Guide to Gallbladder Surgery in Singapore 

Introduction

Gallbladder surgery, specifically for removing gallstones, is a common procedure in Singapore. Gallstones are solid particles or pebble-like stones [1] that form in the gallbladder, leading to significant health issues if not treated. These stones can block the bile ducts, causing pain, infection, and even pancreas inflammation (pancreatitis).

Gallstone-related conditions are prevalent worldwide, and Singapore is no exception. Factors such as unhealthy diets, lack of exercise, rising obesity rates, and an aging population contribute to the increasing prevalence of gallstones. Removing the gallbladder through laparoscopic procedures is considered safe and effective, and usually leads to a full recovery.

Understanding Gallstones

What Are Gallstones?

Gallstones are hardened deposits that form in the gallbladder, a small organ located beneath the liver responsible for storing bile. Bile [2] is a digestive fluid produced by the liver and stored in the gallbladder to help break down fats. Gallstones can vary in size, from tiny grains of sand to large stones, and can range from a single stone to multiple stones at once. They often form when there is an imbalance in the substances that make up bile, such as too much cholesterol or bilirubin, which causes these substances to crystallise and harden.

There are two main types [3] of gallstones: cholesterol gallstones and pigment gallstones. Cholesterol gallstones are the most common, comprising primarily of hardened cholesterol. They form when bile contains too much cholesterol, or when there are not enough bile salts to dissolve it. 

Pigment gallstones, on the other hand, are smaller and darker, made from excess bilirubin, a byproduct of the breakdown of red blood cells. These stones are more likely to develop in individuals with liver diseases, blood disorders, or infections in the bile ducts.

While gallstones may not cause symptoms in some individuals, they can lead to significant health issues if they obstruct the bile ducts. This can result in pain, inflammation, infection, and other complications like pancreatitis. Symptoms [4] of gallstones often include severe pain in the upper abdomen, nausea, vomiting, and digestive discomfort, especially after consuming fatty foods. In these cases where gallstones become symptomatic or cause complications, surgical removal of the gallbladder is often recommended.

Complications of Gallstones 

When a gallstone obstructs the flow of bile through the biliary system, it can cause serious complications [5] by affecting the organs within the system. The blockage forces bile to accumulate in the bile ducts and organs, leading to acute inflammation and creating a breeding ground for bacterial infections. If untreated, these complications can escalate to life-threatening conditions.

Some of the potential complications include:

• Cholecystitis: Inflammation of the gallbladder, often causing severe pain and fever.
• Pancreatitis: Inflammation of the pancreas, which can lead to severe abdominal pain and digestive issues.
• Cholangitis: Inflammation of the bile ducts, which can cause fever, jaundice, and abdominal pain.
• Jaundice: A yellowing of the skin and eyes due to bile entering the bloodstream, indicating a blockage of bile duct.
• Septicemia: A severe and potentially life-threatening blood infection caused by bacteria entering the bloodstream through infected bile ducts or gallbladder.

Prompt medical attention is crucial to avoid these complications, especially if symptoms of infection or inflammation arise.

Causes and Risk Factors

Why do gallstones form? While the exact reason they form is still unknown several factors contribute to the formation of gallstones, including:

• Diet: A diet high in fat and cholesterol and low in fiber increases the risk of gallstones.
• Obesity: Being overweight or obese is one of the most significant risk factors for developing gallstones, particularly cholesterol stones.
• Genetics: A family history of gallstones can increase the likelihood of developing them.
• Age and gender: Gallstones are more common in women and those over the age of 40.
• Pregnancy: Hormonal changes during pregnancy can increase the risk of gallstone formation.
• Rapid weight loss: Losing weight too quickly may lead to an imbalance of cholesterol and bile salts, causing gallstones.

Symptoms and Diagnosis

While some people with gallstones remain asymptomatic, those who experience symptoms typically report the following:

• Abdominal pain: This is the most common symptom, usually occurring in the upper right abdomen or upper middle abdomen and radiating to the back or shoulder. The pain is often sharp and can last several hours.
• Nausea and vomiting: These symptoms frequently accompany gallstone attacks.
• Bloating and indigestion: People with gallstones may also experience a feeling of fullness or discomfort after meals.
• Jaundice: If a stone blocks a bile duct, it can cause jaundice (yellowing of the skin and eyes).

To diagnose gallstones, doctors commonly use the following methods:

• Ultrasound: This is the most common imaging test used to detect gallstones.
• MRI Scan: A more detailed imaging option that can provide a clearer view of the bile ducts and surrounding organs.
• Endoscopic Retrograde Cholangiopancreatography (ERCP): This combines endoscopy and X-ray to locate and sometimes remove stones from the bile duct. 

Types of Gallstone Removal Surgery

There are several surgical options available for gallstone removal or treatment, with each method having its advantages and disadvantages. Let’s look at some of these options. 

Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy [6] is a common surgery for gallbladder removal. It is a minimally invasive procedure where small incisions are made, and a camera (laparoscope) is inserted into the abdomen to guide the surgeon. The gallbladder is then removed through these small incisions.

