Prediction of difficulty and conversion in laparoscopic cholecystectomy

Abstract

Introduction Laparoscopic cholecystectomy is now considered the gold standard for the treatment of symptomatic cholelithiasis. 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. Although the rate of conversion to open surgery and the 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. Various preoperative factors can help in deciding the difficult gallbladder and conversion to open cholecystectomy. The aim of this study is to predict the difficulty of laparoscopic cholecystectomy and the possibility of conversion to open cholecystectomy before surgery using the clinical and ultrasonographic criteria in our set up. Materials and methods A total of 200 patients presenting with symptomatic gall stone disease between January 2011 and June 2012 were included in the study. Every patient included in the study was subjected to the following assessments which were regarded as risk factors for laparoscopic cholecystectomy: patients' characteristics, complaints, history and clinical examination and laboratory data. Results Amongst the 200 patients admitted for laparoscopic cholecystectomy, 47 (23.5%) were male and 153 (76.5%) female, with an average age of 39 years (range 16-62 years).The body mass index ranged from 16.3 to 42.7 with a mean of 32.8 ± 6.28 kg/m 2. Five patients were considered obese (BMI > 35 kg/m 2). Conclusion Male gender, single large stone, thickwalled gallbladder, previous abdominal surgery and contracted gallbladder are the factors that proved to be significant factors in our study.

Preoperative predictors of a difficult laparoscopic cholecystectomy

“…However, the author did not find any significant correlation with surgeon's difficulty or conversion to OC as was also reported by Jethwani et al in their study. 8 16 out of 30 studies reviewed by Hu et al found that older age, more than 60 years or 65 years, was an important risk factor and patients >65 years had three to five-fold chance of conversion to OC. 7 Philip Rothman et al in their meta-analysis concluded that quality of evidence for age as a risk factor for conversion was low.…”

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

“…1 On the same lines, Jetwani et al investigated about role of lower abdominal surgeries in predicting difficulty which was not found to be significant. 8 Vivek et al not also included presence of upper abdominal hernias in their study and found it to be a significant risk factor. 2 They also described that such a history would cause difficulty at the beginning of surgery even at the time of Umbilical port entry and creation of pneumoperitoneum.…”

“…6 Studies by Nidoni et al, Vivek et al, Jethwani et al also found statistical significance in male sex as a risk factor for technical difficulty. 2,7,8 Other authors, though they accept male sex as a risk factor for conversion, could not consolidate it statistically.…”

“…9,10,12 The size of the stone was investigated by Jethwani et al and found to be a significant factor. 8 Larger stones increased the risk of difficulty and conversion. Similarly, multiples stones was proved to be a risk factor by Jethwani et al and Atmaram et al 8,15 Some authors studied the shape and appearance of the gallbladder on Ultrasonogram and while some found that a contracted GB had more chances of conversion intraoperatively, Vivek et al showed that a grossly distended GB too was associated with statistically significant technical difficulty.…”

“…Anomalous anatomy were also a significant factor of intraoperative difficulty. 2,8 As it can be seen, intraoperative factors of difficulty were not uniform among the surgeons, throwing light on the ex-perience of the surgeon. The influence of the surgeon's experience was put into study by Ibrahim et al and Gholipour et al and was found to significantly influence the outcome of surgery.…”