| Abstract|| |
Laparoscopic cholecystectomy (LC) was attempted in 847 patients, 823 (97.2%) were completed laparoscopically and 24 (2.8%) had to be converted to open cholecystectomy (OC). Acute cholecystitis was the commonest reason for conversion (13 out of 24 patients). Patients who had acute cholecystitis are five times at risk for conversion to open than other patients with non-acute cholecystitis (p<0.00I ). Age and sex were not statistically significant predictors for conversion. There were no mortalities and no major bile duct injuries in our series. These data confirms the safety of LC, identify factors which predicts conversion to OC and may be helpful in selecting patients for day care ambulatory LC.
|How to cite this article:|
Merdad AM. Laparoscopic cholecystectomy: Rate and predictors for conversion. Saudi J Gastroenterol 1999;5:117-9
There is no doubt that laparoscopic cholecystectomy is the golden standard for the treatment of symptomatic cholelithiasis, the advantages of this procedure includes reduced postoperative pain, shorter hospitalization, earlier return to normal activity and definitely better cosmesis ,,, . The spread of the procedure in almost all hospitals and the advancement in surgeon's experience and confidence has led to abandoning the open technique to be performed only in failures of the laparoscopically attempted ones. Several questions have been raised about the wisdom of expanding the indications to include all comers with symptomatic gallstones and the long term safety and efficacy of the procedure , .
Conversion from laparoscopic cholecystectomy to open cholecystectomy is still required in as low as 1.5% and up to 19.0% in different published series  . Conversion is related to patient factors, surgeon factors and equipment failure factors but most are converted because of difficulty in delineating the anatomy clearly or complications arising during the procedure ,, . The aim of this study is to determine the rate of conversion from laparoscopic to open cholecystectomy and to determine some factors to predict the conversion to OC which might help in properly selecting patients for Day Care ambulatory LC.
| Patients and methods|| |
Laparoscopic cholecystectomy was first performed in Dr. Bakhsh Private Hospital in Jeddah, Saudi Arabia in January 1992. Files for patients who had laparoscopic cholecystectomy between January 1992 and December 1997 were reviewed. Data collected included demographic data, weight, indications for surgery, related medical problems, history of previous surgery, preoperative liver function tests and reasons for conversion. All patients were considered for laparoscopic cholecystectomy as we believe that there is no absolute contraindication for laparoscopic cholecystectomy. Patients with clinical, biochemical or ultrasound evidence of choledocholithiasis had ERCP performed preoperatively and CBD stones if present were dealt with endoscopically. Patients were considered to have acute cholecystitis if they have right upper quadrant tenderness, fever, leucocytosis and thickness of the gallbladder wall of 3.5 mm or more on ultrasound examination. Laparoscopic cholecystectomy was performed using the closed (veress) technique, the standard four trocars were introduced after insufflation of the peritoneal cavity. Intraoperative cholangiogram was seldom used and only if there is a suspicion of major bile duct injury. Postoperative data was collected to compare the laparoscopically completed cases with the converted ones regarding operative time, hospital stay days, complications and mortality.
| Statistical analysis|| |
Odds ratio is employed to determine the strength of relationship between the study outcome (conversion of LC to open ones) and various factors that may influence its occurrence. Whether the relationships are statistically significant are tested using the chi-square test and confidence interval. The 5% statistical significance level is used for this purpose.
| Results|| |
847 patients had laparoscopy and attempt of removal of their gallbladder, of these 615 (72.6%) were women and 233 (27.4%) were men. The mean age for women was 42.2 (range 20-75) years and for men 45.4 (range 21-70) years. Their weight ranged between 45-137 kgm with a mean of 79.5 kgm. Of the 847 patients, laparoscopic cholecystectomy was completed in 823 (97.2%) and 24 (2.8%) had to be converted to open. The reasons for conversion were summarized in [Table - 1]; the main reason of conversion is the presence of acute cholecystitis with friable gallbladder and dense adhesions to the surrounding structures. There were no injuries to major biliary ducts in our series and we do not perform intraoperative cholangiogram routinely. Nine out of 232 (3.9%) males and 15 out of 615 (2.4%) females were converted to open procedure. In fact the odds for open surgery is 1.60; although males are 60% more at risk for conversion to open surgery, this risk is not statistically significant (95% C.I. 070-3.74) (P=0.260). One hundred forty-one patients had acute cholecystitis of those 13 (9.2%) were converted to open while 128 (90.8%) had their gallbladders removed laparoscopically. On the other hand, 706 patients had non-acute gallbladder problems (chronic cholecystitis), of those 11 (1.6%) converted to open and 695 (98.4%) were completed laparoscopically. Patients who had acute cholecystitis are 5-folds more at risk to be converted to open than those who had chronic one (O.R.=6.4, C.I. 95%, 2.8-14.6). Acute cholecystitis is a statistically significant factor (P<0.001) to predict the possibility to convert to open surgery. The average operative time was longer among the converted cases (130 minutes) versus 70 minutes for laparoscopically completed cases. The mean hospital stay days for converted cases was 5 days and for laparoscopically completed cases 2.97 days. [Table - 2] summarize different variables for comparison between open and laparoscopic cholecystectomies in our series.
| Discussion|| |
Laparoscopic cholecystectomy is the procedure of choice for the management of symptomatic gallstones, despite the improvement in the equipment and the advancement in surgeon's experience all patients undergoing LC are informed of the possibility of converting the procedure to OC. As more and more cases are done on outpatient basis ,, understanding the high risk group and the factors that may predict the conversion and the institutes rate of conversion would be of great help in discussing all possibilities with the patients and comparing results with other institutes from other parts of the world. Knowing the rate of conversion and factors which might predict it, would help also the surgeon to select his patients objectively for Day Care ambulatory surgery and the institute to plan their regular and Day Care beds more effectively. Conversion rates from LC to OC varies widely in different series and ranges between 1.5 to 19.0% 2],,, .
The rate of conversion depends on surgeon's experience, criterias of selection of patients for the laparoscopic procedure and equipment failure rates , . The conversion rate in our series is 2.8% and the commonest cause of conversion is the presence of acute cholecystitis.
The analysis of different factors in our study revealed that the odds for open surgery among patients with acute cholecystitis is 6.4. Hence, a patient who has acute cholecystitis is 5.4 times at risk for converting to open than the non-acute case.
A male patient is 60% more at risk for converting to open. However, both age and sex are not significant predictors.
As more centers including ours are performing LC as Day Care Surgery, knowing predictors for conversion to open surgery would be of great help in institutional planning and patients understanding of their chances of conversion. Laparoscopic cholecystectomy is a safe procedure to deal with different gallbladder problems, an initial laparoscopic approach should be attempted on all cases with a reasonably low threshold to convert if difficulties are encountered.
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Adnan M Merdad
Department of Surgery, King Abdulaziz University Hospital, P.O. Box 6615, Jeddah, 21452
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2]