From the first Gall Bladder removal operation nearly 135 years ago, nothing changed till 35 years back, when Laparoscopic Cholecystectomy (removal of Gall Bladder with camera and fine instruments) was introduced; which remained a standard operation till recent times. Now MSL LC (Mini Scar Less Laparoscopic Cholecystectomy) “Amir-Kennedy Cholecystectomy Technique” is presented as a potential new Gold Standard.

MSL LC (Mini Scar Less Laparoscopic Cholecystectomy), “Amir-Kennedy Cholecystectomy Technique” follows all the cardinal principals of good visualisation and triangulation of instruments with optimal azimuth angles for safe dissection and gall bladder retrieval. There are no short cuts or compromises in safety. The least possible cuts on the skin and muscle separation means that the accumulative length of the incisions (cuts) is so small that it offers the following over and above any other technique currently available for Gall bladder surgery:

• Less post-operative pain
• Minimal or no damage to the muscles
• Quicker recovery
• Early return to work
• No use of permanent foreign material left in the body, like metal clips
• No restriction for exercise or lifting weight after surgery
• Last but not the least, excellent cosmesis with scars so small (Mini Scar Less), that one may find it difficult to identify these, just a few weeks after the surgery – beach and catwalk worthy! Vanity matters!!
  

  Author believes that this is the long-awaited progress in gall bladder surgery, that he has achieved in the form of MSL LC (Mini Scar Less Laparoscopic Cholecystectomy), “Amir-Kennedy Cholecystectomy Technique”.

  Is this the Holy Grail in Gall Bladder surgery? May be for the next 5 years, until its improved further. The journey and quest continues.

  The list of variations for various approaches for Gall bladder surgery are listed in terms of their preference in the opinion of author. The option on the top being most favourable and the rest in a descending order.

  Safety, efficacy, muscle damage, permanent foreign body material used for surgery, post-operative pain, recovery, return to work, return to driving, return to exercise, cosmesis and cost effectiveness of surgery are the parameters considered.

  1. MSL LC (Minimal Scar Less Laparoscopic Cholecystectomy) – “Amir-Kennedy Cholecystectomy Technique”
  2. Needlescopic Cholecystectomy
  3. Standard Cholecystectomy
  4. Robotic Assisted Laparoscopic Cholecystectomy
  5. Single port Cholecystectomy
  6. e-NOTES (embryonic Natural Orifice Transluminal Endoscopic Surgery) Endoscopic & Laparoscopic assisted Cholecystectomy
  7. NOTES (Natural Orifice Transluminal Endoscopic Surgery) Endoscopic & Laparoscopic assisted Cholecystectomy
  8. Open Cholecystectomy

  Comparison of Accumulative Incision Lengths

  Open Cholecystectomy / SILS / e-NOTES / Robotic Assisted Laparoscopic Cholecystectomy / Laparoscopic Cholecystectomy / Needlescopic Cholecystectomy / Mini Scar Less (MSL) Laparoscopic Cholecystectomy, “Amir-Kennedy Technique”
  

  
  Comparison Table

  **Mini Scar Less (MSL) Laparoscopic Cholecystectomy “Amir-Kennedy Cholecystectomy Technique”	1.4cm	14mm	0.55 inch (Just over half an inch)
  Needlescopic Cholecystectomy	1.6cm	16mm	0.63 inch
  Laparoscopic Cholecystectomy	3cm	30mm	1.2 inches
  Robotic Assisted Laparoscopic Cholecystectomy	3cm	30mm	1.2 inches
  SILS (Single Incision Laparoscopic Surgery)	4.5cm	45mm	1.8 inches
  e-NOTES (embryonic Natural Orifice Transluminal Endoscopic Surgery)	4.5cm	45mm	1.8 inches
  ***Open Cholecystectomy	20cm	200mm	8 inches

  *Mini Scar Less – No episode of skin breach is “Scarless”. Even a needle prick leaves a Scar on the skin. “Mini Scar Less” (MSL) means that the scar is so “Minimal” after surgery that it may appear “Scar Less” to the observers; mostly lay persons. This may not be the case in patients who have a tendency to get prominent/ Hypertrophic/ Keloid scars. This may also not be achievable if there was wound infection after the surgery. Caucasians are more likely to get finer and faint scars compared to Asians and Africans.

