ROLE OF DIFFERENT FACTORS AS PREOPERATIVE

PREDICTORS OF CONVERSION OF LAPAROSCOPIC

CHOLECYSTECTOMY TO OPEN CHOLECYSTECTOMY
INTRODUCTION
 Surgery for gallstones is one of the most common procedures
undertaken by general surgeons worldwide
 15% of the adult; affected by gallstones

 80% of the patients with gallstones remain asymptomatic

 Becoming symptomatic increased by 1% every year

 1985 ; laparoscopic cholecystectomy is a gold standard

treatment option
 approximately 75% of all cholecystectomy are
performed laparoscopically
 Probability unforeseen circumstances
 difficulty in creating pneumoperitoneum
 dissecting triangle of Calot
 controlling hemorrhage from gallbladder bed

 Preoperative sensitization of difficulty can better

prepare and help the surgeon to decrease the chance of
various serious complications
 The objective of our study was to identify the
preoperative predictors of conversion of
laparoscopic cholecystectomy into open
cholecystectomy.
 The secondary objective of our study was to
determine the causes of conversion to open
cholecystectomy.
MATERIALS AND METHODS
 A cross-sectional study of 400 patients
 From September 2016 to February 2017

 All patients undergoing laparoscopic cholecystectomy were

included in the study.
 Not including;
 Patients undergoing open cholecystectomy due to the presence of
contraindication to laparoscopic cholecystectomy
 patients in which laparoscopic cholecystectomy was a part of
some other laparoscopic intervention
 Informed Consent
 A structured questionnaire
 All patients underwent general anesthesia
 Decision to place a nasogastric catheter was taken
peroperatively, where gastric distension effected the
surgeon’s view of the triangle of Calot.
 The surgical site was prepared and draped according to the
standard protocols
 Pneumoperitoneum ; close technique (80%) or open
technique (20%)
 Four standard ports;
 Cystic duct and artery were clipped in all
laparoscopic cholecystectomies
 The harmonic device was used for dissection in
gallbladder bed and to achieve hemostasis
 Those who got converted to open, Kocher’s left
subcostal incision was given and vinyl 2/0 was used
to ligate cystic duct and achieve hemostasis
 An 18 Fr drain was placed in subhepatic space in all
the cases
 All procedure details along with peroperative
findings were filled in the questionnaire at the
end of procedure
 The patients who underwent laparoscopic
cholecystectomy were discharged within first 24
h postoperatively
 while those who underwent conversion were kept
for 72 h for intravenous antibiotics and
observation.
 SPSS version 21 was used to analyze the data
 Independent samples t-test
 Chi-square test
 Mann–Whitney test

 A P < 0.05 was considered statistically significant

RESULTS
 The overall mean age of the patients was 43.67 ± 13.54
years
 The male patients were significantly older as
compared to the female patients.
 The conversion rate was higher in patients who had an
elevated total leukocyte count and alanine
aminotransferase before the operation (P < 0.05)
 The rate of conversion was

 significantly higher in male patients aged ≥50 years (P

< 0.05)
 the reasons for the conversion to open
cholecystectomy;
 Difficulty in the dissection of the triangle of Calot
 difficulty in dissecting the gallbladder fossa
 bleeding in gallbladder fossa
 presence of duodenal fistula
 autolyzed gangrenous gallbladder
DISCUSSION
 A significant delay in this decision can result in
increased morbidity and mortality.
 To prevent these dreadful consequences, a large
number of studies have been conducted on the
importance of various preoperative predictors in
determining the chances of conversion of
laparoscopic cholecystectomy to open
cholecystectomy
 The conversion rate in various studies was found to
vary between 2.6% and 7.7%. The conversion rate
in our study was found to be 5%.
 According to a study conducted in a primary care
center, the conversion rate was significantly higher in
male patients >65 years of age (P = 0.006). According
to another study, male patients were 2.3 times more
likely to need conversion to open cholecystectomy as
compared to female patients (P = 0.004). In our
study, there was no statistically significant
difference between the genders in terms of
conversion (P > 0.05).
 Was found to be significantly higher in male patients
aged ≥50 years as compared to female participants of
the same age group (P = 0.033)
 The overall mean age of the participants was
43.67 ± 13.54 years. The male participant’s
average age was 52.37 ± 16.18 years while female
participants’ average age was 42.02 ± 12.30 years
(P = 0.002). In our study, age was not found
to be a significant predictor of conversion
rate.
 According to another study, patients older than
65 years were 2.6 times more likely to need
conversion (P < 0.002). The difference in our
result could be because our study only had
20 patients with age >65.
 In our study, acute cholecystitis and acalculous
acute cholecystitis were found to be
significantly associated with the conversion
rate (P < 0.05). According to a retrospective review, a
patient with acute cholecystitis was 5.63 times likely
to need conversion. This study also concluded that
elevated total leukocyte count and alanine
aminotransferase were associated with increase
conversion rate. Another study done by Oymaci et
al. had similar findings
 According to our study, active or previous
episodes of acute pancreatitis posed neither
significant difficulty in dissecting triangle of
Calot or gallbladder fossa nor did they play a
role in conversion. The same results were endorsed
by a recently published study by Guadagni et al
 According to the study by Donkervoort et al.,
patients with BMI >25 were 3.4 times more likely
to need conversion. In our study, no
statistically significant association was
found between BMI and need to convert.
This might be due to the fact that patients with
BMI >30 were not included in our study.
 Another study by Tiong and Oh also concluded
that BMI was not associated with the conversion
rate
 According to a meta-analysis, diabetes was not
found to be significantly associated with the rate
of conversion. Another study in America
concluded that chronic obstructive pulmonary
disease was not significantly associated with
conversion rate.
 In our study, the mean duration of surgery
was found to be significantly higher in
patients with diabetes.
 Difficulty in the dissection of triangle of Calot,
difficulty in dissecting the gallbladder fossa,
bleeding in gallbladder fossa, presence of
duodenal fistula, and autolyzed gangrenous
gallbladder were the reasons for the conversion
to open cholecystectomy
CONCLUSION
 The rate of conversion of laparoscopic
cholecystectomy to open cholecystectomy was
found to be 5%.
 Male patients aged ≥50 years, acalculous acute
cholecystitis, acute cholecystitis, elevated
preoperative total leukocyte count, and alanine
aminotransferase levels were found to be
significant predictors of conversion to open
cholecystectomy
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