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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 157-160

Role of different factors as preoperative predictors of conversion of laparoscopic cholecystectomy to open cholecystectomy


1 Department of Surgery, Surgical Unit 1, Holy Family Hospital, Rawalpindi, Pakistan
2 Department of Medicine, Shifa College of Medicine, Islamabad, Pakistan

Date of Web Publication15-Dec-2017

Correspondence Address:
Haider Ghazanfar
House Number 19, Askari Villas Chakala Scheme 3, Rawalpindi
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_58_17

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  Abstract 

Aim: Laparoscopic cholecystectomy has become the gold standard for the treatment of gallstones. Background: The objective of our study was to identify the preoperative predictors of conversion of laparoscopic cholecystectomy into open cholecystectomy. Materials and Methods: We carried out a cross-sectional study in the Surgical Unit 1, Holy Family Hospital, Rawalpindi, from September 2016 to February 2017. All patients undergoing laparoscopic cholecystectomy were included in the study. Patients undergoing open cholecystectomy due to the presence of contraindication to laparoscopic cholecystectomy or patients in which laparoscopic cholecystectomy was a part of some other laparoscopic intervention were not included in the study. SPSS version 21 was used to analyze the data. Results: The overall mean age of the patients was 43.67 ± 13.54 years. The male patients were significantly older as compared to the female patients. The conversion rate was higher in patients who had an elevated total leukocyte count and alanine aminotransferase before the operation (P < 0.05). The rate of conversion was significantly higher in male patients aged ≥50 years (P < 0.05). Difficulty in the dissection of the triangle of Calot, difficulty in dissecting the gallbladder fossa, bleeding in gallbladder fossa, presence of duodenal fistula, and autolyzed gangrenous gallbladder were the reasons for the conversion to open cholecystectomy. Conclusion: The rate of conversion of laparoscopic cholecystectomy to open cholecystectomy was found to be 5%. Male patients aged ≥50 years, acalculous acute cholecystitis, acute cholecystitis, elevated preoperative total leukocyte count, and alanine aminotransferase levels were found to be significant predictors of conversion to open cholecystectomy.

Keywords: Conversion, gallbladder disease, laparoscopic cholecystectomy, male


How to cite this article:
Ghazanfar R, Tariq M, Ghazanfar H, Malik S, Changez M, Khan JS. Role of different factors as preoperative predictors of conversion of laparoscopic cholecystectomy to open cholecystectomy. Arch Med Health Sci 2017;5:157-60

How to cite this URL:
Ghazanfar R, Tariq M, Ghazanfar H, Malik S, Changez M, Khan JS. Role of different factors as preoperative predictors of conversion of laparoscopic cholecystectomy to open cholecystectomy. Arch Med Health Sci [serial online] 2017 [cited 2018 May 25];5:157-60. Available from: http://www.amhsjournal.org/text.asp?2017/5/2/157/220828




  Introduction Top


Surgery for gallstones is one of the most common procedures undertaken by general surgeons worldwide.[1] Approximately 15% of the adult population is affected by gallstones. About 80% of the patients with gallstones remain asymptomatic. The rate of becoming symptomatic increased by 1% every year. Ever since its advent in 1985, laparoscopic cholecystectomy has established itself as a gold standard treatment option in terms of economy, better cosmetic results, and earlier return to work.[1] According to a nationwide study done in North America, approximately 75% of all cholecystectomy are performed laparoscopically.[2]

Although technological advances have improved safety profile of this procedure, the chances of life-threatening complications still exist.[3] Although considered a simple procedure, certain factors such as difficulty in creating pneumoperitoneum, dissecting triangle of Calot, and controlling hemorrhage from gallbladder bed can lead to unforeseen circumstances. These might include an increase in operation time, injury to vital structures, and conversion to open procedure. Surgical challenges leading to open cholecystectomy have been one of the major concerns as it can lead to significant morbidity and mortality.[4],[5]

Preoperative sensitization of difficulty can better prepare a surgeon to deal with intraoperative challenges and help the surgeon make an early decision to convert into the open procedure. This might help decrease the chance of various serious complications associated with delayed conversion. The objective of our study was to identify the preoperative predictors of conversion of laparoscopic cholecystectomy into open cholecystectomy. The secondary objective of our study was to determine the causes of conversion to open cholecystectomy.


