Preoperative findings predict conversion from laparoscopic to open cholecystectomy

Current state of minimally invasive general surgical practice in Africa: A systematic review and meta-analysis of the laparoscopic procedures performed and outcomes

BACKGROUND

Minimally invasive surgery, including laparoscopy and robotics, has significantly improved general surgical (GS) practice globally. While robot-assisted GS practice is yet to be adopted in the majority of Africa, laparoscopy has been utilized to improve surgical outcomes. This study aims to review the laparoscopic GS procedures (LGSPs) performed and evaluate outcomes such as conversion to open surgery, morbidity, and mortality in Africa.

METHODS

Four databases (PubMed, Google Scholar, WoS, and AJOL) were searched, identifying 8022 publications. Following screening, 40 studies across Africa that reported LGSPs (n ≥ 2) performed and outcomes met the inclusion criteria. A meta-analysis conducted using R statistical software estimated the pooled prevalences with the 95% CI of conversion, morbidity, and mortality.

RESULTS

A total of 6381 procedures performed in 15 African countries were analyzed in this study. Majority, 72.89%, of the procedures were performed in Senegal, South Africa, and Nigeria. The major procedures performed were cholecystectomy (37.09%), appendicectomy (33.36%), and diagnostic laparoscopy (9.98%). The meta-analysis revealed a conversion rate of 5% [95% CI: 4, 7]. Adhesion (28.13%), hemorrhage (16.67%), technical difficultly (12.50%), and equipment failure (11.46%) were the predominant indications for conversion. Surgical site infection (42.75%) was the major cause of morbidity. The prevalences of morbidity and mortality were 7% [95% CI: 5, 10] and 0.12% [95% CI: 0, 0.29], respectively.

CONCLUSION

A wide range of basic and advanced LGSPs were performed. The outcomes obtained indicate successful implementation of the laparoscopic approach. Importantly, this study serves as a foundational work for further research on minimally invasive surgery in Africa.

Risk Factors and Prevalence Associated With Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy: A Tertiary Care Hospital Experience in Western Mexico

Introduction Laparoscopic cholecystectomy (LC) is a common procedure used for the treatment of different pathologies caused by gallstones in the gallbladder, and one of the most common indications is acute cholecystitis. The definitive treatment for acute cholecystitis is surgery, and LC is the gold standard. Nevertheless, transoperative complications (like intraoperative bleeding, anatomical abnormalities of the gallbladder, etc.) of LC and some other preoperative factors (like dilatation of bile duct, increased gallbladder wall thickness, etc.) can cause or be a risk factor for conversion to open cholecystectomy (OC). The objective of this study was to determine the risk factors and prevalence associated with the conversion from LC to OC in patients with gallbladder pathology and the indication for LC. Materials and methods This was a prospective cohort study. We included patients of both sexes over 18 years of age with gallbladder disease. To determine the risk factors associated with conversion, we performed a bivariate analysis and then a multivariate analysis. Results The rate of conversion to OC was 4.54%. The preoperative factors associated with conversion, in the bivariate analysis, were common bile duct dilatation (p=0.008), emergency surgery (p=0.014), and smoking (p=0.001); the associated intraoperative variables were: laparoscopic surgery duration (p <0.0001), Calot triangle edema (p=0.033), incapacity to hold the gallbladder with atraumatic laparoscopic tweezers (p=0.036), and choledocholithiasis (p=0.042). Laparoscopic Surgery duration was the only factor with a significant association in the multivariate analysis (p=0.0036); we performed a receiver operating characteristic (ROC) curve analysis and found a cut-off point of 120 minutes for the duration of laparoscopic surgery with a sensitivity and a specificity of 67 and 88%, respectively. Conclusion The prevalence of conversion from LC to OC is similar to that reported in the international literature. The risk factors associated with conversion to OC, in this study, should be confirmed in future clinical studies, in this same population, with a larger sample size.

External Validation of Two Scoring Tools to Predict the Operative Duration and Open Conversion of Elective Laparoscopic Cholecystectomy in a Mexican Population

INTRODUCTION

This study aimed to evaluate the use of laparoscopic cholecystectomy (LC) operative time (CholeS score) and conversion to an open procedure (CLOC score) outside their validation dataset in Mexican population.

METHODS

Patients >18 years who underwent elective LC were analyzed in a single-center retrospective chart review study. Association between scores (CholeS and CLOC) with operative time and conversion to open procedures was assessed with Spearman correlation. The predictive accuracy of the CholeS score and CLOC score was evaluated by receiver operator characteristic.

RESULTS

200 patients were included in the study (33 excluded for emergency case or missing data). Spearman coefficient correlations between CholeS or CLOC score and operative time were 0.456 (p < 0.0001) and 0.356 (p < 0.0001), respectively. Area under the curve (AUC) for operative prediction time (>90 min) by CholeS score was 0.786 with a 3.5-point cutoff (80% sensitivity and 63.2% specificity). AUC for open conversion (CLOC score) was 0.78 with a 5-point cutoff (60% sensitivity and 91% specificity). The CLOC score had a 0.740 AUC (64% sensitivity and 72.8% specificity) for operative time >90 min.

CONCLUSIONS

The CholeS and the CLOC scores predicted LC long operative time and risk for conversion to an open procedure, respectively, outside their original validation set.

Preoperative Risk Factors for Conversion from Laparoscopic to Open Cholecystectomy: A Systematic Review and Meta-Analysis

Laparoscopic cholecystectomy is a standard treatment for patients with gallstones in the gallbladder. However, multiple risk factors affect the probability of conversion from laparoscopic cholecystectomy to open surgery. A greater understanding of the preoperative factors related to conversion is crucial to improve patient safety. In the present systematic review, we summarized the current knowledge about the main factors associated with conversion. Next, we carried out several meta-analyses to evaluate the impact of independent clinical risk factors on conversion rate. Male gender (OR = 1.907; 95%CI = 1.254−2.901), age > 60 years (OR = 4.324; 95%CI = 3.396−5.506), acute cholecystitis (OR = 5.475; 95%CI = 2.959−10.130), diabetes (OR = 2.576; 95%CI = 1.687−3.934), hypertension (OR = 1.931; 95%CI = 1.018−3.662), heart diseases (OR = 2.947; 95%CI = 1.047−8.296), obesity (OR = 2.228; 95%CI = 1.162−4.271), and previous upper abdominal surgery (OR = 3.301; 95%CI = 1.965−5.543) increased the probability of conversion. Our analysis of clinical factors suggested the presence of different preoperative conditions, which are non-modifiable but could be useful for planning the surgical scenario and improving the post-operatory phase.

Optimal timing of percutaneous transhepatic gallbladder drainage and subsequent laparoscopic cholecystectomy according to the severity of acute cholecystitis

Backgrounds/Aims

The optimal timing of percutaneous transhepatic gallbladder drainage (PTGBD) and subsequent laparoscopic cholecystectomy (LC) according to the severity of acute cholecystitis (AC) has not been established yet.