• Advantages:
  • Minimally invasive with smaller incisions
  • Less postoperative pain
  • Shorter hospital stay and faster recovery
  • Lower risk of infection and complications
• Disadvantages:
  • Small risk of complication such as bleeding
  • Technically more challenging in cases with infection

Open Cholecystectomy

Open cholecystectomy [7]  is a traditional method of gallbladder removal. It involves a larger incision in the abdomen to access and remove the gallbladder. This method is usually reserved for cases where laparoscopic surgery is not feasible and is a less common option for gallbladder removal today. It may be recommended when there is severe inflammation or suspected gallbladder cancer. 

• Advantages:
  • Direct access to the gallbladder, making it easier to handle complicated cases
  • Suitable for patients with other health conditions that complicate surgery or general anaesthesia
• Disadvantages:
  • Larger incision and longer recovery time
  • Increased pain and risk of complications 

Endoscopic Retrograde Cholangiopancreatography (ERCP) 

A procedure called Endoscopic Retrograde Cholangiopancreatography (ERCP), is increasingly becoming the preferred method for gallstone removal stuck in the bile duct. This specialised procedure is used to diagnose and treat problems in the bile ducts, pancreas, and liver. It is particularly useful for removing stones from the bile duct. The procedure combines endoscopy and X-ray technology to access and treat the affected areas.

In this procedure, a flexible tube with a camera is inserted through the mouth into the digestive system, allowing the surgeon to identify issues and remove stones without removing the gallbladder. 

• Advantages:
  • Minimally invasive, no abdominal incisions
  • Quick recovery with minimal postoperative pain
  • Often performed as an outpatient procedure
• Disadvantages:
  • Limited to stones located in the bile duct
  • May not be effective for all patients or larger stones

The Surgery Process

What to Expect on the Day of Surgery

On the day of surgery, patients are typically required to arrive at the hospital a few hours before the procedure. The preparation involves:

• Checking vital signs (blood pressure, heart rate, etc.)
• Meeting with the surgeon and the team to discuss the procedure
• Administration of general anaesthesia 

Surgical Procedure

The specifics of the surgery will vary depending on the type of procedure. For the Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure, the process is often as follows: 

• Preparation: Before starting the procedure, the patient is given sedation, either through general anaesthesia or a sedative, to ensure comfort and prevent pain. Additionally, a local anaesthetic is applied to numb the throat, making it easier for the endoscope to pass smoothly through the digestive tract.
• Endoscope Insertion: The surgeon carefully inserts a thin, flexible tube called an endoscope through the patient's mouth. This tube is passed down the oesophagus, into the stomach, and finally reaches the duodenum (the first section of the small intestine). Equipped with a small camera, the endoscope allows the surgeon to visually guide the procedure and locate the bile ducts.
• Accessing the Bile Duct: After reaching the duodenum, a thin tube called a catheter is inserted through the endoscope and into the bile ducts. Then, a contrast dye is injected through the catheter, making the bile ducts visible on X-ray images. These images help the surgeon identify any blockages, such as gallstones.
• Removing Gallstones: If gallstones are found within the bile duct, specialized instruments are used to capture and remove them. In some cases, the surgeon may perform a sphincterotomy, a small incision in the bile duct, to assist with the release of the stones.
• Stent Placement: If the bile duct is narrowed due to inflammation or scarring, a stent (a small tube) may be inserted to keep the duct open, ensuring that bile can flow freely.
• Completion: Once the gallstones have been removed and any blockages cleared, the endoscope and other instruments are carefully withdrawn. The patient is then observed as the sedative wears off, typically in a recovery area. Most ERCP procedures are done on an outpatient basis, allowing patients to go home the same day after a few hours of monitoring.

Post-Surgery Care

Immediate Postoperative Care

After surgery, managing pain and preventing infection are the primary goals. Patients may be prescribed painkillers and antibiotics, and they will need to follow strict instructions for wound care, especially after open cholecystectomy. 

For an ERCP, the post-procedure period may be less challenging than an open cholecystectomy but is still important to ensure a smooth recovery and minimise potential complications. Here’s what patients can expect and the steps they should follow after the procedure:

Immediate Post-Procedure Care

After the ERCP procedure, the patient is typically moved to a recovery area where they are monitored as the sedative or anaesthesia wears off. It’s common to feel groggy or tired for a few hours. Patients may also experience a mild sore throat from the endoscope, but this usually resolves within a day or two. In some cases, patients might feel mild bloating or abdominal discomfort due to the air introduced during the procedure. Most of these symptoms subside within a short period, and patients are usually able to return home the same day.

Key tips for immediate post-procedure care:

• Rest and avoid strenuous activities for the rest of the day.
• Drink water and fluids to stay hydrated, but avoid heavy meals until cleared by the doctor.

Recovering at home

Once discharged it's important to follow medical advice to ensure healing and proper recovery at home. These often include: 

• Changing diet: Start with a light diet, such as soft or bland foods, and gradually return to normal eating habits as tolerated. Fatty or greasy foods should be avoided initially to prevent digestive discomfort.
• Taking medications: Take prescribed medications, including pain relief if needed, and antibiotics to prevent infection. 
• Resting: It is normally recommended to avoid heavy lifting or vigorous physical activity for at least 24-48 hours following the procedure. Depending on the extent of the ERCP, more extended rest may be required.

