Laparoscopic cholecystectomy--can conversion be predicted?

The Analysis of Risk Factors in the Conversion from Laparoscopic to Open Cholecystectomy

Laparoscopic cholecystectomy is a standard treatment for cholelithiasis. In situations where laparoscopic cholecystectomy is dangerous, a surgeon may be forced to change from laparoscopy to an open procedure. Data from the literature shows that 2 to 15% of laparoscopic cholecystectomies are converted to open surgery during surgery for various reasons. The aim of this study was to identify the risk factors for the conversion of laparoscopic cholecystectomy to open surgery. A retrospective analysis of medical records and operation protocols was performed. The study group consisted of 263 patients who were converted into open surgery during laparoscopic surgery, and 264 randomly selected patients in the control group. Conversion risk factors were assessed using logistic regression analysis that modeled the probability of a certain event as a function of independent factors. Statistically significant factors in the regression model with all explanatory variables were age, emergency treatment, acute cholecystitis, peritoneal adhesions, chronic cholecystitis, and inflammatory infiltration. The use of predictive risk assessments or nomograms can be the most helpful tool for risk stratification in a clinical scenario. With such predictive tools, clinicians can optimize care based on the known risk factors for the conversion, and patients can be better informed about the risks of their surgery.

A Standardized Ultrasound Scoring System for Preoperative Prediction of Difficult Laparoscopic Cholecystectomy

Purpose

Laparoscopic cholecystectomy (LC) has become the treatment of choice for cholelithiasis. Still some patients required conversion to open cholecystectomy (OC). Our aim was to develop a standardized Ultrasound based scoring system for preoperative prediction of difficult LC.

Methods and materials

Ultrasound findings of 300 patients who underwent LC were reviewed retrospectively. Four parameters (time taken, biliary leakage, duct or arterial injury, and conversion) were analyzed to classify LC as easy or difficult. The following ultrasound findings were analyzed: GB wall thickness, pericholecystic collection, distended GB, impacted stones, multiple stones, CBD diameter and liver size. Out of seven parameters, four were statistically significant in our study. A score of 2 was assigned for the presence of each significant finding and a score of 1 was assigned for the remaining parameters to a total score of 11. A cut-off value of 5 was taken to predict easy and difficult LC.

Results

66 out of 83 cases of difficult LC and 199 out of 217 cases of easy LC were correctly predicted on the basis of scoring system. A score of >5 had sensitivity 80.7% and specificity 91.7% for correctly identifying difficult LC. Prediction came true in 78.8% difficult and 92.6% easy cases. US findings of GB wall thickness, distended GB, impacted stones and dilated CBD were found statistically significant.

Conclusion

This indigenous scoring system is effective in predicting conversion risk of LC to OC. Patients having high risk may be informed and scheduled appropriately and decision to convert to OC in case of anticipated difficulty may be taken earlier.

Predicting Difficult Laparoscopic Cholecystectomy Based on Clinicoradiological Assessment

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic cholelithiasis. However, of all Laparoscopic cholecystectomies, 1-13% requires conversion to an open for various reasons. Thus, for surgeons it would be helpful to establish criteria that would predict difficult laparoscopic cholecystectomy and conversion preoperatively. But there is no clear consensus among the laparoscopic surgeons regarding the parameters predicting the difficult dissection and conversion to open cholecystectomy.

AIM

To assess the clinical and radiological parameters for predicting the difficult laparoscopic cholecystectomy and its conversion.

MATERIALS AND METHODS

This was a prospective study conducted from October 2010 to October 2014. Total of 180 patients meeting the inclusion criteria undergoing LC were included in the study. Four parameters were assessed to predict the difficult LC. These parameters were: 1) Gallbladder wall thickness; 2) Pericholecystic fluid collection; 3) Number of attacks; 4) Total leucocyte count. The statistical analysis was done using Z-test.

RESULTS

Out of 180 patients included in this study 126 (70%) were easy, 44 (24.44%) were difficult and 3 (5.56%) patients required conversion to open cholecystectomy. The overall conversion rate was 5.6%. The TLC>11000, more than 2 previous attacks of cholecystitis, GB wall thickness of >3mm and Pericholecystic collection were all statistically significant for predicting the difficult LC and its conversion.

