Open Cholecystectomy Has a Place in the Laparoscopic Era: a Retrospective Cohort Study

A Study of Factors Leading to Difficult Laparoscopic Cholecystectomy at a Tertiary Care Center in Northeastern India

BACKGROUND

Laparoscopic cholecystectomy (LC) is currently the gold standard of care for managing gallstone disease. The time taken to perform LC depends on both patient-related and surgeon-related factors. Recognizing factors associated with difficult LC (DLC) can aid in appropriate surgeon selection and judicious scheduling of cases.

METHODS

This prospective study was conducted to identify preoperative factors (clinical and ultrasonographic) and intraoperative factors that can help predict or prepare for DLC. The study took place in the Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India. A total of 100 cases of LC were enrolled over a two-year period. All patients had symptomatic cholelithiasis and were scheduled to undergo elective LC. The time taken to perform LC was compared against individual parameters of interest, including clinical features, ultrasonography (USG), and intraoperative findings.

RESULTS

Forty-one LCs were classified as difficult and 59 as non-DLC (NDLC), based on the time limit set by the mean operating time for all LC cases. Seven out of the 41 difficult LCs required conversion to open cholecystectomy (OC). Patient, USG, and intraoperative factors were found to have a significant correlation with difficult LC. Patient factors included male gender, body mass index (BMI), number of past attacks, and previous abdominal surgery. USG factors included calculi number, calculi size, impaction of calculi, and a thick gallbladder (GB) wall. Intraoperative factors included pericholecystic adhesions, Calot's triangle dissection, GB mobilization from the liver bed, and GB specimen extraction.

CONCLUSION

Preoperative identification of difficult LC cases can guide rational allocation of cases based on surgeon experience, leading to better utilization of operating theatre time and reducing the probability of conversion and complications.

The Conversion Rate of Laparoscopic Cholecystectomy to Open Cholecystectomy at King Abdulaziz Medical City, Jeddah, Saudi Arabia: Prevalence and Causes

Introduction Laparoscopic cholecystectomy has emerged as the preeminent surgical technique for cholecystectomy. However, in exceptional circumstances, surgeons may encounter significant obstacles that necessitate reverting to the traditional open approach, which has more undesirable complications. In this study, we aimed to identify the factors underlying conversion and to quantify its prevalence in the medical setting of King Abdulaziz Medical City (KAMC) in Jeddah to lower the rate of conversion. Methodology In this retrospective cross-sectional study, a non-probability consecutive sampling technique was utilized to include all patients over 16 years of age who underwent cholecystectomy at KAMC, Jeddah, between January 2009 and June 2022, excluding any patients with missing data. Results The total number of patients operated for cholecystectomy was 2,632, of which 1924 were female (73.1%) and 708 were males (26.9%). Of these patients, only 69 were converted to open (2.62%). Among them, 32 patients were in the age group >60, with the highest conversion rate (7.80%). The leading causes were adhesions in 55 cases (79.71%) and distorted anatomy in 31 cases (44.92%). Conclusion This study shows distorted anatomy and adhesions to be the leading causes of conversion from laparoscopic cholecystectomy to open approach at KAMC with a conversation rate of 2.62%. Furthermore, this article includes a higher number of patients in a longer period compared to other similar literature, which may give more accountable results that help reduce the conversion rate and complications.

Risk Factors and Prevalence Associated With Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy: A Tertiary Care Hospital Experience in Western Mexico

