MS Part 3 (Thesis) Course Student, BIRDEM General Hospital, Dhaka, Bangladesh7>
Received: 14 February, 2017; Accepted: 19 May, 2017; Published: 22 May, 2017
Faruquzzaman, Doctor, MS Part 3 (Thesis) Course Student, BIRDEM General Hospital, Dhaka, Bangladesh, E-mail:
Faruquzzaman (2017) Contributing Factors and Conversion Prevalence of Laparoscopic Cholecystectomy to Open Surgery. Arch Clin Gastroenterol 3(2): 037-040. 10.17352/2455-2283.000036
© 2017 Faruquzzaman. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Laparoscopic cholecystectomy; Open conversion rate; Causes of conversion
Background: The application of laparoscopic technique for cholecystectomy is expanding very rapidly and now performed in almost all major cities and tertiary level hospitals in our country. The laparoscopic approach brings numerous advantages at the expense of a new set of difficulties leads to open conversion especially in training facilities.
Objective: To determine the rate and associated causative factors of conversion to open cholecystectomy in case of laparoscopic cholecystectomy in our surgical practice.
Methodology: 364 & 387 patients of laparoscopic cholecystectomy in BIRDEM General Hospital, Dhaka, Bangladesh and Khulna Medical College Hospital, Bangladesh were included in this prospective study on the basis of convenient purposive sampling from a period of 30.06.14 to 30.09.16 & 01.01.11 to 30.09.16 respectively.
Result: Among the patients of BIRDEM, 25.5% cases were male and 74.5% patients were female. Mean±SD of age were 43±1.4 and 42±1.7 respectively, whereas among the KMCH patients, 26.1% were male and 73.9% were female. Mean±SD of age were 46±1.3 and 43±1.9 respectively. Among the total 364 cases in BIRDEM, in case of 277 (76.1% approximately), laparoscopic cholecystectomy was done due to chronic cholecystitis whereas in case of KMCH it was 83.2%. The overall conversion rates were 5.2% in BIRDEM and 7.0% in KMCH. Difficulties to define the anatomy of Calot’s triangle is the most important reason for open conversion which were 42.1% and 33.3% in the respective groups. Other important causes were suspicion of CBD injury, bowel injury, cystic artery bleeding, bile duct injury and suspicion of gall bladder cancer. The prevalence rates are relatively higher in male sex, age ≥60 years, in presence of co-morbidities, upper abdominal surgery, acute cholecystitis, history of jaundice, obesity, thickened gall bladder wall on ultrasound and preoperative ERCP which are approximately 8.6%, 9.1%, 6.4%, 9.1%, 8.1%, 9.5%, 8.2%, 7.6% & 7.7% respectively in BIRDEM, whereas these were 8.9%, 7.7%, 7.5%, 10.5%, 10.8%, 9.7%, 9.2%, 8.4% & 9.7% respectively in KMCH.
Conclusion: An appreciation for these predictors of conversion will allow appropriate planning and patient selection by the operating surgeon.
Gall stone disease is a common disease affecting human beings. Langenbach in 1892 done the first cholecystectomy , but the first successful laparoscopic cholecystecomy was done in 1985 by Eric Muhe. Two years later, Philip Mauret improved the method, over the past two decades, laparoscopic cholecystectomy (LC) has become gold standard for the surgical treatment of gallbladder disease. The advantages of LC over open surgery are a shorter hospital stay, less postoperative pain, faster recovery, better cosmoses . The complications encountered during LC are numerous: some that are specific to this unique technique and some that are common to laparoscopic surgery in general. These include complications related to anesthesia; complications related to peritoneal access (e.g., vascular injuries, visceral injuries, and port-site hernia formation); complication related topneumoperitoneum (e.g., cardiac complication, pulmonary complications, and gas embolism); and complications related to thrombo-coagulation. Specific complication of LC are hemorrhage, gall bladder perforation, bile leakage, bile duct injury, and perihepatic collection), and others such as external biliary fistula, wound sepsis, hematoma and foreign body inclusions. Some of these complications and several other factors can necessitate the conversion from LC to open cholecystectomy . The conversion from LC to open cholecystectomy results in a significant change in out-come for the patient because of the higher rate of postoperative complications and the longer hospital stay in addition to the effect and the long term sequel of the cause of conversion itself as in bile duct injury. Conversion to open cholecystectomy is occasionally necessary to avoid or repair injury, delineate confusing anatomic relationships, or treat associated conditions . Therefore, aim of this study is to determine the rate of conversion to open cholecystectomy and associated factors.
