Last updated: 11/24/2009

Surgery to remove the entire gallbladder with all its stones is usually the best treatment, provided the patient is able to tolerate the procedure. A relatively new technique of removing the gallbladder using a laparoscope has resulted in quicker recovery...

and much smaller surgical incisions than the 6-in (15-cm) gash under the right ribs that had previously been the standard procedure; however, not everyone is a candidate for this approach. If the procedure is not expected to have complications, laparoscopic cholecystectomy is performed. Laparoscopic surgery requires a space in the surgical area for visualization and instrument manipulation. The laparoscope with attached video camera is inserted. Several other instruments are inserted through the abdomen (into the surgical field) to assist the surgeon to maneuver around the nearby organs during surgery. The surgeon must take precautions not to accidentally harm anatomical structures in the liver. Once the cystic artery has been divided and the gallbladder dissected from the liver, the gallbladder can be removed.

If the gallbladder is extremely diseased (inflamed, infected, or has large gallstones), the abdominal approach (open cholecystectomy) is recommended. This surgery is usually performed with an incision in the upper midline of the abdomen or on the right side of the abdomen below the rib (right subcostal incision).

If a stone is lodged in the bile ducts, additional surgery must be done to remove it. After surgery, the surgeon will ordinarily insert a drain to collect bile until the system is healed. The drain can also be used to inject contrast material and take x rays during or after surgery.

A procedure called endoscopic retrograde cholangiopancreatoscopy (ERCP) allows the removal of some bile duct stones through the mouth, throat, esophagus, stomach, duodenum, and biliary system without the need for surgical incisions. ERCP can also be used to inject contrast agents into the biliary system, providing finely detailed pictures.

Patients with symptomatic cholelithiasis can be treated with certain medications called oral bile acid litholysis or oral dissolution therapy. This technique is especially effective for dissolving small cholesterol-composed gallstones. Current research indicates that the success rate for oral dissolution treatment is 70–80% with floating stones (those predominantly composed of cholesterol). Approximately 10–20% of patients who receive medication-induced litholysis can have a recurrence within the first two or three years after treatment completion.

Extracorporeal shock wave lithotripsy is a treatment in which shock waves are generated in water by lithotripters (devices that produce the waves). There are several types of lithotripters available for gallbladder removal. One specific lithotripter involves the use of piezoelectric crystals, which allow the shock waves to be accurately focused on a small area to disrupt a stone. This procedure does not generally require analgesia (or anesthesia). Damage to the gallbladder and associated structures (such as the cystic duct) must be present for stone removal after the shock waves break up the stone. Typically, repeated shock wave treatments are necessary to completely remove gallstones. The success rate of the fragmentation of the gallstone and urinary clearance is inversely proportional to stone size and number: patients with a small solitary stone have the best outcome, with high rates of stone clearance (95% are cleared within 12–18 months), while patients with multiple stones are at risk for poor clearance rates. Complications of shock wave lithotripsy include inflammation of the pancreas (pancreatitis) and acute cholecystitis.

A method called contact dissolution of gallstone removal involves direct entry (via a percutaneous transhepatic catheter) of a chemical solvent (such as methyl tertiary-butyl ether, MTBE). MTBE is rapidly removed unchanged from the body via the respiratory system (exhaled air). Side effects in persons receiving contact dissolution therapy include foul-smelling breath, dyspnea (difficulty breathing), vomiting, and drowsiness. Treatment with MTBE can be successful in treating cholesterol gallstones regardless of the number and size of stones. Studies indicate that the success rate for dissolution is well over 95% in persons who receive direct chemical infusions that can last five to 12 hours.