Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates

Abstract Background Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. Methods Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. Results 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. Conclusion Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.

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Laparoscopic subtotal cholecystectomy: a safe approach in difficult cholecystectomy

International Surgery Journal ◽

10.18203/2349-2902.isj20191904 ◽

2019 ◽

Vol 6 (5) ◽

pp. 1767

Author(s):

Hosni Mubarak Khan ◽

Manjunath B. G. ◽

Vasanth G. Shenoy

Keyword(s):

Bile Duct ◽

Bile Duct Injury ◽

Open Cholecystectomy ◽

Gallstone Disease ◽

Subtotal Cholecystectomy ◽

Conversion Rates ◽

Conversion To Open Cholecystectomy ◽

Difficult Cholecystectomy ◽

Symptomatic Gallstone Disease

Background: Laparoscopic cholecystectomy (LC) has been recognized as the new "gold standard" for the treatment of symptomatic gallstone disease. In order to prevent serious bile duct and vascular injuries, conversion is advocated for unclear anatomy at the Calot’s. Our aim was to assess the safety and effectiveness of laparoscopic subtotal cholecystectomy (LSC) in difficult cholecystectomy in order to reduce the incidence of bile duct injury and conversion rates.Methods: An analysis of retrospectively collected data of 452 patients who underwent LC was done at our Hospital during the period of January 2010 to December 2013. In few cases of difficult GB when Calot’s could not be dissected, laparoscopic retrograde cholecystectomy (LRC) was attempted and if that failed we adopted the technique of LSC.Results: A total of 452 patients were included. The median age was 48 years. All the 452 patients were posted for LC. Of the 452 patients, 404 patients underwent LC and the remaining 48 patients had difficult GB. Among the 48 patients having a difficult GB, 44 cases underwent LSC (3 cases underwent LSC Type-1 and 41 cases underwent LSC Type-2) and the remaining 4 cases underwent conversion to open cholecystectomy. The mean operative time was 130mins and median post op stay was 2 days.Conclusions: In our technique of LSC the conversion rates were <1% with no bile duct injury and believe that it is feasible and safe for operating on difficult GB’s.

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Feasibility and safety in difficult laparoscopic cholecystectomies; a single surgeon experience.

Journal of Sheikh Zayed Medical College ◽

10.47883/jszmc.v11i04.149 ◽

2020 ◽

Vol 11 (4) ◽

pp. 12-16

Keyword(s):

Laparoscopic Cholecystectomy ◽

Open Cholecystectomy ◽

Bile Leakage ◽

Cross Sectional Study ◽

City Hospital ◽

Class Iii ◽

Cross Sectional ◽

Surgeon Experience ◽

Conversion To Open Cholecystectomy ◽

Duration Of Surgery

Background: laparoscopic cholecystectomy is commonly used for the treatment of gallstones. Objective: To determine the feasibility and safety of difficult laparoscopic cholecystectomies. Methodology: This cross sectional study was based on retrospective collection of data from patient records, including 323 patients with difficult laparoscopic cholecystectomies was conducted in Department of Surgery, Sharif Medical City Hospital, and Rasheed Hospital, Lahore from June 2010 to December 2019. Difficult cholecystectomy was defined on intraoperative findings based on Nassar intraoperative scoring system. Feasibility was defined as successful accomplishment of procedure without complication and safety was defined as having no intraoperative or postoperative complications. Results: There were 75 (23.21%) male and mean age was 48±8 years. Class I difficulty was observed in 185 (57.3%) patients, class II difficulty in 83 (25.7%) patients, class III difficulty in 44 (13.6%) patients and class IV difficulty in 11 (3.4%) patients. Mean duration of surgery and mean hospital stay were 98.87±11.76 minutes and 1.91±1 days, respectively. Conversion to open cholecystectomy was done in 10 (3.1%). The procedure was feasible in 313 (96.9%) patients. Overall complications were seen in 19 (5.9%) patients. The complications included Common Bile Duct injury in 1 (0.31%) patient, intraoperative bleeding in 1 (0.3%) patients, bile leakage in 2 (0.62%) patients, postoperative jaundice in 3 (0.93%) patients, superficial infections in 10 (3.1%) patients and deep infections in 2 (0.62%) patients. Safety of laparoscopic surgery was seen in 304 (94.1%) patients. Conclusion: Laparoscopic cholecystectomy in difficult situations was found to be feasible and safe in majority of patients. However, it was associated with a longer operative time.

