Page 4 - World Journal of Laparoscopic Surgery

Conversion of LC to Open Surgery
Preoperatively, relevant history and clinical examination Conversion rate was significantly higher in patients who
findings of the patients were noted. Laboratory data and underwent ERCP with either papillotomy and common bile duct
radiological findings were accessed through the online database. (CBD) stone extraction/clearance of sludge (41.9%) and ERCP with
Intraoperative findings of all cases (irrespective of whether stenting (50%) as compared to those patients who had no ERCP
converted or not) were taken from the operative notes. In cases done (2.5%) (p = 0.0001) (Table 3).
converted to open surgery, the operating surgeon would fill a Patients who had clinical features suggestive of acute
checklist regarding the reason for conversion. cholecystitis—tachycardia (pulse rate >100/m), fever (temperature
>99 F), and positive Murphy’s sign—had a higher conversion rate.
Statistical Analysis The findings of leukocytosis [total white blood cell (WBC) count
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Chi-square test and unpaired t-test were applied. Analysis was done >10000/mm ], obstructive jaundice (total bilirubin >1.2 mg/dL; direct
using IBM SPSS® software v 23. bilirubin >0.3 mg/dL; ALP >130 U/L), pancreatitis (amylase >100
U/L; lipase >60 U/L), and hypoalbuminemia (albumin <3.5 g/dL),
results preoperatively, had a significant association with conversion rate
A total of 310 patients planned for LC were included in the study out as shown in Table 2.
of which 38 patients underwent conversion to open (CO) surgery. All patients (310) underwent ultrasonography (US) of the
Hence, the conversion rate in this study was 12.2%. abdomen. Those who had a contrast-enhanced computed
The mean age in the CO group was 58 years, almost 10 more tomography (CT) abdomen (12 patients) or magnetic resonance
than the mean age of 47 years in the LC group. This was found to cholangiopancreatography (5 patients) done were usually in
be statistically significant with a p-value of 0.0001. Patients older addition to a US abdomen. The imaging findings that were assessed
than 50 years had a higher conversion rate. The study population include presence of calculi; pericholecystic fluid collection or fat
had 170 female patients and 140 male patients. Males had a stranding; a distended GB; sludge; GB perforation; a dilated CBD;
significantly higher conversion rate than females (18.6 vs 7%, or presence of CBD calculi, polyp, or pancreatitis.
p = 0.001). Patients who were overweight [body mass index (BMI) Conversion rate was significantly higher in patients with features
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>23 kg/m ] according to the Asian BMI classification had a higher of acute cholecystitis—pericholecystic fluid or fat stranding (43.8 vs
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conversion rate, as compared to the patients with a BMI <23 kg/m 10.5%; p = 0.0001), presence of sludge on imaging (32.3 vs 10.0%;
(25 vs 8.7%, p = 0.0001) (Table 1). p = 0.0001), perforated GB (66.7 vs 33.3%; p = 0.004), and dilated
As shown in Table 2, patients who presented with symptoms CBD/CBD calculi (33.3 vs 10.2%; p = 0.0001) (Table 2).
suggestive of acute cholecystitis, i.e., right upper quadrant GB wall thickness was one of the preoperative imaging findings
(RUQ) pain, vomiting, and fever, had a significantly higher rate that the authors wanted to assess, but in the majority of the cases,
of conversion. There was no significant difference observed in it was not commented upon. A mention of a thickened GB wall or a
conversion rate between patients whose duration of symptoms wall thickness more than 4 mm was made in a total of 24 patients,
was >1 week and <1 week (p = 0.120). out of which 6 were converted (25% conversion rate).
Patients, who had an episode of acute cholecystitis and Patients with a preoperative diagnosis of acute cholecystitis,
were managed conservatively, underwent an elective interval gallstone pancreatitis, and those who underwent a delayed LC
cholecystectomy after 4–6 weeks. This also includes those after 6 weeks post-ERCP had higher conversion rates of 33, 20, and
patients who underwent a delayed LC post-endoscopic retrograde 52%, respectively.
cholangiopancreatography (ERCP) with or without stenting.
Conversion rate was higher (almost 25%) in patients who underwent Reasons for Conversion
an interval cholecystectomy (Table 2). Technical Difficulties
Comorbid conditions such as diabetes mellitus, cardiovascular In all the 38 cases that were converted to open, the peritoneal
disease (ischemic heart disease or hypertension), and cavity was entered, and adequate pneumoperitoneum was
respiratory disease (bronchial asthma or chronic obstructive created. There were no instances of equipment failure and/or
pulmonary disease) had no significant impact on the rate of trocar injuries.
conversion. Also, a history of abdominal surgery was not found to
be significant for conversion (Table 2). Surgical Difficulties Due to Intraoperative Findings
The reasons for conversion in 37 cases due to various surgical
difficulties are mentioned in Table 4, with dense inflammatory
Table 1: Patient characteristics
adhesions leading to a frozen Calot’s triangle and inadequate
Total Converted Conversion Chi-square visualization of structures being the most common causes
cases cases rate value p value (Fig. 1). Aberrant anatomy was the cause for conversion in four
Age cases (Fig. 2).
<50 165 9 5.45% 11.816 <0.001 Surgical difficulties due to intraoperative complication:
>50 145 29 20% One patient had a visceral injury, a transverse colon injury that
Sex necessitated CO surgery. In this case, complete dissection of the
Male 140 26 18.6% 9.461 0.001 GB was done laparoscopically.
Postoperative length of stay (LOS) was significantly longer in
Female 170 12 7% patients who had converted to open as compared to those patients
BMI who had the surgery completed by laparoscopy (8.8 ± 5.9 vs 2.7 ±
<23 242 21 8.7% 13.149 <0.001 1.3; p = 0.0001). Most patients who had a prolonged LOS of more
>23 68 17 25% than 10–12 days were due to surgical site infection (Table 5).

2 World Journal of Laparoscopic Surgery, Volume 15 Issue 1 (January–April 2022)