  Materials and Methods Top


We carried out a cross-sectional study of 400 patients admitted to the Surgical Unit 1, Holy Family Hospital, Rawalpindi, from September 2016 to February 2017. All patients undergoing laparoscopic cholecystectomy were included in the study. Patients undergoing open cholecystectomy due to the presence of contraindication to laparoscopic cholecystectomy or patients in which laparoscopic cholecystectomy was a part of some other laparoscopic intervention were not included in the study. Informed consent was obtained from all the participants. A structured questionnaire was used to collect the demographic data including age, sex, body mass index (BMI), comorbidities, and previous history of gallstones along with preoperative and operative findings from each patient.

All patients underwent general anesthesia for the procedure after receiving a preinduction dose of 1 g ceftriaxone intravenously. The decision to place a nasogastric catheter was taken peroperatively in only those cases where gastric distension effected the surgeon's view of the triangle of Calot. The surgical site was prepared and draped according to the standard protocols. Pneumoperitoneum was created by either close (80%) or open technique (20%). Four standard ports were introduced in all cases. Cystic duct and artery were clipped in all laparoscopic cholecystectomies. The harmonic device was used for dissection in gallbladder bed and to achieve hemostasis. Those who got converted to open, Kocher's left subcostal incision was given and vinyl 2/0 was used to ligate cystic duct and achieve hemostasis. An 18 Fr drain was placed in subhepatic space in all the cases. All procedure details along with peroperative findings were filled in the questionnaire at the end of procedure. The patients who underwent laparoscopic cholecystectomy were discharged within first 24 h postoperatively, while those who underwent conversion were kept for 72 h for intravenous antibiotics and observation.

SPSS version 21 (IBM SPSS Statistics, Armonk, NY) was used to analyze the data. Independent samples t-test was used to analyze the association of gender with age of the participants and duration of the surgery. Chi-square test was used to analyze the association of gender, comorbid, American Society of Anesthesiologists (ASA) grades, BMI, previous abdominal surgeries, previous histories of pancreatitis, acute cholecystitis, and perioperative laboratory findings and diagnosis with the need of conversion to open cholecystectomy. Mann–Whitney test was used to assess the association of conversion to open cholecystectomy with age and preoperative laboratory findings. A P < 0.05 was considered statistically significant.


  Results Top


The overall mean age of the participants was 43.67 ± 13.54 years. Of 400 participants, 62 were males while 336 were females. The mean age of the male participants was 52.37 ± 16.18 years while the mean age of the female participants was 42.02 ± 12.30 years (P = 0.002). A total of 332 participants had a normal BMI while 68 participants were overweight. There was no statistically significant difference in BMI between the male and female participants (P > 0.05). According to the ASA Classification, 344 participants were ASA Class 1 and 2 while 56 participants were ASA Class 3 and 4. There was no statistically significant difference in ASA Class between the female and male participants (P > 0.05). About 108 participants had controlled hypertension while 56 participants had diabetes and 16 participants had the chronic obstructive pulmonary disease. Around 36 participants had a significant cardiac risk factor. There was no statistically significant difference in comorbidities between the female and male participants (P > 0.05). This has been presented in [Table 1].
Table 1: Baseline characteristics of the participants

