Surgery to remove the gallbladder (cholecystectomy) can become necessary for many reasons:
Moderate to severe gallstones and inflammation of the bile duct can send someone to the hospital with intense pain. Inflammation of the abdominal lining (peritonitis) , high pressure in the blood vessels near the liver (portal hypertension) and other conditions might make it necessary to see a surgeon about these conditions.
Gallbladder surgery can be done laparoscopically – with several small incisions in the abdomen – or, via open surgery with a single large incision in the abdomen.
Dr. Richard Nitzberg, board-certified surgeon with Summit Medical Group, has performed more than 2,000 laparoscopic gallbladder surgeries.
He discusses all the “ins and outs” of laparoscopic gallbladder surgeries.
Selected Podcast
Gallbladder Surgery
Featured Speaker:
He has been featured in the Castle Connolly "Top Doctors in the New York Metro Area," Castle Connolly "America's Top Doctors," and New Jersey Monthly "Top Doctors" listings. Dr. Nitzberg's Castle Connolly listings have been reprinted in US News and World Report and Inside Jersey.
Richard Nitzberg, MD
Richard S. Nitzberg, MD, specializes in general and vascular surgery as well as hernia and laparoscopic surgery. During his 20 years of practice, he has performed more than 1800 hernia surgeries and more than 2,000 laparoscopic gallbladder surgeries. Dr. Nitzberg also runs the Summit Medical Group Vein Center, which provides treatment for spider and varicose veins with leading-edge laser treatment.He has been featured in the Castle Connolly "Top Doctors in the New York Metro Area," Castle Connolly "America's Top Doctors," and New Jersey Monthly "Top Doctors" listings. Dr. Nitzberg's Castle Connolly listings have been reprinted in US News and World Report and Inside Jersey.
Transcription:
Gallbladder Surgery
Melanie Cole (Host): You feel pains under your rib cage or in your abdomen. You’re not quite sure what it is and could it be your gallbladder. My guest is Dr. Richard Nitzberg, he is board-certified general and vascular surgeon and the vice chair of Summit Medical Group Surgery. Welcome to the show Dr. Nitzberg, tell us what is the gallbladder; what does it do.
Dr. Richard Nitzberg (Guest): Well, the gallbladder sits, lives right underneath the liver and what it does is it fills up with bile, it collects bile as a storage organ and when you have, say, a fatty meal, the gallbladder will contract and will squirt that bile down through what’s called a cystic duct into the common bile duct, which then goes into the intestine and it meets up with this fatty meal that you just had and the bile helps to digest that fatty meal. The nice thing about this whole thing is that if you do have a gallbladder issue, you can actually live without that storage organ. The bile still gets into the intestines, you don’t quite get as much bile as you normally would if you had your gallbladder but you still have enough to go ahead and digest your food, so it’s not a tragedy if you don’t have your gallbladder at all. That’s why, millions of people can live without their gallbladders.
Melanie: So, what might be some symptoms that would send someone to come and see you worried about their gallbladder?
Dr. Nitzberg: So, typically what patients will complain of and it is usually episodic, they have a lot of different symptoms, they will complain of nausea, sometimes vomiting, they will feel very full or what we call bloated. They may have some belching, burping, feeling a gaseous feeling. Typically, they have some discomfort right underneath the breastplate, we say below their xiphoid right underneath the upper part of the abdomen, which can be right in the center or can be right underneath the ribcage on the right side and not infrequently, you’ll see that the pain actually radiates through the back as well right between the shoulder blades and the patients will give you that history as well.
Melanie: If people come to you, they have these symptoms, how do you diagnose that it is their gallbladder and then how do you decide what to do about it?
Dr. Nitzberg: There are a couple of tests that we do, typically the first test we do is an ultrasound. An ultrasound will tell us whether or not the patient has gallstones or not. Gallstones are typically what causes gallbladder pain or the pain from gallbladder disease. What happens is the stone usually gets stuck in what’s called the cystic duct and when the gallbladder contracts, it’s contracting against the obstruction which in this case is the stone, it’s like having a baby’s head in the uterus and then when a woman goes into labor, the uterus starts to contract, the baby’s head is way down low, sort of down by the cervix and when the uterus contracts and there’s an obstruction there which in this case is the baby’s head is quite painful. The same idea when there’s a gallstone stuck in the cystic duct and the gallbladder contracts in response to a fatty meal and there’s a stone obstructing the cystic duct; that’s why the patients have the symptoms of pain and discomfort, that’s where the pain comes from, but sometimes, the ultrasound does not show gallstones. You could have something called biliary dyskinesia or basically dysfunction or malfunction of the gallbladder and in that case, we do a nuclear scan, it’s usually called a HIDA scan or DISIDA scan. Those are just different names for what’s called a nuclear medical scan that helps you to determine whether or not the patient may have that other entity, which is biliary dyskinesia. So, those are the two typical ways, we make the diagnosis.