Material and Methods
This prospective study was carried out in Surgery Unit 1 of BIRDEM General Hospital, Dhaka, Bangladesh from 30.06.14 to 30.09.16 & in Department of Surgery, Khulna Medical College Hospital (KMCH), Khulna, Bangladesh from 01.01.11 to 30.09.16 with the patients of laparoscopic cholecystectomy. Respective patients of 20 to 80 years age group with ASA I, II or III included as study population. Different pathology (for which operation was done), BMI, co-morbidity were confounding variable here. Patients with congenital anomaly and morbid obesity were excluded from study population. Convenient purposive sampling was used as the sampling technique. Data were processed, presented in tabulated form and discussed with compare & comparison on the basis of statistical analysis.
The age and sex distribution of the study population of BIRDEM General Hospital, Dhaka is presented in table 1 which suggest that majority of the patients were female (74.5%). Mean±SD of age was 43±1.4 and 42±1.7 in case of male and female patients respectively (Table 1). On the other hand, the demographic distribution of the study population of KMCH, Khulna is presented in table 2 which suggest that majority of the patients were female (73.9%). Mean±SD of age was 46±1.3 and 43±1.9 in case of male and female patients respectively.
Majority of the patients of laparoscopic cholecystectomy in BIRDEM were due to chronic cholecystitis (76.1%) followed by 17.0% due to acute cholecystitis. In case of KMCH, these were 83.2% & 9.6% respectively (Table 3).
The results of this study suggests that (Table 4) difficulties to define the anatomy of the intended site initially is the most important reason for open conversion which were 42.1% and 33.3% in the respective groups.
Gender, age, co-morbidities, previous abdominal surgery, acute cholecystitis, History of jaundice, obesity, Gall bladder wall on ultrasound, history of preoperative ERCP etc. are also important and clinically significant relevant factors for the open conversion of laparoscopic cholecystectomy (Table 5).
Laparoscopic cholecystectomy has become the procedure of choice for management of symptomatic gall bladder stone disease [6-10]. The advantages to the patient and the economic benefits to society have been reported . However the risk of conversion to open surgery is always present. The actual rates of conversion reported in the literatures are quite variable [6-10], ranging from 0% to 20%. In our study the conversion rate was 7.3% of the 261 attempted Laparoscopic cholecystectomies. Although conversion to open surgery is not a complication, laparotomy is associated with greater morbidity and prolonged convalescence than laparoscopy. Therefore, understanding the risk of conversion allows the patient to make a better informed decision about surgery.
In this study among the patients of BIRDEM, 25.5% cases were male (out of total 364 patients) and 74.5% patients were female. In male group, most of the patients (11.8%) were in 41-50 years of age group followed by 6.3% were in 51-60 years age group, whereas among the female patients it was 40.4% and 19.0% respectively. Mean±SD of age were 43±1.4 and 42±1.7 in case of male and female patients respectively (Table 1). On the other hand, in case of study population at KMCH, 387 patients were included among whom 26.1% were male and 73.9% were female. Most of the male patients (15.8%) were in 41-50 years age group, whereas in case of female it was 32.8%. Mean±SD of age were 46±1.3 and 43±1.9 respectively (Table 2).
Among the total 364 cases in BIRDEM, in case of 277 (76.1% approximately), laparoscopic cholecystectomy was done due to chronic cholecystitis and in 17.0% (62 out of total 364) cases, it was performed due to acute cholecystitis whereas in case of KMCH these were 83.2% and 9.6% respectively. Only in 1.1% cases in BIRDEM and 0.8% cases in KMCH, it was associated with carcinoma of gall bladder (Table 3).
From the surgeons’ perspective, understanding the factors associated with an increased likelihood of conversion allows more objective selection of patients. The risk of conversion is related to surgeon factors, and possibly equipment factors. The surgeon experience is very important.
The overall conversion rates were 5.2% in BIRDEM and 7.0% in KMCH (Figure 1). Out of total 364 cases in BIRDEM, conversion was required in cases of 19 patients, whereas in KMCH 27 conversion was done out of total 387 patients. It is important to mention that open conversion is not always due to a complication, rather most often it reflects the correct and judicious judgment of the operating surgeon.
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