Bile is made in the liver as a part of the metabolic activity of the body. It consists of waste products of the body and contains enzymes that are important in the digestion of food. The bile excreted from the liver is sent to the duodenum via the biliary tree. The biliary tree consists of multiple small ducts which merge to form the bile duct. The biliary tree can be divided into into a part inside the liver which is called intrahepatic portion and the part outside the liver which is the extrahepatic portion.  Gall bladder is a structure attached to the biliary system which helps in storage and release of bile in response to a meal.

Gall bladder removal Surgery - Cholecystectomy

Gallbladder is a small, tear-drop shaped organ located under the liver (see Figure 1). Its main function is to store bile and release in response to a meal. Bile helps in digestion of fat in the food. When your gallbladder is removed the biliary system will takeover this function and there will be no harmful effects on digestion.

Cholecystectomy is the surgery that is performed to remove the gallbladder. The gallbladder can be removed in one of two ways—laparoscopically (keyhole) or through an open incision (surgical cut). Laparoscopic (keyhole) surgery is performed 95% of the time but there may be instances that open surgery with larger surgical cut has to be performed.

In laparoscopic surgery four small incisions less than 1 cm will be made in the abdomen and the gallbladder will be taken out through one of the incisions after the dissection. This is generally done as a day procedure and patient is discharged within 24 hours most of the time. Open surgery may need additional hospital stay for the management of pain.

Figure 2. Laparoscopic cholecystectomy incisions

Figure 3. Open cholecystectomy incision

One of the incisions will be in or near your navel (belly button). Your surgeon will insert an instrument called a laparoscope through this incision. The laparoscope is a thin tube that has a video camera at the tip. Carbon dioxide gas is blown into your abdomen (belly) so that it expands. This makes room for your surgeon to see your organs and tissues. Other instruments will be inserted through three other incisions to help to remove your gallbladder. Your gallbladder will then removed through an incision at your navel. The laparoscopic gallbladder removal surgery takes about 1 to 2 hours.

Open surgery

In about 5% of cases, the gallbladder needs to be removed through a larger incision on your abdomen. This surgery takes about 2 hours. This is done generally when the surgery is difficult, and it is no longer safe to do it laparoscopically.

 Laparoscopic cholecystectomy is the standard procedure in most patients. Symptomatic gallstones: either due to acute or chronic inflammation or biliary colic are the usual indications. Biliary colic usually presents with right sided recurrent pain. Chronic cholecystitis usually gives rise to symptoms to gastritis. Acute cholecystitis the pain is associated with fever.

Cholecystectomy sometimes can be complicated. Injury to the biliary system is one of the feared complications. It can vary from simple bile leak to completed cut off to the biliary tree. Bile duct injury must be manged in a specialised centre for a good outcome.

Bile duct injuries

 Bile duct injuries has become a serious concern in laparoscopic cholecystectomy Proper training and extreme care can reduce the risk of this unfortunate complication. According to literature the incidence is around 0.05%. the degree of injury can vary from simple bile leak to complete damage of the bile duct. North Colombo Centre for liver diseases (CNCLD) gets many referrals with bile duct injuries. We have the state-of-the-art facilities including interventional radiology, ERCP for comprehensive management of such bile duct injuries.   We are more inclined towards immediate repair of bile duct injuries compared to delayed approach in some canters.

Choledochal cyst

Choledochal cysts are abnormal dilatation in the biliary tree without a significant distal obstruction. They present with abdominal discomfort pain or fever and occasionally jaundice. These carry a risk of malignancy towards the latter part of life. Due to this surgical excision and reconstruction of the biliary drainage system is recommended in them. After removing the dilated part of the bile duct small bowel is used to create an anastomosis for the biliary drainage.

Tumours in the biliary tree

 Commonest type of cancer in the biliary tree are cholangiocarcinomas. They are very aggressive type of a cancer. Usual presentation is yellowish discoloration of eyes without pain. Surgical resection is the best treatment in them as it gives a chance of cure. All the other treatment are intended to relieve symptoms.

