Is it necessary to remove all gallstones?

Today, 10 per cent of North Americans share this medical problem

What should you do if you are diagnosed with gallstones?

Today, 10 per cent of North Americans share this medical problem. For some patients surgery is the prudent choice. But now, a report from the Canadian Medical Protective Association (CMPA), shows that, in some cases, leaving gallstones to the crematorium can prevent serious complications and even death.

In 1991, Dr. Joacques Perissat at the University of Bordeau, in France, removed a gallbladder by laparoscopic (keyhole) surgery. This innovation provided a huge advantage for patients from a technical standpoint. But is it fool-proof?

The CMPA reports that during a four-year period the most frequent complications of gallstone surgery were injury to the biliary duct that carries bile to the intestines, bowel injury, and hemorrhage. During that time 31 patients either died, or suffered serious harm.

Patients, the report states, should be informed of potential troubles prior to surgery.

The term, keyhole surgery, unfortunately leaves the impression that tiny incisions mean a simple uncomplicated operation. But it’s an entirely different ballgame than operating through a large incision. Rather than holding a scalpel, surgeons watch a video camera while using instruments that hold, cut and suture tissues. This makes the learning curve for doctors longer than scalpel surgery. So the old saying remains true, whether you’re a plumber or surgeon, “Practice makes perfect.”

How and why do complications occur?

Small clips are used in laparoscopy to control bleeding or close arteries. Sometimes too many are used near the bile duct, either injuring it, or blocking the passage of bile. Or, the surgeon may make an anatomical mistake.

There’s another old saying that, “Wise generals know when to retreat.”

But some surgeons, once a laparoscopy is started, dislike admitting defeat even when it’s apparent it would be wise to stop the procedure and return to a regular scalpel incision.

No hesitancy is warranted if a small gallstone suddenly blocks the bile duct, triggering severe pain and requiring an emergency operation.

But today an increasing number of patients are being referred for abdominal ultrasounds to make a diagnosis. Often this results in finding ‘incidental gallstones’ which may have been present for years, but are not causing any problems.

I vividly recall making rounds with the professor of surgery at The Harvard Medical School who gave students this sage advice.

“Remember, you can never make a patient feel better who has no symptoms, particularly when the gallstone is a large one unable to enter the small bile duct causing blockage.”

In this situation the best treatment is to leave the gallstone eventually to the crematorium, unless it’s causing repeated attacks of pain. But the decision must always be left to your doctor.

If this advice has unintentionally worried readers about laparoscopy, let me reassure you about this procedure. It’s the one I would ask for, were I a patient, because when it’s performed without any trouble, the sun shines, birds sing, and God is in heaven.

The incisions are tiny, there’s less bleeding, less post-operative pain, quicker healing and a return to normal sooner. So, normally it’s a win/win situation.

As you might have concluded at this point, the best way to go to surgery is on a first-class ticket. Namely, to have surgery carried out by a skilled surgeon.

But I’m sure some readers will say, “This is easy advice for you to give as you’re a surgeon. But it’s not so easy for us.” I admit this is true, but your family doctor can direct you to skilled hands.

But here is a Gifford-Jones Surgical Tip if you need more assurance. If you’re fortunate to know a scrub nurse, one who hands surgeons their instruments day after day, ask her or him, who they would recommend for the operation.

Then, don’t make this bad mistake. If you visit the surgeon and discover that he or she has the personality of Dracula, don’t make the error of seeking another surgeon. Remember, it’s his hands that are operating on you, not his personality.

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