Methods

This single-center, retrospective study included 695 patients with grade I or II AC without common bile duct stones who underwent PTGBD and subsequent LC between January 2010 and December 2019. Difficult surgery (DS) (open conversion, subtotal cholecystectomy, adjacent organ injury, transfusion, operation time ≥ 90 minutes, or estimated blood loss ≥ 100 mL) and poor postoperative outcome (PPO) (postoperative hospital stay ≥ 7 days or Clavien-Dindo grade ≥ II postoperative complication) were defined to comprehensively evaluate intraoperative and postoperative outcomes, respectively.

Results

Of 695 patients, 403 had grade I AC and 292 had grade II AC. According to the receiver operating characteristic curve and multivariate logistic regression analyses, an interval from symptom onset to PTGBD of > 3.5 days and an interval from PTGBD to LC of > 7.5 days were significant predictors of DS and PPO, respectively, in grade I AC. In grade II AC, the timing of PTGBD and subsequent LC were not statistically related to DS or PPO.

Conclusions

In grade I AC, performing PTGBD within 3.5 days after symptom onset can reduce surgical difficulties and subsequently performing LC within 7.5 days after PTGBD can improve postoperative outcomes. In grade II AC, early PTGBD cannot improve the surgical difficulty. In addition, the timing of subsequent LC is not correlated with surgical difficulties or postoperative outcomes.

Routine use of ICG to enhance operative safety in emergency laparoscopic cholecystectomy: a randomized controlled trial

OBJECTIVE

To test the hypothesis that ICG fluorescence cholangiography (ICG-FC) helps to identify critical structures during laparoscopic cholecystectomy (LC) and hence reduce biliary injuries and conversions. In LC, biliary injury and conversion often happen if the biliary anatomy is misidentified.

METHODS

This was a single-center randomized controlled trial from 2017 to 2019. Patients with acute cholecystitis requiring LC were assessed for eligibility for the trial. Patients in the trial were randomized to undergo either conventional LC (conventional arm) or LC with ICG-FC (ICG arm). Conversion rate and biliary injury incidence were outcome measures.

RESULTS

Totally 92 patients participated (46 patients in each arm). The median age was 61 years in both arms (p = 0.472). The conventional arm had 22 men and 24 women; the ICG arm had 24 men and 22 women (p = 0.677). The two arms were comparable in all perioperative parameters. The time from ICG injection to surgery was 67 (16-1150) min. Both arms had an 8.7% conversion rate (p = 1.000). The median operative time was 140.5 min in the conventional arm and 149.5 min in the ICG arm (p = 0.086). The complication rate was 15.2% in the former and 10.9% in the latter (p = 0.536), and both had a 2.2% bile leakage rate. The median hospital stay was 3.5d in the former and 4.0d in the latter (p = 0.380).

CONCLUSION

ICG-FC did not make any difference in conversion or complication rate. Its routine use in LC is questionable. However, it may be helpful in difficult cholecystectomies and may be used as an adjunct.

TRIAL REGISTRATION

The trial was registered with the Institutional Review Board of University of Hong Kong/Hospital Authority Hong Kong West Cluster ( http://www.med.hku.hk/en/research/ethics-and-integrity/human-ethics ). Registration number: UW17-492.

Patient and surgeon factors contributing to bailout cholecystectomies: a single-institutional retrospective analysis

BACKGROUND

Laparoscopic cholecystectomies continue to pose trouble for surgeons in the face of severe inflammation. In the advent of inability to perform an adequate dissection, a "bailout cholecystectomy" is advocated. Conversion to open or subtotal cholecystectomy is among the standard bailout procedures in such instances.

METHODS

We performed a retrospective single institution review from January 2016 to August 2019. All patients who underwent a cholecystectomy were included, while those with a concurrent operation, malignancy, planned as an open cholecystectomy, or performed by a low volume surgeon were excluded. Patient characteristics, operative reports, and outcomes were collected, as were surgeon characteristics such as years of experience, case volume, and bailout rate. Univariable and multivariable analysis were performed.

RESULTS

2458 (92.6%) underwent laparoscopic total cholecystectomy (LTC) and 196 (7.4%) underwent a bailout cholecystectomy (BOC). BOC patients tended to be older (p < 0.001), male (p < 0.001), have a longer duration of symptoms (p < 0.001), and higher ASA class (p < 0.001). They also had more signs of biliary inflammation, as evidenced by increased leukocytosis (p < 0.001), tachycardia (p < 0.001), bilirubinemia (p = 0.003), common bile duct dilation (p < 0.001), and gallbladder wall thickening (p < 0.001). The BOC cohort also had increased rates of complications, including bile leak (16%, p < 0.001), retained stone (5.1%, p = 0.005), operative time (114 min vs 79 min, p < 0.001), and secondary interventions (22.7%, p < 0.001). Male gender (aOR = 2.8, p < 0.001), preoperative diagnosis of acute cholecystitis (aOR = 2.2, p = 0.032), right upper quadrant tenderness (aOR = 3.0, p = 0.008), Asian race (aOR = 2.7, p = 0.014), and intraoperative adhesions (aOR = 13.0, p < 0.001) were found to carry independent risk for BOC. Surgeon bailout rate ≥ 7% was also found to be an independent risk factor for conversion to BOC.

CONCLUSIONS

Male gender, signs of biliary inflammation (tachycardia, leukocytosis, dilated CBD, and diagnosis of acute cholecystitis), as well as surgeon bailout rate of 7% were independent risk factors for BOC.

Statistical models to preoperatively predict operative difficulty in laparoscopic cholecystectomy: A systematic review

BACKGROUND

Laparoscopic cholecystectomy operative difficulty is highly variable and influences outcomes. This systematic review analyzes the performance and clinical value of statistical models to preoperatively predict laparoscopic cholecystectomy operative difficulty.

METHODS

PRISMA guidelines were followed. PubMed, Embase, and the Cochrane Library were searched until June 2020. Primary studies developing or validating preoperative models predicting laparoscopic cholecystectomy operative difficulty in cohorts of >100 patients were included. Studies not reporting performance metrics or enough information for clinical implementation were excluded. Data were extracted according to CHARMS, and study quality was assessed using the PROBAST tool.

RESULTS

In total, 2,654 articles were identified, and 22 met eligibility criteria. Eighteen were model development, whereas 4 were validation studies. Eighteen studies were at high risk of bias. However, 11 studies showed low concern for applicability. Identified models predict 9 definitions of laparoscopic cholecystectomy operative difficulty, the most common being conversion to open surgery and operating time. The most validated models predict an intraoperative difficulty scale and procedures >90 minutes with an area under the curve of >0.70 and >0.76, respectively. Commonly used predictors include demographic variables such as age and gender (9/18 models) and ultrasound findings such as gallbladder wall thickness (11/18). Clinical implementation was never studied.

