Laparoscopic cholecystectomy after a quarter century: why do we still convert?

Abstract

Background Laparoscopic cholecystectomy (LC) is the gold standard procedure for gallbladder removal. However, conversion to open surgery is sometimes needed. The factors underlying a surgeon's decision to convert a laparoscopic case to an open case are complex and poorly understood. With decreasing experience in open cholecystectomy, this procedure is however no longer the “safe” alternative it once was. With such an impending paradigm shift, this study aimed to identify the main reasons for conversion and ultimately to develop guidelines to help reduce the conversion rates. Methods Using the National Surgical Quality Improvement Program (NSQIP) database and financial records, the authors retrospectively reviewed 1,193 cholecystectomies performed at their institution from 2002 to 2009 and identified 70 conversions. Two independent surgeons reviewed the operative notes and determined the reasons for conversion. The number of ports at the time and the extent of dissection before conversion were assessed and used to create new conversion categories. Hospital length of stay (LOS), 30-day complications, operative times and charges, and hospital charges were compared between the new groups. Results In 91% of conversion cases, the conversion was elective. In 49% of these conversions, the number of ports was fewer than four. According to the new conversion categories, most conversions were performed after minimal or no attempt at dissection. There were no differences in LOS, complications, operating room charges, or hospital charges between categories. Of the six emergent conversions (9%), bleeding and concern about common bile duct (CBD) injury were the main reasons. One CBD injury occurred. Conclusions In 49% of the cases, conversion was performed without a genuine attempt at laparoscopic dissection. Considering this new insight into the circumstances of conversion, the authors recommend that surgeons make a genuine effort at a laparoscopic approach, as reflected by placing four ports and trying to elevate the gallbladder before converting a case to an open approach.

Risk Factors for Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis

“…In converted cases, the extent of dissection before conversion was classified as minimal, some, and extensive dissection, according to a previous report. 14 …”

Risk Factors for Conversion during Laparoscopic Cholecystectomy: Retrospective Analysis of Ten Years' Experience at a Single Tertiary Referral Centre

“…Conversion to OC may be required in about 5-10% [5,6,7,8,9,10,11]. Many causes for conversion have been reported in the literature, including patient-related and disease-related factors, and some reports outlined different risk factors for conversion to OC [4,9,12].…”

Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul‐de‐sac or the birth pangs of a new technical framework?

“…Both open conversion and fundus-first technique are controversial as to whether they are useful in avoiding or reducing the risk of BDI. Lengyel et al [46] did not find a significant difference in the complication rate between laparoscopic and open conversion groups and concluded that open conversion should be determined only after surgeons make a genuine effort at a laparoscopic approach. All extreme vasculobiliary injuries reported by Strasberg and Gouma [47] occurred during conversion to an open cholecystectomy and fundus-first technique, raising a red flag to rely on these procedures without knowing their disadvantages.…”