Guided Series

An estimated 20 million Americans have gallstones. Before we talk about how gallbladder surgery is done, here is a tour of the gallbladder and the biliary tree, the foundation for everything else in this series.

Your liver makes bile around the clock, but your gallbladder only releases it when you eat. Here is the hormone that triggers the squeeze — CCK — and why that pathway matters clinically.

Most gallstones are cholesterol stones that form when bile tips out of balance. Here is how a crystal becomes sludge and then a stone, who is at higher risk, and why most people never know they have them.

Whether a gallstone causes trouble comes down to one question: is it blocking the gallbladder's outlet? Here is why some stones trigger biliary colic and need surgery, while most silent stones never cause a problem and are safely left alone.

What happens when a gallstone blocks the gallbladder's outlet and stays there. How the Tokyo Guidelines 2018 define, diagnose, and grade acute cholecystitis, why the operation belongs on the same admission, and what we do when the patient is too sick for one.

What happens when a gallstone leaves the gallbladder and lodges in the common bile duct. How the blockage causes jaundice, how the Tokyo Guidelines diagnose and grade the infection that can follow, why two guidelines run two different clocks, and when the gallbladder should come out.

A gallstone that stops where the bile duct and the pancreatic duct meet blocks both. How the obstruction sets off autodigestion, how the Revised Atlanta Classification grades severity, what the fluid and feeding trials changed, who actually needs an urgent ERCP, and why the gallbladder comes out before discharge.

Four tests image the gallbladder: ultrasound, HIDA, MRCP, and CT. Each answers a different question. Three patient presentations show which test comes first, what each one shows, and why a second scan does not mean the first one failed.

Three gallbladder problems that are not stones: a gallbladder that will not empty, growths on the lining, and a wall that has calcified. How each one is found, what the guidelines say about size and risk, and how I decide whether it needs to come out.

A walk through robotic gallbladder removal in the order it happens: where the four incisions go, how I get in at Palmer's Point, how the duct and the artery are isolated and divided, and why the gallbladder comes out in a bag.

Last week I walked through a gallbladder operation step by step. This week: the six things that keep it safe, including a guideline published this year that changes the argument for taking an X-ray of the ducts.

Before gallbladder surgery, the question patients ask most is what they will be able to eat afterward. The answer depends on how the body recycles bile acid. Diet, diarrhea, why it usually stops, and what I do when it does not.

Three situations that do not follow the usual gallbladder pattern: an inflamed gallbladder with no stones, pain that continues after the gallbladder is out, and gallbladder surgery through a single incision.

More than 750,000 cholecystectomies are done in the US each year, yet surgeons do not agree on whether to use the robot. Part 1 of a three-part series weighs the elective evidence, cost included.

Part 2 turns to the emergency gallbladder: inflamed, swollen, and distorted. The robotic vs. laparoscopic evidence in acute cholecystectomy is entirely observational and genuinely split, and here is how to read it.

Part 3 of the bonus series. The case for adopting robotic cholecystectomy, the strongest evidence against it, and why the field has not decided.