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Concurrent Biliary Disease Increases the Risk for Conversion and Bile Duct Injury in Laparoscopic Cholecystectomy: A Retrospective Analysis at a County Teaching Hospital

The American Surgeon ◽

10.1177/000313481708301002 ◽

2017 ◽

Vol 83 (10) ◽

pp. 1024-1028 ◽

Cited By ~ 2

Author(s):

Lara H. Spence ◽

Samuel Schwartz ◽

Amy H. Kaji ◽

David Plurad ◽

Dennis Kim

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Biliary Tract ◽

Bile Duct Injury ◽

Odds Ratio ◽

Open Cholecystectomy ◽

Biliary Tract Disease ◽

Endoscopic Retrograde ◽

Conversion To Open Cholecystectomy ◽

Tract Disease

Biliary tract disease remains a common indication for operative intervention. The incidence of concurrent biliary tract disease (>2 biliary tract disease processes) is unknown and the impact of more than one biliary tract diagnosis on outcomes remains to be defined. The objective of this study was to determine the effect of concurrent biliary tract disease on conversion rate and outcomes after laparoscopic cholecystectomy. A 5-year retrospective analysis of all patients who underwent a laparoscopic cholecystectomy was performed comparing those with a single biliary diagnosis to patients with concurrent biliary tract disease. Variables analyzed were conversion to open cholecystectomy, incidence of bile duct injury, use of endoscopic retrograde cholangiopancreatography and/or intraoperative cholangiogram, length of surgery, and duration of hospitalization. The incidence of concurrent biliary tract disease was 9 per cent and a conversion to open cholecystectomy was performed in 16 per cent of patients. After adjusting for confounding factors, concurrent biliary tract disease was predictive of conversion (odds ratio 1.6, 95% confidence interval 1.1–2.3, P = 0.03) and bile duct injury (odds ratio 2.5, 95% confidence interval 0.8–5, P = 0.01). Concurrent biliary tract disease patients were more likely to undergo intraoperative cholangiogram or endoscopic retrograde cholangiopancreatography, as well as longer operation and length of stay.

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Laparoscopic cholecystectomy: Conversion rate and complcation

Journal of Society of Surgeons of Nepal ◽

10.3126/jssn.v18i3.15305 ◽

2016 ◽

Vol 18 (3) ◽

pp. 43

Author(s):

BR Malla ◽

HN Joshi ◽

N Rajbhandari ◽

YR Shakya ◽

B Karki ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Conversion Rate ◽

Open Cholecystectomy ◽

Gallbladder Disease ◽

Conversion To Open Surgery ◽

Calot’S Triangle ◽

Conversion Rates ◽

Conversion To Open Cholecystectomy ◽

Previous Laparotomy ◽

History Of

Introduction and Objective: Laparoscopic Cholecystectomy is the standard surgical treatment for gallbladder disease. However, conversion to open surgery is not the complication. Different centers have reported different conversion rates and post operative complications. The objective of this study is to identify conversion rate and post operative complication of laparoscopic cholecystectomyMaterials and Methods: This retrospective study included all laparoscopic cholecystectomies attempted in Dhulikhel hospital during the year 2015. Files of all patients were reviewed to find out the demography of the patients and the indication of Laparoscopic cholecystectomy. The rate of conversion to open cholecystectomy, the underlying reasons for conversion and postoperative complications were analyzed.Results: Out of 324 cases attempted laparoscopic cholecystetomies, two cases with the history of previous laparotomy were excluded to rule out the bias in the result. Out of 322 cases 226(70.18%)were female and 96(29.81%) were male . The mean age was 38 years. Over all conversion rate to open cholecystetomy was 1.86% with frozen calot’s triangle as the most common reason for conversion. The over all postoperative complication was 1.24% with no major bile duct injury.Conclusion: Laparoscopic cholecystectomy can safely be done with low conversion rate and complication.

