Why Gallstones Need Surgery — And When They Don’t

By Prof. Dr. Zahid Mahmood — General, Laparoscopic & Laser Surgeon, Lahore

One of the most common questions I hear from patients newly diagnosed with gallstones is a simple, fair one: do these actually need to come out? It’s a reasonable question, because not every gallstone requires surgery — but once gallstones start causing trouble, the reasoning for removing the gallbladder becomes very clear, and understanding that reasoning helps patients make sense of what can otherwise feel like a big decision. This article explains exactly why symptomatic gallstones are treated surgically, what can go wrong if they’re left alone, and the specific situations where surgery is recommended even without any symptoms at all.

Why gallstones form in the first place

Most gallstones in this part of the world form when bile becomes overloaded with cholesterol, which then crystallises out of solution inside the gallbladder — a process influenced by genetics, diet, obesity, and how efficiently the gallbladder empties itself. A smaller proportion are pigment stones, related to factors like liver disease or conditions that break down red blood cells more than normal. Regardless of the type, once the gallbladder’s internal environment favours stone formation, it tends to keep doing so — which is an important point I’ll come back to.

Silent gallstones: usually genuinely fine to leave alone

A great many gallstones are found entirely by accident, on a scan done for some other reason, in a patient who has never had a symptom. For these patients, the honest, evidence-based advice is reassuring: silent gallstones do not need surgery. Long-term studies following patients with these incidental, symptomless stones have shown that only around 18% go on to develop biliary pain over the next 20 years, with the yearly risk actually falling over time — highest in the first five years, and lower after that. In other words, the great majority of people with silent gallstones will never have a problem from them, and operating on every patient with an incidental finding on a scan would mean operating on many people who would never have needed it.

What changes once symptoms begin

The picture shifts once gallstones start causing actual symptoms, and this is really the heart of the answer to “why surgery.” The classic symptom is a specific kind of pain — usually felt in the upper right or central upper abdomen, sometimes spreading to the back, that is dull, continuous, and often severe, typically lasting anywhere from several minutes to a few hours. It frequently strikes at night, sometimes waking the patient, and is often triggered by a fatty meal. In most of these episodes, the stone that triggered the pain slips back into the body of the gallbladder and the attack settles on its own — which is exactly why patients often describe a pattern of recurring episodes over weeks or months, interspersed with periods of feeling completely fine, rather than one single continuous problem.

This pattern matters enormously for decision-making. Once a patient has had one genuine attack of gallstone pain, the same stones are still there afterward, and further episodes are the norm rather than the exception. Each attack carries with it a real, if variable, risk of progressing into one of the more serious complications described below, rather than simply repeating as a mild, self-limiting pain indefinitely.

Why removing the gallbladder — not just the stones

Patients sometimes ask why we don’t just remove the stones and leave the gallbladder in place. The honest answer is that this doesn’t solve the underlying problem. The conditions that caused the original stones to form — the composition of the bile, how the gallbladder empties, the local environment inside it — remain exactly the same afterward, and new stones reliably form again over time. Removing the gallbladder itself, rather than just its contents, is what actually eliminates the problem at its source, and is why cholecystectomy (not stone extraction) has always been the definitive treatment for symptomatic gallstone disease.

Why some people form stones and others don’t

Patients often ask what made them form gallstones in the first place, since it can feel random. The truth is it usually isn’t — a combination of factors tips the balance: being female, increasing age, a family tendency, obesity and a high-calorie diet, rapid weight loss (including after bariatric surgery), certain medications including some hormonal contraceptives, and conditions or surgery affecting the lower small intestine, which can all make bile more likely to form crystals rather than staying in solution. None of this means gallstones are anyone’s “fault” — many patients with none of these risk factors still form them, and many with several never do — but understanding the general pattern helps explain why gallstones are so common rather than a rare, unlucky event.

What can go wrong if symptomatic gallstones are left untreated

This is where the case for surgery becomes most concrete. Once gallstones are symptomatic, a range of genuine complications can follow, and I discuss these honestly with every patient rather than simply saying “it could get worse”:

Acute cholecystitis — a stone blocks the outlet of the gallbladder, and the trapped bile leads to inflammation and often infection of the gallbladder wall itself. This typically causes persistent pain, fever, and marked tenderness, and usually needs hospital admission.
Empyema of the gallbladder — if acute cholecystitis isn’t resolved, the gallbladder can fill with frank pus, a more severe and dangerous form of infection.
Perforation — in advanced, untreated inflammation, the gallbladder wall can become so damaged that it perforates, spilling infection into the abdominal cavity — a genuine surgical emergency.
A stone migrating into the bile duct — causing jaundice (yellowing of the skin and eyes), or, if bacteria take hold in an obstructed duct, a severe infection called acute cholangitis, which can become life-threatening very quickly.
Acute pancreatitis — a stone passing through the shared drainage point at the bottom of the bile duct can trigger sudden, severe inflammation of the pancreas, one of the two major causes of this serious condition.
Gallstone ileus — rare, but striking: a large stone can erode directly through the gallbladder wall into the bowel and cause a bowel obstruction.
Chronic cholecystitis — repeated, lower-grade inflammation over months or years, leading to a scarred, poorly functioning gallbladder and often persistent digestive symptoms.