Melanie: And then if you decide that they have to have surgery, what is involved, is this laparoscopic? Tell us about surgery to remove the gallbladder.
Dr. Nitzberg: Well, the surgery really has been revolutionized since really about 1990, that is when I first started doing these laparoscopic procedures and that’s what it is, it is laparoscopy versus an open procedure. We used to have to make a cut underneath the right side of the rib cage. The old days, it was a fairly large cut that became a much smaller cut, but now since 1990, we have been doing these all laparoscopically; I mean, I honestly cannot remember the last time, I had opened up someone and do it the old fashion way as be 10 to 15 years. It’s so atypical that you have to do that. Nowadays, you can almost always remove the gallbladder through the laparoscope which means in general, you make a number of incisions, can be anywhere between three or four incisions underneath, you know, in the abdomen, very small incisions. There is something called a single incision procedure that can be done as well. The danger of the single incision is that you typically have to make a bigger incision than you normally would if you do it laparoscopically which was just with four small incisions and when you have to make that bigger incision, those patients almost have an eight times greater occurrence of hernia formation. So, not everyone has adopted the single incision surgery. Most of us are still doing the laparoscopic with just the three or four small incisions for that reason.
Melanie: So with this surgery, give the patients a little bit of a walkthrough of what they can expect.
Dr. Nitzberg: Well typically, a patient comes in the day of surgery. They are fasting the night before surgery. They come in and they have a surgery; I just actually finished one about 15 minutes ago. It typically takes between, you know, anywhere between 25 to 30 to 35 minutes to do and then, they stick around for a few hours to make sure they’re okay and then they go home the same day. They are up walking the night of surgery. They can walk upstairs, downstairs and outside. They can start with some liquids to make sure they keep those down and then make an advance to their normal diet and they can shower and get their incisions wet the next day. Typically when I do it, there’s no dressing. There is just some superglue over the incisions. Now that doesn’t mean, you’re not sore. They will have some soreness usually around the belly button or right underneath the breastplate. They can have some soreness around the incisions and you might have a little shoulder pain on the right side for about 48 hours; the reason for that is when you do the procedure, you put carbon dioxide or some type of gas in the abdomen and that usually gets trapped underneath the diaphragms which refers pain to the right shoulder. So for about 48 hours, the patient may have some right shoulder pain, which typically goes away over the course of 24 to 48 hours, but I would say in terms of going back to the normal activities, 85 percent of patients are back to work within a week, some sooner. I tend to go a little slow with my patients in terms of full bode activities, I don’t want them to get a hernia, so I go a little bit slow in terms of major lifting and heavy weights and that kind of stuff, but they can usually within 2 or 3 weeks they can start to do elliptical and bike, stationary bike, and perhaps even treadmill and that kind of thing after about 2 or 3 weeks.
Melanie: Dr. Nitzberg, how well does it work if someone had really severe gallstones and maybe those are in the common bile duct as well, can you still get gallstones if you’ve had your gallbladder removed.
Dr. Nitzberg: You can, but that’s very rare, that’s usually because a stone was left behind in the common duct or you can have primary bile duct stones in the common bile duct, I mean that’s exceedingly rare, I’ve maybe seen 1 or 2 of those in my whole career, I’ve been in practice since about 1990, so it’s very, very unusual. It usually once you’ve removed the gallbladder, you’ve removed the source of making those stones, you’ve taken care of the problem, but you bring up a good issue which is that a lot of patients ask me, well can you take out the stones and leave my gallbladder and the answer is no. You have to take out the gallbladder or you’ll reform the stones and you’ll right back to where you started.
Melanie: Is there any way to prevent gallstones. Is there anything you’d like to give us as your best advice for the listeners, you mentioned fatty foods at the beginning of the segment. What might we do to prevent this from happening in the first place.
Dr. Nitzberg: Well it has been associated with patients who are overweight, so you can watch your weight but I mean I have to honest with you, a lot of my patients are thin and have no fat on them what so ever. A lot of gallstones is really just hereditary, your mom had it, your dad had it, your brother has it, aunt and uncle had it, that kind of thing. So other than changing your relatives you really can’t do much in terms of preventing it in a lot of cases.
Melanie: So then in the last minute or so Dr Nitzberg, kind of wrap it up for us, about the gallbladder you know, an attack, symptoms, and really what people can expect.