CONCLUSION

The difficult laparoscopic cholecystectomy and conversion to open surgery can be predicted preoperatively based on number of previous attacks of cholecystitis, WBC count, Gall bladder wall thickness and Pericholecystic collection.

Difficult situations in laparoscopic cholecystectomy: a multicentric retrospective study

INTRODUCTION

Difficult laparoscopic cholecystectomy (LC) is the most common "difficult" surgical procedure performed today, which possesses the potential to place the patient at significant operative risk. We present our retrospective study and experience of 8347 patients with LC since June 1995 to December 2011 at 2 large centers: Mariampur and GSVM Medical College, LLR Hospital, Kanpur, with discussions regarding the practical aspects of LC in difficult situations with respect to conversion to open cholecystectomy.

METHODS

A retrospective analysis of patients who underwent LC from June 1995 to December 2011 was performed. The analysis was performed in relation to the need for conversion and the factors responsible for conversion.

RESULTS

Out of 8347 cases, 2187 cases (26.2%) were identified as difficult. LC was performed successfully in 8265 cases (total completion rate, 99.02%). Of the 2187 difficult cases, LC was completed successfully in 2105 cases (completion rate in difficult cases, 96.25%) and converted to open cholecystectomy in 82 cases (conversion rate in difficult cases, 3.75%).

CONCLUSIONS

Because of the increasing exposure and expertise of surgeons dealing with complex gall bladder laparoscopies, rates of conversion to open cholecystectomy are decreasing and many difficult cases are now handled laparoscopically. However, if required, conversion should not be considered as a failure for the benefit of the patient.

Acute cholecystitis: risk factors for conversion to an open procedure

BACKGROUND

Laparoscopic cholecystectomy is one of the most common general surgical procedures performed. Conversion to an open procedure (CTO) is associated with increased morbidity and length of stay. Patients presenting with acute cholecystitis are at higher risk for CTO. Studies have attempted to examine risk factors for CTO in patients who undergo laparoscopic cholecystectomy for acute cholecystitis but are limited by small sample size. The aim of this study was to identify preoperative variables that predict higher risk for CTO in patients presenting with acute cholecystitis.

MATERIALS AND METHODS

Patients undergoing laparoscopic cholecystectomy for acute cholecystitis from 2005-2011 were identified from the American College of Surgeons' National Surgical Quality Improvement Program Participant Use File. Patients who underwent successful laparoscopic surgery were compared with those who required CTO. Demographics, comorbidities, and 30-d outcomes were analyzed. Multivariable logistic regression was used for variables with P value <0.1, with CTO used as the dependent variable.

RESULTS

A total of 7242 patients underwent laparoscopic cholecystectomy for acute cholecystitis. CTO was reported in 436 patients (6.0%). Those who required conversion were older (60.7 ± 16.2 versus 51.6 ± 18.0, P = 0.0001) and mean body mass index was greater (30.8 ± 7.6 versus 30.0 ± 7.3, P = 0.033) compared with those whose procedure was completed laparoscopically. Vascular, cardiac, renal, pulmonary, neurologic, hepatic disease, diabetes, and bleeding disorders were more prevalent in CTO patients. Mortality (2.3% versus 0.7%, P < 0.0001), overall morbidity (21.8% versus 6.0%, P < 0.0001), serious morbidity (14.9% versus 3.8%, P < 0.0001), reoperation (3.4% versus 1.4%, P = 0.001), and surgical site infection (9.2% versus 1.8%, P < 0.0001) rates, as well as length of stay (8.6 ± 13.0 versus 3.4 ± 6.7, P < 0.0001) were greater in those requiring CTO. The following factors were independently associated with CTO: age (odds ratio [OR], 1.01, P = 0.015), male gender (OR, 1.77, P = 0.005), body mass index (OR, 1.04, P < 0.0001), preoperative alkaline phosphatase (OR, 1.01, P = 0.0005), white blood cell count (OR, 1.06, P = 0.0001), and albumin (OR, 0.52, P = 0.0001).

CONCLUSIONS

CTO for acute cholecystitis remains low but not clinically negligible. The identified risk factors can potentially guide management and patient selection for delayed intervention for acute cholecystitis.