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Utility of pre-operative abdominal ultrasound to predict conversion to open cholecystectomy

International Surgery Journal ◽

10.18203/2349-2902.isj20213985 ◽

2021 ◽

Vol 8 (10) ◽

pp. 3007

Author(s):

Reetesh Sharma ◽

Ramesh Dumbre ◽

Arun Fernandese ◽

Deepak Phalgune

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Common Bile Duct ◽

Wall Thickness ◽

Open Cholecystectomy ◽

Fluid Collection ◽

Biliary Tree ◽

Gallbladder Wall ◽

Significant Difference ◽

Conversion To Open Cholecystectomy

Background: Many factors like unclear Calot triangle anatomy, intensely inflamed and thick gallbladder, dense adhesions in the operative area, obscure biliary tree anatomy, local inflammation like pancreatitis contribute to the conversion of laparoscopic cholecystectomy to open cholecystectomy. The aim of the present study was to find the utility of abdomen sonography parameters that predict the conversion from laparoscopic to open cholecystectomy.Methods: Ninety patients aged between 20 and 75 years with the diagnosis of cholelithiasis/cholecystitis were included in this observational study. Every patient underwent ultrasonography (USG). The USG findings such as gallbladder wall thickness, presence or absence of stones, number of calculi, size of the calculi, presence of abdominal adhesions, size of the common bile duct was recorded. If feasible, laparoscopic cholecystectomy was done. If not, the procedure was converted to open cholecystectomy. Association of USG findings was correlated with conversion to open cholecystectomy. The comparison of the qualitative variables was done using Fisher’s exact test. Results: Of 90 patients, 7 (7.8%) had a conversion to open cholecystectomy. There was no statistically significant difference of USG parameters studied such as gallbladder wall thickness >4 mm, pericholecystic fluid collection, common bile duct diameter >7 mm, presence of calculus, number of calculi, size of calculus >6 mm and adhesions/fibrosis in patients who required conversion to open cholecystectomy and who were operated laparoscopically.Conclusions: Pre-operative USG parameters did not predict conversion to open cholecystectomy.

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Laparoscopic subtotal cholecystectomy after percutaneous transhepatic gallbladder drainage for grade II or III acute cholecystitis

BMC Surgery ◽

10.1186/s12893-021-01387-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Masafumi Ie ◽

Morihiro Katsura ◽

Yukihiro Kanda ◽

Takashi Kato ◽

Kazuya Sunagawa ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Postoperative Complications ◽

Acute Cholecystitis ◽

Gallbladder Drainage ◽

Open Conversion ◽

Subtotal Cholecystectomy ◽

Conversion Rates ◽

Significant Difference ◽

Percutaneous Transhepatic Gallbladder Drainage ◽

Grade Ii

Abstract Background Severe adhesions and fibrosis between the posterior wall of the gallbladder and liver bed often render total cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) difficult, leading to high open conversion rates. Since the publication of Tokyo Guidelines 2018 (TG18), our policy has shifted from open conversion to subtotal cholecystectomy (SC) when total laparoscopic cholecystectomy for difficult cases of cholecystitis is not feasible. Recently, SC has been frequently applied as bailout surgery for complicated cholecystitis. Nonetheless, the efficacy and validity of laparoscopic SC after PTGBD remain unclear. This study aimed to evaluate the safety and feasibility of laparoscopic SC after PTGBD for grade II or III acute cholecystitis (AC) by comparing two periods of altered surgical strategies. Methods This retrospective cohort study was conducted between January 2013 and December 2020. A total of 44 eligible patients with grade II or III AC were divided according to the time of cholecystitis onset into the pre-TG18 group (2013–2017, n = 17) and post-TG18 group (2018–2020, n = 27). Patients’ background demographics, surgical method, surgical results, and postoperative complications were compared. Results The interval between PTGBD and surgery was significantly longer in the post-TG18 group than in the pre-TG18 group (15 [interquartile range: 9–42] days vs. 8 [4–11] days; P = 0.010). The frequency of laparoscopic cholecystectomy significantly increased from 52.9% in the pre-TG18 group to 88.9% in the post-TG18 group (P = 0.007), whereas the frequency of SC was 23.5% and 40.7%, respectively, which showed no statistically significant difference (P = 0.241). However, the rate of laparoscopic SC significantly increased from 0 to 90.9% among 15 SC cases, whereas the rate of open SC significantly plummeted from 100 to 9.1% (P = 0.001). Significant differences in the operative time, amount of intraoperative bleeding, and incidence of postoperative complications (wound infection and subhepatic abscess) were not observed. Mortality, bile leakage, and bile duct injury did not occur in either group. Conclusions For grade II or III AC after PTGBD, aggressive adoption of SC increased the completion rate of laparoscopic surgery. Laparoscopic SC is a safe and feasible treatment option.

