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Predictors for Conversion to Open Appendectomy in Patients Undergoing Laparoscopic Appendectomy
appendix mass, abscess, perforated appendix and diffuse peritonitis with significant p value (p = 0.001). Another study conducted by
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or other pelvic or right iliac fossa pathologies or technical problems, Suresh Kumar et al. also has similar conversion in diabetic patient as
and lack of space for dissection. Even though these pathologies can 3 underwent conversion out of 12 patients of DM and 16%
be dealt with minimal access surgery, conversion to open surgery conversion in hypertensive patients.
may become mandatory in a small number of cases. The presence Another predictor for conversion to OA in our study is ASA grade
of comorbidities is the independent factor related to conversion >2 points. Out of 60 patients, there were 51 patients (85%) with
during laparoscopic appendicectomy. 1 ASA grade 1 point, while 9 (15%) patients were ASA grade >2 point.
Conversion from laparoscopic to open appendicectomy Among nine patients, eight were converted to OA with ASA grade
known as conversion appendicectomy (CA), further increases >2 point. There was a significant association with conversion of ASA
the operative time, along with loss of benefits of minimal access grade to open procedure (p = 0.001). A similar study conducted by
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surgery. Therefore, developing a preoperative criterion to decide Wagner et al. in which 12 patients (29.7%) out of 39 patients were
ideal operative approach for individual may be useful. converted to OA with ASA grade >2 points, which is significant
with p = 0.001.

MAterIAls And Methods In our study, leukocyte count was >12,000 in 25 patients
The proposed study titled “Predictors for conversion to OA in (41.67%) out of which 9 patients (36%) were converted to OA with
patients undergoing laparoscopic appendectomy (LA) based on significant p value (p = 0.021947) in comparison to normal leukocyte
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clinical presentations, ultrasonography (USG) findings and Tzanaki’s count. Study conducted by Manuneethimaran et al. had the similar
scoring” was carried out in PG Department of Surgery, SRN Hospital result the high WBC count is associated with higher conversion to
associated with MLN Medical College, Prayagraj from September open procedure with WBC count (16,380 ± 1,015) having significant
2018 to September 2019 after approval from the ethical committee p value (p ≤ 0.01).
and after obtaining written and informed consent either from Tzanaki’s score is a diagnostic score which includes right iliac
patient or their legal heir. fossa tenderness, rebound tenderness, leukocytosis (>12,000), and
The study was conducted on the patients admitted in the USG finding. In this study, 21 patients (35%) had score ≤9, while
Department of Surgery, SRN Hospital, MLN Medical College 39 patients (65%) had score ≥10. There was 11 patients (52.38%)
between September 2018 and September 2019 who underwent converted to OA out of 21 having score ≤9 in comparison to 1
conversion appendectomy. patient (2.56%) having score ≥10. This shows significant association
Patients were evaluated and their complete biodata were Tzanaki’s score to more conversion in population having ≤9 score
recorded after taking detailed history. Based on history, clinical while less conversion in population having ≥10 score.
examination, laboratory investigations, and ultrasound of abdomen In our study, USG finding was included in Tzanaki’s scoring
and pelvis, appendicitis diagnosed. The parameters studied system, so individual finding of USG is not significantly associated
include age, sex, previous history of acute appendicitis any lower with conversion to open appendicectomy. In general, USG showing
abdominal surgeries in the past, symptoms, duration of symptoms, as appendicular mass, appendicular adhesion, pericecal adhesion,
sign, white blood cell (WBC) count, ultrasound abdomen and pelvis and perforation had higher impact on decision on conversion.
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findings, American Society of Anesthesiologists (ASA) grading, and Study by Suresh Kumar et al. has similar result with association
intraoperative findings including reasons for conversion. of USG finding.
Other clinical features, such as pain, fever, nausea, and vomiting,
results were not significantly associated with conversion in our study as
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statically insignificant value (p ≥ 0.05). Manuneethimaran et al.
In our study of 60 patients undergoing appendicectomy, conversion study having similar result to pain, fever, nausea, and vomiting is
to OA occurred in 12 patients (20%). The conversion rate in this study not a predictor with insignificant p value (p ≥ 0.05) for conversion
much higher than other studies performed before because of small of LA to OA.
sample size of this study.
In our study, age group of 10–39 years had lower rate of
conversion in comparison to age group of ≥40 years. Out of 60 dIscussIon
patients, 12 patients converted to open out of which 8 patients In our study, by univariable analysis, a number of risk factors
(66.67%) were ≥40 years, with significant p value (p = 0.000124). for conversion to OA were identified. These include advanced
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A study conducted by Manuneethimaran et al. shows almost age, male sex, ASA score >2 points, higher leukocyte count, and
similar age group (48 ± 16) associated with more conversion with severity of inflammation as shown in USG (pericecal adhesion,
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significant p (<0.01) value. Other study by Antonacci et al. had periappendicular adhesion, perforated appendix with peritonitis,
similar age group (36 ± 19.3) associated with more conversion with gangrenous appendix).
significant p (<0.001) value. Multivariable analysis incorporating these factors available to
In our study, 38 patients (63.33%) were male, while 22 patients the surgeon preoperatively identified advanced age, ASA score >2
(36.67%) were female, out of which male patients had more points, and severity of adhesion in USG are significantly associated
conversion (21.05%) in comparison to female patients (18.18%) with conversion. These results highlight the complex nature of the
which did not have significant association (p = 0.946606). decision to convert, in as much as baseline patient characteristics,
Conversion in patients with comorbid conditions in our study disease severity, and surgeon factors, as each independently
had significant association as out of 11 patients with comorbid impacts the probability of successful laparoscopic procedure.
conditions [6 hypertension (HTN), 4 diabetes mellitus (DM), 1 Thus, a careful assessment of the patient risk factors, blood
asthma], 10 (90.90%) were converted to OA with significant investigations, and Tzanaki’s scoring will help segregate patients
p value (p = 0.00001) in Fisher’s exact test. A similar study was into one group which can be safely taken up for laparoscopic
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performed by Antonacci et al. in which conversion rate was high appendectomies without much risk of conversion to OA and
World Journal of Laparoscopic Surgery, Volume 13 Issue 2 (May–August 2020) 75