CONCLUSION

There is a longstanding interest in estimating laparoscopic cholecystectomy operative difficulty. Models to preoperatively predict laparoscopic cholecystectomy operative difficulty have generally good performance and seem applicable. However, an unambiguous definition of operative difficulty, validations, and clinical studies are needed to implement patients' stratification in laparoscopic cholecystectomy.

Conversion from laparoscopic to open cholecystectomy: Risk factor analysis based on clinical, laboratory, and ultrasound parameters

INTRODUCTION AND AIMS

The standard of care for gallbladder disease is laparoscopic cholecystectomy. Difficult dissection of the hepatocytic triangle and bleeding can result in conversion to open cholecystectomy, which is associated with increased morbidity. Identifying risk factors for conversion in the context of acute cholecystitis will allow patient care to be individualized and improve outcomes.

MATERIALS AND METHODS

A retrospective case-control study included all patients diagnosed with acute cholecystitis, according to the 2018 Tokyo Guidelines, admitted to a tertiary care academic center, from January 1991 to January 2012. Using logistic regression, we analyzed variables to identify risk factors for conversion. Variables that were found to be significant predictors of conversion in the univariate analysis were included in a multivariate model. We then performed an exploratory analysis to identify the risk factor summation pathway with the highest sensitivity for conversion.

RESULTS

The study included 321 patients with acute cholecystitis. Their mean age was 49 years (±16.8 SD), 65% were females, and 35% were males. Thirty-nine cases (12.14%) were converted to open surgery. In the univariate analysis, older age, male sex, gallbladder wall thickness, and pericholecystic fluid were associated with a higher risk for conversion. In the multivariate analysis all of the variables, except pericholecystic fluid, were associated with conversion. Our risk factor summation model had a sensitivity of 84%.

CONCLUSIONS

Preoperative clinical data can be utilized to identify patients with a higher risk of conversion to open cholecystectomy. Being aware of such risk factors can help improve perioperative planning and preparedness in challenging cases.

Efficacy of Thiol Disulfide Homeostasis and Ischemia Modified Albumin Values in Estimating the Degree of Difficulty for Laparoscopic Cholecystectomy

Aim:

The aim of this study was to investigate the efficacy of thiol disulfide homeostasis and Ischemia Modified Albumin (IMA) values in predicting the technical difficulties that might be encountered during laparoscopic cholecystectomy.

Materials and Methods:

The study included 65 patients who underwent laparoscopic cholecystectomy due to cholelithiasis at the General Surgery Clinic of Ankara Numune Training and Research Hospital. All patients’ demographic data, previous history of cholecystitis, a history of chronic illness, preoperative white blood count (WBC), liver function tests (AST, ALT), amylase and lipase levels, intra-operative adhesion score, the ultrasonographic appearance of gall bladder, duration of hospital stay, duration of operation, thiol disulfide and IMA values were evaluated.

Results:

Native thiol and total thiol averages were higher in patients without a history of cholecystitis, and on the other hand, disulfide, disulfide/native thiol rate, disulfide/total thiol rate, native thiol/total thiol rate and IMA averages were higher in patients with a history of cholecystitis. While there was a statistically significant negative correlation between native and total thiol values and age, duration of surgery and duration of hospital stay; IMA, disulfide, disulfide/Total thiol, Native/Total thiol and disulfide/Native thiol rates were higher in older patients with a longer duration of surgery and hospital stay. In addition, preoperative IMA, disulfide, disulfide/Total thiol, Native/Total thiol and disulfide/Native thiol were observed to increase as the degree of intraoperative pericholecystic adhesion increased.

Conclusion:

We believe that the evaluation of thiol disulfide homeostasis and IMA parameters prior to laparoscopic cholecystectomy can be used as an effective method for predicting intraoperative difficulties.

Conversion from laparoscopic to open cholecystectomy: Risk factor analysis based on clinical, laboratory, and ultrasound parameters

INTRODUCTION AND AIMS

The standard of care for gallbladder disease is laparoscopic cholecystectomy. Difficult dissection of the hepatocytic triangle and bleeding can result in conversion to open cholecystectomy, which is associated with increased morbidity. Identifying risk factors for conversion in the context of acute cholecystitis will allow patient care to be individualized and improve outcomes.

MATERIALS AND METHODS

A retrospective case-control study included all patients diagnosed with acute cholecystitis, according to the 2018 Tokyo Guidelines, admitted to a tertiary care academic center, from January 1991 to January 2012. Using logistic regression, we analyzed variables to identify risk factors for conversion. Variables that were found to be significant predictors of conversion in the univariate analysis were included in a multivariate model. We then performed an exploratory analysis to identify the risk factor summation pathway with the highest sensitivity for conversion.

RESULTS

The study included 321 patients with acute cholecystitis. Their mean age was 49 years (±16.8 SD), 65% were females, and 35% were males. Thirty-nine cases (12.14%) were converted to open surgery. In the univariate analysis, older age, male sex, gallbladder wall thickness, and pericholecystic fluid were associated with a higher risk for conversion. In the multivariate analysis all of the variables, except pericholecystic fluid, were associated with conversion. Our risk factor summation model had a sensitivity of 84%.

CONCLUSIONS

Preoperative clinical data can be utilized to identify patients with a higher risk of conversion to open cholecystectomy. Being aware of such risk factors can help improve perioperative planning and preparedness in challenging cases.

A prospective cohort study for prediction of difficult laparoscopic cholecystectomy

Introduction

Difficult laparoscopic cholecystectomy (DLC) is a stressful condition for surgeon which is followed by greater risk for various injuries (biliary, vascular etc.) Preoperative factors that are related to DLC are landmarks for surgeon to assess the possibilities for overcoming difficulties and making early decision about conversion to an open surgery. In prospective cohort study we evaluated and defined the importance and impact of preoperative parameters on difficulties encountered during surgery, defined DLC, predictors of DLC and index of DLC.

Materials and methods

All patients in the study were operated by the same surgeon. We defined the total duration of the operation as the time from insertion of Veress needle to the extraction of gallbladder (GB) and DLC as a laparoscopic cholecystectomy (LC) that lasted longer than the average duration of LC and the value of one standard deviation.

Results

Multivariate logistic regression analysis identified five predictors significantly related to DLC: GB wall thickness > 4 mm, GB fibrosis, leukocytosis ˃10 × 10⁹ g/L, ˃ 5 pain attacks that lasted longer than 4 h and diabetes mellitus. The sensitivity of the generated index of DLC in our series is 81.8% and specificity 97.2%.

Conclusion

Preoperative prediction of DLC is important for the surgeon, for his operating strategy, better organization of work in operating room, reduction of treatment expenses, as well as for the patient, for his timely information, giving a consent for an operation and a better psychological preparation for possible open cholecystectomy (OC).

H•

There is no consensus on the definition of difficult laparoscopic cholecystectomy (DLC) and its treatment.

•

We defined DLC as an operation that lasts longer than the average duration of LC and the value of one standard deviation.

