Associate Professor Adam Bartlett General, Hepato-Pancreatico-Biliary (HPB), Laparoscopic & Robotic Surgeon

The gallbladder is a small pear-shaped organ that lies in the right upper quadrant of your abdomen adjacent to your liver, under your ribs. The liver makes bile and excretes it into a tube (bile duct) that drains into the first part of the small bowel; the duodenum. The gallbladder is an out-pouch of the bile duct that collects and stores bile produced by the liver. When one eats a “fatty” meal the gallbladder is stimulated to contract, excreting the bile into the duodenum, enabling the absorption of fat. In about 10% of the population, stones form within the gallbladder, called “gallstones”. These begin as small crystals that increase in size over time and can cause symptoms. These symptoms commonly occur after eating, particularly when fat is consumed, causing pain, restlessness and nausea (biliary colic). The pain typically lasts for minutes or a few hours, and may occur randomly. Most people who go on to develop more severe complications of gallstones usually have had biliary colic previously.

It is not known why some people develop gallstones. Some factors that have been shown to be associated with the development of gallstones include female gender, obesity, family history, increasing age, and having previously had babies.

Gallstones can lead to the development of:

Biliary colic: This is characterised by severe upper abdominal pain associated with nausea/vomiting and restlessness due to contraction of the gallbladder against a gallstone impacted in the neck. It typically occurs after eating, especially fatty foods, and last minutes to hours.

Acute cholecystitis is a severe infection of the gallbladder. It usually begins like biliary colic, but the pain becomes constant, and is associated with fever. Acute cholecystitis usually requires hospital admission for intravenous antibiotics and can be managed surgically by the acute removal of the gallbladder. Surgery can usually be safely deferred until the infection/inflammation has all settled (around 6 weeks), making the surgery easier and safer.

Cholangitis: If stones pass from the gallbladder into the bile duct, they may cause partial or complete blockage of bile flow. This will lead to stasis of bile within the liver, causing an abnormality in the liver function blood tests. If severe you may become jaundiced (yellow), and pass dark urine. When associated with fever and pain, it indicates infection of the bile – termed cholangitis. This is a medical emergency, and requires urgent decompression of the blockage either at the time that the gallbladder is removed (operative exploration) or endoscopically prior to the removal of the gallbladder.

Pancreatitis: The pancreas is a digestive organ intimately related to the bile ducts. Occasionally gallstones can pass out of the gallbladder and into the bile ducts, causing obstruction to the pancreatic duct, leading to inflammation of the pancreas, a condition called pancreatitis. Pancreatitis can range from minor back pain through to a severe life threatening illness. The gallbladder is usually removed as soon as possible following an episode of pancreatitis to lessen the chance of a further attack.

Gallbladder cancer is a rare tumour condition that usually affects older people with a long history of gallstones. Gallstones predispose to the cancer, but fear of cancer in itself is not an indication for surgery because it is so rare. Gallbladder cancer may be discovered incidentally during the removal of a gallbladder, and is usually cured in these circumstances. More advanced cancers may require much larger operations (liver resection), or even be incurable.

Patients with gallstones and symptoms of biliary colic should have a cholecystectomy, before they develop severe complications. Occasionally patients without gallstones, who have significant symptoms, will require a cholecystectomy. Rarely, patients with large gallbladder polyps (growths) will have a cholecystectomy because of the possibility of developing gallbladder cancer.

The most common method of removing the gallbladder is by laparoscopic (keyhole) surgery. A camera, known as a laparoscope, connected to a high intensity light is introduced through a small incision through your umbilicus (belly button). A further three little puncture wounds are made (one in the upper abdomen and two under your ribs on the right hand side) to allow the surgical instruments to be introduced. To provide space for the surgery to be performed, your abdomen is filled with carbon dioxide. Once the gallbladder is dissected off the liver and the connections to the bile ducts and blood vessels are clipped, it is removed through the umbilical incision. The procedure normally takes 30 – 60 minutes. In about 3-5% of cases the gallbladder cannot be safely removed laparoscopically and a traditional open technique is required (laparotomy). This requires a 15 cm incision in your upper abdomen parallel with your right rib cage. This is a bigger procedure and will result in a hospital stay of several days (on average between 2-5 days). In view of the small chance of needing “open” surgery you will be asked to consent to both techniques.

