Laparoscopic Cholecystectomy After a Quarter of a Century: Why Do We Still Convert?

Balazs I Lengyel, MD, Dan E Azagury, MD, Maria T Panizales, MS, Jill Steinberg, MPH RN, David C Brooks, MD, Stanley W Ashley, MD, Ali Tavakkolizadeh, MD. Department of General Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; Surgical Planning Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

BACKGROUND: Laparoscopic Cholecystectomy (LC) is the gold standard procedure for gallbladder removal in the United States. Although conversion to open surgery is sometimes necessary, the factors underlying this decision are often unclear. However, an association between the duration of laparoscopic procedures and increased complications and cost is frequently hypothesized, suggesting that clinicians should consider early conversion. The purpose of this study is 1) to identify the main reasons of conversion; 2) compare the outcome of converted LC versus long LC that remain non-converted.

METHODS: Using the NSQIP database and financial records, we retrospectively reviewed 1,193 cholecystectomies performed at our institution between 2002 and 2009. We compared the longest 10% of all laparoscopic cases (Long-LC) with converted (CONV) procedures. Length of stay (LOS), 30-day complications, operative times and charges, as well as hospital charges were compared. An independent surgical reviewer identified the reasons and circumstances of conversion in all CONV cases. Primary conversion was defined as due to pre-existing adhesions or inflammatory changes precluding laparoscopy. Secondary conversion was defined as being performed due to a complication secondary to a surgical maneuver. Number of trocars inserted at the time of conversion and length of dissection before conversion was also evaluated. Poisson regression and Wilcoxon test were used to compare outcomes.

RESULTS: 110 Long-LC and 62 CONV cases were included in the analysis (Table 1). Long-LC took on average 35 minutes longer to perform, however there were no differences in the post-operative complication rates between the groups. LOS was significantly shorter in the Long-LC compared to CONV group (1.4 vs. 4.6, respectively, p<0.01). Although Long-LC cases had higher operative charges, the overall hospital charges for Long-LC cases were substantially lower (Table 1). In 91% of CONV cases, the conversion was primary. In 92% of primary conversions, the conversion followed minimal or no attempt at dissection. In 24% of these conversions, the average number of trocars placed before conversion was less than 2 (1.3 ± 1.3), further highlighting lack of laparoscopic attempt at dealing with adhesions. Out of 5 secondary conversions, bleeding occurred in 2 cases and concerns of CBD injury in 3 other cases. There were however no actual CBD injuries.

CONCLUSIONS: Comparing CONV with Long –LC, conversion is associated with shorter operative times, but leads to a 3-day increase in LOS and significantly higher hospital charges, without a reduction in complications. In more than 90% of CONV group, conversion was carried out without serious attempt at adhesiolysis or dissection. Our outcome data however, favors pursuing a laparoscopic approach instead of early conversion to open surgery. With such an approach, a high percentage of conversions can be prevented with no increased risk to the patient, and significant benefit to the health care system.

Table 1. Outcome and charge data

Number of cases11062
Median OR time (min)12388<0.01
Post-operative complication rate (%)911NS
Length of Stay (days)1.44.6<0.01
Total hospital charges ($)24,20031,768<0.01

Session: SS06
Program Number: S032

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