Conversion of laparoscopic to open cholecystectomy. An analysis of risk factors

The feasibility and safety of laparoscopic transcystic common bile duct exploration after prior gastrectomy

The increased incidence of gallstones can be linked to previous gastrectomy (PG). However, the success rate of endoscopic retrograde cholangiopan-creatography after gastrectomy has significantly reduced. In such cases, laparoscopic transcystic common bile duct exploration (LTCBDE) may be an alternative. In this study, LTCBDE was evaluated for its safety and feasibility in patients with PG. We retrospectively evaluated 300 patients who underwent LTCBDE between January 2015 and June 2023. The subjects were divided into 2 groups according to their PG status: PG group and No-PG group. The perioperative data from the 2 groups were compared. The operation time in the PG group was longer than that in the No-PG group (184.69 ± 20.28 minutes vs 152.19 ± 26.37 minutes, P < .01). There was no significant difference in intraoperative blood loss (61.19 ± 41.65 mL vs 50.83 ± 30.47 mL, P = .087), postoperative hospital stay (6.36 ± 1.94 days vs 5.94 ± 1.36 days, P = .125), total complication rate (18.6 % vs 14.1 %, P = .382), stone clearance rate (93.2 % vs 96.3 %, P = .303), stone recurrence rate (3.4 % vs 1.7 %, P = .395), and conversion rate (6.8 % vs 7.0 %, P = .941) between the 2 groups. No deaths occurred in either groups. A history of gastrectomy may not affect the feasibility and safety of LTCBDE, because its perioperative results are comparable to those of patients with a history of No-gastrectomy.

Preoperative difficulty factors in delayed laparoscopic cholecystectomy: Tokyo Guidelines 2018 surgical difficulty score analysis

INTRODUCTION

Tokyo Guidelines 2018 (TG18) recommend early laparoscopic cholecystectomy (LC) for low-risk acute cholecystitis (AC); however, some patients undergo delayed LC (DLC) after conservative treatment. DLC, influenced by chronic inflammation, is a difficult procedure. Previous studies on LC difficulty lacked objective measures. Recently, TG18 introduced a novel 25 findings difficulty score, which objectively assesses intraoperative factors. The purpose of this study was to use the difficulty score proposed in TG18 to identify and investigate the predictors of preoperative high-difficulty cases of DLC for AC.

METHODS

We retrospectively reviewed 100 patients with DLC after conservative AC treatment. The surgical difficulty of DLC was evaluated using a difficulty score. Based on previous studies, the highest scores in each category were categorized as grades A-C.

RESULTS

The severity of AC was mild in 51 patients and moderate in 49. Surgical outcomes revealed a distribution of difficulty scores, with grade C indicating high difficulty, showing significant differences in operative time, blood loss, achieving a critical view of safety, bailout procedures, and postoperative hospital stay compared with grades A and B. Regarding the preoperative risk factors, multivariate analysis identified age >61 years (p = .008), body mass index >27.0 kg/m2 (p = .007), and gallbladder wall thickness >6.2 mm (p = .001) as independent risk factors for grade C in DLC.

CONCLUSION

The difficulty score proposed in TG18 provides an objective framework for evaluating surgical difficulty, allowing for more accurate risk assessments and improved preoperative planning in DLC for AC.

Laparoscopic common bile duct exploration following prior gastrectomy: surgical safety and feasibility

PURPOSE

Previous gastrectomy (PG) can lead to an increased incidence of biliary stones. However, the success rate of endoscopic retrograde cholangiopancreatography after gastrectomy remains low. In such cases, laparoscopic common bile duct exploration (LCBDE) may be an alternative. The aim of this study was to evaluate the safety and feasibility of LCBDE for patients who underwent PG.

METHODS

A retrospective analysis of patients with a history of LCBDE was conducted. Patients were divided into two groups according to their PG status, and their perioperative data were compared.

RESULTS

The outcomes of 27 patients with a history of gastrectomy were compared with those of 155 without a history of gastrectomy who underwent LCBDE. PG patients experienced longer hospitalization times (P = 0.006), more postoperative bleeding (p = 0.021), a lower incidence of preoperative endoscopic retrograde cholangiopancreatography (P < 0.001), and a higher incidence of T-tube application (p = 0.002) than those without gastrectomy. However, there were no significant differences in estimated blood loss volume, operation time, bile leakage status, pancreatitis status, stone clearance rate, readmission rate, or recurrence rate.

CONCLUSIONS

Although LCBDE following gastrectomy may require laborious perioperative management, a history of gastrectomy might not influence the feasibility or safety of LCBDE, as its perioperative outcomes are comparable to those in patients without a history of gastrectomy.

Previous nonhepatectomy abdominal surgery did not increase the difficulty in laparoscopic hepatectomy for hepatocellular carcinoma: A case–control study in 100 consecutive patients

Objectives

Laparoscopic hepatectomy (LH) is still technically challenging for patients with previous nonhepatectomy abdominal surgery (AS). Therefore, this study aimed to assess the difficulty of performing LH for patients with hepatocellular carcinoma (HCC) and a history of nonhepatectomy AS during the initial developing period of LH.

Materials and Methods

The retrospective study enrolled patients who were newly diagnosed with HCC receiving LH from January 2013 to June 2021. Demographic characteristics, perioperative variables, and surgical complications were prospectively collected.

Results

One hundred patients were reviewed consecutively, comprising 23 in the AS group and 77 in the non-AS group. No significant differences were observed in median IWATE score (5 vs. 5, P = 0.194), operative time (219 vs. 200 min, P = 0.609), blood loss (100.0 vs. 200.0 mL, P = 0.734), transfusion rate (4.3% vs. 10.4%, P = 0.374), duration of parenchyma transection (90.0 vs. 72.4 min, P = 0.673), and mean nonparenchymal transection time (191.0 vs. 125.0 min, P = 0.228), without increasing the conversion rate (0.0% vs. 3.9%, P = 0.336), postoperative complications (30.3% vs. 33.8%, P = 0.488), and postoperative hospital stay (6 vs. 7 days, P = 0.060) in AS group and non-AS groups.

Conclusion

History of previous nonhepatectomy AS can lead to longer nonparenchymal transection time instead of conversion and did not increase the difficulty. Prolonged nonparenchymal transection time did not increase the surgical complications, prolong the postoperative hospital stay, and compromise the survival outcomes.

New Scoring System for Prediction of Surgical Difficulty During Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage

Background

The surgical difficulty of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) remains unknown. This study aimed to establish a scoring system (SS) to predict the necessity of a bailout procedure during LC after PTGBD and to evaluate the relationship between SS and perioperative complications.

Methods

We retrospectively studied 70 patients who underwent LC after PTGBD. Preoperative factors potentially predictive of the need for the bailout procedure were analyzed. The SS included significantly predictive factors, with their cutoff values determined by receiver operating characteristic curves. Patients were assigned a score of 1 when exhibiting only one of these abnormalities. We compared the perioperative factors between three groups with scores of 0, 1, or 2. The SS was applied to another series of 65 patients for validation. We compared the score-2 patient perioperative factors between LC with the bailout procedure and open cholecystectomy from the beginning (OC).

Results

Independent predictors were time until PTGBD after symptom onset and the maximal wall gallbladder thickness (cutoff values: 3 days and 10 mm, respectively). The high-score group was significantly associated with bile duct injury (BDI). The sensitivity and specificity of our SS were 75.0% and 98.1% in validation, respectively. The score-2 OC and laparoscopic subtotal cholecystectomy (LSC) groups had no BDI.

Conclusions

The SS using time until PTGBD after symptom onset and gallbladder wall thickness for predicting the need for the bailout procedure correctly predicted the need. The scores might be associated with the risk of BDI, and LSC or OC might be a better choice for score-2 patients.

Safety and feasibility of laparoscopic left hepatectomy for the treatment of hepatolithiasis in patients with previous abdominal surgery

Background

The aim of the study was to compare the benefits and drawbacks of laparoscopic left hepatectomy (LLH) in patients with previous abdominal surgery (PAS) with those in patients without PAS and confirm the safety and feasibility of LLH as a treatment for patients with hepatolithiasis and PAS.