A hernia is an abnormal protrusion on an organ through a weakness in the abdominal wall. The abdominal muscles are usually strong enough to keep your internal organs in place but when a weakness develops they may protrude through the musculature, leading to a hernia. An inguinal (pronounced "ing-win-al") hernia is the most common type of hernia. An inguinal hernia usually occurs when fatty tissue or a part of your bowel, such as the small or large intestine, protrudes through the inguinal canal through into your groin at the top of your inner thigh. The inguinal canal is a potential passage that allows for the passage of the testicles in men to descend into the scrotum during development, taking with them blood vessels and the spermatic cord. In women a remnant persists as the round ligament. As a result of the canal either remaining open at the time of development or becoming more open from musculature weakness, fatty tissue or a part of your bowel, such as the small or large intestine, protrudes through the inguinal canal, forming an inguinal hernia. Straining, for example on the toilet or lifting heavy weights, increases pressure inside the abdomen and can trigger a hernia. Inguinal hernias occur mainly in men and more common with age, due to weakening of the abdominal wall.

Most inguinal hernia appear as a swelling in your groin or as an enlarged scrotum, which may be painful. The swelling will often appear when you are straining or lifting something and disappear when you lie down and relax. In a small number of people they may present with bowel obstruction due to incarceration of bowel within the hernia, which is a medical emergency.

Most people with an inguinal hernia have pain, and repairing the hernia will alleviate the pain. In addition an inguinal hernia is potentially dangerous as the herniated bowel may become incarcerated leading to bowel obstruction or strangulation as a result of the blood supply to the bowel being compromised. Only surgery can repair the hernia, they will not go away on their own. There are two approaches:

Open hernia repair: This is the traditional approach where an incision is made over the inguinal area, the hernia is reduced (pushed back into the abdomen) and synthetic mesh is placed over the weakness in the abdominal wall to prevent further herniation. This operation can be done under a general anaesthetic (where you will be asleep), or under local anaesthetic with sedation (where you will be awake).

Laparoscopic hernia repair: This is also called “keyhole” surgery. A camera, known as a laparoscope, connected to a high intensity light is introduced through a small incision just below your umbilicus (belly button). A further two little puncture wounds (5mm) are made below this in the midline to allow the surgical instruments to be introduced. To provide space for the surgery to be performed the area is filled with carbon dioxide. The hernia is pulled back into the abdomen; a piece of synthetic mesh is placed over the hole and tacked into place to prevent further herniation.

There are advantages and disadvantages to both methods. With the laparoscopic approach there is usually less pain after the operation both immediately post operatively and long term, you are less likely to have wound infections, and consequently it is associated with a quicker return to normal activity. The laparoscopic hernia operation takes slightly longer, and it can only be done under a general anaesthetic. The risk of hernia recurrence is difficult to compare. In a large analysis of some 7000 patients that underwent hernia repair, the recurrence rate was reported to be around 2-3% for open repair and 5-6% for laparoscopic repair (O’Reilly E et al., Annals of Surgery, 2012; 255(5):846). In another analysis involving around 7000 patients, there was no difference in the recurrence rate with the laparoscopic approach (McCormack K, et al., Cochrane Database Syst Rev. 2003(1):CD001785). It appears that the recurrence rate is dependent upon a number of factors, including size, whether it is bilateral or unilateral or recurrent. Discuss the advantages and disadvantages of laparoscopic and open surgery with your surgeon before deciding on the most appropriate treatment for you.