Dr. Nitzberg: Well the key thing really is just be aware of the symptoms, the ones that I described earlier. The fullness, the abdominal pain, be aware that if you’re having any type of abdominal pain that seems unusual to you, you need to see your primary care physician or your gastroenterologist or you can come to me or whatever and we will evaluate that and make sure it’s not the gallbladder that’s causing the problem. And if it turns out to be your gallbladder, there’s really a very safe and very expeditious way of taking care of it now which is really the best way to deal with this problem, which is a laparoscopic cholecystectomy or laparoscopic removal of the gallbladder.
Melanie: Thank you so much Dr. Richard Nitzberg, board certified surgeon with Summit Medical Group. He has performed more than 2000 laparoscopic gallbladder surgeries. He is certainly somebody that you can trust. You’re listening to SMG Radio. For more information you can go to SummitMedicalGroup.com, that’s SummitMedicalGroup.com. This Melanie Cole, thanks for listening.
Gallbladder Surgery
Melanie Cole (Host): You feel pains under your rib cage or in your abdomen. You’re not quite sure what it is and could it be your gallbladder. My guest is Dr. Richard Nitzberg, he is board-certified general and vascular surgeon and the vice chair of Summit Medical Group Surgery. Welcome to the show Dr. Nitzberg, tell us what is the gallbladder; what does it do.
Dr. Richard Nitzberg (Guest): Well, the gallbladder sits, lives right underneath the liver and what it does is it fills up with bile, it collects bile as a storage organ and when you have, say, a fatty meal, the gallbladder will contract and will squirt that bile down through what’s called a cystic duct into the common bile duct, which then goes into the intestine and it meets up with this fatty meal that you just had and the bile helps to digest that fatty meal. The nice thing about this whole thing is that if you do have a gallbladder issue, you can actually live without that storage organ. The bile still gets into the intestines, you don’t quite get as much bile as you normally would if you had your gallbladder but you still have enough to go ahead and digest your food, so it’s not a tragedy if you don’t have your gallbladder at all. That’s why, millions of people can live without their gallbladders.
Melanie: So, what might be some symptoms that would send someone to come and see you worried about their gallbladder?
Dr. Nitzberg: So, typically what patients will complain of and it is usually episodic, they have a lot of different symptoms, they will complain of nausea, sometimes vomiting, they will feel very full or what we call bloated. They may have some belching, burping, feeling a gaseous feeling. Typically, they have some discomfort right underneath the breastplate, we say below their xiphoid right underneath the upper part of the abdomen, which can be right in the center or can be right underneath the ribcage on the right side and not infrequently, you’ll see that the pain actually radiates through the back as well right between the shoulder blades and the patients will give you that history as well.
Melanie: If people come to you, they have these symptoms, how do you diagnose that it is their gallbladder and then how do you decide what to do about it?
Dr. Nitzberg: There are a couple of tests that we do, typically the first test we do is an ultrasound. An ultrasound will tell us whether or not the patient has gallstones or not. Gallstones are typically what causes gallbladder pain or the pain from gallbladder disease. What happens is the stone usually gets stuck in what’s called the cystic duct and when the gallbladder contracts, it’s contracting against the obstruction which in this case is the stone, it’s like having a baby’s head in the uterus and then when a woman goes into labor, the uterus starts to contract, the baby’s head is way down low, sort of down by the cervix and when the uterus contracts and there’s an obstruction there which in this case is the baby’s head is quite painful. The same idea when there’s a gallstone stuck in the cystic duct and the gallbladder contracts in response to a fatty meal and there’s a stone obstructing the cystic duct; that’s why the patients have the symptoms of pain and discomfort, that’s where the pain comes from, but sometimes, the ultrasound does not show gallstones. You could have something called biliary dyskinesia or basically dysfunction or malfunction of the gallbladder and in that case, we do a nuclear scan, it’s usually called a HIDA scan or DISIDA scan. Those are just different names for what’s called a nuclear medical scan that helps you to determine whether or not the patient may have that other entity, which is biliary dyskinesia. So, those are the two typical ways, we make the diagnosis.
Melanie: And then if you decide that they have to have surgery, what is involved, is this laparoscopic? Tell us about surgery to remove the gallbladder.