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Indication for the surgery was acute cholecystitis in 252 (63.0%) participants; acalculous acute cholecystitis in 96 (24.0%) participants, acute cholecystitis with biliary obstruction leading to pancreatitis in 28 (7.0%), and 24 (6.0%) participants had interval cholecystectomy following an episode of acute cholecystitis. Acute cholecystitis with cholecystolithiasis (66.67% vs. 43.75%) was found to be more common in a female, while acute cholecystitis with biliary obstruction leading to pancreatitis (18.75% vs. 4.76%) was found to be more common in males (P < 0.05). This has been presented in [Table 2].
Table 2: Indication for surgery

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The mean number of years of gallstone disease was 1.76 ± 2.80 years. About 72 participants had the previous history of pancreatitis while 28 participants had acute pancreatitis at the time of current admission. Common biliary duct dilation was found in 28 participants while 336 participants had fatty liver. About 24 participants had hepatitis B while 16 participants had hepatitis C. Values of total leukocyte count, amylase, total bilirubin, alanine aminotransferase, and alkaline phosphatase are depicted in [Table 3]. There was no significant difference between these values and gender of the participants (P > 0.05).
Table 3: Preoperative laboratory values

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The mean duration of surgery was found to be 42.94 ± 22.00 min. The mean duration of surgery in male participants was 45.56 ± 20.13 min while the mean duration of surgery in female participants was 42.44 ± 22.29 min. This difference was not found to be significant (P > 0.05). The peroperation findings have been presented in [Table 4].
Table 4: Peroperative findings

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The surgeon faced considerable difficulty in dissecting the triangle of Calot and gallbladder fossa in 156 and 172 participants, respectively. About 132 participants had significant gallbladder fossa bleeding. There was a need to wash gallbladder fossa in 196 participants. The conversion rate was found to be 5%. There was a need to convert to open cholecystectomy in four out of the 64 male participants (6.25%) and 16 out of the 336 female participants (4.76%). The reason for conversion in the four male participants was difficulty in dissection of the triangle of Calot and gallbladder fossa due to the presence of autolyzed gangrenous gallbladder. The reason for conversion in the female participants was difficulty in dissection of triangle of Calot (8 participants), difficulty in dissecting the gallbladder fossa (12 participants), bleeding in gallbladder fossa (4 participants), and presence of duodenal fistula (4 participants).

The rate of conversion was higher in patients who underwent laparoscopy cholecystectomy due to acalculous acute cholecystitis (P = 0.06) and acute cholecystitis (P < 0.001). The conversion rate was higher in patients who had an elevated total leukocyte count (P < 0.001) and alanine aminotransferase (P = 0.033) before the operation. There was no statistically significant difference between the genders in terms of conversion (P > 0.05). After adjusting age, the rate of conversion to open cholecystectomy was found to be significantly higher in male patients ≥50 years as compared to female participants of the same age group (P = 0.033). Overweight patients had a higher conversion rate (6.67%) as compared to patients with normal BMI (4.34%). This difference was not found to be significant (P > 0.05). ASA Class grade was not found to be significantly associated with the conversion rate (P > 0.05). The previous history of pancreatitis and acute cholecystitis was not found to be significantly associated with conversion to open cholecystectomy (P > 0.05).


  Discussion Top


The decision to convert to open cholecystectomy is usually taken after a considerable time has been spent on trying to successfully perform the laparoscopic procedure. A significant delay in this decision can result in increased morbidity and mortality. To prevent these dreadful consequences, a large number of studies have been conducted on the importance of various preoperative predictors in determining the chances of conversion of laparoscopic cholecystectomy to open cholecystectomy.[6] The conversion rate in various studies was found to vary between 2.6% and 7.7%.[7] The conversion rate in our study was found to be 5%, which was similar to the conversion rate found in the majority of the studies.

According to a study conducted in a primary care center, the conversion rate was significantly higher in male patients >65 years of age (P = 0.006).[8] According to another study, male patients were 2.3 times more likely to need conversion to open cholecystectomy as compared to female patients (P = 0.004).[4] According to several other studies, male gender was not found to be an independent risk factor for conversion to open cholecystectomy.[9],[10] In our study, there was no statistically significant difference between the genders in terms of conversion (P > 0.05). Only after adjusting age, the rate of conversion to open cholecystectomy was found to be significantly higher in male patients aged ≥50 years as compared to female participants of the same age group (P = 0.033).