  **Standard accumulative incision length in all comers

  ***Average accumulative incision length; may be longer in obese patients

May 1991; Ennis General Hospital, County Clare, Ireland; Professor Amir Nisar observed his first Laparoscopic Gall Bladder surgery.

May 2020; Three decades on Professor Amir Nisar is now Performing Laparoscopic MSL (MiniScarLess) Cholecystectomy on his patients.

Laproscopic MiniScarLess Clipless Cholycystectomy is far superior to Conventional Laproscopic Cholycystectomy surgery, Robotic Cholycystectomy surgery, Needlespcopic Cholycystectomy surgery, Single port Cholycystectomy surgery and eNOTES / NOTES / No-Scar Cholycystectomy.

Safe Laparascopic Cholecystectomy

The journey would not have been the same without learning the safe “Kennedy’s Technique” from Professor Robin Kennedy in Yeovil District Hospital, Somerset, England United Kingdom, in the early 90s.

This great surgeon, thinker and perfectionist’s teaching to Professor Nisar, about this very safe technique is a gift, for which gratitude and prayers are expressed for him, every time this surgery is performed safely by Professor Robin Kennedy’s prodigy.

This is not only about the safe surgery on gall bladder but also the common bile duct and various management strategies, shown, taught, and trained by Professor Kennedy, which have illuminated Professor Amir Nisar’s paths of management of simple and complex biliary diseases.

Laparoscopic Cholecystectomy, though a common operation, should never be taken lightly because of the risk of potentially life-threatening complications if something goes wrong at the surgery.

Experience in Teaching and Training Laparoscopic Cholecystectomy to other Surgeons

Professor Nisar has taught, lectured, and performed live surgery on the Royal College of Surgeons of England courses of safe Laparoscopic Cholecystectomy for 23 years. He has learned many strategies for performing safe, gall bladder surgery. His extensive experience with open and laparoscopic gall bladder and common bile duct surgeries makes him an experienced and safe gall bladder surgeon.

Laparoscopic MSL (MiniScarLess) Cholecystectomy

In this latest innovation, Professor Nisar uses a technique that leaves minimal (almost no scars) clinically unnoticeable scars in the abdomen in most cases. In Gall Bladder surgery, scars are in the upper abdomen and can be prominent. With MSL approach, the scars are not noticeable to even surgeon’s trained eyes after the surgery. In our experience, both surgeon and his patients have found these scars cosmetically acceptable and pleasing.

Painless Cholecystectomy

Professor Amir uses eight important parameters in his operative technique to keep the pain after surgery to bare minimum and even completely painless in most cases; hence the name painless cholecystectomy.

At what age one develops gallstones

Common age group is 35- 55 years. However, one can have this as a newborn or even in 90s.

Symptoms of Gallstones:

Pain from gallstones generally occurs in the right upper abdomen and it radiates to the back between the shoulder blades. Sometimes the pain from gallstones can just be in upper abdomen without radiating to the back.

The pain is severe and females often describe this as worse than labour pain.

What causes pain:

Pain from gallstones can be triggered by eating a fatty meal or drink. Fatty meal causes strong contraction of gall bladder on the stones. It’s like walking on a pebble beach without slippers.  At times the stone may become impacted in the outlet (neck) of gall bladder.

(Animation of a gallbladder contracting on stones)

Do all gallstones cause symptoms:

No, most gallstones remain asymptomatic and one may not be aware of their presence.

What are Gallstones:

Gallstones, medically known as cholelithiasis, are small or large stones present in the gall bladder. Gall stones can be very small or large, single or multiple. Mostly the gallstones have a smooth surface. The colour can range from pale whitish (cholesterol stones) to dark brown (Pigment stones)

(Gall Bladder stones photo)

What is Bile:

Bile is a liquid produced in the liver from 500 mls to one liter in a day. It exits the liver through the tubes (right and left hepatic ducts), most of it enters the small intestine directly, some enters the gall bladder where it is concentrated. Whenever signals get to gall bladder after eating food, gall bladder contracts and the bile from the gall bladder flows into the duodenum (small bowel).