Dr. Nitzberg: Well, the surgery really has been revolutionized since really about 1990, that is when I first started doing these laparoscopic procedures and that’s what it is, it is laparoscopy versus an open procedure. We used to have to make a cut underneath the right side of the rib cage. The old days, it was a fairly large cut that became a much smaller cut, but now since 1990, we have been doing these all laparoscopically; I mean, I honestly cannot remember the last time, I had opened up someone and do it the old fashion way as be 10 to 15 years. It’s so atypical that you have to do that. Nowadays, you can almost always remove the gallbladder through the laparoscope which means in general, you make a number of incisions, can be anywhere between three or four incisions underneath, you know, in the abdomen, very small incisions. There is something called a single incision procedure that can be done as well. The danger of the single incision is that you typically have to make a bigger incision than you normally would if you do it laparoscopically which was just with four small incisions and when you have to make that bigger incision, those patients almost have an eight times greater occurrence of hernia formation. So, not everyone has adopted the single incision surgery. Most of us are still doing the laparoscopic with just the three or four small incisions for that reason.
Melanie: So with this surgery, give the patients a little bit of a walkthrough of what they can expect.
Dr. Nitzberg: Well typically, a patient comes in the day of surgery. They are fasting the night before surgery. They come in and they have a surgery; I just actually finished one about 15 minutes ago. It typically takes between, you know, anywhere between 25 to 30 to 35 minutes to do and then, they stick around for a few hours to make sure they’re okay and then they go home the same day. They are up walking the night of surgery. They can walk upstairs, downstairs and outside. They can start with some liquids to make sure they keep those down and then make an advance to their normal diet and they can shower and get their incisions wet the next day. Typically when I do it, there’s no dressing. There is just some superglue over the incisions. Now that doesn’t mean, you’re not sore. They will have some soreness usually around the belly button or right underneath the breastplate. They can have some soreness around the incisions and you might have a little shoulder pain on the right side for about 48 hours; the reason for that is when you do the procedure, you put carbon dioxide or some type of gas in the abdomen and that usually gets trapped underneath the diaphragms which refers pain to the right shoulder. So for about 48 hours, the patient may have some right shoulder pain, which typically goes away over the course of 24 to 48 hours, but I would say in terms of going back to the normal activities, 85 percent of patients are back to work within a week, some sooner. I tend to go a little slow with my patients in terms of full bode activities, I don’t want them to get a hernia, so I go a little bit slow in terms of major lifting and heavy weights and that kind of stuff, but they can usually within 2 or 3 weeks they can start to do elliptical and bike, stationary bike, and perhaps even treadmill and that kind of thing after about 2 or 3 weeks.
Melanie: Dr. Nitzberg, how well does it work if someone had really severe gallstones and maybe those are in the common bile duct as well, can you still get gallstones if you’ve had your gallbladder removed.
Dr. Nitzberg: You can, but that’s very rare, that’s usually because a stone was left behind in the common duct or you can have primary bile duct stones in the common bile duct, I mean that’s exceedingly rare, I’ve maybe seen 1 or 2 of those in my whole career, I’ve been in practice since about 1990, so it’s very, very unusual. It usually once you’ve removed the gallbladder, you’ve removed the source of making those stones, you’ve taken care of the problem, but you bring up a good issue which is that a lot of patients ask me, well can you take out the stones and leave my gallbladder and the answer is no. You have to take out the gallbladder or you’ll reform the stones and you’ll right back to where you started.
Melanie: Is there any way to prevent gallstones. Is there anything you’d like to give us as your best advice for the listeners, you mentioned fatty foods at the beginning of the segment. What might we do to prevent this from happening in the first place.
Dr. Nitzberg: Well it has been associated with patients who are overweight, so you can watch your weight but I mean I have to honest with you, a lot of my patients are thin and have no fat on them what so ever. A lot of gallstones is really just hereditary, your mom had it, your dad had it, your brother has it, aunt and uncle had it, that kind of thing. So other than changing your relatives you really can’t do much in terms of preventing it in a lot of cases.
Melanie: So then in the last minute or so Dr Nitzberg, kind of wrap it up for us, about the gallbladder you know, an attack, symptoms, and really what people can expect.
Dr. Nitzberg: Well the key thing really is just be aware of the symptoms, the ones that I described earlier. The fullness, the abdominal pain, be aware that if you’re having any type of abdominal pain that seems unusual to you, you need to see your primary care physician or your gastroenterologist or you can come to me or whatever and we will evaluate that and make sure it’s not the gallbladder that’s causing the problem. And if it turns out to be your gallbladder, there’s really a very safe and very expeditious way of taking care of it now which is really the best way to deal with this problem, which is a laparoscopic cholecystectomy or laparoscopic removal of the gallbladder.
Melanie: Thank you so much Dr. Richard Nitzberg, board certified surgeon with Summit Medical Group. He has performed more than 2000 laparoscopic gallbladder surgeries. He is certainly somebody that you can trust. You’re listening to SMG Radio. For more information you can go to SummitMedicalGroup.com, that’s SummitMedicalGroup.com. This Melanie Cole, thanks for listening.