The liver is the largest solid organ in the body and is located in the upper right-quadrant of the abdomen under the rib cage. Functionally it is a major source of proteins for the body and processes much of the food we eat, playing a critical role in carbohydrate and lipid metabolism. It also is an important “filter” for the removal of drugs and toxins, and helps to fight infections. The liver also produces bile that is secreted via the bile ducts into the gut. The gallbladder, although not part of the liver, is intimately associated with the inferior surface of the liver and is connected to the main bile duct via the cystic duct. Bile is stored within the gallbladder and during eating the gallbladder contracts and secretes it into the gut to facilitate absorption of fat.

Anatomically the liver lies beneath the diaphragm and on top of the right kidney and intestines. The liver weighs approximately 2% of a person’s body weight (1.5kg). The liver is the only organ in the body that has a double blood supply. Oxygenated blood flows in from the hepatic artery and nutrient- rich blood flows through the portal vein from the gut. Blood leaves the liver through the three hepatic veins (left, middle, right) into the vena cava to return to the heart.

The liver can be divided into a right and left lobe. Within each lobe the liver can be divided into segments, based on the division of the blood vessels within the liver. The segments are numbered from one to eight in Roman numerals. The left lobe is composed of segments II - IV, while the right lobe is composed of segments V - VIII. From the outside it is not possible to determine the division between the segments. Pre-operatively radiological imaging of the liver (CT, MRI, USS) is used to define the segmental anatomy, while intra-operatively USS can be used directly on the surface of the liver. The segmental anatomy of the liver provides the basis for determining the plane of transection during liver resections.

The liver is the only organ in the body that is able to regenerate (regrow). This means that when part of the liver is removed, the volume of the remaining liver increases (hypertrophies) until it returns to the volume of the original whole liver. Bile ducts and blood vessels do not re-grow, rather the remnant liver increases in size. This normally takes up to 8 – 12 weeks following a major liver resection. Up to 70% of a healthy liver can be removed. However, in the presence of chronic liver disease or chemotherapy, a larger remnant is required, reducing the amount of liver that can be removed.

Liver resection refers to the removal of a portion of the liver. This operation is usually done to remove various types of liver tumours, either primary (arisen within the liver) or secondary (spread to the liver from elsewhere). The principal aim of performing a liver resection is to completely remove the tumour without leaving any tumour behind. The success of liver resection depends upon the location of the tumour, the number of tumours, the amount of liver left after removal of the tumour, and the biology of the tumour.

Most patients who require a liver resection have metastases (secondaries) from a colorectal (bowel) cancer. Less commonly other secondary cancers from neuroendocrine tumours (like carcinoid), renal cancer or melanoma are resected. The most common primary liver cancer that is resected is hepatocellular carcinoma (HCC or Hepatoma). This is a cancer that originates in liver cells (primary), and is usually associated with underlying chronic liver disease. Primary cancers of the bile ducts, cholangiocarcinoma, are less commonly resected. There are a number of benign lesions that occur in the liver. Most don’t cause any symptoms or problems and can be monitored or left alone. Sometimes it is not possible to be sure of a diagnosis and resection is undertaken to establish the diagnosis. Biopsy of the liver is not routinely recommended as it has the potential to cause bleeding and spread of the cancer.

The most common method of removing part of the liver is by an open operation (laparotomy). In some instances it is possible to undertake the operation laparoscopically (keyhole surgery). The open technique is the preferred method for major resections particularly and in those tumours that are difficult to access. Only a minority of liver resections can be performed laparoscopically. A camera, known as a laparoscope, connected to a high intensity light is introduced through a small incision and a further three puncture wounds are made to allow the surgical instruments to be introduced. Once the liver has been resected a small incision is made low down in the abdomen to allow the tumour to be extracted. Irrespective of the method used the principles are the same: the liver is mobilised. The vessels to the portion being resected are isolated and controlled. A cut is then made through the liver substance (parenchyma) and care is taken to seal off the blood vessels and bile ducts that pass across the plane of transection.