Materials and Methods

This retrospective comparative study included 111 patients who underwent LLH for hepatolithiasis (with PAS, n = 41; without PAS, n = 70) from August 2017 to August 2019. Patients' general information, surgical outcomes, hospital stay duration, hospitalisation cost, post-operative laboratory data and post-operative complications were evaluated.

Results

No statistically significant difference was noted in the post-operative laboratory data between patients with and without PAS (P > 0.05). Longer operative times were required for patients with PAS than for those without PAS (P = 0.025). Hospitalisation cost, hospital stay duration, blood loss, open conversion and post-operative complications were not significantly different between patients with and without PAS (P > 0.05). No cases of mortality were noted.

Conclusions

LLH is a safe and feasible treatment for patients with hepatolithiasis and PAS.

Hand-assisted Laparoscopic Repeat Hepatectomy for Secondary Liver Neoplasm

BACKGROUND

Hand-assisted laparoscopic surgery is a widely accepted alternative to an open approach. The use of this technique in repeat liver resection is limited due to technical difficulties caused by postsurgical adhesions. We aimed to assess the feasibility and safety of hand-assisted laparoscopic repeat hepatectomy (HALRH).

MATERIALS AND METHODS

This was a retrospective study of the medical files of patients who had undergone HALRH between 2010 and 2017 in 2 university-affiliated medical centers.

RESULTS

Sixteen patients with repeat hepatectomy were included with a median age of 67.5 years. The first liver resection was a traditional laparotomy for 9 patients and hand-assisted laparoscopic surgery for 7 patients. The conversion rate to open surgery was 6%. The median operative time, blood loss during surgery, and postoperative hospital stay were 166 minutes, 400 mL, and 7 days, respectively. R0 resections were achieved in 88% of patients. The median number of tumors and tumor size were 1 and of 25 mm, respectively. There were no mortalities or major complications postoperatively. For patients with colorectal liver metastases, the median follow-up and overall survival were 21 and 43 months, respectively.

CONCLUSION

The findings suggest HALRH to be safe and feasible. Future ERAS guidelines should evaluate this approach for liver surgery.

Laparoscopic repeat hepatectomy for treating recurrent liver cancer

Background

Laparoscopic repeat hepatectomy (LRH) is a technically challenging procedure, so LRH for recurrent liver cancer has not been widely accepted. The aim of this study was to perform a systematic review of the current literature to identify and evaluate available data of LRH for recurrent hepatocellular carcinoma (rHCC) and metastases tumour of liver, especially of colorectal liver metastases (CRLM), focusing on the safety and feasibility.

Methods

A comprehensive search of the PubMed database was performed for all studies published in English evaluating LRH for rHCC and recurrent metastases tumour of liver from 1^st January, 2005 to 1^st June, 2019.

Results

A total of 15 studies which comprised 444 patients and reported outcomes for the efficacy and safety of LRH in the treatment of rHCC or CRLM were included in the present review. Moreover, nine studies compared the perioperative outcomes of LRH versus open repeat hepatectomy (ORH). LRH was superior to ORH with reduced blood loss, shorter operative time, shorter hospital stay and lower morbidity rates.

Conclusions

LRH can safely performed in rHCC or CRLM patients with cirrhosis, previous open hepatectomy, multiple recurrent lesions and tumours located in difficult posterosuperior segments.

Acute cholecystitis: predictive clinico-radiological assessment for conversion of laparoscopic cholecystectomy

BACKGROUND

Previous studies evaluating predictive factors for the conversion from laparoscopic to open cholecystectomy have reported conflicting conclusions.

PURPOSE

To create a risk assessment model to predict the conversion from laparoscopic to open cholecystectomy in patients with acute calculous cholecystitis.

MATERIAL AND METHODS

A retrospective review of patients with acute calculous cholecystitis with available preoperative contrast-enhanced computed tomography (CT) findings who underwent laparoscopic cholecystectomy was performed. Forty-four parameters-including demographics, clinical history, laboratory data, and CT findings-were analyzed.

RESULTS

Among the included 581 patients, conversion occurred in 113 (19%) cases. Multivariate analysis identified obesity (odd ratio [OR] 2.58, P = 0.04), history of abdominal surgery (OR 1.78, P = 0.03), and prolonged prothrombin time (OR 1.98, P = 0.03) as predictors of conversion. In preoperative CT findings, the absence of gallbladder wall enhancement (OR 3.15, P = 0.03), presence of a gallstone in the gallbladder infundibulum (OR 2.11, P = 0.04), and inflammation of the hepatic pedicle (OR 1.71, P = 0.04) were associated with conversion. Inter-observer agreement for CT study interpretation was very good (range 0.81-1.00). A model was created to calculate the risk for conversion, with an area under the receiver operating characteristic curve of 0.87. The risk for conversion, estimated based on the number of factors identified, was in the range of 5.3% (with one factor) to 86.4% (with six factors).

CONCLUSION

Obesity, history of abdominal surgery, prolonged prothrombin time, absence of gallbladder wall enhancement, presence of a gallstone in the gallbladder infundibulum, and inflammation of the hepatic pedicle are associated with conversion of laparoscopic to open cholecystectomy.

The Analysis of Risk Factors in the Conversion from Laparoscopic to Open Cholecystectomy

Laparoscopic cholecystectomy is a standard treatment for cholelithiasis. In situations where laparoscopic cholecystectomy is dangerous, a surgeon may be forced to change from laparoscopy to an open procedure. Data from the literature shows that 2 to 15% of laparoscopic cholecystectomies are converted to open surgery during surgery for various reasons. The aim of this study was to identify the risk factors for the conversion of laparoscopic cholecystectomy to open surgery. A retrospective analysis of medical records and operation protocols was performed. The study group consisted of 263 patients who were converted into open surgery during laparoscopic surgery, and 264 randomly selected patients in the control group. Conversion risk factors were assessed using logistic regression analysis that modeled the probability of a certain event as a function of independent factors. Statistically significant factors in the regression model with all explanatory variables were age, emergency treatment, acute cholecystitis, peritoneal adhesions, chronic cholecystitis, and inflammatory infiltration. The use of predictive risk assessments or nomograms can be the most helpful tool for risk stratification in a clinical scenario. With such predictive tools, clinicians can optimize care based on the known risk factors for the conversion, and patients can be better informed about the risks of their surgery.

Laparoscopic repeat liver resection

Recurrence of liver cancers inside the liver are often treated with liver resection (LR). However, increased risks of complications and conversion during operation were reported in laparoscopic repeat LR (LRLR). The indication is still controversial. One multi-institutional propensity score matching analysis of LRLR vs open repeat LR for hepatocellular carcinoma, two propensity score matching analyses for colorectal metastases, and two meta-analyses including hepatocellular carcinoma, intrahepatic cholangiocarcinoma, metastases, and other tumors have been reported to date. LRLR was reported with better to comparable short-term and similar long-term outcomes. Furthermore, the shorter operation time and the smaller amount of intraoperative bleeding for LRLR was reported for the patients who had undergone laparoscopic rather than open LR as an earlier procedure. The speculations are presented, that complete dissection of adhesion can be dodged and laparoscopic minor repeated LR can minimize the liver functional deterioration in cirrhotic patients. LRLR, as a powerful local therapy, could contribute to the long-term outcomes of those with deteriorated liver function. However, the procedure is now in its developing stage worldwide and further accumulation of experiences and evaluation are needed.

Laparoscopic repeat liver resection for hepatocellular carcinoma: a multicentre propensity score-based study

BACKGROUND

In the absence of randomized controlled data and even propensity-matched data, indications for, and outcomes of, laparoscopic repeat liver resection for hepatocellular carcinoma (HCC) remain uncertain. This study aimed to clarify the current indications for laparoscopic repeat liver resection for HCC, and to evaluate outcomes.

METHODS

Forty-two liver surgery centres around the world registered patients who underwent repeat liver resection for HCC. Patient characteristics, preoperative liver function, tumour characteristics, surgical method, and short- and long-term outcomes were recorded.