(Animation of Bile flowing from liver into gut and some going into the gall bladder)

Does bile digest fat?:

No, it just helps top break it down into smaller particles like “dish washing liquids”, then it becomes easier for water to wash it away. The digestion of fat in the gut is carried out by enzymes from the gland pancreas.

Gall Bladder Anatomy:

Gall bladder is a small pear-shaped organ attached to the lower surface of liver. It capacity is only 50-70 mls. It is attached by a ting tube (Cystic duct) to the main tube (common bile duct) connecting the liver to the duodenum (small bowel).

(Photo of gall bladder, liver and common bile duct, like below)

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Function (purpose) of Gall Bladder:

Gall bladder stones and concentrates a small amount to bile. The bile is continuously produced in the liver and it keeps trickling into the intestine. Between 500 mls to 100 mls of bile is produced by liver in 24 hours. The concentrated bile from the gall bladder is emptied into the duodenum (first 25 cm of small bowel) in response to the signals generated by gut after eating food; especially fatty food.

(Animation with food coming on stomach and the duodenum and gallbladder contracting and pouring bile onto the food in duodenum)

What causes gallstones formation:

There can me many reasons. Infection of gall bladder, infection of bile, poor contraction or obstruction of gall bladder and change in the constituents of the liquid bile are some of the common causes.

How the stones are formed in Gall Bladder:

Initially the infection, stasis or altered chemistry of bile causes some small deposits of bile or cholesterol pigments in the gall bladder, described as sand particles. Over the course of time more deposition on the top of these changes the small particles into small stones. Some can become very large in size over period of time. Some large stones can be of the size of and shape of an egg.

(Animation; some sedimentation and then the stones and getting bigger, multiple small ones; one big in the Hartman’s)

INCIDENCE/EPIDEMIOLOGY

Gallstones are a common medical condition all over the world. In United Kingdom alone about 80,000 to 100,000 gall bladder surgeries are performed yearly for gallstones. The actual number of people harboring stones in the general population is much higher.

Cholesterol and mixed stones are common in Europe and United States, whereas stone is more common in Asians and Africans. 

RISK FACTORS

Immutable risk factors and associations:

Its more common in females over the age of 40.

Common in Caucasians.

Genetics and family

Modifiable Risk Factors: 

Obesity

Metabolic syndromes

Pregnancy

High-fat diet

Diabetes 

Cholesterol rich diet

Poor fiber diet

Certain blood disorders like sickle cell anemia or leukemia

Medications containing estrogen, such as oral contraceptives or HRT drugs

Rapid weight loss

Diseases like Liver cirrhosis and Crohn disease

Gallbladder stasis (due to spinal injury or drugs, like somatostatin), 

Sedentary life

Complications of Gallstones:

(Similar phot with less captions will help)

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Gallstones presence can lead to numerous symptoms and complications when they are within the gallbladder. When they escape the gall bladder and enter the common bile duct then the complications are different and can be life threatening as well.

1. Symptoms and complications of Gallstones when inside the gallbladder:

These can cause vague symptoms as nausea, change in taste or mild fever.

Flatulent Dyspepsia

Commonly observed in obese, fatty women complaining of heartburn, abdominal discomfort, belching and fatty food intolerance.

Pain / Gallstone colic

Medically termed as biliary colic. Its Severe, colicky pain felt mostly in the upper abdomen. Pain can shoot to the back or between the shoulder blades often associated with vomiting, restlessness, and sweating. Strong pain killers, clinical assessment and sometimes admission in the hospital is required.

Dyskinesia of gallbladder (poorly contracting gallbladder):

Patients can have gall bladder pain even without gallstones. Specialist surgical opinion will help to solve this mystery; which can be debilitating for patients and can take a long time to diagnose.