Introduction Laparoscopic cholecystectomy (LC) is a common procedure used for the treatment of different pathologies caused by gallstones in the gallbladder, and one of the most common indications is acute cholecystitis. The definitive treatment for acute cholecystitis is surgery, and LC is the gold standard. Nevertheless, transoperative complications (like intraoperative bleeding, anatomical abnormalities of the gallbladder, etc.) of LC and some other preoperative factors (like dilatation of bile duct, increased gallbladder wall thickness, etc.) can cause or be a risk factor for conversion to open cholecystectomy (OC). The objective of this study was to determine the risk factors and prevalence associated with the conversion from LC to OC in patients with gallbladder pathology and the indication for LC. Materials and methods This was a prospective cohort study. We included patients of both sexes over 18 years of age with gallbladder disease. To determine the risk factors associated with conversion, we performed a bivariate analysis and then a multivariate analysis. Results The rate of conversion to OC was 4.54%. The preoperative factors associated with conversion, in the bivariate analysis, were common bile duct dilatation (p=0.008), emergency surgery (p=0.014), and smoking (p=0.001); the associated intraoperative variables were: laparoscopic surgery duration (p <0.0001), Calot triangle edema (p=0.033), incapacity to hold the gallbladder with atraumatic laparoscopic tweezers (p=0.036), and choledocholithiasis (p=0.042). Laparoscopic Surgery duration was the only factor with a significant association in the multivariate analysis (p=0.0036); we performed a receiver operating characteristic (ROC) curve analysis and found a cut-off point of 120 minutes for the duration of laparoscopic surgery with a sensitivity and a specificity of 67 and 88%, respectively. Conclusion The prevalence of conversion from LC to OC is similar to that reported in the international literature. The risk factors associated with conversion to OC, in this study, should be confirmed in future clinical studies, in this same population, with a larger sample size.

Preoperative Risk Factors for Conversion from Laparoscopic to Open Cholecystectomy: A Systematic Review and Meta-Analysis

Laparoscopic cholecystectomy is a standard treatment for patients with gallstones in the gallbladder. However, multiple risk factors affect the probability of conversion from laparoscopic cholecystectomy to open surgery. A greater understanding of the preoperative factors related to conversion is crucial to improve patient safety. In the present systematic review, we summarized the current knowledge about the main factors associated with conversion. Next, we carried out several meta-analyses to evaluate the impact of independent clinical risk factors on conversion rate. Male gender (OR = 1.907; 95%CI = 1.254−2.901), age > 60 years (OR = 4.324; 95%CI = 3.396−5.506), acute cholecystitis (OR = 5.475; 95%CI = 2.959−10.130), diabetes (OR = 2.576; 95%CI = 1.687−3.934), hypertension (OR = 1.931; 95%CI = 1.018−3.662), heart diseases (OR = 2.947; 95%CI = 1.047−8.296), obesity (OR = 2.228; 95%CI = 1.162−4.271), and previous upper abdominal surgery (OR = 3.301; 95%CI = 1.965−5.543) increased the probability of conversion. Our analysis of clinical factors suggested the presence of different preoperative conditions, which are non-modifiable but could be useful for planning the surgical scenario and improving the post-operatory phase.

Cholecystectomy-Associated Complications in Kidney Transplant Recipients Compared With the General Population

Cholelithiasis is one of the most prevalent diseases in the general population. Among kidney transplant (KT) recipients, atypical clinical presentation may delay the diagnosis and proper treatment. This single-center retrospective cohort study compared cholelithiasis clinical presentation and cholecystectomy-associated complications in 230 KT recipients and in 172 members of the general population. KT recipients had a higher proportion of men, comorbidities, biliary pancreatitis, choledocholithiasis, and acute cholecystitis clinical presentations than the general population. KT recipients presented higher American Society of Anesthesiologists scores and higher rates of emergency surgeries (15.7% vs 9.9%, P = .091), conversion (5.7% vs 1.2%, P = .019), drainage (7.8% vs 2.3%, P = .016), postoperative complications (10% vs 4.7%, P = .047), and longer hospital length of stay (1 vs 1 days, interquartile range, 2 vs 0 days; P < .001). There were 5 deaths, all of which occurred in KT recipients. History of diabetes mellitus, renal function, and surgical conversion were independent risk factors associated with postoperative complications. Male sex and level of renal function were independent risk factors associated with postoperative acute cholecystitis. KT was an independent risk factor associated with postoperative choledocholithiasis (adjusted odds ratio, 5.89; 95% confidence interval, 3.03-15.66) and pancreatitis (adjusted odds ratio, 6.89; 95% confidence interval, 2.99-11.61). In conclusion, KT recipients with cholelithiasis have an increased risk for clinical and surgical complications compared with the general population.

Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury: A multicenter study

BACKGROUND

Bile duct injury (BDI) after cholecystectomy remains a significant surgical challenge. No guideline exists to guide the timing of repair, while few studies compare early versus late repair BDI. This study aimed to analyze the outcomes in patients undergoing immediate, intermediate, and delayed repair of BDI.

METHODS

We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020. The patients were divided into three groups based on the time of BDI reconstruction. Group 1 underwent an immediate reconstruction (within the first 72 hours post-cholecystectomy, n = 156); group 2 underwent an intermediate reconstruction (from 4 days to 6 weeks post-cholecystectomy, n = 75), and group 3 underwent delayed reconstruction (after 6 weeks post-cholecystectomy, n = 181).

RESULTS

Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cirrhosis compared with groups 1 and 3. Favorable outcome was observed in 111 (71.2%) patients in group 1, 31 (41.3%) patients in group 2, and 157 (86.7%) patients in group 3 (P = 0.0001). Multivariate analysis identified that complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of favorable outcome in group 1, the use of external stent was an independent factor of favorable outcome in group 2, and level E4 BDI was an independent factor of unfavorable outcome in group 3. Transected BDI and level E4 BDI were independent factors of unfavorable outcome.

CONCLUSIONS

Favorable outcomes were more frequently observed in the immediate and delayed reconstruction of post-cholecystectomy BDI. Complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of a favorable outcome.

Management of Major Postcholecystectomy Biliary Injuries: An Analysis of Surgical Results in 62 Patients

Background:

Management of injuries sustained during cholecystectomy requires expertise and involves a patient who is troubled, usually drained of personal resources. There has been an increase in incidence with laparoscopic cholecystectomy. The standard surgical management done for major biliary injuries is Roux-en-Y Hepaticojejunostomy (R-en-Y HJ).

Materials and Methods:

Patients managed surgically for definitive management of biliary injuries in the form of R-en-Y HJ were included. Data were collected from prospectively maintained records and through outpatient follow-up. Demographic data, early and late surgical complications, long-term outcomes, and follow-up results were analyzed.

Results:

Among the 62 patients, 26 were males, with a mean age of 37.4 ± 13.5 years. A total of 24 patients presented with ongoing biliary fistula. The Strasberg–Bismuth type of injury included types E1 in 8 (13%), E2 in 31 (50%), E3 in 19 (30.6%), and E4 in four patients (6.4%). There were no postoperative mortality and morbidity in 27.4% of patients. Atrophy–hypertrophy complex was seen in four patients, vascular injury in six patients, and an internal fistulisation with duodenum in two patients. Presence of comorbidities (P = 0.05), male gender (P = 0.03), tobacco use (P = 0.04), low albumin (P = 0.016), and more proximal (E4-E1) type of injury (P = 0.008) were independent predictors of postoperative morbidity (P < 0.05). The mean duration of patient follow-up was 26.2 ± 21.1 months.

Conclusion:

Optimization of preoperative nutrition, avoidance of intraoperative blood transfusion, proper timing of repair, and tension-free R-en-Y HJ draining all the ducts which is done at an experienced hepatobiliary center provide the best outcome.

Selective Cholecystectomy: using an evidence-based prediction model to plan for cholecystectomy

BACKGROUND

Symptomatic gall stones are treated safely and efficiently with laparoscopic cholecystectomy. Conversion to open cholecystectomy may be associated with adverse outcomes. Accurate prediction of conversion should decrease the incidence of conversion and improve patient care.

METHODS

The recent literature on conversion at laparoscopic cholecystectomy is reviewed to identify robust prediction models that are both internally and externally validated.

RESULTS

Two prediction models are identified which meet these criteria.

CONCLUSIONS

The Cairns Prediction Model using nomograms, is an easily applied tool predicting conversion, which is presently in use. Routine use of this tool should decrease conversion, and improve the process of patient consent.