Laparoscopic cholecystectomy for acute cholecystitis performed by residents in surgery: a risk factor for conversion to open laparotomy?

Preoperative Magnetic Resonance Cholangiopancreatography for Detecting Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis

Previous studies have shown that signal intensity variations in the gallbladder wall on magnetic resonance imaging (MRI) are associated with necrosis and fibrosis in the gallbladder of acute cholecystitis (AC). However, the association between MRI findings and operative outcomes remains unclear. We retrospectively identified 321 patients who underwent preoperative magnetic resonance cholangiopancreatography (MRCP) and early laparoscopic cholecystectomy (LC) for AC. Based on the gallbladder wall signal intensity on MRI, these patients were divided into high signal intensity (HSI), intermediate signal intensity (ISI), and low signal intensity (LSI) groups. Comparisons of bailout procedure rates (open conversion and laparoscopic subtotal cholecystectomy) and operating times were performed. The recorded bailout procedure rates were 6.8% (7/103 cases), 26.7% (31/116 cases), and 40.2% (41/102 cases), and the median operating times were 95, 110, and 138 minutes in the HSI, ISI, and LSI groups, respectively (both p < 0.001). During the multivariate analysis, the LSI of the gallbladder wall was an independent predictor of both the bailout procedure (odds ratio [OR] 5.30; 95% CI 2.11–13.30; p < 0.001) and prolonged surgery (≥144 min) (OR 6.10, 95% CI 2.74–13.60, p < 0.001). Preoperative MRCP/MRI assessment could be a novel method for predicting surgical difficulty during LC for AC.

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 pyloromyotomy: effect of resident training on complications

PURPOSE

The purpose of this study was to characterize the safety of laparoscopic pyloromyotomy and examine the effect of resident training on the occurrence of complications.

METHODS

Five hundred consecutive infants who underwent laparoscopic pyloromyotomy between January 1997 and December 2005 were reviewed and analyzed.

RESULTS

Laparoscopic pyloromyotomy was successfully completed in 489 patients (97.8%). Four hundred seventeen patients were boys (83%). Intraoperative complication occurred in 8 (1.6%) patients (mucosal perforation, 7; serosal injury to the duodenum, 1). All were immediately recognized and uneventfully repaired. Six patients (1.2%) required revision pyloromyotomy for persistent or recurrent gastric outlet obstruction. There were 7 wound complications (1.4%) and no deaths. Pediatric surgery residents performed 81% of the operations, whereas 16% were done by general surgery residents (postgraduate years 3-4). There was a 5.4-fold increased risk of mucosal perforation or incomplete pyloromyotomy when a general surgery resident rather than a pediatric surgery resident performed the operation (95% confidence interval, 1.8-15.8; P = .003). These effects persisted even after controlling for weight, age, and attending experience.

CONCLUSIONS

The laparoscopic pyloromyotomy has an excellent success rate with low morbidity. The occurrence of complications is increased when the operation is performed by a general surgery resident, even when directly supervised by pediatric surgical faculty.

Risk factors influencing conversion of laparoscopic to open cholecystectomy

BACKGROUND

Conversion of laparoscopic to open cholecystectomy is required in certain cases for the safe completion of the operation. Some factors contribute more to the need for conversion.

METHODS

Over a 13-year period, the laparoscopic cholecystectomy procedure was attempted in 1263 patients whose mean age was 54 years and 28% being male. The conversion was necessary in 98 cases whose mean age was 60 years, with 42% being male. All data were studied retrospectively. Six factors were examined statistically for a possible correlation with the conversion rate, as well as the trend of it over time.

RESULTS

The main reason for conversion was the unclear anatomy owing to previous inflammation, followed by bleeding and choledocholithiasis suspicion, gallbladder carcinoma, bile duct injury, or spilled gallstones. The overall conversion rate was 7.75%. It was significantly increased in males (11.6%) and the elderly (12.4 %), gallbladder inflammation (29%), and morbid obesity (50%). Conversion rate did not change significantly in the first half period (8.1%) of the study, the second half-period (7.6%), in patients with diabetes mellitus (6.7%), or hematological disorders (6%).

CONCLUSIONS

The risk for the conversion of laparoscopic cholecystectomy increases significantly in males, the elderly, obese patients, and when inflammation is present. This observation remains unchanged over time. Diabetes mellitus and hematologic disorders do not predispose in a higher risk for conversion.

Fundus-first laparoscopic cholecystectomy

BACKGROUND

Fundus-first dissection (FFD) is an established technique to deal with difficult open cholecystectomies. Although the indications for such an approach are similar for laparoscopic cholecystectomy (LC), FFD is not widely practiced because of difficulties that arise with liver retraction, the dissection of dense adhesions, or obscured cystic pedicles, often necessitating conversion to an open procedure.