RESULTS

Analyses showed that the laparoscopic procedure was generally used in patients with relatively poor performance status and liver function, but favourable tumour characteristics. Intraoperative blood loss (mean(s.d.) 254(551) versus 748(1128) ml; P < 0·001), duration of operation (248(156) versus 285(167) min; P < 0·001), morbidity (12·7 versus 18·1 per cent; P = 0·006) and duration of postoperative hospital stay (10·1(14·3) versus 11·8(11·8) days; P = 0·013) were significantly reduced for laparoscopic compared with open procedures, whereas survival time was comparable (median 10·04 versus 8·94 years; P = 0·297). Propensity score matching showed that laparoscopic repeat liver resection for HCC resulted in less intraoperative blood loss (268(730) versus 497(784) ml; P = 0·001) and a longer operation time (272(187) versus 232(129); P = 0·007) than the open approach, and similar survival time (12·55 versus 8·94 years; P = 0·086).

CONCLUSION

Laparoscopic repeat liver resection is feasible in selected patients with recurrent HCC.

A Retrospective and Prospective Study to Develop a Pre-operative Difficulty Score for Laparoscopic Cholecystectomy

BACKGROUND

The objectives of this study were to develop a grading system to enable pre-operative prediction of technical difficulty of laparoscopic cholecystectomy using retrospective data and to attempt to validate our scoring system prospectively.

METHODS

Retrospective analysis was conducted of 100 consecutive patients. Pre-operative variables were collected based on a template devised by the American College of Surgeons. Outcomes were duration of surgery, conversion to open and post-operative complications. Multivariate analysis with subsequent measurement of hazard ratios was used to formulate a weighted grading system. Prospective analysis was performed of 100 consecutive patients who were scored pre-operatively. Outcomes were duration of surgery and length of stay.

RESULTS

Retrospective univariate analysis identified four variables associated with an increase in duration of surgery: male gender (p = 0.023), age (p = 0.000), body mass index (BMI) (p = 0.000) and pre-operative endoscopic retrograde cholangiopancreatography (ERCP) (p = 0.001). Prospective analysis revealed weak positive correlations between the scoring system and duration of surgery (0.34) and length of stay (0.40).

CONCLUSION

We have identified four pre-operative variables that predicted a longer duration of surgery. Preliminary results suggest a positive correlation between this scoring system and duration of surgery. An adequately powered prospective multi-centre study is needed to validate our findings.

Hepatic Pedicle Occlusion with the Pringle Maneuver During Difficult Laparoscopic Cholecystectomy Reduces the Conversion Rate

BACKGROUND

In the presence of cholecystitis or portal hypertension, hemorrhage is common during laparoscopic cholecystectomy (LC) because the vessels of Calot's triangle are fragile and tortuous. Bleeding can obstruct surgical field visibility and increase conversion rates and risk of common bile duct injury. The Pringle maneuver is a simple occlusion approach that could limit blood flow from the hepatic pedicle, thus controlling bleeding to provide a clear surgical field to reduce conversion rate. In this study, we aimed to investigate the feasibility, effectiveness and safety of hepatic pedicle occlusion with the Pringle maneuver during difficult LC.

METHODS

From 2011 to 2015, LC with hepatic pedicle occlusion by the Pringle maneuver was performed in 67 patients (Pringle group). Another group of 67 cases with matched clinical parameters where LC was performed without the Pringle maneuver (non-Pringle group) was retrieved from a database to serve as the control group.

RESULTS

The Pringle group had a significantly lower conversion rate (1.49% vs. 11.9%; P = 0.038), less blood loss (37.5 ± 24.1 mL vs. 94.5 ± 67.8 mL; P = 0.002), shorter postoperative hospitalization (2.5 ± 1.4 days vs. 3.5 ± 2.5 days; P = 0.005), and lower cost ($1343 ± $751 USD vs. $1674 ± $609 USD; P = 0.024) than non-Pringle group. There was one case each of bile duct injury and readmission within 30 days because of bile leakage in the non-Pringle group, but none in the Pringle group.

CONCLUSIONS

Hepatic pedicle occlusion could provide a clear surgical field and enable the recognition of structures during LC. The Pringle maneuver offers a feasible and safe approach to lower conversion rates in difficult LC.

Status and perspective of laparoscopic repeat liver resection

Liver resection (LR) is now actively applied to intrahepatic recurrence of liver metastases and hepatocellular carcinoma. Although indications of laparoscopic LR (LLR) have been expanded, there are increased risks of intraoperative complications and conversion in repeat LLR. Controversy still exists for the indication. There are 16 reports of small series to date. These studies generally reported that repeat LLR has better short-term outcomes than open (reduced bleedings, less or similar morbidity and shorter hospital stay) without compromising the long-term outcomes. The fact that complete adhesiolysis can be avoided in repeat LLR is also reported. In the comparison of previous procedures, it is reported that the operation time for repeat LLR was shorter for the patients previously treated with LLR than open. Furthermore, it is speculated that LLR for minor repeat LR of cirrhotic liver can be minimized the deterioration of liver function by LR. However, further experience and evaluation of anatomical resection or resections exposing major vessels as repeat LLR, especially after previous anatomical resection, are needed. There should be a chance to prolong the overall survival of the patients by using LLR as a powerful local therapy which can be applied repeatedly with minimal deterioration of liver function.

The safety and feasibility of laparoscopic common bile duct exploration for treatment patients with previous abdominal surgery

The purpose of this study was to evaluate the safety and feasibility of laparoscopic common bile duct exploration (LCBDE) in patients with previous abdominal surgery (PAS). The outcomes were compared in 139 patients (103 upper and 36 lower abdominal surgeries) with PAS and 361 without PAS who underwent LCBDE. The operative time, hospital stay, rate of open conversion, postoperative complications, duct clearance, and blood loss were compared. Patients with PAS had longer operative times (P = 0.006), higher hospital costs (P = 0.043), and a higher incidence of wound complications (P = 0.011) than those without PAS. However, there were no statistically significant in the open conversion rate, blood loss, hospital stay, bile leakage, biliary strictures, residual stones, and mortality between patients with and without PAS (P > 0.05). Moreover, compared with those without PAS, patients with previous upper abdominal surgery (PUAS) had longer operative times (P = 0.005), higher hospital costs (P = 0.030), and a higher open conversion rate (P = 0.043), but patients with previous lower abdominal surgery (PLAS) had a higher incidence of wound complications (P  = 0.022). LCBDE is considered safe and feasible for patients with PAS, including those with PUAS.

Risk factors for conversion of laparoscopic cholecystectomy to open surgery - A systematic literature review of 30 studies

BACKGROUND

The study aims to evaluate the methodological quality of publications relating to predicting the need of conversion from laparoscopic to open cholecystectomy and to describe identified prognostic factors.

METHOD

Only English full-text articles with their own unique observations from more than 300 patients were included. Only data using multivariate analysis of risk factors were selected. Quality assessment criteria stratifying the risk of bias were constructed and applied.

RESULTS

The methodological quality of the studies were mostly heterogeneous. Most studies performed well in half of the quality criteria and considered similar risk factors, such as male gender and old age, as significant. Several studies developed prediction models for risk of conversion. Independent risk factors appeared to have additive effects.

CONCLUSION

A detailed critical review of studies of prediction models and risk stratification for conversion from laparoscopic to open cholecystectomy is presented. One study is identified of high quality with a potential to be used in clinical practice, and external validation of this model is recommended.

Evidence-based clinical practice guidelines for cholelithiasis 2016

Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.

Preoperative hypoalbuminemia is an independent risk factor for conversion from laparoscopic to open cholecystectomy in patients with cholecystolithiasis

INTRODUCTION

Laparoscopic cholecystectomy (LC) is regarded as the first choice for patients with cholecystolithiasis, but some patients require conversion to open cholecystectomy (OC) because of inflammation-related incidents. Therefore, the aim of this study is to explore the risk factors for conversion to OC in patients undergoing elective LC for cholecystolithiasis.

METHODS

This study included 461 patients who underwent elective LC for cholecystolithiasis were between April 2000 and September 2010. Receiver-operator curve (ROC) analysis was used to define the ideal cut-off values of clinicolaboratory characteristics, and the area under the ROC for conversion was also measured. Univariate and multivariate analyses using preoperative clinicolaboratory characteristics were performed to investigate the most significant risk factors for conversion to OC in patients with cholecystolithiasis.