Significance of ultrasonography in selecting methods for the treatment of acute cholecystitis

Surgical removal of the gallbladder is indicated in nearly all cases of complicated acute cholecystitis. In the 1990s, laparoscopic cholecystectomy became the method of choice in the treatment of cholecystolithiasis. Due to a large inflammatory reaction in the course of acute inflammation, a laparoscopic procedure is conducted in technically difficult conditions and entails the risk of complications.

The value of percutaneous ultrasound in predicting conversion from laparoscopic to open cholecystectomy due to acute cholecystitis

Background

Laparoscopic cholecystectomy has become the treatment of choice for gallstone disease. Advantages of the laparoscopic approach include lower morbidity and mortality rates, reduced length of hospital stay, and earlier return to work. In acute cholecystitis, severe inflammation makes laparoscopic dissection technically more demanding, with a higher risk of related complications that require conversion to open cholecystectomy.

Methods

We reviewed the records of 5,596 patients who underwent cholecystectomy between 1993 and 2011 in a single institution. A laparoscopic approach was undertaken in 4,105 patients (73.4 %). The ultrasound signs of acute cholecystitis were found in 542 patients (13.2 %) who underwent laparoscopic cholecystectomy. We analyzed the ultrasound presentations of acute cholecystitis in patients who required conversion to open cholecystectomy and compared them with the ultrasound signs of acute cholecystitis in patients who had a completed laparoscopic cholecystectomy.

Results

A conversion to open cholecystectomy in patients with acute cholecystitis was necessary in 24 % (n = 130) of the patients compared to 3.4 % of the patients with uncomplicated gallstone disease. The most frequent ultrasound findings in patients requiring conversion were a pericholecystic exudate in 42 %, a difficult identification of anatomical structures due to local severe inflammation in 34 %, and gallbladder wall thickening of >5 mm in 31 %. Additionally, when the duration of symptoms exceeded 3 days, more than half of the patients required conversion to open cholecystectomy and the conversion rate was fivefold higher than for those with a shorter duration of acute cholecystitis.

Conclusions

In patients with severe acute cholecystitis found on ultrasound, combined with gallbladder wall thickening to >5 mm, pericholecystic exudates or abscess adjacent to the gallbladder, difficulty identifying anatomical structures within Calot’s triangle, specifically when the duration of symptoms exceeds 3 days, cholecystectomy should be done as an open approach because of the high risk of conversion.

Does the Difficulty of Laparoscopic Cholecystectomy Differ Between Genders?

Some studies have shown that severe fibrosis and anatomical anomalies are more common in men, and subsequently, laparoscopic cholecystectomy is more difficult in male than female patients. We aimed to evaluate the effect of gender in patients who underwent laparoscopic cholecystectomy, with regard to the conversion rate, the differences in histological inflammation severity, and anatomical difficulty. We reviewed retrospectively 915 patients with symptomatic cholelithiasis who underwent laparoscopic cholecystectomy in the First Department of General Surgery at Vakif Gureba Training and Research Hospital. Patients were divided into male (group 1) and female (group 2) groups. Both groups were compared with demographic criteria, the type of inflammation found on resected gallbladder, anatomical difficulty, gallbladder perforation during the operation, length of operation time, conversion rate, and omental and organ adhesions to the gallbladder. Of the 915 patients, 173 patients (19 %) were males (group 1), and 742 (81 %) were females (group 2). Mean age was 53 ± 12 (range 22 to 80) years in group 1 and 49 ± 13 (range 17 to 85) years in group 2. The average duration of surgery was 71 ± 33 min (range 20 to 160) in group 1 and 58 ± 27 min (range 15 to 135) in group 2 (p < 0.001). The conversion rate between groups was significantly different (p < 0.05). Inflammatory findings (acute or chronic) in resected gallbladder between groups 1 and 2 were significantly different (p < 0.0001 and p < 0.05, respectively). The frequency of adhesions between the gallbladder and omentum and other organs was higher in male (p = 0.003 and p = 0.0006, respectively). Anatomical difficulty was more prominent in male patients (p < 0.0001). The findings of higher scores of anatomical difficulty in operation and inflammation in cholecystectomy specimens, as well as higher rates of conversion in males, suggested that laparoscopic gallbladder surgery is more difficult in men.