METHODS

The aim of this study was to evaluate the indications for FFD and the technical aspects of the procedure in cases with a difficult cystic pedicle. Prospectively collected data and video recordings of cases of fundus-first laparoscopic cholecystectomy (FFLC) were analyzed. The great majority were difficult cases, so we also reviewed the safety aspects of this approach and assessed its effect on the conversion rate.

RESULTS

FFLC was resorted to in 35 cases (5%) of 710 consecutive LCs with difficulty grade II (two cases), III (13 cases), or IV (20 cases). There were 16 male patients (46% vs 9% males in the whole), and the mean age was 56 years (ranges, 28-87). The reasons for FFD were dense adhesions preventing the exposure of the cystic pedicle in 14 cases, large Hartmann's pouch stones in 10 cases, short dilated cystic ducts in six cases, and Mirizzi syndrome in three cases. Two cases had contracted "burn-out" gallbladders. Intraoperative cholangiography (IOC) was possible in 24 patients, failed in 10 (29%), and was not attemped in one. Seven patients had bile duct stones and required bile duct exploration. FFLC was completed in 31 patients, 28 of whom were seriously considered for conversion prior to commencing FFD. Conversion was still necessary after trial FFD in four cases (11%) two with Mirizzi abnormalities, one with bile duct stones, and one with dense adhesions. The mean operative time was 125 min, (range, 50-230). There were no operative or technique-related complications.

CONCLUSION

FFLC is feasible and is a safe option for cases with a difficult cystic pedicle. Its use reduced the conversion rate of the series from a potential 5.2% to 1.2%, However, subtotal cholecystectomy or conversion must not be delayed if, after the neck of the gallbladder is reached the anatomy is still unclear.

Postgraduate year does not influence operating time in laparoscopic cholecystectomy

BACKGROUND

Surgical resident education may contribute to increased operating time, thus increasing costs at teaching institutions. It is possible that junior residents, in particular, with less experience could contribute to longer operating times for laparoscopic cholecystectomy. We hypothesized that all general surgery residents, regardless of level of training and with proper supervision, could complete a laparoscopic cholecystectomy in a safe and timely fashion.

MATERIALS AND METHODS

A retrospective study was performed using data collected from laparoscopic cholecystectomies completed under the supervision of one attending surgeon over a 2-year period. Operating times were recorded, the operating surgeon was identified, and cases were assigned an acuity level based on pathologic findings. Operative times were compared after dividing surgeons into three groups (junior residents, senior residents, and staff).

RESULTS

Seventy-one cases were entered into the study. There were no differences when comparing mean operating times among the three groups (P = 0.2, analysis of variance). The pathologic acuity in each group was similar (P = 0.8, Fisher's exact test). There was a difference when evaluating the operating times for the pathologic level of acuity (P = 0.002, Kruskal-Wallis test).

CONCLUSIONS

Resident level does not affect the operating time in performing laparoscopic cholecystectomy. The pathologic acuity of the gallbladders was distributed similarly for all three groups. There was a difference in mean operating time based on pathologic acuity. Laparoscopic cholecystectomy can be performed in a safe and efficient manner at a teaching institution.

Cusum analysis of trends in operative selection and conversion rates for laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) requires a high degree of technical ability, spatial resolution and dexterity. Assessing trainees and competent operators is an important aspect of quality assurance in patient care. Most institutions quote mean conversion rate as a method of comparing operators' performance. The purpose of the present study was to use the technique of cumulative sum (cusum) analysis to determine whether a learning curve phenomenon exists in operators performing LC.

METHODS

Data were obtained retrospectively by reviewing the operative records of all patients undergoing elective and acute cholecystectomy for a 30-month period coinciding with the commencement of LC at North Shore Hospital. Patients' age and gender, date and type of operative procedure, duration of operation, and name of operator were recorded. Mean and cusum-transformed data were derived for all operations as well as for four individual operators' performances.

RESULTS

Over the study period a total of 614 cholecystectomies was performed, with 85% attempted laparoscopically. A total of 9.8% required conversion to the open technique. Time trend analysis with the cusum technique for all surgeons revealed an inverse relationship between selection rate and conversion rate. Analysis of four individual surgeons revealed three different time trend profiles.

CONCLUSION

There was a direct inverse relationship between conversion rate and selection rate, in that careful selection is associated with a low conversion rate. Comparison of individual surgeons' performance showed wide variation, with only one surgeon exhibiting the phenomenon of a learning curve. Contrary to other reports, we found that performance on LC was not always related to operative experience. This highlights the need for a more objective method to analyse operator competence than operator experience alone.

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.