Laparoscopic cholecystectomy - Is there a need to convert?

Abstract

Introduction:The difficult gallbladder is the most common ‘difficult’ laparoscopic surgery being performed by general surgeons all over the world and the potential one that places the patient at significant risk. We present our experience of 6147 cases since January 1993 in a single center with respect to conversion to open cholecystectomy.Methods:Patients who underwent laparoscopic cholecystectomy (LC) from January 1993 to December 2004 were analyzed. The cases were analyzed in relation to conversion rate to open surgery, factors affecting the conversion, and completion rate of LC. Patients having absolute contraindications to LC like cardiovascular and pulmonary disease were not included in the study.Results:Out of 6147 cases, 1518 patients (21.5%) were identified as difficult cases. Laparoscopic cholecystectomy was successfully completed in 6125 patients with a completion rate of 99.6%. Laparoscopic procedure had to be converted to the open procedure in 22 patients with a conversion rate of 0.36% of the total LCs performed and 1.66% of the difficult cases. Conversion had to be done due to several reasons.Conclusion:It can be reliably concluded that LC is the preferred method even in the difficult cases. Our study emphasizes that although the rate of conversion to open surgery and complication rate are low in experienced hands the surgeon should keep a low threshold for conversion to open surgery and it should be taken as a step in the interest of the patient rather than be looked upon as an insult to the surgeon.

“Laparoscopic Cholecystectomy: A Single Surgeon’s Experience in some of the Teaching Hospitals of West Bengal”

“…Among the surgical causes, commonest difficulty encountered was frozen Calot's triangle with fibrosed thick walled gall bladder, seen in 92 patients (42 %), while insufficient insufflations due to gas leak was the commonest nonsurgical cause evident in 10 patients (35 %). Similar results have been in earlier studies [7,14,15]. Seventeen (8 %) patients with empyema gall bladder and the patient with Pott's paraplegia who had unresolved inflammation had difficult cholecystectomy.…”

“…Instead of defining "difficult" LC based only on clinico-anatomical situations, we had arbitrarily chosen a time frame for the same (1 h), since instrument failure in this series was an important factor not only prolonging surgery but was also detrimental to the safe completion of the laparoscopic procedure. The incidence of surgical causes of "difficult LC" in our study is similar to that reported in some other previous studies [14,15]. Among the surgical causes, commonest difficulty encountered was frozen Calot's triangle with fibrosed thick walled gall bladder, seen in 92 patients (42 %), while insufficient insufflations due to gas leak was the commonest nonsurgical cause evident in 10 patients (35 %).…”

“…The latter was considerably higher than that reported in some other series [14]. Le et al in a recent study also found that inflammation, adhesions, and anatomic difficulty were the three most common causes of conversion, though their conversion rate was much lower i.e., 2.6 % [19].…”

A comprehensive review of the factors predicting technical difficulty in laparoscopic cholecystectomy

“…Signs of acute cholecystitis were investigated by authors either with clinical signs or laboratory parameters like WBC count. 1,3,4,7,11,13,14 Constantini et al found that a WBC count of greater than 9000 had a statistically significant correlation with conversion whereas Nidoni et al mentioned counts more than 11000 as significant in his study. 1,7 Clinical signs of cholecystitis like pain and fever were found to be significant in prediction of difficulty by all authors, except in study by Constantini et al, where only the elevated WBC count was significant.…”

Laparoscopic Cholecystectomy in Empyema Gall Bladder - Its Safety and Feasibility.

“…[16][17][18][19] As was suggested by Hunter " to get it while its hot" 20 , the safety and feasibility of laparoscopic cholecystectomy has been pushed to its limits as more and more surgeons are performing them in acute cholecystitis. Very few studies have reported its safety profile in Empyema Gall Bladder.…”