Gallstones and gallbladder surgery, explained

The short answer

Gallstones are hardened deposits, usually cholesterol, that form in the gallbladder, a small pouch under the liver that stores bile. Plenty of people have gallstones and never find out; the stones just sit there like a rock collection nobody asked for. Trouble starts when one blocks the flow of bile.

How they announce themselves

Biliary colic is a steady, often severe pain in the upper right or middle of the abdomen, sometimes spreading to the right shoulder or back, frequently after a fatty meal (the gallbladder has opinions about cheeseburgers) and lasting from about 30 minutes to several hours. Fever, pain that won't quit, yellowing of the skin or eyes (jaundice), dark urine or pale stools suggest a complication and need prompt medical attention.

When stones start causing real trouble

Acute cholecystitis is inflammation of the gallbladder from a stuck stone. A stone that escapes into the common bile duct (choledocholithiasis) can cause jaundice, pancreatitis, or cholangitis, an infection of the bile ducts classically signaled by fever, jaundice and right upper abdominal pain (Charcot's triad). Mirizzi syndrome, a stone in the gallbladder neck pressing on the main bile duct, is rarer. In the show's telling, the Brotherhood named a home for the laparoscopically insane after it; in real life it's just a very inconvenient syndrome.

The eviction process

Gallstones that cause symptoms are usually treated by removing the gallbladder, most often laparoscopically (laparoscopic cholecystectomy). You can live perfectly well without it; it's more of a storage closet than a load-bearing wall. Stones in the bile duct may be removed endoscopically before or after surgery (ERCP) or during the operation by exploring the duct, which is the play-by-play action in Fourth and Gall. Surgeons may take an X-ray of the ducts during the operation (an intraoperative cholangiogram) to check for stragglers.