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Posterior infundibular dissection: safety first in laparoscopic cholecystectomy

Surgical Endoscopy ◽

10.1007/s00464-020-08281-1 ◽

2021 ◽

Author(s):

Mazen Iskandar ◽

Abe Fingerhut ◽

George Ferzli

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Infrared Imaging ◽

Open Cholecystectomy ◽

Lateral Border ◽

Critical View Of Safety ◽

Bile Duct Injuries ◽

Conversion To Open Cholecystectomy ◽

Technical Details ◽

Safety First

Abstract Background Laparoscopic cholecystectomy is still fraught with bile duct injuries (BDI). A number of methods such as intra-operative cholangiography, use of indocyanine green (ICG) with infrared imaging, and the critical view of safety (CVS) have been suggested to ensure safer Laparoscopic cholecystectomy (LC).To these, we add posterior infundibular dissection as the initial operative maneuver during LC. Here, we report specific technical details of this approach developed over 30 years with no bile duct injuries and update our experience in 1402 LC. Methods In this manuscript, we present a detailed and illustrated description of a posterior infundibular dissection as the initial approach to laparoscopic cholecystectomy (LC). This technique developed after thirty years of experience with LC and have used it routinely over the past ten years with no bile duct injury. Results Between January of 2010 and December 2019, 1402 Laparoscopic cholecystectomies were performed using the posterior infundibular approach. Operations performed on elective basis constituted 80.3% (1122/1402) and 19.97% were emergent (280/1402). One intra-operative cholangiogram was performed after a posterior sectoral duct was identified. There was one conversion to open cholecystectomy due to bleeding. There were 4 bile leaks that were managed with endoscopic retrograde cholangio-pancreatography (ERCP). There were no bile duct injuries. Conclusion Adopting an initial posterior mobilization of the gallbladder infundibulum lessens the need for medial and cephalad dissection to the node of Lund, allowing for a safer laparoscopic cholecystectomy. In fact the safety of the technique comes from the initial dissection of the lateral border of the infundibulum. The risk of BDI can be reduced to null as was our experience. This approach does not preclude the use of other intra-operative maneuvers or methods.

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Laparoscopic subtotal cholecystectomy a boon to difficult gall bladder

International Surgery Journal ◽

10.18203/2349-2902.isj20205883 ◽

2020 ◽

Vol 8 (1) ◽

pp. 215

Author(s):

Santosh Kumar Singh ◽

Devendra Shukla ◽

Pradeep Kumar Singh ◽

Ila Katyayan

Keyword(s):

Laparoscopic Cholecystectomy ◽

Gall Bladder ◽

Operative Time ◽

Open Cholecystectomy ◽

Open Procedure ◽

Subtotal Cholecystectomy ◽

Operative Outcomes ◽

Conversion To Open Cholecystectomy ◽

Hospital Stays ◽

A Prospective Study

Background: Subtotal laparoscopic cholecystectomy has been in practice to treat difficult gall bladder for 100s of years. It keeps the benefit of being a minimally invasive and single-stage procedure. Thus, it remains a better option over conversion to open cholecystectomy as well as cholecystostomy which was a two-stage surgery practiced in earlier days.Methods: It was a prospective study focusing on indications, type and complications of subtotal laparoscopic cholecystectomy. It also compared the per-operative and post-operative outcomes of all cases of subtotal laparoscopic cholecystectomy (48) with cases of laparoscopic cholecystectomy that were converted to open procedure (30) performed over a period of 1 year. Patients were followed for 12 months post-surgery.Results: Acute cholecystitis is one of the most common indication of subtotal cholecystectomy. Also, it was associated with lesser mean operative time, postoperative hospital stays and postoperative complications when compared with conversion (to open) cholecystectomy.Conclusions: Subtotal cholecystectomy is a better option than open cholecystectomy in cases of difficult gall bladder.