The overall mean age of the participants was 43.67 ± 13.54 years. The male participant's average age was 52.37 ± 16.18 years while female participants' average age was 42.02 ± 12.30 years (P = 0.002). In our study, age was not found to be a significant predictor of conversion rate. This was in contradiction to another study. According to another study, patients older than 65 years were 2.6 times more likely to need conversion (P < 0.002).[4] The difference in our result could be because our study only had 20 patients with age >65.

In our study, acute cholecystitis and acalculous acute cholecystitis were found to be significantly associated with the conversion rate (P < 0.05). According to a retrospective review, a patient with acute cholecystitis was 5.63 times likely to need conversion.[11] This study also concluded that elevated total leukocyte count and alanine aminotransferase were associated with increase conversion rate. Another study done by Oymaci et al. had similar findings.[12] Our study had similar findings. According to our study, active or previous episodes of acute pancreatitis posed neither significant difficulty in dissecting triangle of Calot or gallbladder fossa nor did they play a role in conversion. The same results were endorsed by a recently published study by Guadagni et al.[13]

Obesity is not considered to be a contraindication to laparoscopic procedure; however, several international studies count obesity as one of the most important predictors of difficult cholecystectomy.[14] This may be due to several problems more prevalent in obese such as difficulty in creating pneumoperitoneum, increase fat content in the triangle of Calot, and more chances of bleeding from gallbladder fossa due to associated fatty liver. According to the study by Donkervoort et al., patients with BMI >25 were 3.4 times more likely to need conversion.[4] In our study, no statistically significant association was found between BMI and need to convert. This might be due to the fact that patients with BMI >30 were not included in our study. Another study by Tiong and Oh also concluded that BMI was not associated with the conversion rate.[15]

According to a meta-analysis, diabetes was not found to be significantly associated with the rate of conversion.[16] Another study in America concluded that chronic obstructive pulmonary disease was not significantly associated with conversion rate.[17] In our study, the mean duration of surgery was found to be significantly higher in patients with diabetes (P < 0.001). Hypertension, diabetes, and chronic obstructive pulmonary diseases were not found to be significantly associated with the rate of conversion.

Difficulty in the dissection of triangle of Calot, difficulty in dissecting the gallbladder fossa, bleeding in gallbladder fossa, presence of duodenal fistula, and autolyzed gangrenous gallbladder were the reasons for the conversion to open cholecystectomy. Another study done in Pakistan cited dense adhesions followed by obscure anatomy at Calot's triangle as the most common reason for conversion to open cholecystectomy.[18] A retrospective analysis of 5164 consecutive laparoscopic operations yielded a similar result.[7]


  Conclusion Top


The rate of conversion of laparoscopic cholecystectomy to open cholecystectomy was found to be 5%. Male patients aged ≥50 years, acalculous acute cholecystitis, acute cholecystitis, elevated preoperative total leukocyte count, and alanine aminotransferase levels were found to be significant predictors of conversion to open cholecystectomy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Calland JF, Tanaka K, Foley E, Bovbjerg VE, Markey DW, Blome S, et al. Outpatient laparoscopic cholecystectomy: Patient outcomes after implementation of a clinical pathway. Ann Surg 2001;233:704-15.  Back to cited text no. 1
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Livingston EH, Rege RV. A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg 2004;188:205-11.  Back to cited text no. 2
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Abbasoğlu O, Tekant Y, Alper A, Aydın Ü, Balık A, Bostancı B, et al. Prevention and acute management of biliary injuries during laparoscopic cholecystectomy: Expert consensus statement. Ulus Cerrahi Derg 2016;32:300-5.  Back to cited text no. 3
    