Infection / Inflammation /

Acute Cholecystitis in medical terms occurs when a gallstone gets lodged in the neck of the gallbladder (Hartmann’s pouch), causing bile stasis leading to gallbladder inflammation. Cholecystitis is an acute condition and can cause severe pain, vomiting, nausea, and fever. Strong pain killers, clinical assessment, blood tests, antibiotics and admission in the hospital is required.

Acalculous Cholecystitis (Infection of Gall bladder without any stones):

This condition is noted in very sick patients and requires specialist input of an experienced surgeon. What may look like an inflamed gallbladder on scan be a gangrenous gall bladder.

Mucocele

It occurs when a stone is completely blocking the gall bladder outlet blocking the cystic duct or the Hartman’s pouch, but there is no infection. This leads to a distension of the gall bladder and pain. One notices “white bile” in the gall bladder at surgery. Surgery is required in this situation.

Empyema

It’s a completely blocked gall bladder like a mucocele with superadded infection as well. Its like an abscess, where simple antibiotics will not work. Emergency decompression or removal of gall bladder is required after appropriate assessment by a surgeon in a hospital.

Perforation of gall bladder

Perforation in abdominal cavity is a rare condition. Impacted stone, diabetes, or virus can precipitate an empyema causing gangrene of gallbladder and perforation.

High-grade fever, chills, and pain in the abdomen are common symptoms. Emergency treatment in a hospital with immediate surgery can be lifesaving in this situation.

Fistula formation:

In case on chronic cholecystitis a stone in gall bladder can erode into duodenum or large bowel, leading to Cholecystoduodenal fistula or a Cholecystocolonic fistula. This can happen silently and may come to attention while having tests done for any reason. Generally these can be left alone and observed it not giving any symptoms to the patient.

Mirizzi’s Syndrome:

A stone impacted in the Hartman’s pouch or the cystic duct if not causing a full blockage of the gallbladder outlet can keep getting bigger and can fistulate (erode) into the common bile duct.This can lead to pain, infection, jaundice or even sepsis and requires input from a specialist surgeon urgently. This should ideally be dealt with Laparoscopically and may also require an ERCP (Endoscopic Retrograde Cholangio Pancreaticography).

Small bowel Obstruction / Gallstone Ileus:
A large gallstone escaping the gall bladder due to Cholecystoduodenal fistula can get impacted in small bowel and cause a complete blockage requiring emergency surgery to relive the obstruction and remove the gallstone from small bowel.

Gallbladder Cancer:

The likelihood of cancer is not common, but chronic cholecystitis or cholelithiasis can pose an increased risk of gallbladder cancer. Gallbladder polyps and Porcelain gall bladder are also considered as risk factors for gallbladder cancer.

Gall Bladder cancer carries a poor prognosis.

1. 
   Complications of Gallstones in the Common Bile Duct (CBD)

Though the complications are fewer than of the stones within the gallbladder but these are much more serious and potentially life threatening.

Obstructive Jaundice:

Obstruction to the bile outflow causes obstructive jaundice. Jaundice with yellow skin, yellow eyes, dark colored urine, clay-colored stools, and itching are the usual symptoms.

One need to see a surgeon to get the advice and treatment.

Generally, one requires ERCP and Laparoscopic Cholecystectomy.

Cholangitis:

It is the bacterial infection of common bile duct causing abdominal tenderness, chills, fever, and rigors. This is a very scary situation for the patient and requires urgent attention, admission in the hospital and antibiotic treatment with appropriate decompression of the system.

Gallstones Pancreatitis 

There is no greater or worse complication of gallstones than acute pancreatitis or inflammation of pancreas due to a gallstone blocking the common opening of the common bile duct with the pancreatic duct.

Patient requires emergency admission in the hospital and appropriate care, investigations and treatment.

In mild pancreatitis one may get better in a day or two. In moderate cases one may lose the function of pancreas and become diabetic for life long. In some cases of severe pancreatitis, this may me life threatening.