Liver is the largest internal organ which plays an important role in storing of vitamins and minerals, detoxification, temperature regulation, synthesizing plasma proteins and maintaining internal environment in an optimum level. It is placed in the right upper abdomen in close relationship to the intestines, right kidney below the right lung and the heart.

Liver Transplant

Optimum function of the liver is essential for life. Liver transplant is the treatment for advanced liver failure as there is no machine to replace the function of the liver as the dialysis machine in renal failure. Liver transplant involves removal of the existing liver and replacement with a part or a full liver obtained from a donor. Liver donation can happen from a living donor or a cadaveric donor. In the case of living donation part of the donor liver is transplanted. Full liver is transplanted when the donor is brin dead.

Donor and recipients blood group and the liver weight is considered for matching in liver transplantation. Liver transplant is a complex surgery and has significant risk involved. Sometimes the transplanted liver might not work in an optimum manner making it essential to transplant a new liver immediately.  The recipient needs to be on immunosuppression lifelong. Long term immune suppression can increase the risk of chronic medical conditions such as diabetes and renal failure.

If all these risks are managed well a liver transplant recipient can live a near normal life with fulfilment of many aspirations in life.

Hepatoma

Hepatoma is the commonest primary liver tumour. In Sri Lanka incidence of hepatoma is rising. Worldwide hepatitis B and C are the commonest causes. However in Sri Lanka fatty liver related liver disease is  the commonest cause. Most types of Hepatomas are slow growing tumours. Distant metastases are not common like other cancers. In Sri Lankans diffuse variant of hepatomas are common and this variety spreads faster than other types.

The best form of treatment is Surgery. Liver transplant gives best results but all tumours are not suitable for transplantation. Surgical resection gives chance for cure in suitable patients. Ablation either with radiofrequency or alcohol injection are other treatment options. Sometimes for smaller tumours ablation gives almost similar results to surgery. Larger majority of patients undergo trans arterial treatment. It is a form of treatment that slows disease progression. Sorafenib is a newer form of medical treatment that may be used when other options cannot be offered. When the hepatoma is not suitable for any of the above treatments patient can be managed  treating the symptoms only which is called palliative care.

Liver metastasis from other primary sites

Liver is a common site for metastasis from other cancers. The commonest primary site for liver metastasis is larger intestine. Apart from this any other primary from gastrointestinal system can spread to liver. Breast cancer is another common primary cancer that spreads to liver. Of all the secondary deposits colon metastasis gives good results after surgical resection. 50-60 % of the patients can be cured after successful resection. Selected patients with metastasis from other primary sites are currently considered for surgical resection with chance of giving them long term survival. This is further enhanced when the surgical treatment is combined with newly available chemotherapy agent before and after the surgery.

Benign diseases of liver

Benign diseases are common incidental findings. Many benign lesions are detected in ultrasound scans when performed to investigate for other causes. Commonest benign lesions are haemangiomas and simple cysts. These lesions like haemangiomas, simple cysts and focal nodular hyperplasia do not need active treatment unless they are symptomatic. They do not carry a malignant potential. Other lesions like hepatic adenomas are offered resection depending on the size of the lesion. Most of the lesions can be diagnosed from CT or a MRI scan. However, some of the lesions do not have typical radiological features to diagnose them. This becomes an issue, and some may require liver biopsy and even resection for the purpose of diagnosis.

Fatty liver

Fatty liver is the commonest liver parenchymal disease. In Sri Lanka it has become a rising problem.

South Asians are predisposed to fatty liver disease due to inherent gene profile. This together with high carbohydrate diet and increasingly sedentary lifestyle makes fatty liver disease an epidemic especially in the urban and suburban population in Sri Lanka. About 10% of the people with fatty liver disease progress to cirrhosis over time. In Sri Lanka fatty liver related cirrhosis has become the predominant aetiology in patients presenting  to hospitals with end stage liver disease.