Laparoscopic cholecystectomy: What is the price of conversion?

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold standard procedure for gallbladder removal. Conversion to an open procedure is sometimes deemed necessary, especially in complex cases in which a prolonged laparoscopic operative time is anticipated. A prolonged LC case is thought to be associated with increased complications and cost and therefore generally discouraged. The purpose of this study was to test this assumption, and compare outcomes and cost of converted and prolonged LC cases.

METHODS

By using institutional National Surgical Quality Improvement Program and financial databases, we retrospectively reviewed and compared prolonged laparoscopic cases (Long-LC) with converted (CONV) procedures. Surgical times, length of stay (LOS), 30-day complications, operative room, and total hospital charges were compared between the 2 groups.

RESULTS

A total of 101 Long-LC and 66 CONV cases met our inclusion criteria. Long-LC cases were 19 minutes longer than CONV cases (123 vs 104 min; P < .01). No differences in postoperative complications were found between the 2 groups (P > .05). When Poisson regression was used, we found that LOS was significantly shorter in the Long-LC compared with CONV group (1 day vs 4 days; P < .01). Long-LC cases had greater operative charges ($15,278 vs $13,128; P < .01). However, hospital charges for Long-LC cases were 26% less than for CONV cases ($23,946 vs $32,446; P < .01).

CONCLUSION

Conversion is associated with a 3-day increase in LOS. Long-LC cases have greater operative room charges, but overall hospital charges were 26% less than CONV cases. Our data suggest that decision making regarding conversion should focus on safety and not time considerations.

Male gender is not a risk factor for the outcome of laparoscopic cholecystectomy: a single surgeon experience

BACKGROUND/AIM

Previous studies regarding the outcome of laparoscopic cholecystectomy (LC) in men have reported inconsistent findings. We conducted this prospective study to test the hypothesis that the outcome of LC is worse in men than women.

MATERIALS AND METHODS

Between 1997 and 2002, a total of 391 consecutive LCs were performed by a single surgeon at King Fahd Hospital of the University. We collected and analyzed data including age, gender, body mass index (kg/m(2)), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), comorbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay.

RESULTS

Bivariate analysis showed that both genders were matched for age, ASA class and mode of admission. The incidences of AC (P = 0.003) and comorbid disease (P = 0.031) were significantly higher in men. Women were significantly more obese than men (P < 0.001) and had a higher incidence of previous abdominal surgery (P = 0.017). There were no statistical differences between genders with regard to rates of conversion (P = 0.372) and complications (P = 0.647) and operation time (P = 0.063). The postoperative stay was significantly longer in men than women (P = 0.001). Logistic regression analysis showed that male gender was not an independent predictor of conversion (Odds ratio [OR] = 0.37 and P = 0.43) or complications (OR = 0.42, P = 0.42). Linear regression analysis showed that male gender was not an independent predictor of the operation time, but was associated with a longer postoperative stay (P = 0.02).

CONCLUSION

Male gender is not an independent risk factor for satisfactory outcome of LC in the experience of a single surgeon.

Risk factors influencing conversion of laparoscopic to open cholecystectomy

BACKGROUND

Conversion of laparoscopic to open cholecystectomy is required in certain cases for the safe completion of the operation. Some factors contribute more to the need for conversion.

METHODS

Over a 13-year period, the laparoscopic cholecystectomy procedure was attempted in 1263 patients whose mean age was 54 years and 28% being male. The conversion was necessary in 98 cases whose mean age was 60 years, with 42% being male. All data were studied retrospectively. Six factors were examined statistically for a possible correlation with the conversion rate, as well as the trend of it over time.

RESULTS

The main reason for conversion was the unclear anatomy owing to previous inflammation, followed by bleeding and choledocholithiasis suspicion, gallbladder carcinoma, bile duct injury, or spilled gallstones. The overall conversion rate was 7.75%. It was significantly increased in males (11.6%) and the elderly (12.4 %), gallbladder inflammation (29%), and morbid obesity (50%). Conversion rate did not change significantly in the first half period (8.1%) of the study, the second half-period (7.6%), in patients with diabetes mellitus (6.7%), or hematological disorders (6%).