The pancreas is located deep in the body, behind the stomach, just anterior to the vertebral body. It is shaped a little bit like a fish – extending almost horizontally from the first part of the small bowel (duodenum) on the right to the hilum of the spleen on the left. It is about 15 cm long and less than 5 cm wide. The pancreas is composed of two types of glands. The exocrine pancreas makes up the majority of the gland. It makes pancreatic "juice” that is composed of enzymes that help to break down food you eat. The pancreatic juice is secreted into the pancreatic duct that joins the bile to empty the contents into the first part of the small intestine (duodenum). The endocrine pancreas is composed of clusters of cells called islets, that make hormones like insulin that help balance the amount of sugar in the blood.

Cancer can develop in both the exocrine and endocrine cells of the pancreas. Tumours formed by the exocrine cells are much more common. Not all of the tumours in the pancreas are malignant, some are benign. It is important to know whether a tumour is from the exocrine or endocrine part of the pancreas as it is treated in different ways, and has a different prognosis.

Exocrine tumours are the most common type of pancreas cancer. The majority arise within the glands of the exocrine pancreas and are called adenocarcinomas. A special type of cancer called ampullary cancer arises within the distal bile duct where it empties into the small intestine. This type of cancer often presents with jaundice, so is usually found at an earlier stage. Adenocarcinoma of the pancreas is typically an aggressive tumour with a poor outcome unless it can be completely removed. Treatment of exocrine cancer of the pancreas depends upon the stage of the cancer. Unfortunately most patients with adenocarcinoma of the pancreas present too late to be removed by surgery, and are managed palliatively. Even if curative resection is possible, only around one in five patients will be cured.

Endocrine tumours of the pancreas are rare. They are also known as islet cell tumours or neuroendocrine tumours (NET) and are divided into different types depending upon the hormones that they produce. Most endocrine pancreatic tumours are benign, but they can be malignant. Rarely, the pancreas is a site for secondaries (metastases) from cancers elsewhere. Some tumours can present as cysts. The majority are benign and can be safely watched.

Pancreatic resection refers to the removal of a portion of the pancreas. This operation is usually done to remove various types of liver tumours. The principal aim of performing pancreatic resection is to completely remove the tumour without leaving any tumour behind. The success of pancreatic resection depends upon the location, size and type of tumour.

Pancreatic resection is mainly performed to remove pancreatic cancer. Most patients who require pancreatic resection have a primary cancer that has arisen within the pancreas, usually adenocarcinoma. Less commonly tumours can arise from the endocrine pancreas. Sometimes it is not possible to determine whether the tumour is benign or malignant and resection is performed to remove the tumour and establish the diagnosis. Biopsy of the pancreas is not routinely recommended as it has the potential to cause bleeding and spread of the cancer.

There are two principal types of operations:

1. Removal of the head of the pancreas, the duodenum and bile ducts (including gallbladder) with or without the distal stomach – known as a pancreaticoduodenectomy or Whipple’s procedure. The Whipple operation is performed for cancer that is located in the head of the pancreas.

2. Removal of the body and or tail of the pancreas with or without the spleen – known as a distal pancreatectomy. It is performed for tumours that are located in the neck, body or tail of the pancreas. It is technically more straightforward than a Whipple, and can be performed either by an open operation or laparoscopically.

The spleen is an organ involved in the production and maintenance of red blood cells, the production of white blood cells, and plays an important role in the immune system. Because of its wide variety of functions, the spleen may be affected by many conditions involving the blood or lymph system, and by infection, malignancies, liver disease and parasites.

Splenectomy is an operation to remove the spleen. Splenectomy is performed if the spleen has been damaged in a serious accident, has been damaged by disease, contains a tumour, or has become overactive (hyper-splenism). It can be performed either by open technique (laparotomy) or laparoscopically (keyhole surgery). In the presence of a large spleen it is sometimes not possible to remove it laparoscopically.