RESULTS

Multivariate analysis using nine parameters selected by univariate analyses demonstrated that γ-glutamyltransferase (<20/>20 IU/L) (odds ratio, 8.777; 95% confidence interval, 1.132-68.06; P = 0.038), albumin (<3.8/>3.8 g/dL) (odds ratio, 0.329; 95% confidence interval, 0.127-0.850; P = 0.022), and platelet count (<27/>27 × 10⁴ /mm³ ) (odds ratio, 2.573; 95% confidence interval, 1.048-6.319; P = 0.039) were associated with conversion. Among these three parameters, ROC curve analysis disclosed that albumin (0.705) had the largest area under the ROC (γ-glutamyltransferase, 0.622, platelet count, 0.536) for conversion.

CONCLUSIONS

Preoperative hypoalbuminemia is the most important risk factor for conversion to OC in patients undergoing elective LC for cholecystolithiasis.

Difficult situations in laparoscopic cholecystectomy: a multicentric retrospective study

INTRODUCTION

Difficult laparoscopic cholecystectomy (LC) is the most common "difficult" surgical procedure performed today, which possesses the potential to place the patient at significant operative risk. We present our retrospective study and experience of 8347 patients with LC since June 1995 to December 2011 at 2 large centers: Mariampur and GSVM Medical College, LLR Hospital, Kanpur, with discussions regarding the practical aspects of LC in difficult situations with respect to conversion to open cholecystectomy.

METHODS

A retrospective analysis of patients who underwent LC from June 1995 to December 2011 was performed. The analysis was performed in relation to the need for conversion and the factors responsible for conversion.

RESULTS

Out of 8347 cases, 2187 cases (26.2%) were identified as difficult. LC was performed successfully in 8265 cases (total completion rate, 99.02%). Of the 2187 difficult cases, LC was completed successfully in 2105 cases (completion rate in difficult cases, 96.25%) and converted to open cholecystectomy in 82 cases (conversion rate in difficult cases, 3.75%).

CONCLUSIONS

Because of the increasing exposure and expertise of surgeons dealing with complex gall bladder laparoscopies, rates of conversion to open cholecystectomy are decreasing and many difficult cases are now handled laparoscopically. However, if required, conversion should not be considered as a failure for the benefit of the patient.

Pure laparoscopic hepatectomy as repeat surgery and repeat hepatectomy

AIM

To assess clinical outcomes of laparoscopic hepatectomy (LH) in patients with a history of upper abdominal surgery and repeat hepatectomy.

METHODS

This study compared the perioperative courses of patients receiving LH at our institution that had or had not previously undergone upper abdominal surgery. Of the 80 patients who underwent LH, 22 had prior abdominal surgeries, including hepatectomy (n = 12), pancreatectomy (n = 3), cholecystectomy and common bile duct excision (n = 1), splenectomy (n = 1), total gastrectomy (n = 1), colectomy with the involvement of transverse colon (n = 3), and extended hysterectomy with extensive lymph-node dissection up to the upper abdomen (n = 1). Clinical indicators including operating time, blood loss, hospital stay, and morbidity were compared among the groups.

RESULTS

Eighteen of the 22 patients who had undergone previous surgery had severe adhesions in the area around the liver. However, there were no conversions to laparotomy in this group. In the 58 patients without a history of upper abdominal surgery, the median operative time was 301 min and blood loss was 150 mL. In patients with upper abdominal surgical history or repeat hepatectomy, the operative times were 351 and 301 min, and blood loss was 100 and 50 mL, respectively. The median postoperative stay was 17, 13 and 12 d for patients with no history of upper abdominal surgery, patients with a history, and patients with repeat hepatectomy, respectively. There were five cases with complications in the group with no surgical history, compared to only one case in the group with a prior history. There were no statistically significant differences in the perioperative results between the groups with and without upper abdominal surgical history, or with repeat hepatectomy.

CONCLUSION

LH is feasible and safe in patients with a history of upper abdominal surgery or repeat hepatectomy.

Male gender impact on the outcome of laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVES

Our aim was to assess the impact of male gender on the outcomes of laparoscopic cholecystectomy by eliminating associated risk factors for conversion.

METHODS

A quantitative comparative study was set up on the background of our null hypothesis that male gender has no impact on the outcomes of laparoscopic cholecystectomy. We performed a retrospective study of 241 patients and recorded the duration of surgery, length of postoperative hospital stay, conversion rate, and procedure-specific complications. Risk factors for conversion were excluded. Inferential statistics were applied, and a 2-sided P value of < .05 was considered the cutoff point to indicate the amount of evidence against the null hypothesis. We used SPSS for Windows, version 12 (IBM, Armonk, New York). Parametric data were analyzed with the independent-samples t test, and nonparametric data were analyzed with the χ(2) test.

RESULTS

A total of 175 women (72.6%) and 66 men (27.4%) underwent laparoscopic cholecystectomy. The mean age was 51.4 ± 14.8 years for women and 55 ± 12.7 years for men (P = .08). Women had a higher body mass index (28.4 ± 4.5) than men (26.8 ± 3.5) (P < .005). There were no statistically significant differences in the conversion rate and perioperative morbidity rate. The conversion rate was 2.9% for women and 7.5% for men (P = .142); the morbidity rate was 10.2% and 12.1%, respectively (P = .66). The mean duration of surgery was longer in men, at 67.9 ± 27.8 minutes, than in women, at 56.5 ± 23.98 minutes (P < .002). Both genders had an equal length of postoperative hospital stay, with 1.9 ± 1.8 days for men and 1.9 ± 2.1 days for women (P = .8).

CONCLUSIONS

Male gender has no impact on the outcomes of laparoscopic cholecystectomy. Gender affects the duration of surgery. Larger-scale studies may disclose the factors responsible for variations in the operative time.

The degree of gallbladder wall thickness and its impact on outcomes after laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is the gold-standard procedure for management of symptomatic gallstone disease. Increased rates of conversion to an open procedure, increased postoperative complications, and longer lengths of stay are seen in thick-walled gallbladders. Previous studies have only evaluated gallbladder walls as being thick or not thick, without looking at the degree of thickness. We hypothesized that, the more severe the wall thickening, the greater the chance of conversions and complications, and the longer the lengths of stay.

METHODS

All attempted laparoscopic cholecystectomies in our institution between 2006 and 2009 were retrospectively reviewed. Patients undergoing cholecystectomy for reasons other than gallstones (e.g., polyps or cancer) and those without preoperative ultrasounds were excluded. Patients were divided into four groups based on the degree of gallbladder wall thickness: normal (1-2 mm), mildly thickened (3-4 mm), moderately thickened (5-6 mm), and severely thickened (7 mm and above). Outcomes were compared amongst the groups.

RESULTS

874 patients were included in the study. There were 68 conversions (7.8 %) and 58 complications (6.6 %). The incidence of conversions was 3.1, 5.1, 14.9, and 16.8 % in the four groups, respectively (p < 0.001, χ (2)), and the incidence of complications was 1.8, 6.7, 9.1, and 13.1 %, respectively (p = 0.001, χ (2)). The mean (± standard deviation, SD) length of stay in days was 1.09 ± 1.42, 1.83 ± 3.24, 2.54 ± 3.40 and 3.54 ± 4.61, respectively [p < 0.001, analysis of variance (ANOVA)].

CONCLUSIONS

A greater degree of gallbladder wall thickness is associated with an increased risk of conversion, increased postoperative complications, and longer lengths of stay. Classifying patients according to degree of gallbladder wall thickness gives more accurate assessment of the risk of surgery, as well as potential outcomes.

Laparoscopic cholecystectomy: What is the price of conversion?

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold standard procedure for gallbladder removal. Conversion to an open procedure is sometimes deemed necessary, especially in complex cases in which a prolonged laparoscopic operative time is anticipated. A prolonged LC case is thought to be associated with increased complications and cost and therefore generally discouraged. The purpose of this study was to test this assumption, and compare outcomes and cost of converted and prolonged LC cases.

