Urska Gajsek, MD, Nikica Andromako, MD. Department of Abdominal Surgery, University Clinical Centre Maribor, Slovenia, Europe.
BACKGROUND: Laparoscopic cholecystectomy has become the standard method for the elective treatment of patients with biliary colic and complications of gallstone disease, such as acute cholecystitis, gallstone pancreatitis and bile duct stones. Conversion to an open procedure should not be considered a complication it is a rational decision of a surgeon when important anatomical structures cannot be clearly identified. Reported rates range from 0,18%- 30%1,2
OBJECTIVES: This is a retrospective analysis of a large series of cholecystectomy performed at a terciary care center between January 1998 and July 2013 by trained surgeons and surgical residents. The data from all patients operated for gallstone disease in this period was collected and compared with those in the literature.
RESULTS: Between January 1998 and July 2013 6765 patients underwent a gallstone disease surgery. We performed 36.9% (2498) conventional cholecystectomies and 63.1% (4267) laparoscopic operations. There was 2,7% (186 cases) conversion rate. The most common reason was inability to define anatomy in patients with adhesions in severe inflamed gallbladder 61.3% (114 cases). Bile duct injury and uncontrolled bleeding was reported in 5.4% (10 cases), 2.7% (5 cases), respectively. Intrahepatal gallbladder or abscess, porcelain gallbladder, large stones, gangrene of the gallbladder and obesity were the reason for conversion in 16,6% (31cases). The rare causes were diaphragm perforation, suspected malignancy, acute appendicitis, injury of mesenteries and severe liver cirrhosis.
CONCLUSION: Conversion occurred in 2,7% in all laparoscopic cholecystectomies and was similar to that found in the reports. 1,2
Intense inflammation with adhesions and inability to identified the main anatomical structures was the main reason (61,3%). Preoperative patients assessment for a risk for conversion from laparoscopic to open cholecystectomy3 can decrease the problems in training cases, and management of difficult cases may be left to experienced surgeons therefore lowering complications and conversion rate.
1. Hunter JG. Acute cholecystitis revisited: get it while it’s hot. Ann Surg. Apr 1998;227(4):468-9.
2. Hussain A. Difficult laparoscopic cholecystectomy: current evidence and strategies of management. Surg Laparasc Endosc Percutan Tech. Aug 2011;21(4):211-7.
3. Kologlu M, Tutuncu T et al. Using a risk score for conversion from laparoscopic to open cholecystectomy in resident training. Surgery. Mar 2004;135(3):282-7.