Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates

Abstract

Background Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. Methods Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. Results 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. Conclusion Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.

Subtotal cholecystectomy for difficult acute cholecystitis: how to finalize safely by laparoscopy—a systematic review

“…There was a corresponding increase in LSTC rates, which went from 0.12 to 0.28% [30]. As reported in the literature, in cases in which it is not possible to complete a laparoscopic subtotal cholecystectomy due to advanced fibrosis and inflammation, conversion to the open technique is preferable [31,32]. All young surgeons mainly trained in laparoscopy have to consider it.…”

Factors Leading to Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy

“…Nassar et al 18 presented this idea from a newer perspective which is very much relevant to lower and middle income country like ours with lesser number of trained professionals performing laparoscopic cholecystectomy. They came up with very interesting results.…”

Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies

“…Two cases of bile duct injuries occurred in the whole series but were not converted. They were recognised, stents and drains were inserted, and the patients referred to a liver surgery unit for reconstructive surgery within 24 h. The causes of conversion in the whole series have previously been published [13]. The source of bile leakage was likely to be the cystic duct stump in 11 patients, although reintervention was needed in only 3.…”