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Donkervoort SC, Dijksman LM, de Nes LC, Versluis PG, Derksen J, Gerhards MF, et al. Outcome of laparoscopic cholecystectomy conversion: Is the surgeon's selection needed? Surg Endosc 2012;26:2360-6.  Back to cited text no. 4
    
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Radunovic M, Lazovic R, Popovic N, Magdelinic M, Bulajic M, Radunovic L, et al. Complications of laparoscopic cholecystectomy: Our experience from a retrospective analysis. Open Access Maced J Med Sci 2016;4:641-6.  Back to cited text no. 5
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Terho PM, Leppäniemi AK, Mentula PJ. Laparoscopic cholecystectomy for acute calculous cholecystitis: A retrospective study assessing risk factors for conversion and complications. World J Emerg Surg 2016;11:54.  Back to cited text no. 6
    
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Genc V, Sulaimanov M, Cipe G, Basceken SI, Erverdi N, Gurel M, et al. What necessitates the conversion to open cholecystectomy? A retrospective analysis of 5164 consecutive laparoscopic operations. Clinics (Sao Paulo) 2011;66:417-20.  Back to cited text no. 7
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Ambe PC, Köhler L. Is the male gender an independent risk factor for complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis? Int Surg 2015;100:854-9.  Back to cited text no. 8
    
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Bazoua G, Tilston MP. Male gender impact on the outcome of laparoscopic cholecystectomy. JSLS 2014;18:50-4.  Back to cited text no. 9
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Al-Mulhim AA. Male gender is not a risk factor for the outcome of laparoscopic cholecystectomy: A single surgeon experience. Saudi J Gastroenterol 2008;14:73-9.  Back to cited text no. 10
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11.
Licciardello A, Arena M, Nicosia A, Di Stefano B, Calì G, Arena G, et al. Preoperative risk factors for conversion from laparoscopic to open cholecystectomy. Eur Rev Med Pharmacol Sci 2014;18:60-8.  Back to cited text no. 11
    
12.
Oymaci E, Ucar AD, Aydogan S, Sari E, Erkan N, Yildirim M, et al. Evaluation of affecting factors for conversion to open cholecystectomy in acute cholecystitis. Prz Gastroenterol 2014;9:336-41.  Back to cited text no. 12
    
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Guadagni S, Cengeli I, Palmeri M, Bastiani L, Bertolucci A, Modesti M, et al. Early cholecystectomy for non-severe acute gallstone pancreatitis: Easier said than done. Minerva Chir 2017;72:91-7.  Back to cited text no. 13
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Goonawardena J, Gunnarsson R, de Costa A. Predicting conversion from laparoscopic to open cholecystectomy presented as a probability nomogram based on preoperative patient risk factors. Am J Surg 2015;210:492-500.  Back to cited text no. 14
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Tiong L, Oh J. Safety and efficacy of a laparoscopic cholecystectomy in the morbid and super obese patients. HPB (Oxford) 2015;17:600-4.  Back to cited text no. 15
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Philip Rothman J, Burcharth J, Pommergaard HC, Viereck S, Rosenberg J. Preoperative risk factors for conversion of laparoscopic cholecystectomy to open surgery - A systematic review and meta-analysis of observational studies. Dig Surg 2016;33:414-23.  Back to cited text no. 16
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Lowndes B, Thiels CA, Habermann EB, Bingener J, Hallbeck S, Yu D, et al. Impact of patient factors on operative duration during laparoscopic cholecystectomy: Evaluation from the national surgical quality improvement program database. Am J Surg 2016;212:289-96.  Back to cited text no. 17
    
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Rashid T, Naheed A, Farooq U, Iqbal M, Barkat N. Conversion of laparoscopic cholecystectomy into open cholecystectomy: An experience in 300 cases. J Ayub Med Coll Abbottabad 2016;28:116-9.  Back to cited text no. 18
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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