•

DLC is a possible introduction to conversion but not an inevitable pathway to conversion.

•

The precise consensus on predictors of DLC hasn’t been made.

•

Thickened GB wall > 4 mm, GB fibrosis, >5 attacks of disease and pain lasting > 4 hours, WBC >10 x10⁹ g/L and diabetes mellitus are predictors of DLC.

Acute cholecystitis: predictive clinico-radiological assessment for conversion of laparoscopic cholecystectomy

BACKGROUND

Previous studies evaluating predictive factors for the conversion from laparoscopic to open cholecystectomy have reported conflicting conclusions.

PURPOSE

To create a risk assessment model to predict the conversion from laparoscopic to open cholecystectomy in patients with acute calculous cholecystitis.

MATERIAL AND METHODS

A retrospective review of patients with acute calculous cholecystitis with available preoperative contrast-enhanced computed tomography (CT) findings who underwent laparoscopic cholecystectomy was performed. Forty-four parameters-including demographics, clinical history, laboratory data, and CT findings-were analyzed.

RESULTS

Among the included 581 patients, conversion occurred in 113 (19%) cases. Multivariate analysis identified obesity (odd ratio [OR] 2.58, P = 0.04), history of abdominal surgery (OR 1.78, P = 0.03), and prolonged prothrombin time (OR 1.98, P = 0.03) as predictors of conversion. In preoperative CT findings, the absence of gallbladder wall enhancement (OR 3.15, P = 0.03), presence of a gallstone in the gallbladder infundibulum (OR 2.11, P = 0.04), and inflammation of the hepatic pedicle (OR 1.71, P = 0.04) were associated with conversion. Inter-observer agreement for CT study interpretation was very good (range 0.81-1.00). A model was created to calculate the risk for conversion, with an area under the receiver operating characteristic curve of 0.87. The risk for conversion, estimated based on the number of factors identified, was in the range of 5.3% (with one factor) to 86.4% (with six factors).

CONCLUSION

Obesity, history of abdominal surgery, prolonged prothrombin time, absence of gallbladder wall enhancement, presence of a gallstone in the gallbladder infundibulum, and inflammation of the hepatic pedicle are associated with conversion of laparoscopic to open cholecystectomy.

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.

Fluorescent cholangiography significantly improves patient outcomes for laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the most common elective abdominal surgery in the USA, with over 750,000 performed annually. Fluorescent cholangiography (FC) using indocyanine green dye (ICG) permits identification of extrahepatic biliary structures to facilitate dissection without requiring cystic duct cannulation. Achieving the "critical view of safety" with assistance of ICG cholangiogram may support identification of anatomy, safely reduce conversion to open procedures, and decrease operative time. We assess the utility of FC with respect to anatomic visualization during LC and its effects on patient outcomes.

METHODS

A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy at a single academic center from 2013 to 2019. Exclusion criteria were primary open and single incision cholecystectomy. Patient factors included age, sex, BMI, and Charlson Comorbidity Index. Outcomes included operative time, conversion to open procedure, length of stay (LOS), mortality rate, and 30-day complications. A multivariable logistic regression was performed to determine independent predictors for open conversion.

RESULTS

A total of 1389 patients underwent laparoscopic cholecystectomy. 69.8% were female; mean age 48.6 years (range 15-94), average BMI 29.4 kg/m² (13.3-55.6). 989 patients (71.2%) underwent LC without fluorescence and 400 (28.8%) underwent FC with ICG. 30-day mortality detected 2 cases in the non-ICG group and zero with ICG. ICG reduced operative time by 26.47 min per case (p < 0.0001). For patients with BMI ≥ 30 kg/m², operative duration for ICG vs non-ICG groups was 75.57 vs 104.9 min respectively (p < 0.0001). ICG required conversion to open at a rate of 1.5%, while non-ICG converted at a rate of 8.5% (p < 0.0001). Conversion rate remained significant with multivariable analysis (OR 0.212, p = 0.001). A total of 19 cases were aborted (1.35%), 8 in the ICG group (1.96%) and 11 in the non-ICG group (1.10%), these cases were not included in LC totals. Average LOS was 0.69 vs 1.54 days in the ICG compared to non-ICG LCs (p < 0.0001), respectively. Injuries were more common in the non-ICG group, with 9 patients sustaining Strasberg class A injuries in the non-ICG group and 2 in the ICG group. 1 CBDI occurred in the non-ICG group. There was no significant difference in 30-day complication rates between groups.

CONCLUSION

ICG cholangiography is a non-invasive adjunct to laparoscopic cholecystectomy, leading to improved patient outcomes with respect to operative times, decreased conversion to open procedures, and shorter length of hospitalization. Fluorescence cholangiography improves visualization of biliary anatomy, thereby decreasing rate of CBDI, Strasberg A injuries, and mortality. These findings support ICG as standard of care during laparoscopic cholecystectomy.

Clinical presentation and outcomes of cholecystectomy for acute cholecystitis in patients with diabetes - A matched pair analysis. A pilot study

PURPOSE

The primary aim of this study is to compare the clinical course and laboratory parameters of acute cholecystitis in patients with diabetes vs. patients without diabetes.

MATERIALS AND METHODS

The study involved patients who underwent emergency cholecystectomy in the Department of General, Endocrine and Transplant Surgery of University Clinical Center in Gdansk (Poland) between 2007 and 2017. There were 267 patients included in the study. The control group of 197 patients was age and sex matched at a 3:1 ratio. The following was compared between the groups: symptoms at admission, course of surgery, postoperative course, length of hospitalization, total costs of hospitalization and antibiotic therapy, other than routine perioperative prophylaxis.

RESULTS

There was no significant difference between the patients with and without diabetes regarding symptoms at admission. Operative and postoperative complication rates were significantly higher in the patients with diabetes. The operative time and length of hospitalization were significantly longer in the study group. The conversion rate was not higher in the study group, but classic surgery was performed significantly more often. The patients without diabetes had less pronounced symptoms with more locally advanced disease.

CONCLUSIONS

Our study demonstrates that patients with diabetes have a significantly more eventful course of acute cholecystitis than patients without diabetes. Patients with diabetes should therefore be qualified for cholecystectomy early in the course of acute cholecystitis.

Sustaining a laparoscopic program in resource-limited environments: results and lessons learned over 13 years in Botswana

BACKGROUND

Metrics of sustainability and frank descriptions of the unique challenges, successes, failures, and lessons learned from a longitudinal laparoscopic program in resource-limited environments are lacking. We set out to evaluate the safety and sustainability of the laparoscopic cholecystectomy program at Princess Marina Hospital, the largest tertiary and teaching hospital in Botswana.

METHODS

We assessed the clinical outcomes of patients who underwent laparoscopic cholecystectomy, comparing them with patients who underwent open cholecystectomy from January 2013 to December 2018. Technical independence and sustainability factors were measured and discussed.

