Title: Preoperative Predictors for Conversion in Laparoscopic Cholecystectomy
Authors: Prof Dr Braja Mohan Mishra, Dr A.N Behera, Dr Ravi Kumar Jha
DOI: https://dx.doi.org/10.18535/jmscr/v5i12.34
Abstract
Introduction: Laparoscopic cholecystectomy has rejuvenated general surgery and in very short time has become the gold standard operation for benign gallbladder disease, but the procedure is technically more demanding than the classical open cholecystectomy. Although introduction of laparoscopic cholecystectomy has dramatically affected the management of patients with biliary disease, but even today there are numerous challenges and unanswered questions that remain, regarding issues related to application of laparoscopic techniques to this very common clinical disorder. Greater chances of damage to the common bile duct and surrounding viscera exist.
Aims and Objectives: The aim of our study was to evaluate some preoperative factors, which can reliably predict the chances of conversion to the open procedure and the complications during laparoscopic cholecystectomy. This may benefit the patients because beforehand information about the possibility of complications and conversion to the open procedure can be made available. The patient can be mentally prepared and can adjust his or her expectations accordingly. In addition, the surgeon can directly perform the classical open cholecystectomy in the patients with presumed difficult surgery thus saving operating time and the conversion rate.
Material and Methods: This prospective study was conducted on 250 patients undergoing laparoscopic cholecystectomy in the department of Surgery, VIMSAR, BURLA, and over a period of 24 months from november2015 to november 2017, to evaluate and correlate the clinical, biochemical and ultrasonographic findings with the operative findings for anticipating difficult laparoscopic cholecystectomy. The parameters which were studied are age ≥ 65 years, sex, acute cholecystitis, number of acute attacks in the past, history of upper abdominal surgery, WBC count (≥ 10000), total bilirubin (≥ 1.5 mg/dl), ALP (≥ 310 IU/L), gallbladder wall thickness (≥ 4 mm), pericholecystic collection, gallbladder size (contracted gallbladder), stone impaction at neck/cystic duct and Mirizzi’s syndrome.
The risk of organ injury was minimized in our study by using open trocar placement (a Hasson cannula was used). Patients with previous lower abdominal surgeries were also included in our study.
The operative parameters taken to assess the difficulty of the laparoscopic cholecystectomy were total time taken to operate from the insertion of the trocar to the extraction of the gallbladder (more than 90 mins), tear of gallbladder with spillage of bile and stones, and conversion to open cholecystectomy. The surgeons experienced in laparoscopic cholecystectomy performed the surgeries.
Results: In this study the rate of conversion was found to be 7.2%, Male to female ratio was 1:5.62. The majority of patients were in the age group of 41 – 50 years. The mean age was 41.9 with standard deviation of 9.9. The conversion rate is highest in the age group of 51 -60 years. Overall 46 out of 250 patients were predicted to be difficult cases based on clinical parameters out of which 30 were difficult on surgery and 18 out of the 46 cases got converted. Out of 250 patients 13 patients were predicted to be difficult based on biochemical parameters of which 10 were difficult on surgery. Out of 10 difficult cases 4 got converted to open procedure. Out of 250 patients 30 were predicted to be difficult of which 23 were found to be difficult on ultrasonographic parameters. Out of these 23 difficult cases 13 got converted to open procedure. In this study, on multivariate logistic regression analysis male sex, acute cholecystitis, WBC more than 10000/ cumm, contracted gallbladder and stone impaction at neck region were found to be significant predictive factors for conversion of laparoscopic cholecystectomy to open cholecystectomy. Most common reason for difficult laparoscopic cholecystectomy and conversion to open procedure was adhesions in the Calot’s triangle and with the surrounding structures. The intra-operative complications that occurred in this study were cystic artery tear, bleeding from gallbladder bed, tear of gallbladder and spillage of stones and bile.
Conclusion: From this study, we can conclude that preoperative clinical, biochemical and ultrasonographic parameters are good predictors of difficulty in laparoscopic cholecystectomy in the majority of cases and should be used as a screening procedure. It can help surgeons to get an idea of the potential difficulty to be faced in a particular patient.