Clinicians suggesting or patients considering wait and watch on their gallstones must consider this small but potentially life-threatening complications of gallstones in their mind.

GALLBLADDER ASSESSMENT 

Gallstones infection (cholecystitis) or obstruction (empyema) presents with colicky pain in the upper abdomen with severe nausea, vomiting, and low-grade fevers initially.

Clinical Assessment

• Positive Murphy’s Sign (tenderness below right ribs)
• Boas’s Sign (Hypoaesthesia between shoulder blades)
• Upper abdominal guarding and rigidity
• Abdominal Tenderness

GALLBLADDER INVESTIGATIONS

Blood Tests:

Full blood count (white cell count is raised)

CRP is elevated

Liver Function tests

Amylase

Abdominal Ultrasound

It is a simple, painless, and noninvasive test, the same as pregnancy scans. Gel is applied to the abdomen, and a probe is used to bounce high-frequency sound waves off structures in the abdomen. 

Ultrasound gives a clear view of the abdominal organs and is an excellent test for checking the gallbladder wall thickening and the gallstone diagnosis.

CT scan

It is done when ultrasound findings are not clear. It provides good views of the pancreas and helps with the diagnosis of pancreatitis. Its not the best test for stones in the gall bladder and less sensitive than an ultrasound.

Magnetic resonance cholangiopancreatography (MRCP)

An MRI scan provides valuable information in gallbladder diagnosis. Using magnetic waves, it provides high-resolution images of the biliary tree, ductal system, pancreas, and gallbladder. MRCP is required when stones are suspected in the common bile duct.

Endoscopic retrograde cholangiopancreatography (ERCP) 

ERCP is an endoscopic procedure in which a flexible tube is inserted through the mouth, stomach, and into the small intestine. Then the doctor injects dye and with fluoroscopy can see the bile duct system. When stones are confirmed, then one can remove these by cutting the sphincter of Oddi (tip of common bile duct opening) and retrieving all the stones. Sometimes a stent (fine plastic tube) is left behind to maintain the flow of bile. Laparoscopic Cholecystectomy can be done in the same setting to avoid another anaesthetic.

Endoscopic ultrasound

A small, flexible tube with an ultrasound probe on end is inserted through the mouth to the intestines. Choledocholithiasis and gallstone pancreatitis can be diagnosed through endoscopic ultrasound; though rarely.

HIDA scan (cholescintigraphy)

Its used to check the function of the gall bladder in case of. HIDA Scan is a nuclear test in which a radioactive dye is injected intravenously and is secreted into the bile. The natural path of bile is followed, and if the scan shows the failure of bile ejection from the gallbladder.

Abdominal X-ray

Not usually used for gall stones. Abdominal X-rays can show gallstones, but does not give a definitive diagnosis. Sometimes it can confirm gallstone Ileus; still a CT scan will be required to confirm the diagnosis.

SELF-TREATMENT

Gallstone pain is acute and sharp in nature. Self-treatment options are limited. Some are:

Painkillers
Over the counter, painkillers can provide temporary relief in gallstone pain. However, in the case of acute cholecystitis, OTC painkillers will not be very effective and one will need to see a doctor.

Heat Therapy
Applying heat relaxes muscles, relieves pain, and is soothing. A heated compress releases tension due to bile build-up and provides relief. This is should only be used temporarily while seeking medical advice.

Peppermint Tea

Menthol promotes pain relief. Peppermint tea does not provide immediate relief, but regular drinking can reduce gallbladder flare-ups and pain in only some cases.

SEEKING MEDICAL ADVICE

Gallstone pain can wax and wane. It can remain asymptomatic for long periods of time but can always flare up unexpectedly. Seeking medical opinion on time is beneficial in terms of health, time, resources and avoiding complications.

If you are experiencing any of these symptoms, then see a doctor immediately.

• Nausea and vomiting
• Prolonged abdominal pain lasting more than 4 hours
• Fever 
• Chills and rigors
• Yellowish tinge in the white of the eyes or skin
• Clay-colored stools
• Fatty food intolerance
• Dark-colored urine

MANAGEMENT

The following options are viable to avoid gallstones in the first instance.