RESULTS

Two hundred and twenty-six laparoscopic cholecystectomies (LC) and 39 open cholecystectomies (OC) were performed. Four surgeons who trained as part of the inaugural laparoscopic program performed 48.2% of LC. Eleven surgeons who trained elsewhere performed the remainder. Overall, 94.2% of LC were performed without expatriate surgeons. The conversion rate was 25/226 (11.1%). There were 3 bile duct injuries in the LC group (3/226, 1.3%) and none in the OC group. There was one mortality in the OC group (1/39, 2.6%) and none in the LC group. Fostering a trusting relationship among all stakeholder was identified as the major key to success, while the development of a system-based strategy was identified as the most significant ongoing challenge.

CONCLUSION

The laparoscopic cholecystectomy program in Botswana initially established between 2006 and 2012 has moved into its sustainability phase, characterized by increased usage of laparoscopy and greater independent operating by local surgeons, all while maintaining patient safety. Sustaining a laparoscopic program in resource-limited environments has particular challenges which may differ from country to country.

Identification of risk factors for open conversion from laparoscopic cholecystectomy for acute cholecystitis based on computed tomography findings

PURPOSE

Laparoscopic cholecystectomy (LC) is performed widely for acute cholecystitis (AC). This study was conducted to identify the predictors for conversion cholecystectomy (CC) for AC.

METHODS

The subjects of this study were 395 patients who underwent emergency surgery for AC between 2011 and 2019. Univariate and multivariate analyses were performed to establish the significance of the risk factors for CC in patients with grades II and III AC.

RESULTS

There were 162 TG18 GII and GIII patients in the LC group and 31 in the CC group. Univariate analysis revealed significant differences in performance status (p = 0.039), C-reactive protein levels (p = 0.016), albumin levels (p = 0.002), gallbladder (GB) wall thickness (p = 0.045), poor contrast of the GB wall (p = 0.035), severe inflammation around the GB (p < 0.001), enhancement of the liver bed (p = 0.048), and duodenal edema (p < 0.001) between the groups. Multivariate analysis identified hypoalbuminemia (p = 0.043) and duodenal edema (p = 0.014) as independent risk factors for CC.

CONCLUSIONS

Most patients with grade I AC underwent LC and had better surgical outcomes than those with grades II and III AC. The most appropriate surgical procedure should be selected based on preoperative imaging of the GB and the neighboring organs and by the presence of hypoalbuminemia.

Laparoscopic cholecystectomy: which predicting factors of conversion? Two Italian center's studies

BACKGROUND

Laparoscopic cholecystectomy represents the gold standard technique for the treatment of lithiasic gallbladder disease. Although it has many advantages, laparoscopic cholecystectomy is not risk-free and in special situations there is a need for conversion into an open procedure, in order to minimize postoperative complications and to complete the procedure safely. The aim of this study was to identify factors that can predict the conversion to open cholecystectomy.

METHODS

We analyzed 1323 patients undergoing laparoscopic cholecystectomy over the last five years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome. Among these, 116 patients (8.7%) were converted into laparotomic cholecystectomy. Clinical, demographic, surgical and pathological data from these patients were included in a prospective database. A univariate analysis was performed followed by a multivariate logistic regression.

RESULTS

On univariate analysis, the factors significantly correlated with conversion to open were the ASA score higher than 3 and the comorbidity, specifically cardiovascular disease, diabetes and chronic renal failure (P<0.001). Patients with a higher mean age had a higher risk of conversion to open (61.9±17.1 vs. 54.1±15.2, P<0.001). Previous abdominal surgery and previous episodes of cholecystitis and/or pancreatitis were not statistically significant factors for conversion. There were four deaths in the group of converted patients and two in the laparoscopic group (P<0.001). Operative morbility was higher in the conversion group (22% versus 8%, P<0.001). Multivariate analysis showed that the factors significantly correlated to conversion were: age <65 years old (P=0.031 OR: 1.6), ASA score 3-4 (P=0.013, OR:1.8), history of ERCP (P=0.16 OR:1.7), emergency procedure (P=0.011, OR:1.7); CRP higher than 0,5 (P<0.001, OR:3.3), acute cholecystitis (P<0.001, OR:1.4). Further multivariate analysis of morbidity, postoperative mortality and home discharge showed that conversion had a significant influence on overall post-operative complications (P=0.011, OR:2.01), while mortality (P=0.143) and discharge at home were less statistically influenced.

CONCLUSIONS

Our results show that most of the independent risk factors for conversion cannot be modified by delaying surgery. Many factors reported in the literature did not significantly impact conversion rates in our results.

Percutaneous cholecystostomy as treatment for acute cholecystitis: What has happened over the last five years? A literature review

Acute cholecystitis is one of the most frequent diseases faced by the general surgeon. In recent decades, different prognostic factors have been observed, and effective treatments described, to improve the results in patients with said pathology (lower morbidity and mortality, shorter hospital stay, and minimum conversion of laparoscopic to open procedures). In general, laparoscopic cholecystectomy is the standard treatment for acute cholecystitis, but it is not exempt from complications, especially in patients with numerous comorbidities or those that are critically ill. Percutaneous cholecystostomy emerged as a less invasive alternative for the treatment of acute cholecystitis in patients with organ failure or a prohibitive surgical risk. Even though it is an effective procedure, its usefulness and precise indications are subjects of debate. In addition, there is little evidence on cholecystostomy catheter management. We carried out a review of the literature covering the main aspects physicians involved in the management of acute cholecystitis should be familiar with.

Preoperative and Operative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy in Pakistan

Introduction

The currently available literature suggests a wide range of conversion (4.9-20%) from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) despite the increase in surgical expertise. Open cholecystectomy is important as the last resort for safe surgical practice in complicated cases. Increased number of pre-operative and perioperative risk factors need to be identified to pre-empt conversion. However, there has been a significant decrease in conversion rates over the past few decades. This study was conducted to determine conversion rates in our population and to identify any significant risks for conversion.

Methods

This prospective study was conducted at the Shifa International Hospital, Islamabad, Pakistan, including 1081 cholecystectomies, performed over a two-year period from January 2017 to January 2019. Comparison of risk factors between the two groups; laparoscopic cholecystectomy (LC) group and conversion to open cholecystectomy (OC) group was done. Statistical analysis was done using SPSS 24.0.1. P<0.05 were considered significant.

Results

In our study, the overall conversion rate was 7.78%. Factors of conversion to open cholecystectomy (OC) included age ≥65, morbid obesity, diabetes mellitus, and previous abdominal surgery. Deranged alkaline phosphatase (ALP), increased total bilirubin, increased common bile duct (CBD) diameter, and multiple stones in ultrasonography showed a statistically significant association with the conversion. Per-operative findings of increased adhesions >50%, empyema gallbladder (GB), perforated GB, and scleroatrophic GB showed a higher risk of conversion too (p <0.05). However, there was no statistical association with preoperative endoscopic retrograde cholangiopancreatography (ERCP) to OC in our population.