Monitoring for Complications

While ERCP is generally safe, there is a risk of complications [8], including pancreatitis (inflammation of the pancreas), infections, bleeding, or bile duct injuries. It’s important to watch for any unusual symptoms and seek medical attention if needed.

Signs to watch for include:

• Severe or worsening abdominal pain, particularly in the upper abdomen
• Fever or chills, which could indicate an infection
• Nausea or vomiting that persists
• Yellowing of the skin or eyes (jaundice), suggesting a bile duct issue
• Difficulty swallowing or severe throat pain beyond the first 24 hours

Patients should attend any scheduled follow-up appointments to ensure proper recovery and discuss any concerns with their healthcare provider. Most patients recover quickly after ERCP and can return to their normal activities within a few days. If there are any symptoms experienced after the ERCP that cause concern, you should contact your doctor immediately.

Choosing a Surgeon for Gallbladder Surgery in Singapore

When selecting a surgeon for gallbladder surgery in Singapore, consider the following:

• Experience and Specialisation: Look for a surgeon who specialises in minimally invasive procedures like laparoscopic or endoscopic surgery.
• Accreditation: Choose a hospital or clinic that is accredited and has modern surgical facilities.
• Patient Reviews: Research patient experiences to gauge the quality of care.
• Questions: Book a consultation with an experienced surgeon where you can ask questions about the surgery or your symptoms. 

Dr. Lee Chin Li at Lee Surgery and Endoscopy in Singapore is an experienced surgeon with niche areas of expertise in performing minimally invasive surgeries for the gallbladder. Prior to his private practice, he was the founding Head of the Division of Hepatobiliary & Pancreatic Surgery and Consultant General Surgeon, Juronghealth Campus, National University Health System (NUHS). Contact us today to book a consultation. 

Costs of Gallbladder Surgery

The cost of gallbladder surgery in Singapore varies depending on the type of procedure, the hospital or clinic, and the surgeon’s experience. On average, these are the costs:

• Laparoscopic Cholecystectomy: $6,000 to $15,000
• Open Cholecystectomy: $10,000 to $20,000
• Endoscopic Surgery (ERCP): $4,000 to $8,000

Most gallbladder surgeries are covered by health insurance in Singapore, but patients should check with their providers for specific coverage details.

Conclusion

Gallbladder surgery is a common and safe procedure in Singapore, with endoscopic surgery being the most preferred option for its minimally invasive nature and quick recovery. Patients experiencing symptoms of gallstones should consult with their doctor to discuss the best treatment option.

Frequently Asked Questions (FAQs)

Why is gallbladder surgery needed?

Gallbladder surgery is often required when gallstones cause symptoms such as pain, nausea, vomiting, or complications like inflammation (cholecystitis) or infection.

Can I live without a gallbladder?

Yes, you can live without a gallbladder. The liver will continue to produce bile, which will flow directly into the small intestine, aiding in digestion.

Are gallstones hereditary?
There may be a genetic component to gallstone formation, as family history can increase the risk of developing gallstones.

What should I do if I suspect I have gallstones?
If you experience symptoms such as severe abdominal pain or discomfort, it’s essential to seek medical attention for evaluation and potential treatment.

How effective is ERCP?

ERCP is highly effective for diagnosing and treating various bile duct and pancreatic conditions. However, the effectiveness can vary based on the specific condition and individual circumstances.

References 

1. National University Hospital Singapore. (n.d.). Gallstones: Diseases and conditions. Retrieved September 20, 2024, from https://www.nuh.com.sg/health-resources/diseases-and-conditions/gallstones
2. Ness, T., & Edye, M. (2019). Gallstones. In StatPearls. StatPearls Publishing. Retrieved September 23, 2024 from: https://www.ncbi.nlm.nih.gov/books/NBK542254/
3. Mayo Clinic. (n.d.). Gallstones: Symptoms and causes. Mayo Clinic. Retrieved September 20, 2024, from https://www.mayoclinic.org/diseases-conditions/gallstones/symptoms-causes/syc-20354214
4. Johns Hopkins Medicine. (n.d.). Gallstones. Retrieved September 23, 2024, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/gallstones
5. Cleveland Clinic. (n.d.). Gallstones: Symptoms, causes, diagnosis, and treatment. Retrieved September 23, 2024, from https://my.clevelandclinic.org/health/diseases/7313-gallstones
6. Hassler KR, Collins JT, Philip K, et al. Laparoscopic Cholecystectomy. [Updated 2023 Jan 23]. In StatPearls. StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK448145/
7. Thompson, G. (2023). Laparoscopic cholecystectomy technique. Medscape. Retrieved September 24, 2024, from https://emedicine.medscape.com/article/1582261-technique?form=fpf
8. Szary, N. M., & Al-Kawas, F. H. (2013). Complications of endoscopic retrograde cholangiopancreatography: how to avoid and manage them. Gastroenterology & hepatology, 9(8), 496–504. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3980992/