• Conservative Lifestyle sedentary life is the root cause of many health issues. Obesity and high cholesterol are some of the factors of gallstones. Regular exercise and a balanced diet maintain weight and cholesterol levels.

Gallstone risk can be minimized by keeping a few points in mind.

• Avoid skipping meals. Try to maintain a routine of your meals for each day. Irregular meals and fasting can increase gallstone risk.
• Rapid weight loss can cause gallstone. Try and lose weight slowly. 
• Eat high-fiber, low cholesterol foods. Vegetables, grains, and fruits make a balanced diet.  
• Try to maintain a healthy weight. 

Temporary measures:

Exercise and high-fiber, low-fat diet prevents gallstones may reduce the pain flare ups in gallstone patients. For gallstone patients, this is a temporary treatment option while waiting for a definitive medical intervention, which is necessary to avoid any complication.

1. Medical Treatment

Medical Treatment was suitable obly for some small stones. Once popular in 1970’s it is not used anymore. Medication was used to dissolve stones. Medicine had to be used for may months or a few years. Soon after stopping the medication patients would get stone recurrence.

• Shock Wave Lithotripsy (SWL)

While useful in Kidney stone SWL or Laser treatments are not an option for stones in

the gallbladder.

• Olive oil remedies, mixtures and potions

These are not recommended and can be very dangerous if strong contraction of the gallbladder will expel the stone on the common bile duct, thus causing with potential complications alike acute pancreatitis, which could be life threatening.

• Surgical Treatment
• surgical removal is the gold standard treatment option for gallstones. This can be offered safely in experienced hands and prevents complications and the complete removal of gallstones.
• Operation in the form of Laparoscopic Cholecystectomy is the most commonly performed surgical procedure that involves four small cuts in the abdomen. A laparoscope (a camera with light source) is introduced in the abdomen. . The surgeon Introduces 3 fine instruments, not much thicker than chopsticks to separate the gallbladder from the adjoining organs and remove it carefully through one of the small incisions.

Laparoscopic Cholecystectomy is a minimally invasive procedure which is done as one night stay in the hospital. This can be performed in suitable patients as day case as well.

RISKS OF WAITING

1. Acute gallbladder inflammation (cholecystitis)
2. Bile duct stone (choledocholithiasis)
3. Acute bacterial infection (cholangitis)
4. Pancreatic infection (pancreatitis)
5. Perforation of gall bladder
6. Cholangitis (severe infection)

SURGICAL RISKS FACTORS

Laparoscopic Cholecystectomy is well established for more than 30 years. It is performed under full general anaesthetic. It takes a good surgeon and team about 15 – 25 minutes to perform a standard Laparoscopic Cholecystectomy.

Prior to this the operation of removal of gall bladder was done with long open cut just below the right ribcage. Hospital stay used to be 5-7 days after surgery and recovery would take weeks and months.

Risks of Cholecystectomy open or Laparoscopic are:

• Bleeding
• Damage to the neighboring organs such as liver or intestine
• Damage to common bile duct (very serious complication)
• Postoperative infection
• Postoperative pain

No surgery should be taken lightly. The above-mentioned risks all combined are quoted as less than 1%. The complications mentioned can be severe, may require a reoperation. The complication of damage to common bile duct is very serious indeed and much more common than generally quoted. In United Kingdom its incidence is 1:250, which unfortunately is unacceptably too high.

In experience hands of specialist upper Gastro Intestinal (Upper GI) surgeons the incidence of damage to common bile duct will lower than 1:1000.

In case of this rare occurrence in upper GI surgeon’s hands they ae able to reocgnise it and deal with this skillfully and in a timely fashion.

GOLD STANDARD TREATMENT FOR GALLSTONES

Currently, laparoscopic cholecystectomy is the gold standard for gallstone treatment. It has fewer complications, rapid recovery, less post-op pain, early mobilisation, return to driving, and early return to work and exercise.

It also provides quick and effective treatment for gallstones and prevents recurrence and complications.