Conclusion

An open cholecystectomy is a safe approach for patients with complicated gallbladder disease. No doubt laparoscopic cholecystectomy is the gold standard having its outstanding benefits. This study identifies predictors of choice for OC in addition to the decision to convert to OC. In view of the raised morbidity and mortality associated with open cholecystectomy, distinguishing these predictors will serve to decrease the rate of OC and to address these factors preoperatively.

Predicting Conversion from Laparoscopic to Open Cholecystectomy: A Single Institution Retrospective Study

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard surgical treatment for benign gallbladder disease. Nevertheless, conversion to open cholecystectomy (OC) is needed in some cases. The aim of this study is to calculate our institutional conversion rate and to identify the variables that are implicated in increasing the risk of conversion (LC-OC).

MATERIALS AND METHODS

We carried out a retrospective study of all cases of LC performed at the American University of Beirut Medical Center between 2000 and 2015. Each (LC-OC) case was randomly matched to a laparoscopically completed case by the same consultant within the same year of practice, as the LC-OC case, in a 1:5 ratio. Forty-eight parameters were compared between the two study groups.

RESULTS

Forty-eight out of 4668 LC were converted to OC over the 15-year study period; the conversion rate in our study was 1.03%. The variables that were found to be most predictive of conversion were male gender, advanced age, prior history of laparotomy, especially in the setting of prior gunshot wound, a history of restrictive or constrictive lung disease and anemia (Hb < 9 g/dl). The most common intraoperative reasons for conversion were perceived difficult anatomy or obscured view secondary to severe adhesions or significant inflammation. Patients who were in the LC-OC arm had a longer length of hospital stay.

CONCLUSION

Advance age, male gender, significant comorbidities and history of prior laparotomies have a high risk of conversion. Patients with these risk factors should be counseled for the possibility of conversion to open surgery preoperatively. Further research is needed to determine whether these high risks patients should be operated on by surgeons with more extensive experience in minimal invasive surgery.

Risk Factors for Open Conversion in Minimally Invasive Cholecystectomy

Background and Objectives:

Open conversion (OC) occurs in 5 to 10% of laparoscopic cholecystectomies (LCs) and results in suboptimal outcomes. Herein, we report our experience with OC in cholecystectomy performed with the minimally invasive (MIS) approach.

Methods:

Data from 960 minimally invasive cholecystectomies performed in the University of Illinois at Chicago (UIC) Division of General, Minimally Invasive, and Robotic Surgery were retrospectively compiled. Patient demographics and outcomes were analyzed for the major indicators that may predispose to OC.

Results:

Male gender and intraoperative diagnosis of acute or gangrenous cholecystitis were identified as statistically significant individual predictors for OC. Conversion incidence was significantly lower in every paired demographic combination when compared with the laparoscopic data.

Conclusions:

Our retrospective study identified some specific factors associated with significantly higher risk of OC in both laparoscopic and robotic cholecystectomy. The impact of these risk factors seems to be lesser in the robotic than in the laparoscopic approach. Further investigation is necessary to validate these findings.

External validation of the Cairns Prediction Model (CPM) to predict conversion from laparoscopic to open cholecystectomy

BACKGROUND

Valid and user-friendly prediction models for conversion to open cholecystectomy allow for proper planning prior to surgery. The Cairns Prediction Model (CPM) has been in use clinically in the original study site for the past three years, but has not been tested at other sites.

METHODS

A retrospective, single-centred study collected ultrasonic measurements and clinical variables alongside with conversion status from consecutive patients who underwent laparoscopic cholecystectomy from 2013 to 2016 in The Townsville Hospital, North Queensland, Australia. An area under the curve (AUC) was calculated to externally validate of the CPM.

RESULTS

Conversion was necessary in 43 (4.2%) out of 1035 patients. External validation showed an area under the curve of 0.87 (95% CI 0.82-0.93, p = 1.1 × 10^-14).

CONCLUSIONS

In comparison with most previously published models, which have an AUC of approximately 0.80 or less, the CPM has the highest AUC of all published prediction models both for internal and external validation.

Impact of obesity on surgical outcome after single-incision laparoscopic cholecystectomy

Introduction:

Single-incision laparoscopic cholecystectomy (SILC) is widely used as a treatment option for gallbladder disease. However, obesity has been considered a relative contraindication to this approach due to more advanced technical difficulties. The aim of this report was to review our experience with SILC to evaluate the impact of body mass index (BMI) on the surgical outcome.

Patients and Methods:

Between May 2009 and February 2013, 237 patients underwent SILC at our institute. Pre- and post-operative data of the 17 obese patients (O-group) (BMI ≥30 kg/m²) and 220 non-obese patients (NO-group) (BMI <29.9 kg/m²) were compared retrospectively. SILC was performed under general anaesthesia, using glove technique. Indications for surgery included benign gallbladder disease, except for emergent surgeries.

Results:

Mean age of patients was significantly higher in the NO-group than O-group (58.9 ± 13.5 years vs. 50.8 ± 14.0 years, P = 0.025). SILC was successfully completed in 233 patients (98.3%). Four patients (1.7%) in the NO-group required an additional port, and one patient was converted to an open procedure. The median operative time was 70 ± 25 min in the NO-group and 75.2 ± 18.3 min in the O-group. All complications were minor, except for one case in the NO-group that suffered with leakage of the cystic duct stump, for which endoscopic nasobiliary drainage was need.

Conclusion:

Our findings show that obesity, intended as a BMI ≥30 kg/m², does not have an adverse impact on the technical difficulty and post-operative outcomes of SILC. Obesity-related comorbidities did not increase the risks for SILC.

The utilization of fluorescent cholangiography during robotic cholecystectomy at an inner-city academic medical center

In recent years, fluorescent cholangiography using Indocyanine green (ICG) dye has been used to aid identification of structures during robotic cholecystectomy. We sought to compare cholecystectomy with ICG dye versus laparoscopic cholecystectomy at an inner-city academic medical center. Between January 2013 and July 2016, we identified 287 patients of which 191 patients underwent laparoscopic cholecystectomy and 96 patients underwent robotic cholecystectomy with ICG dye. Preoperative risk variables of interest included age, sex, race, body mass index (BMI), and acute cholecystitis. Primary outcome of interest was conversion to open procedures while secondary outcome was length of stay. The two groups were similar in their BMI (31.98 vs. 31.10 kg/m² for the laparoscopic and robotic, respectively, p = 0.32). The laparoscopic group had a greater mean age compared to the robotic group (47.77 vs. 43.61 years, p = 0.04). There was no significant difference in sex and emergency surgery between the two groups. Fewer open conversions were found in the robotic than the laparoscopic group [2 (2.1%) vs. 17 (8.9%), p = 0.03]. In multiple logistic regression, robotic cholecystectomy with ICG also showed a lower risk of conversion compared to laparoscopic cholecystectomy, but the difference did not reach statistical significance (OR 0.42, 95% CI 0.11-1.65, p = 0.22). ICG fluorescent cholangiography during robotic cholecystectomy may contribute to proper identification of biliary structures and may reduce the rates of open conversion. The preliminary results of fewer open conversions are promising. Further studies with a large randomized prospective controlled study should be taken for further evaluation.