METHODS

By using institutional National Surgical Quality Improvement Program and financial databases, we retrospectively reviewed and compared prolonged laparoscopic cases (Long-LC) with converted (CONV) procedures. Surgical times, length of stay (LOS), 30-day complications, operative room, and total hospital charges were compared between the 2 groups.

RESULTS

A total of 101 Long-LC and 66 CONV cases met our inclusion criteria. Long-LC cases were 19 minutes longer than CONV cases (123 vs 104 min; P < .01). No differences in postoperative complications were found between the 2 groups (P > .05). When Poisson regression was used, we found that LOS was significantly shorter in the Long-LC compared with CONV group (1 day vs 4 days; P < .01). Long-LC cases had greater operative charges ($15,278 vs $13,128; P < .01). However, hospital charges for Long-LC cases were 26% less than for CONV cases ($23,946 vs $32,446; P < .01).

CONCLUSION

Conversion is associated with a 3-day increase in LOS. Long-LC cases have greater operative room charges, but overall hospital charges were 26% less than CONV cases. Our data suggest that decision making regarding conversion should focus on safety and not time considerations.

Laparoscopic liver resection in patients with a history of upper abdominal surgery

BACKGROUND

The liver is the organ where tumors most frequently metastasize. Hepatic recurrence after resection of hepatocellular carcinoma also occasionally occurs. With the increasing use of laparoscopic surgery for hepatic tumors, there may be a high probability that laparoscopic liver resection can be performed in patients with a surgical history. The purpose of this study was to assess the feasibility and clinical outcomes of laparoscopic liver resection in patients a history of upper abdominal surgery.

METHODS

Of 202 laparoscopic liver resections, 47 patients underwent laparoscopic liver resection after previous upper abdominal surgery between January 2004 and July 2009. Fifty-five previous surgeries were performed in the 47 patients. The previous types of surgical procedures included hepatobiliary and pancreatic (HPB) procedures (n=25) and non-HPB procedures (colorectal malignancies, subtotal gastrectomy, and splenectomy; n=22).

RESULTS

In patients with a history of surgery, the mean operative time for laparoscopic liver resection was 312.3 min and the mean blood loss was 481.0 ml. In 42 patients (89.4%), there were severe adhesions in the hepatoduodenal ligament and hilar areas. Transfusion was required in 7 patients (14.9%). There was one conversion to a laparotomy due to severe adhesions. Complications occurred in 11 patients (23.4%) and the mean hospital stay was 10.6 days. When we compare patients with and without a history of surgery, there were no differences in the above-mentioned perioperative results. However, among patients with a history of surgery, patients who underwent HPB procedures had longer operative times and higher postoperative morbidities than those who had not undergone HPB procedures.

CONCLUSION

Laparoscopic liver resection in patients with a history of upper abdominal surgery is feasible and safe.

Risk factors in laparoscopic cholecystectomy: a multivariate analysis

BACKGROUND

Laparoscopic cholecystectomy (LC) is the operation of choice in the treatment of symptomatic gallstone disease. The aim of this study is to identify risk factors for LC, outcomes include operating time, length of stay, conversion rate, morbidity and mortality.

METHODS

All patients undergoing LC between 1998 and 2007 in a single district general hospital. Risk factors were examined using uni- and multivariate analysis.

RESULTS

2117 patients underwent LC, with 1706 (80.6%) patients operated on electively. Male patients were older, had more co-morbidity and more emergency surgery than females. The median post-operative hospital stay was one day, and was positively correlated with the complexity of surgery. Conversion rates were higher in male patients (OR 1.47, p = 0.047) than in females, and increased with co-morbidity. Emergency surgery (OR 1.75, p = 0.005), male gender (OR 1.68, p = 0.005), increasing co-morbidity and complexity of surgery were all positively associated with the incidence of complications (153/2117 [7.2%]), whereas only male gender was significantly associated with mortality (OR 5.71, p = 0.025).

CONCLUSION

Adverse outcome from LC is particularly associated with male gender, but also the patient's co-morbidity, complexity and urgency of surgery. Risk-adjusted outcome analysis is desirable to ensure an informed consent process.

Effects of previous abdominal surgery incision type on complications and conversion rate in laparoscopic cholecystectomy

For laparoscopic cholecystectomy, previous abdominal operations are seen as a relative contraindication. The purpose of this study was to investigate the effects of the incision type of previous abdominal surgery on laparoscopic cholecystectomy in terms of complications and conversion to open surgery. Data from 677 patients who had previously undergone abdominal surgery before undergoing laparoscopic cholecystectomy were prospectively collected and evaluated. From the previous operations, the incisions were upper abdominal in 66 patients, lower abdominal in 567, and upper plus lower in 44. Conversion rates in the upper, lower and upper plus lower groups were 27.27%, 2.82%, and 25%, respectively. Intraoperative major complications were bile duct injury (1 patient, upper plus lower incision group), small bowel mesentery injury, and aortic injury (1 patient each, both in the lower incision group). Postoperative major intra-abdominal complications were duodenal injury (1 patient, upper incision group) and small intestine injury (1 patient, lower incision group). The lower abdominal incision group had fewer adhesions in the upper abdomen than did the other 2 groups, and as a result had a much lower conversion rate.

Rate of conversion and complications of laparoscopic cholecystectomy in a tertiary care center in Saudi Arabia

BACKGROUND AND OBJECTIVES

Problems during laparoscopic cholecystectomy include bile duct injury, conversion to open operation, and other postoperative complications. We retrospectively evaluated the causes for conversion and the rate of conversion from laparoscopic to open cholecystectomy and assessed the postoperative complications.

METHODS

Of 340 patients who presented with symptomatic gall bladder disease over a 2-year period, 290 (85%) patients were evaluated on an elective basis and scheduled for surgery, while the remaining 50 (14.7%) patients were admitted emergently with a diagnosis of acute cholecystitis.

RESULTS

The mean age of the patients was 41.9 (12.6) years. Conversion to laparotomy occurred in 17 patients (5%). The incidence of complications was 3.2%. The most common complication was postoperative transient pyrexia, which was seen in four patients (1.2%) followed by postoperative wound infection in three patients (0.9%), postoperative fluid collection and bile duct injury in two patients each (0.6%).

CONCLUSION

Laparoscopic cholecystectomy remains the 'gold standard' by which all other treatment modalities are judged. Conversion from laparoscopic to open cholecystectomy should be based on the sound clinical judgment of the surgeon and not be due to a lack of individual expertise.

Identification of risk factors for an unfavorable laparoscopic cholecystectomy course after endoscopic retrograde cholangiography in the treatment of choledocholithiasis

BACKGROUND

Laparoscopic cholecystectomy (LC) after an endoscopic retrograde cholangiography (ERC) has higher rates for complications and conversion caused by unpredictable adhesions. The risk factors for an adverse outcome of LC after an ERC were analyzed.

METHODS

Variables from patients treated by LC after ERC for cholelithiasis in two clinics from 1996 to 2003 were retrospectively stored in a database. Complications and conversions were recorded.

RESULTS

A total of 140 patients underwent LC after ERC (83 from clinic A and 57 from clinic B), 31% (44/140) of whom were men. Peri- or postoperative complications occurred for 28 patients (20%). For 19 patients (14%), a conversion was necessary. Significant variables associated with complications and conversions were an elevated level of C-reactive protein (CRP) at the time of LC (odds ratio [OR], 10.2; 95% confidence interval [CI], 1.1-91, P = 0.037 for both) and severe adhesions during laparoscopy (OR, 3.6; 95% CI, 1.5-8.6; P = 0.003 and OR, 5.2; 95% CI, 1.9-14.4; P = 0.002, respectively). Male gender (OR, 2.8; 95% CI, 1.1-7.6; P = 0.037) and serum bilirubin level at the time of ERC (OR, 3.7; 95% CI, 1.24-11; P = 0.014) were associated with conversion only. Time after ERC (LC within 1 week vs. >1 week or < or = 2 weeks vs. 2-6 weeks vs. >6 weeks or < or = 6 weeks vs. >6 weeks) was not associated with complications or conversion. Multivariate regression analysis showed a pre-LC CRP exceeding 6 to be predictive of complications (OR, 10.5; 95% CI, 1.1-95; P = 0.040) and conversion (OR, 10.6; 95% CI, 1.1-99; P = 0.034).