CONCLUSIONS

The risk for the conversion of laparoscopic cholecystectomy increases significantly in males, the elderly, obese patients, and when inflammation is present. This observation remains unchanged over time. Diabetes mellitus and hematologic disorders do not predispose in a higher risk for conversion.

Laparoscopic cholecystectomy for acute cholecystitis: the evolving trend in an institution

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold standard for symptomatic cholecystolithiasis. Technical maturation and advances in instrumentation have enabled the application of this procedure for acute cholecystitis (AC). We review the evolving role of LC for AC in our institution.

METHODS

A retrospective study was conducted of patients who received LC for AC between January 1994 and June 2001. Patients' demographics, clinical findings and perioperative outcomes were evaluated.

RESULTS

There were 140 men and 141 women with a mean age of 56.9 years (range, 23-89 years). Two hundred and eighteen of these patients underwent successful LC. There were 63 conversions (22.4%) for uncertain anatomy and difficult dissection (41), gangrenous or perforated gallbladder (16) and bleeding (6). The conversion rates as stratified to surgeon's seniority were 25.1%, 22.8% and 9.7% for registrar, senior registrar and consultant, respectively. The mean operative time was 84.3 minutes (range, 30-255 minutes) and the mean postoperative stay was 5.8 days (range, 1-35 days). The overall complication rate was 11.6%, including two bile duct injuries and two perioperative deaths.

CONCLUSION

LC for AC is safe and effective and associated with a low incidence of complications when routinely applied by surgical residents. The conversion rate is related to operators' surgical experience.

Factores intraoperatorios predictivos del fracaso del régimen ambulatorio tras colecistectomía laparoscópica

OBJECTIVES

To determine which intraoperative factors during ambulatory laparoscopic cholecystectomy predict postoperative admission.

MATERIAL AND METHOD

Between January 1999 and August 2003, we attempted 410 consecutive laparoscopic cholecystectomies. Intraoperative variables were analyzed using univariate and multivariate methods. An intraoperative score was applied to determine the probability of successful ambulatory surgery in each patient.

RESULTS

A total of 88.5% of the patients were strictly ambulatory. Forty-two patients required overnight admission, mostly due to social factors, and five patients required admission after 24-48 hours. Intraoperative variables predictive of postoperative admission were an operating time of more than 60 minutes (p = 0.011), gallbladder dissection with anatomic difficulty (p = 0.001), and cystic artery hemorrhage (p = 0.041). Surgical access to the abdominal cavity, gallbladder perforation, trocar wound or hepatic bed bleeding, intensity or grade of hemorrhage, and gallbladder extraction were not predictive variables.

CONCLUSIONS

Ambulatory laparoscopic cholecystectomy is a safe and effective procedure. Operating time, correct dissection of gallbladder structures and hemorrhage of the gallbladder hilus, especially of the cystic artery, play a major role in the success or failure of ambulatory laparoscopic cholecystectomy.

A nationwide study of conversion from laparoscopic to open cholecystectomy

PURPOSE

To determine the national incidence and risk factors for conversion from laparoscopic to open cholecystectomy.

BACKGROUND

Most series reporting the rates at which laparoscopic cholecystectomies are performed, relative to the open procedure, have come from centers specializing in laparoscopic surgery. The rates at which conversions occur from these centers may not reflect those in community practice. We sought to determine the actual, and therefore acceptable, conversion rate by examining nationally representative discharge data.

METHODS

The National Hospital Discharge database for 1998 to 2001 was acquired from the Centers for Disease Control. All gallbladder disease related admissions were extracted, and the cholecystectomies (ICD-9-CM codes 51.2X) were analyzed using the SAS package. Stepwise logistic regression was used to determine what factors were associated with the risk of conversion from laparoscopic to open cholecystectomy.

RESULTS

Approximately 25% of all cholecystectomies are performed by the open technique. Of the remaining 75%, there is an approximately 5% to 10% conversion rate. The major risk factors for conversion included male sex, obesity, and cholecystitis. Concurrent choledocholithiasis, cholelithiasis, and cholecystitis were associated with a conversion rate of 25%. Length of stay (LOS) was reduced for laparoscopic operations and although conversion added 2 to 3 days to the LOS, for most cases the LOS was still less than for primary open operations.