Concurrent Biliary Disease Increases the Risk for Conversion and Bile Duct Injury in Laparoscopic Cholecystectomy: A Retrospective Analysis at a County Teaching Hospital

Biliary tract disease remains a common indication for operative intervention. The incidence of concurrent biliary tract disease (>2 biliary tract disease processes) is unknown and the impact of more than one biliary tract diagnosis on outcomes remains to be defined. The objective of this study was to determine the effect of concurrent biliary tract disease on conversion rate and outcomes after laparoscopic cholecystectomy. A 5-year retrospective analysis of all patients who underwent a laparoscopic cholecystectomy was performed comparing those with a single biliary diagnosis to patients with concurrent biliary tract disease. Variables analyzed were conversion to open cholecystectomy, incidence of bile duct injury, use of endoscopic retrograde cholangiopancreatography and/or intraoperative cholangiogram, length of surgery, and duration of hospitalization. The incidence of concurrent biliary tract disease was 9 per cent and a conversion to open cholecystectomy was performed in 16 per cent of patients. After adjusting for confounding factors, concurrent biliary tract disease was predictive of conversion (odds ratio 1.6, 95% confidence interval 1.1–2.3, P = 0.03) and bile duct injury (odds ratio 2.5, 95% confidence interval 0.8–5, P = 0.01). Concurrent biliary tract disease patients were more likely to undergo intraoperative cholangiogram or endoscopic retrograde cholangiopancreatography, as well as longer operation and length of stay.

Risk factors for conversion of laparoscopic cholecystectomy to open surgery - A systematic literature review of 30 studies

BACKGROUND

The study aims to evaluate the methodological quality of publications relating to predicting the need of conversion from laparoscopic to open cholecystectomy and to describe identified prognostic factors.

METHOD

Only English full-text articles with their own unique observations from more than 300 patients were included. Only data using multivariate analysis of risk factors were selected. Quality assessment criteria stratifying the risk of bias were constructed and applied.

RESULTS

The methodological quality of the studies were mostly heterogeneous. Most studies performed well in half of the quality criteria and considered similar risk factors, such as male gender and old age, as significant. Several studies developed prediction models for risk of conversion. Independent risk factors appeared to have additive effects.

CONCLUSION

A detailed critical review of studies of prediction models and risk stratification for conversion from laparoscopic to open cholecystectomy is presented. One study is identified of high quality with a potential to be used in clinical practice, and external validation of this model is recommended.

Prediction of Surgical Difficulty in Laparoscopic Cholecystectomy for Acute Cholecystitis Performed Within 24 Hours After Hospital Admission

The objective of this study was to identify preoperative factors predicting operative difficulty in patients who underwent laparoscopic cholecystectomy for acute cholecystitis within 24 hours after hospital admission. Many reports have described the superiority of performing laparoscopic cholecystectomy in the early phase of acute cholecystitis. Recently, even earlier cholecystectomy within 24 hours after hospital admission has been recommended. However, the factors that influence surgical difficulty in this patient population have not been well scrutinized. We analyzed patients who underwent laparoscopic cholecystectomy for acute cholecystitis within 24 hours of hospital presentation from 2007 to 2015. The primary outcome was the operation time. We also analyzed the amount of blood loss and the rate of conversion to open surgery. Seventy-three patients were enrolled. Mean age at surgery was 66 ± 16 years, and 52 patients were male. The mean operation time was 128 ± 59 minutes. Body mass index ≥25 kg/m2 [odds ratio (OR) = 3.6; 95% confidence interval (CI): 1.4–30.9] and dirty fat sign on preoperative computed tomography (OR = 5.3; 95% CI: 1.0–34.2) were significantly associated with increased operative time. Dirty fat sign was also significantly associated with increases in the amount of blood loss and conversion rate. Surgery should be performed more carefully in patients with these risk factors in laparoscopic cholecystectomy for acute cholecystitis performed within 24 hours of hospital presentation.

Is the male gender an independent risk factor for complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis?

This paper was designed to investigate the gender dependent risk of complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. Laparoscopic cholecystectomy is the standard procedure for benign gallbladder disorders. The role of gender as an independent risk factor for complicated laparoscopic cholecystectomy remains unclear. A retrospective single-center analysis of laparoscopic cholecystectomies performed for acute cholecystitis over a 5-year period in a community hospital was performed. Within the period of examination, 1884 laparoscopic cholecystectomies were performed. The diagnosis was acute cholecystitis in 779 cases (462 female, 317 male). The male group was significantly older (P = 0.001). Surgery lasted significantly longer in the male group (P = 0.008). Conversion was done in 35 cases (4.5%). There was no significant difference in the rate of conversion between both groups. However the rate of conversion was significantly higher in male patients > 65 years (P = 0.006). The length of postoperative hospital stay was significantly longer in the male group (P = 0.007), in the group > 65 years (P = 0.001) and following conversion to open surgery (P = 0.001). The male gender was identified as an independent risk factor for prolonged laparoscopic cholecystectomy on multivariate analysis. The male gender could be an independent risk factor for complicated or challenging surgery in patients undergoing laparoscopic cholecystectomy for acute cholecystitis.

Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a validated risk score derived from a prospective U.K. database of 8820 patients

BACKGROUND

Laparoscopic cholecystectomy is commonly performed, and several factors increase the risk of open conversion, prolonging operating time and hospital stay. Preoperative stratification would improve consent, scheduling and identify appropriate training cases. The aim of this study was to develop a validated risk score for conversion for use in clinical practice.

PATIENTS AND METHODS

Preoperative patient and disease-related variables were identified from a prospective cholecystectomy database (CholeS) of 8820 patients, divided into main and validation sets. Preoperative predictors of conversion were identified by multivariable binary logistic regression. A risk score was developed and validated using a forward stepwise approach.

RESULTS

Some 297 procedures (3.4%) were converted. The risk score was derived from six significant predictors: age (p = 0.005), sex (p < 0.001), indication for surgery (p < 0.001), ASA (p < 0.001), thick-walled gallbladder (p = 0.040) and CBD diameter (p = 0.004). Testing the score on the validation set yielded an AUROC = 0.766 (p < 0.001), and a score >6 identified patients at high risk of conversion (7.1% vs. 1.2%).

CONCLUSION

This validated risk score allows preoperative identification of patients at six-fold increased risk of conversion to open cholecystectomy.

