrow,” He answered.
“Well, you may want to wait until the weekend,” I countered.
Owen’s case started well enough. Pneumoperitoneum established without difficulty, all the trocars placed and then I looked in with the scope.
No gallbladder.
All I saw was a bit of omentum stuck to the spot where the gallbladder was supposed to be.
It must be underneath those adhesions.
I teased the omentum away and was rewarded with a structure which looked like it was the gallbladder. It was small to say the least, but it was where the gallbladder was supposed to sit and I was sure I could see the common bile duct.
Once the adhesions were gone I began to retract the gallbladder superiorly as is almost always done during laparoscopic gallbladder surgery. The gallbladder was not only shrunken it was very hard to grasp. Every time I tried to grab it, it would slip away. Finally, all I could do was push the liver superiorly. As I tried to dissect this diminutive little beast it tore. I did see some stones inside but I realized I was fighting a losing battle.
“Scalpel, please and get all the instruments to open,” I requested.
Better to have a big incision and a healthy, whole patient, than four small incisions and a piece of the common bile duct in the specimen jar.
Over the years I have never had a patient complain that they had to have open surgery. However, they definitely are not happy if they require multiple surgeries to fix a complication.
For the next hour and a half I wrestled with Owen’s little nubbin of a gallbladder. I managed to separate it from the liver and I thought I found his cystic duct and junction with the common bile duct. The cystic duct was very short. I stitched it closed, being careful not to narrow his CBD and I left a drain in place.
I delivered a gallbladder which was the size of a nickel and contained a couple of stones which filled its tiny lumen.
Two hours of work for that little thing?
Owen woke up without a hitch.
“No golf for a few weeks,” I informed him.
“There goes my handicap,” he answered.
At least I’m done.
My phone went off.
“Consult, ICU 21. Tad Schultz, acute cholecystitis.”
I thought I was done.
It was now 3:30 in the afternoon. My plan to be done and home by one was just a fading memory.
I guess I need to go check out Tad. I wonder why he’s in ICU if it’s just his gallbladder which is the problem?
Tad was not in the ICU just because of his gallbladder. He had undergone coronary artery bypass surgery thirty six hours ago. Now he was complaining of severe upper abdominal pain, nausea and vomiting, all of which had commenced twelve hours earlier.
“Hello, Mr. Schultz. I’m Dr. Gelber, one of the General surgeons here. They tell me you have pain in your abdomen?” I inquired.
He was sitting still in his bed, an oxygen cannula draped across his face which was flushed. The monitor to the right of his bed gave a clue to his condition. Heart rate was 112, blood pressure 100/50, Respirations 22, oxygen saturation was 100%.
Looks like something is going on; something more than just post op discomfort.
“It hurts right here,” he replied as he pointed to the right upper quadrant of his abdomen, right where his gallbladder sat.
“It hurts to move, to breath, even to smile,” he added.
I wonder if it’s more than just his gallbladder?
“Any nausea or vomiting?”
“All night.”
“Had a pain like this before?”
I palpated his abdomen. He winced when I lightly tapped beneath the right costal margin (below the ribs).
It feels like there’s a mass there.”
“I’ll be back in a few minutes,” I said and I went to check the results of any testing which had been done.
I sat a the computer, waiting for Tad’s data to appear.
I don’t feel like ding another surgery today, especially on someone fresh from open heart surgery.
The tests revealed that his white Blood Cell count was 23,000, H/H 10.5 and 32. Total bilirubin was 2.0, ALT 125, AST 114 and Alkaline Phosphatase 201. His other labs were more or less normal. Ultrasound revealed a very distended gallbladder with stones and a thickened wall at 10 mm.
No question, Tad is sick and the culprit is his gallbladder. Surgery would best be avoided if possible. Maybe Dr. L can help.
Dr. L was our local, friendly Interventional Radiologist.
“Percutaneous cholecystostomy, if you have the time,” I requested from Dr. L. “Mr. Schultz, ICU 21. I think it would be best if he does not have to have surgery again so soon.”
Dr. L agreed and two hours later Tad was sitting up, smiling with a tube running from his right flank to a bag which was filled with golden brown bile.
It was not definitive treatment, but the drainage procedure bought time, allowing Tad to recover from his open heart surgery without further complication. Six weeks later he had a second surgery, an uncomplicated laparoscopic cholecystectomy.
The day ended at around 6:00 pm. I had performed four cholecystectomies, tackling gallbladders of a variety of shapes and complexities. My hand was still a little sore from battling Michelle’s ostrich egg of a gallstone, but otherwise it had been a successful day.
Cholecystectomy can be one of the easiest surgeries to perform or extremely difficult. An elective gallbladder surgery in a thin patient with little inflammation and normal anatomy may take all of ten minutes. Meanwhile, at the other end of the spectrum, a case like Owen, a small contracted, fibrotic gallbladder with anatomy which is unclear will cause the best surgeon to pause and rue the day he chose to work with a scalpel, rather than sit a dark room all day and read chest X-Rays.
I thought about the surgeon’s prayer.
“Lord, please protect me from the interesting cases and don’t let me screw up today.”
Maybe it needs an addendum:
“And please make all the gallbladder surgeries easy.”