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Determinants of conversion during laparoscopic cholecystectomy among a sample of Iraqi patients

International Surgery Journal ◽

10.18203/2349-2902.isj20182462 ◽

2018 ◽

Vol 5 (7) ◽

pp. 2455

Author(s):

Abutalib B. Alluaibi ◽

Bahaa K. Hassan ◽

Alaa H. Ali ◽

Ahmed A. Muhsen

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Gall Bladder ◽

Acute Cholecystitis ◽

Open Cholecystectomy ◽

Male Gender ◽

Visceral Injury ◽

Previous Abdominal Surgery ◽

Calot’S Triangle ◽

Conversion To Open Cholecystectomy

Background: Laparoscopic cholecystectomy has become a standard technique for gall bladder surgery of symptomatic cholelithiasis. However, conversion to open cholecystectomy is sometimes necessary. The aim of the present study was to assess the predictive factors that increase the possibility of conversion of laparoscopic cholecystectomy to open cholecystectomy.Methods: A total of 621 laparoscopic cholecystectomies were attempted at AL-Mawanee General Hospital and AL-Sader Teaching Hospital in Basrah, IRAQ from June 2012 till June 2016.Of these,43 had to be converted to open cholecystectomies. Patients assessed according to different factors, including age, sex, acute cholecystitis, adhesions of gallbladder and calot's triangle, obesity, previous abdominal surgery, anatomical variation of gallbladder and Calot's triangle and intraoperative complications (bleeding, bile duct injury, visceral injury).Results: Conversion to open cholecystectomy was performed in 43 patients (6.92%). The significant factors for conversions were adhesions of gallbladder and Calot's triangle(39.53%) followed by acute cholecystitis(34.88%). Rate of conversion in other factors are as the following i.e., isolated male gender (0%), age (0%), previous abdominal surgery (9.3%), obesity (2.33%), anatomical variations of gall bladder and calot's triangle (2.33%), intra operative complications including bleeding (4.65%), bile duct injury (4.65%), visceral injury (2.33%) were insignificant factors for conversion.Conclusions: Adhesions of gallbladder and calot's triangle is the most common predictive factor and cause for conversion from laparoscopic cholecystectomy to open cholecystectomy. Acute cholecystitis found to be the strongest factor for conversion despite its incidence is lower than adhesions of gall bladder and calots triangle. Male gender and age more than fifty years are not direct predictive factors for conversions.

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Retrospective analysis of complications in 3600 patients of laparoscopic cholecystectomy

International Surgery Journal ◽

10.18203/2349-2902.isj20202410 ◽

2020 ◽

Vol 7 (6) ◽

pp. 1942

Author(s):

Ritvik Resutra ◽

Rajive Gupta ◽

Madhu Gupta

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Acute Inflammation ◽

Open Cholecystectomy ◽

Treatment Modalities ◽

Common Complication ◽

Private Hospitals ◽

Jammu And Kashmir ◽

Conversion To Open Cholecystectomy ◽

Complications Of Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy results in specific complications which occur frequently as compared to open cholecystectomy. Several aspects of these complications and their treatment modalities were analyzed.Methods: 3600 cases of laparoscopic cholecystectomy performed by a single surgeon at various private hospitals in Jammu (Jammu and Kashmir), India during the period of 18 years from March 2002 to March 2020 were analyzed for the complications and their management.Results: Complications of laparoscopic cholecystectomy occurred in 14.5% of the patients. The most common complication was haemorrhage. Conversion to open cholecystectomy was necessary in 41 (1.13%) patients due to obscure anatomy as a result of adhesions and acute inflammation. In the study, 6 deaths (0.16%) were recorded.Conclusions: Laparoscopic surgeon should remain highly vigilant to detect major complications like injury to small gut at the time of entry into the peritoneal cavity or bile duct injury during laparoscopic cholecystectomy at an earliest and should timely manage such cases to save the life of the patient.

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