CONCLUSION

Male gender, bilirubin levels during ERC, severe adhesions during LC, and pre-LC CRP levels were associated with an adverse outcome for an LC after endoscopic cholangiography. The time between LC and ERC failed to be a significant risk factor in this larger series.

Conversion after laparoscopic cholecystectomy in England

BACKGROUND

Laparoscopic cholecystectomy is the procedure of choice for the treatment of symptomatic gallstones. Conversion to open surgery is reported to be necessary in 5-10% of cases. This study aimed to define those factors associated in English hospitals with the need to convert a laparoscopic cholecystectomy to an open procedure. These included patient-related and particularly nonpatient-related factors.

METHODS

Using data derived from a national administrative database, Hospital Episode Statistics, patients undergoing cholecystectomy in acute National Health Service (NHS) hospitals in England during the financial years 2004-2006 were studied. The individual surgeon caseload and the hospital conversion rate were calculated using data from the first (baseline) year. Factors affecting the need for conversion were analyzed using data from the second (index) year.

RESULTS

The study included 43,821 laparoscopic cholecystectomies undertaken from 2005 to 2006 in English hospitals. The overall conversion rate was 5.2%: 4.6% for elective procedures and 9.4% for emergency procedures. Patient-related factors that were good predictors of conversion included male sex, emergency admission, old age, and complicated gallstone disease (p < 0.001). Nonpatient-related factors that were good predictors of conversion included the laparoscopic cholecystectomy caseload of individual consultant surgeons and the overall hospital conversion rate in the previous year (all p < 0.001).

CONCLUSIONS

Conversion after laparoscopic cholecystectomy is less common as consultant caseload increases. This suggests that operation should be undertaken only by surgeons with an adequate caseload. There is a wide variation in conversion rates among hospitals. This has important implications for training as well as for the organization and accreditation of cholecystectomy services on a national basis.

Male gender is not a risk factor for the outcome of laparoscopic cholecystectomy: a single surgeon experience

BACKGROUND/AIM

Previous studies regarding the outcome of laparoscopic cholecystectomy (LC) in men have reported inconsistent findings. We conducted this prospective study to test the hypothesis that the outcome of LC is worse in men than women.

MATERIALS AND METHODS

Between 1997 and 2002, a total of 391 consecutive LCs were performed by a single surgeon at King Fahd Hospital of the University. We collected and analyzed data including age, gender, body mass index (kg/m(2)), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), comorbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay.

RESULTS

Bivariate analysis showed that both genders were matched for age, ASA class and mode of admission. The incidences of AC (P = 0.003) and comorbid disease (P = 0.031) were significantly higher in men. Women were significantly more obese than men (P < 0.001) and had a higher incidence of previous abdominal surgery (P = 0.017). There were no statistical differences between genders with regard to rates of conversion (P = 0.372) and complications (P = 0.647) and operation time (P = 0.063). The postoperative stay was significantly longer in men than women (P = 0.001). Logistic regression analysis showed that male gender was not an independent predictor of conversion (Odds ratio [OR] = 0.37 and P = 0.43) or complications (OR = 0.42, P = 0.42). Linear regression analysis showed that male gender was not an independent predictor of the operation time, but was associated with a longer postoperative stay (P = 0.02).

CONCLUSION

Male gender is not an independent risk factor for satisfactory outcome of LC in the experience of a single surgeon.

Preoperative findings predict conversion from laparoscopic to open cholecystectomy

BACKGROUND

Previous studies evaluating predictive factors for conversion from laparoscopic to open cholecystectomy have drawn conflicting conclusions. We evaluated objective preoperative variables to create an accurate, accessible risk score to predict conversion.

METHODS

A retrospective review was performed of laparoscopic cholecystectomy patients at an urban tertiary care center. Seventy characteristics were subjected to bivariate and multivariate logistic regression analysis to identify parameters that independently predict conversion to open cholecystectomy. A model was created based on this analysis.

RESULTS

Laparoscopic cholecystectomy was performed on 1377 patients for benign gallbladder disease over a 71-month period. There were 112 (8.1%) conversions to open cholecystectomy. The correlation between the preoperative clinical diagnosis and pathologic diagnosis for acute and chronic cholecystitis was 48.6% and 94.6%, respectively. Multivariate analysis identified male gender, elevated white blood cell count, low serum albumin, ultrasound finding of pericholecystic fluid, diabetes mellitus, and elevated total bilirubin as independent predictors of conversion. These 6 factors were also associated with the pathologic diagnosis of acute cholecystitis. A model to calculate the risk for conversion was created with an area under the receiver operator curve of 0.83. The risk for conversion also can be estimated based on the number of factors identified present and ranged from 2% when 1 factor was present to 89% with 6 factors.

CONCLUSIONS

These results demonstrate that conversion to open cholecystectomy can be predicted based on parameters available preoperatively. Conversion is more likely in patients who have acute cholecystitis; however, the correlation between its clinical and pathologic diagnosis is poor. Improvements in the ability to determine the risk for conversion have important implications for surgical care.

Risk factors for conversion to open surgery in patients undergoing laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is the gold standard treatment for most gallbladder diseases. Conversion to open cholecystectomy is necessary in some patients for any of a number of factors. Identifying these factors will help the patient, the surgeon, and the hospital.

METHODS

One thousand laparoscopic cholecystectomies were performed from May 1998 to May 2004 in Changi General Hospital, Singapore; 103 patients (10.3%) required conversion to open cholecystectomy. All data were kept prospectively and analyzed retrospectively.

RESULTS

The patients who had conversion were mostly men (P < 0.0001), were heavier (P < 0.05), had acute cholecystitis (P < 0.0001), and had a history of upper abdominal surgery (P < 0.001). There were no differences in terms of race (P = 0.315) and presence of diabetes mellitus (P = 0.126). Diabetic patients who had conversion had a significantly higher glycosylated hemoglobin (Hba1c) (8.9% +/- 0.6%; P < 0.038). Patients who had conversion had a higher total white count (P < 0.05), but liver function tests were similar between the two groups. There was a higher conversion rate among the junior surgeons than the more experience surgeons (P < 0.032).

CONCLUSIONS

The significant risk factors for conversion were male gender, advanced age (> 60 years), higher body weight > 65 kg, acute cholecystitis, previous upper abdominal surgery, junior surgeons, and diabetes associated with Hba1c > 6. Chronic liver disease was not found to be a risk factor (P = 0.345), and performing laparoscopic cholecystectomy in cirrhotic patients is safe. Identifying risk factors will help the surgeon to plan and counsel the patient and introduce new policies to the unit. Some of the risk factors are similar to those reported from international centers, but others may be unique to our department.

Conversion of elective laparoscopic to open cholecystectomy between 1993 and 2004

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic gallbladder disease. The identification of factors that reliably predict the likely need to convert LC to an open procedure would provide short-term benefits in terms of patient education and postoperative expectations.

METHODS

Between 1993 and 2004, 1179 elective LCs were attempted from a total of 1339 elective cholecystectomies. The change in conversion rate between 1993-1999 and 2000-2004 was analysed. Factors predictive of higher risk for conversion were also identified.

RESULTS

Eighty-nine LCs (7.5 per cent) required conversion. Gallbladder wall thickness and a history of common bile duct (CBD) stones, treated by preoperative endoscopic sphincterotomy, were predictors of conversion. The proportion of patients who underwent LC was the same in 1993-1999 (87.5 per cent) and 2000-2004 (88.8 per cent), but the conversion rate increased significantly from 5.3 to 10.6 per cent in these two time intervals. In addition, the proportion of patients with a history of CBD stones rose significantly, from 6.4 per cent in 1993-1999 to 11.0 per cent in 2000-2004.

CONCLUSION

The conversion rate increased over the 12-year interval of the study. A history of preoperative endoscopic sphincterotomy and a thickened gallbladder wall contributed to the likelihood of conversion.

Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome

In view of the substantial, at times conflicting, literature on conversion to open surgery during laparoscopic cholecystectomy (LC), we have considered it timely to review the subject to identify the risk factors for conversion and its consequences. The review is based on a complete literature search covering the period 1990 to 2005. The search identified 109 publications on the subject: 68 retrospective series, 16 prospective nonrandomized studies, 8 prospective randomized clinical trials, 5 prospective case-controlled studies, 5 reviews and 7 others (3 observational, 2 population-based studies, 1 national survey, and 1 editorial). As the majority of reported studies are retrospective, firm conclusions cannot be reached. Single factors that appear to be important include male gender, extreme old age, morbid obesity, cirrhosis, previous upper abdominal surgery, severe/advanced acute and chronic disease, and emergency LC. The combination of patient- and disease-related risk factors increases the conversion risk. In the training of residents, the number of cases needed for reaching proficiency exceeds 200 cases. The value of predictive scoring systems is important in the selection of cases for resident training. Conversion exerts adverse effects on operating time, postoperative morbidity, and hospital costs, especially when it is enforced. There appears to be no absolute contraindication to LC that is agreed upon by all. There is consensus on certain individual risk factors and their additive effect on the likelihood of conversion. Predictive systems based on these factors appear to be useful in selection of cases for resident training.

Reasons for conversion from laparoscopic to open or hand-assisted adrenalectomy: review of 261 laparoscopic adrenalectomies from 1993 to 2003

Over the past decade, laparoscopic adrenalectomy has become the operation of choice for resecting adrenal tumors. However, few reported data exist regarding the reasons for conversion from laparoscopic to open or hand-assisted adrenalectomy. We retrospectively reviewed the records of 261 consecutive laparoscopic adrenalectomies performed by one surgeon between 1993 and 2003. Laparoscopic adrenalectomy could not be completed in 8 of the 261 patients (3%); four of the operations were converted to hand-assisted laparoscopic adrenalectomy and four to open adrenalectomy. The reasons for the conversion were as follows: In three patients the tumor was too adherent to surrounding structures to be resected laparoscopically; in three patients the tumor was found to have malignant features during laparoscopy, and the operation was converted to achieve proper resection margins; in two patients the tumors were too large (15 and 16 cm, respectively) to be safely removed laparoscopically. The eight resected tumors included three pheochromocytomas, one myelolipoma, one angiomyolipoma, one solitary fibrous tumor, one liposarcoma, and one metastatic hepatocellular carcinoma. There were no cases in which conversion was required emergently for bleeding or other intraoperative catastrophes. All eight of the tumors removed were at least 5 cm in size (range 5-16 cm). The mean length of hospitalization was 4.4 days (range 3-8 days).

Reasons for conversion from laparoscopic to open cholecystectomy: a 10-year review

Laparoscopic cholecystectomy is now considered the "gold standard" operation for patients with gallstone disease. A number of patients require conversion to an open cholecystectomy for the safe completion of the procedure. This study investigates how the etiology and incidence of conversion from laparoscopic to open cholecystectomy has changed over time. All 5884 patients undergoing laparoscopic cholecystectomy between March 1991 and June 2001 were prospectively collected in a database. A total of 310 patients (5.2%) had had their cholecystectomies converted to an open procedure. The mortality rate for these patients was 0.7%. Causes for conversion were inability to correctly identify anatomy (50%), "other" indications (16%), bleeding (14%), suspected choledocholithiasis (11%), and suspected bile duct injury (8%). After an initial learning curve in thin patients with symptomatic cholelithiasis, inclusion of patients with acute cholecystitis, morbid obesity, or a prior celiotomy resulted in a peak conversion rate of 11% by 1994. From 1994 to the first half of 2001, the conversion rate has declined significantly for all patients (10% to 1%), as well as for patients with acute cholecystitis (26% to 1%). Although unclear anatomy secondary to inflammation remains the most common reason for conversion, the impact of acute cholecystitis on the operative outcome has decreased with time.

Predictive factors for conversion of laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has replaced open cholecystectomy for the treatment of gallbladder disease. However, certain cases still require conversion to open procedures. Identifying these patients at risk for conversion remains difficult. This study identifies risk factors that may predict conversion from a laparoscopic to an open procedure.

METHODS

From January 1996 to January 2000, a total of 1,347 laparoscopic cholecystectomies were performed at the Cleveland Clinic Foundation (CCF). A retrospective analysis of 34 parameters including patient demographics, clinical history, laboratory data, ultrasound results, and intraoperative details was performed. Stepwise, multivariate logistic regression was used to determine those variables predicting conversion of laparoscopic cholecystectomy.

RESULTS

Seventy-one (5.3%) laparoscopic cholecystectomies required conversion. Multivariate analysis revealed that for all cases, a white blood cell count >9 (2.9 greater odds ratio [OR] of conversion P = 0.006) and a gallbladder wall thickness >0.4 cm (7.2 OR, P <0.001) predicted conversion to open cholecystectomy. However, when patients with acute cholecystitis were evaluated only a body mass index >30 kg/m(2) (5.6 OR, P = 0.02) predicted conversion. For patients undergoing elective cholecystectomy, a body mass index >40 kg/m(2) (33.1 OR, P = 0.01) and a wall thickness >0.4 cm (24.7 OR, P <0.004) predicted conversion. Finally, an ASA >2 (5.3 OR, P = 0.01) predicted conversion in patients undergoing nonelective cholecystectomies.

CONCLUSIONS

Obese patients with acute cholecystitis undergoing laparoscopic cholecystectomy have an increased chance of conversion. Likewise, patients with multiple comorbid diseases undergoing nonelective laparoscopic cholecystectomy are more likely to require conversion. Finally, in an elective laparoscopic cholecystectomy, morbidly obese patients with chronic cholecystitis and a thickened gallbladder wall are more likely to require conversion. These factors can help counsel patients undergoing laparoscopic cholecystectomy with regards to the probability of conversion to an open procedure.

Risk factors for conversion of laparoscopic to open cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the treatment of choice for symptomatic gallstones; however conversion to open cholecystectomy (OC) remains a possibility. Unfortunately, preoperative factors indicating risk of conversion are unclear. Therefore, we aimed to identify risk factors associated with conversion of LC to OC.

PATIENTS AND MATERIALS

Records of 564 patients undergoing LC in 1995 and 1996 were reviewed. Patients were assigned to one of two groups: (1) acute cholecystitis defined by the presence of gallstones, fever, leukocyte count >10(4), and inflammation on ultrasound or histology; (2) chronic cholecystitis that included all other symptomatic patients. Demographics, history, and physical, laboratory, and radiology data, operative note, and the pathology report were reviewed.

RESULTS

161 of 564 patients, had acute and 403 patients had chronic cholecystitis; 16 acute cholecystitis patients (10%) were converted from LC to OC and 17 chronic cholecystitis patients (4%) had LC converted to OC. Patients having open conversion were significantly older, had greater prevalence of cardiovascular disease, and were more likely to be males. LC conversion to OC in acute cholecystitis patients was associated with a greater leukocyte count; in gangrenous cholecystitis patients, 29% had open conversion.

CONCLUSIONS

Importantly, these risk factors-older men, presence of cardiovascular disease, male gender, acute cholecystitis, and severe inflammation-are determined preoperatively, permitting the surgeon to better inform patients about the conversion risk from LC to OC. While acute cholecystitis was associated with more than a twofold increased conversion rate, only 10% of these patients could not be completed laparoscopically. Therefore, acute cholecystitis alone should not preclude an attempt at laparoscopic cholecystectomy.

Predictive factors for the type of surgery in acute cholecystitis

BACKGROUND

Whereas early cholecystectomy is accepted as the optimal timing for surgery, the best treatment modality for acute cholecystitis (AC) is still under debate. In this series, we aimed to assess the current treatment of AC in a single institution. In addition, preoperative criteria were defined predicting the severity of inflammation.

METHODS

From January 1995 to June 1999, 236 patients undergoing cholecystectomy for AC were prospectively evaluated. Outcome measures were the treatment modality, the severity of inflammation, white blood cell (WBC) count, C-reactive protein (CRP), morbidity, and hospital stay.