CONCLUSIONS

Three quarters of all cholecystectomies are performed laparoscopically, and the national conversion rate is 5% to 10%. Cholecystitis, choledocholithiasis, male sex, and obesity are major predictors for conversion. The data presented in terms of conversion rates and LOS were derived from population-adjusted hospital discharge data and represent the current U.S. experience for cholecystectomy. From these data the community experience for conversion rates, risk factors, and LOS can be derived.

Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and pregnancy

Previous surgery, obesity, and pregnancy should no longer be considered contraindications to laparoscopic surgery. Surgeons should exercise good judgement in patient selection, use meticulous surgical techniques, and prepare thoroughly for the planned procedure. Patients and surgeons should be aware of increased conversion rates. With these caveats in mind, these patients can still experience the advantages of minimally invasive surgery without increased risks.

[Laparoscopy or laparotomy in acute cholecystitis (200 cases). Comparison of the results and factors predictive of conversion]

STUDY AIM

The aim of this prospective study was to compare the results of cholecystectomy for acute cholecystitis through laparoscopic and open approach and to assess factors responsible for conversion into laparotomy.

PATIENTS AND METHODS

From January 1991 to October 1997, 200 patients with calculous acute cholecystitis were operated on in the same center, 100 through laparoscopy and 100 through laparotomy. Choice between these two procedures was only dependent on the disresponsibility of videolaparoscopic material. Comparison between laparoscopy and laparotomy groups concerned postoperative mortality and morbidity rates, hospital stay duration and late results. Intraoperative conversion into laparotomy occurred in 24 patients and factors responsible for conversion were assessed with univaried and multivaried analysis.

RESULTS

Both groups were comparable with regard to sex ratio, age, ASA score but associated diseases incidence, plastron, fever above 38 degrees C and leucocytosis were significantly more frequent in the laparotomy group and delay between diagnosis and surgery was significantly longer in the laparoscopic group. There were two postoperative deaths in the laparotomy group, 0 in the laparoscopic group (NS). Morbidity rate was higher (32% versus 10%) (p = 0.0002) and hospital stay longer (12 +/- 10 days, versus 5 +/- 3) in the laparotomy group (p = 0.00005). Late results were similar in both groups. Conversion rate into laparotomy was 24%. Factors predisposing significantly to conversion were in univaried analysis: plastron, fever above 38 degrees C, leucocytosis, delay between diagnosis and surgery above 4 days, presence on ultrasonography of pericholecystic liquid and gallbladder wall edema, presence of "Klebsiella" in gallbladder bile. With multivaried analysis, leucocytosis and delay between diagnosis and surgery were the only independent factors.

CONCLUSION

Videolaparoscopic cholecystectomy is a safe and efficient technique in the treatment of acute cholecystitis, with a lower postoperative morbidity rate and a shorter hospital stay. Conversion rate into laparotomy is significantly dependent on leucocytosis and delay between diagnosis and surgery. Laparoscopic cholecystectomy should be performed as soon as possible in acute cholecystitis.

OUR FIRST HUNDRED LAPAROSCOPIC CHOLECYSTECTOMIES

Hundred patients with symptomatic gallstone disease underwent laparosopic cholecystectomy between June 1996 and August 1997. There were 78 females and 22 males, with a mean age of 46.2 (SD 17.8; range 21 to 85) years. The common presentations were right upper abdominal pain (n=66), acute cholecystitis (n=8) and history of jaundice (n=11). Sixteen patients underwent ERCP for suspected CBD stones. Endoscopic papillotomy and basketing cleared the CBD of all calculi in 12. Three patients required conversion to open cholecystectomy because of dense adhesions (n=2) and to control intraoperative haemorrhage (n=1). Mean operating time was 67.2 (SD 39.2; range 22 to 186) minutes. The mean requirement of analgesics was 2.8 (SD 1.3; range 2 to 5) doses and post-operative hospital stay was 1.6 (SD 1.4; range 1 to 7) days. All patients resumed normal activity within 14 days of operation and are well and satisfied with their operation at a median follow up of 8.6 months.