Preoperative hypoalbuminemia is an independent risk factor for conversion from laparoscopic to open cholecystectomy in patients with cholecystolithiasis

INTRODUCTION

Laparoscopic cholecystectomy (LC) is regarded as the first choice for patients with cholecystolithiasis, but some patients require conversion to open cholecystectomy (OC) because of inflammation-related incidents. Therefore, the aim of this study is to explore the risk factors for conversion to OC in patients undergoing elective LC for cholecystolithiasis.

METHODS

This study included 461 patients who underwent elective LC for cholecystolithiasis were between April 2000 and September 2010. Receiver-operator curve (ROC) analysis was used to define the ideal cut-off values of clinicolaboratory characteristics, and the area under the ROC for conversion was also measured. Univariate and multivariate analyses using preoperative clinicolaboratory characteristics were performed to investigate the most significant risk factors for conversion to OC in patients with cholecystolithiasis.

RESULTS

Multivariate analysis using nine parameters selected by univariate analyses demonstrated that γ-glutamyltransferase (<20/>20 IU/L) (odds ratio, 8.777; 95% confidence interval, 1.132-68.06; P = 0.038), albumin (<3.8/>3.8 g/dL) (odds ratio, 0.329; 95% confidence interval, 0.127-0.850; P = 0.022), and platelet count (<27/>27 × 10⁴ /mm³ ) (odds ratio, 2.573; 95% confidence interval, 1.048-6.319; P = 0.039) were associated with conversion. Among these three parameters, ROC curve analysis disclosed that albumin (0.705) had the largest area under the ROC (γ-glutamyltransferase, 0.622, platelet count, 0.536) for conversion.

CONCLUSIONS

Preoperative hypoalbuminemia is the most important risk factor for conversion to OC in patients undergoing elective LC for cholecystolithiasis.

Preoperative factors predicting the need for additional ports during single-incision laparoscopic cholecystectomy

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) is gaining popularity as a minimally invasive technique that provides some benefits in terms of improved cosmesis. However, the insertion of an additional port is required in a subset of cases.

METHODS

We retrospectively analyzed 308 SILC procedures in patients with benign gallbladder diseases, except acute cholecystitis, to identify preoperative factors predicting the need for an additional port.

RESULTS

SILC was completed with a single incision in 272 patients (88%); the insertion of at least one additional port was required in 36 patients (12%). The additional port requirement was associated with a longer operative time (P < 0.0001), greater intraoperative blood loss (P < 0.0001), and longer postoperative hospital stay (P = 0.0002). Multivariate analysis revealed male gender (odds ratio: 2.57, P = 0.0170), prior history of upper abdominal surgery (odds ratio: 5.53, P = 0.0132), and a higher preoperative white blood cell count (odds ratio: 3.62, P = 0.0244) to be independent factors associated with the requirement for an additional port.

CONCLUSION

Our results suggest that gender, prior history of upper abdominal surgery, and white blood cell count can predict the likelihood of requiring an additional port in SILC.

How to predict difficult laparoscopic cholecystectomy? Proposal for a simple preoperative scoring system

BACKGROUND

Few studies have used operative time as a reflection of the surgical difficulty to create a preoperative score of operative difficulty in laparoscopic cholecystectomies (DiLCs score).

METHODS

Patients who benefited from cholecystectomy between 2010 and 2015 were reviewed. Difficult procedures were identified using the deviations from the operative time for simple cholecystectomies. Logistic regression analyses were carried out to build risk-assessment models and derive the DiLC score.

RESULTS

Overall, 644 patients were identified. Multivariate analyses identified male sex, previous cholecystitis attack, fibrinogen, neutrophil, and alkaline phosphatase count to be predictive of operative difficulties. Risk-assessment model was generated with an area under the receiver-operator curve of .80. Internal validation was performed using the bootstrap method.

CONCLUSIONS

The DiLC score is a simple and reliable tool which could be used to improve patient counseling, optimize surgical planning, detect procedures at risk, identify patients eligible for outpatient care, and enhance resident training.

[Not Available]

OBJECTIVES

Database review to analyse age and sex differences in complication and conversion rates and influence on return to normal daily activities and work after laparoscopic cholecystectomy (LC).

METHODS

658 patients had a laparoscopic cholecystectomy for proven gallstones between 9/4/2001 and 15/2/2006 under the care of one surgeon (F. H.) at Benenden hospital, Kent, UK.

RESULTS

We had a 65.5% response rate with 431 replies at a mean follow up of 22.4 months (2.3-52.8). There was a male to female ratio of 5:23 with a mean age of 54.2 years (22-83). Using linear regression we found no significant correlation with operative time and variables of age and sex (df = 2, 251, R (2) = 0.03, F = 0.574, p < 0.564). No significant correlation with number of complications and age or sex (df = 2, 334, R (2) = 0.004, F = 1.615, p < 0.200). Age (Exp(B) = 1.040, p < 0.51) and sex (Exp(B) = 0.863, p < 0.855) had no effect on conversion. No difference was found in relation to age and sex with return to normal daily activities (df = 2, 307, F = 0.904, p < 0.406). Age was a non-significant predictor of return to work (Beta = 0.040, p < 0.572) however men return to work significantly sooner (Beta = 0.191, p < 0.007).

CONCLUSIONS

Operative time, number of complications, conversion to open and return to normal daily activities may not be affected by age or sex of patients. Hospital stay may be longer in older patients. Men appear to return to work sooner. Further analysis with validated questionnaires are required.

Single-Site Robotic Cholecystectomy at an Inner-City Academic Center

Introduction:

We investigate the safety and efficacy of single-site robotic cholecystectomy compared to laparoscopic cholecystectomy at an inner-city academic medical center.

Materials and Methods:

Retrospective analysis comparing single-site robotic to laparoscopic cholecystectomies from August 1, 2013, to January 31, 2015, was conducted. Age, gender, race, body mass index (BMI), total operative time (docking and console time for robotic cases), length of stay, comorbidities, and conversion to open procedures were examined. The χ² and Student's t test were used for categorical and continuous data, respectively. A P ≤ 0.05 was considered statistically significant.

Results:

From August 2013 to January 2015, 70 single-site robotic cholecystectomies and 70 laparoscopic cholecystectomies were performed. Patients were older (mean age, 40.3 years vs 47.6 years; P = .0084), had a higher mean BMI (29.5 vs 32.4 kg/m²; P = .011), and had a higher assigned ASA (American Society of Anesthesiologists) classification (P = .024) in the laparoscopic than in the single-site group. Hypertension was more common in the laparoscopic group (P = .0078). Average docking time was 11.5 (SD 5.7) minutes, and the average console time was 52.8 (SD 22.5) minutes in the single-site group. Total operating time for the laparoscopic and single-site groups was not significantly different (111.5 minutes vs 106.0 minutes; P = .38). There were more conversions to open procedures in the laparoscopic compared to the single-site group (11 vs 1; P = .007). There were no biliary tree injuries and no deaths in either group.

Conclusion:

Single-site robotic cholecystectomy is safe to perform in an inner-city academic hospital setting. Surgical resident involvement does not adversely affect outcomes.