RESULTS

There were 115 laparoscopic cholecystectomies (LC), 77 primary open cholecystectomies (OC), and 44 conversions (CON) to OC. Patients with LC were significantly younger, in better condition, with a shorter duration of symptoms and lower CRP levels and WBC counts compared with OC and CON (P <0.001). Postoperative complications, reinterventions, and mean hospital stay were significantly increased after OC and CON (P <0.001). Overall mortality was 2.5%. Advanced AC was predominantly found in OC and CON (P <0.001). Patients with advanced AC were significantly older, predominantly male, and had a prolonged duration of symptoms as well as increased CRP levels and WBC counts (P <0.001). The conversion rate increased from 10% for mild AC up to 48% for necrotizing AC.

CONCLUSIONS

Based on laboratory (CRP, WBC), demographic (age, sex), and individual (American Society of Anesthesiologists classification, duration of symptoms) findings, it is possible to reliably predict the severity of inflammation. Therefore, an individualized surgical approach can be used for each patient and type of AC.

Training Background as a Factor in the Conversion Rate of Laparoscopic Cholecystectomy

The present study reports findings concerning the impact of the learning environment on the conversion rate of laparoscopic cholecystectomy (LC) to open cholecystectomy (OC). At Metro-West Medical Center (Framingham, MA) seven surgeons performed 866 LCs between 1990 and 1995. Group I consisted of three surgeons who learned the procedure as part of their General Surgery Residency training, whereas the remaining four surgeons representing Group II learned the procedure through private courses. We emphasize the importance of the surgeons’ training background on the conversion rates, operative times, and length of hospitalization for patients undergoing LC. The conversion rates, operative times, and complication rates were analyzed with and without a 2-year period of adjustment to compensate for the learning curve of early procedures. Operative times and conversion rates from LC to OC were lower for cases done by surgeons from Group I, even when the learning curve was corrected. The complication rates were higher for surgeons in Group II, but this did not reach statistical significance. As surgeons from Group II gained more experience their operation times and conversion rates decreased. However, there still was a statistically significant difference in favor of surgeons who learned the procedure as part of a structured curriculum. These data suggest a long-lasting influence of the learning environment on the conversion rates and operative times.

A risk score for conversion from laparoscopic to open cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has become the standard operative procedure for cholelithiasis, but there are still some patients requiring conversion to open cholecystectomy mainly because of technical difficulty. Our aim was to develop a risk score for prediction of conversion from laparoscopic to open cholecystectomy.

METHODS

Preoperative clinical, laboratory, and radiologic parameters of 1,000 patients who underwent laparoscopic cholecystectomy were analyzed for their effect on conversion rates. Six parameters (male sex, abdominal tenderness, previous upper abdominal operation, sonographically thickened gallbladder wall, age over 60 years, preoperative diagnosis of acute cholecystitis) were found to have significant effect in multivariate analysis. A constant and coefficients for these variables were calculated and formed the risk score.

RESULTS

Overall 48 patients required conversion to open cholecystectomy (4.8%). These patients had significantly higher scores (mean 6.9 versus -7.2, P <0.001). Increasing scores resulted with significant increases in conversion rates and probabilities (P <0.001). Ideal cut-off point for this score was -3; conversion rate was 1.6% under -3, but 11.4% over this value (P <0.001).

CONCLUSIONS

Conversion risk can be predicted easily by this score. Patients having high risk may be informed and scheduled appropriately. An experienced surgeon has to operate on these patients, and he or she has to make an early decision to convert in case of difficulty.

Elective laparoscopic cholecystectomy: preoperative prediction of duration of surgery

BACKGROUND

Efficient use of operating time has become a key concern. The aim of this study was to determine preoperative factors that can predict extended duration of operating time (>90 min) for laparoscopic cholecystectomy (LC).

METHODS

Data collected prospectively on 827 consecutive patients who underwent elective LC between 1990 and 1997 were analyzed. Factors evaluated included age, gender; body mass index; comorbidity; duration of symptoms; history of jaundice, pancreatitis, or abdominal surgery; dilated common bile duct or thick-walled gallbladder on ultrasound; preoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES); and surgeon experience. Univariate and multivariate analyses were performed to identify factors predicting a long operation.

RESULTS

Operating time was longer than 90 min in 276 patients (33%). Predictors of extended operation time were age older than 55 years (odds ratio [OR] = 9.7), preoperative ES (OR = 2.8), and a thick-walled gallbladder on ultrasound (OR = 2.5).

CONCLUSION

These predictors may be useful in planning theater lists and anesthesia management, and in selecting patients for day surgery.

Standardization of surgeon-controlled variables: impact on outcome in patients with acute cholecystitis

OBJECTIVE

To examine the effect of standardization of surgeon-controlled variables on patient outcome after cholecystectomy for two cohorts of patients with acute cholecystitis (AC).

SUMMARY BACKGROUND DATA

Laparoscopic cholecystectomy (LC), when performed efficiently and safely, offers patients with AC a more rapid recovery and decreases the length of stay, thus reducing the health care utilization. Numerous studies have focused on the characteristics of patients with AC that may predict the conversion of LC to open cholecystectomy. However, analysis of these factors offers little insight for improving the outcome of patients with AC, because patient-controlled variables are difficult to influence. In the present study, treatment variables that were under the surgeon's control were standardized and the effects of these changes on the outcome of patients with AC were quantified.

METHODS

Beginning in August 1997, a standardized treatment protocol was initiated for patients with suspected AC. LC was initiated as early as practical from the time of admission. All operations were performed in a specially equipped and staffed laparoscopic surgery suite, and all patients were supervised by one of two attending surgeons with a special interest in laparoscopic interventions. Two cohorts of patients with AC were retrospectively analyzed: 39 patients from the 12 months before initiation of this protocol (period 1) and 49 patients from the 12 months after its inception (period 2). Medical records were reviewed for demographic, perioperative, and outcome data. Surgical reports were reviewed to ascertain the reason for conversion and whether laparoscopic technical modifications were used.

RESULTS

No significant difference was noted between the groups with regard to patient demographics, clinical presentation, or radiologic or laboratory parameters. After protocol initiation, patients received definitive treatment closer to the time of admission and had a greater percentage of laparoscopically completed cholecystectomies. Furthermore, the patients in period 2 had a significantly decreased postoperative length of stay and hospital charges than the earlier ones. Complications were infrequent and not significantly different between the groups. Two or more laparoscopic technical modifications were used in 95% of the successful LCs during period 2 versus 33.3% during period 1.

CONCLUSIONS

By controlling when, where, and by whom LC for AC was performed, the authors have significantly improved the percentage of cholecystectomies that were completed laparoscopically. This has led to improved outcomes and lower hospital charges for patients with AC at this municipal hospital.

Patterns of morbidity and resource consumption associated with laparoscopic cholecystectomy in a VA medical center

BACKGROUND

The generally low incidence of morbidity and reduced rate of health care resource consumption commonly associated with laparoscopic cholecystectomy (LC) have been established from studies of patient populations which are distinct from that served by the Department of Veterans Affairs (VA) health care system. We sought to assess the outcomes of this procedure when performed on VA beneficiaries.

MATERIALS AND METHODS

Demographic and perioperative data for all patients undergoing attempted LC in our facility were recorded in a prospective database beginning 1 January 1993. The information in this registry was analyzed to determine the demographics of the treated population, the spectrum of biliary tract disease encountered, and patterns of morbidity and resource consumption.

RESULTS

LC was attempted in 141 cases. Median patient age was 62 years. The indication for surgery was either acute cholecystitis or biliary pancreatitis in 63 cases (45%). Thirteen patients (9%) developed major complications. These patients were significantly older (mean age 68 vs 59 years) than patients whose course was uncomplicated. Twenty-seven cases (19%) required conversion to an open procedure, most commonly for acute cholecystitis. Progressive cholecystitis was associated with a conversion rate of 64%. Both conversion and the development of a major complication produced significant increases in length of stay.

CONCLUSIONS

The population undergoing attempted LC in the VA system is characterized by relatively advanced age and high incidences of comorbid illness and complicated biliary tract disease. These attributes increase the frequency of major morbidity and of conversion to open cholecystectomy, which in turn increase resource consumption. Comparisons between the outcomes of attempted LC in VA centers and "benchmark" results obtained in other settings should be controlled for these factors.