None of this means every patient with gallstone pain will develop one of these complications — most don’t, at least not immediately — but the risk is real and cumulative with each further episode, which is exactly why, once gallstones become symptomatic, I recommend addressing them properly with surgery rather than simply managing each attack as it comes and hoping the next one settles down just as easily.

When surgery is recommended even without symptoms

There are specific situations where I recommend removing the gallbladder even in a patient who has never had a symptomatic attack, because the stones themselves — or the gallbladder — carry a higher-than-usual risk in these particular circumstances:

Large gallstones, generally over 3 cm, which carry an increased long-term risk of gallbladder cancer
A stone that has already moved into the bile duct, even if the gallbladder itself hasn’t caused pain
Certain blood conditions that cause ongoing red blood cell breakdown, such as hereditary spherocytosis or sickle cell disease, which predispose to pigment stones and complications
Gallbladder polyps larger than 1 cm found alongside gallstones, where cancer risk needs to be taken seriously
A calcified, “porcelain” gallbladder wall — a specific finding on imaging that carries a genuine cancer risk
Patients from regions or backgrounds with a notably higher background rate of gallbladder cancer, where the threshold for prophylactic removal is lower
Patients undergoing certain other major operations, such as bariatric (weight-loss) surgery or organ transplantation, where gallstones are more likely to become symptomatic afterward and are often dealt with proactively at the same time

Outside of these specific situations, a silent gallstone found incidentally remains a case for watchful waiting, not automatic surgery.

What about the surgery itself?

Laparoscopic (keyhole) cholecystectomy is the standard approach for the great majority of patients — removing the whole gallbladder through a few small incisions, typically as a day-case or overnight-stay procedure, with a quick return to normal activity. When a patient presents with an acute attack of cholecystitis, current evidence supports operating relatively early, within the first week or so of the attack starting, in centres with the right expertise and facilities, since this shortens overall hospital stay compared to treating the acute inflammation first and returning for surgery much later.

I know many patients approach the idea of “having an organ removed” with some anxiety, so it’s worth being direct: laparoscopic cholecystectomy is one of the most commonly performed operations in general surgery worldwide, with a well-established safety record in experienced hands. Serious complications are uncommon, most patients go home the same day or the next, and the small keyhole scars fade well over the following months. This isn’t to dismiss that it’s still a real operation deserving proper preparation and a genuine discussion of individual risk — but it shouldn’t be feared as some rare or experimental procedure; it’s one of the most routine and well-understood operations I perform.

Living without a gallbladder

A question I’m asked in almost every consultation: what happens afterward? The honest answer is reassuring — the gallbladder is a storage organ for bile, not a factory that produces something irreplaceable. The liver continues to produce bile exactly as before; it simply flows more directly into the intestine rather than being stored and concentrated between meals. The great majority of patients notice no meaningful difference in digestion afterward, and normal diet can be resumed. A minority of patients notice looser stools, particularly after a very fatty meal, in the weeks after surgery, which for most people settles with time.

What you should do

If you have gallstones found incidentally with no symptoms, there is genuinely no rush — ongoing awareness of the warning signs below is enough for most people. If you’ve had one or more episodes of the kind of pain described above, please don’t simply wait for the next attack to pass on its own — each episode carries real risk, and a planned, elective operation while you’re otherwise well is a far better position to be in than an emergency operation during a severe attack.

Warning signs worth getting checked

Recurring upper abdominal pain, especially after fatty meals, lasting minutes to hours
Pain waking you at night
Fever alongside abdominal pain — possible acute cholecystitis
Yellowing of the skin or eyes (jaundice)
Dark urine or pale stools alongside abdominal pain
Sudden, severe abdominal pain radiating to the back — possible gallstone pancreatitis

To book a consultation with Prof. Dr. Zahid Mahmood, call 0300 413 0159 or visit professorzahid.com.

This article is for general awareness and does not replace a personal medical consultation.

Why Gallstones Need Surgery — And When They Don’t

Why Gallstones Need Surgery — And When They Don’t

Why gallstones form in the first place

Silent gallstones: usually genuinely fine to leave alone

What changes once symptoms begin

Why removing the gallbladder — not just the stones

Why some people form stones and others don’t

What can go wrong if symptomatic gallstones are left untreated

When surgery is recommended even without symptoms

What about the surgery itself?

Living without a gallbladder

What you should do

Warning signs worth getting checked

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