Utility of pre-operative abdominal ultrasound to predict 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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Early versus Delayed Single-Stage Laparoscopic Eradication for Both Gallstones and Common Bile Duct Stones in Mild Acute Biliary Pancreatitis

The American Surgeon ◽

10.1177/000313480507100812 ◽

2005 ◽

Vol 71 (8) ◽

pp. 682-686 ◽

Cited By ~ 9

Author(s):

John Griniatsos ◽

Evangelos Karvounis ◽

Alberto Isla

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Common Bile Duct ◽

Single Stage ◽

Definitive Treatment ◽

Morbidity Rate ◽

Biliary Pancreatitis ◽

Acute Biliary Pancreatitis ◽

Laparoscopic Management ◽

Significant Difference

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n = 20), whereas 24 patients underwent an operation later on and constitute the delay group (n = 24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.

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A study on clinical and radiological factors for predicting difficult laparoscopic cholecystectomy preoperatively

International Surgery Journal ◽

10.18203/2349-2902.isj20173878 ◽

2017 ◽

Vol 4 (9) ◽

pp. 3015

Author(s):

Arun Prasath S. ◽

Surag Kajoor Rathnakar ◽

Nagaraja Anekal L.

Keyword(s):

Laparoscopic Cholecystectomy ◽

Abdominal Surgery ◽

Open Cholecystectomy ◽

Fluid Collection ◽

Gall Stone ◽

Stone Disease ◽

Elderly Age ◽

Conversion To Open Cholecystectomy ◽

Upper Abdominal ◽

A Prospective Study

Background: Laparoscopic cholecystectomy considered as the gold standard treatment for symptomatic gall stone disease has 1-13% conversion rate to an open procedure due to various reasons. Present study aims to predict difficult laparoscopic cholecystectomy preoperatively using clinical and sonological factors.Methods: This is a prospective study done on 190 patients who were posted for laparoscopic cholecystectomy from March 2015 to February 2017. Parameters taken into consideration were: age, number of previous attacks of acute cholecystitis, impacted gallstone, thickness of GB wall, pericholecystic fluid collection, history of upper abdominal surgery and obesity. All surgeries were performed by surgeons with minimum ten years of experience on laparoscopic cholecystectomy and ultrasound of the abdomen was performed by senior radiologists with experience of minimum five years.Results: Out of 190 patients, difficulty was experienced in 48 patients of which conversion to open cholecystectomy was needed for 11 patients. Elderly age, multiple attacks of pain abdomen (>2), palpable GB, impacted gallstone, thickness of GB wall >3 mm, peri-GB fluid collection, adhesions due to previous abdominal surgery and obesity were all found to be independent risk factors leading to difficult laparoscopic cholecystectomy.Conclusions: Though there is no definite scoring system to predict difficult LC, there is scope for further refinement to make the same less cumbersome and easier to handle using the above clinical and radiological factors.

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Three-Port versus Four-Port Laparoscopic Cholecystectomy: A Randomized Controlled Trial

Nepal Medical College Journal ◽

10.3126/nmcj.v21i1.24849 ◽

2019 ◽

Vol 21 (1) ◽

pp. 40-43

Author(s):

Rabin Koirala ◽

TM Gurung ◽

A Rajbhandari ◽

P Rai

Keyword(s):

Laparoscopic Cholecystectomy ◽

Postoperative Pain ◽

Hospital Stay ◽

Controlled Trial ◽

Open Cholecystectomy ◽

Analgesic Requirement ◽

Safe Alternative ◽

Average Hospital ◽

Significant Difference ◽

Conversion To Open Cholecystectomy

Laparoscopic cholecystectomy (LC) is one of the most common surgery performed and is traditionally performed using four ports. With the aim of improving patient’s comfort, port numbers have been reduced to single port. But feasibility and the extra expense that comes with single and double port LC has made them less attractive. Three port LC can be a safe alternative to four port LC, and various research has shown its safety. This study compares the three port LC with the traditional four port LC with the objective of assessing feasibility and benefit of the decreased port number. We evaluated 217 patients who were randomly allocated for three port and four port LC. Both the groups were compared for operative time, assessment of postoperative pain, days of hospital stay and postoperative recovery time after discharge. The parameters were compared using Statistical Package for the Social Sciences (SPSS) version 16. Among 217 patients, 123 underwent three port LC and 94 underwent four port LC. The larger number were females (79.7%), and with comparable age group of patients. Rate of conversion to open cholecystectomy, postoperative pain scale, analgesic requirement, average hospital stay and port site infection rates were comparable in both groups of patients. The average time taken for operation was less in three port LC than the four port LC but this was not statistically significant. There is no significant difference between 3 port and 4 port LC in terms of time required for the surgery, conversion rate, complication and duration of hospital stay.

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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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Significance of Preoperative Ultrasound Measurement of Gallbladder Wall Thickness

The American Surgeon ◽

10.1177/000313480707300922 ◽

2007 ◽

Vol 73 (9) ◽

pp. 926-929 ◽

Cited By ~ 1

Author(s):

James Majeski

Keyword(s):

Laparoscopic Cholecystectomy ◽

Acute Cholecystitis ◽

Wall Thickness ◽

Open Cholecystectomy ◽

Acalculous Cholecystitis ◽

Gallbladder Wall ◽

Chronic Cholecystitis ◽

Entire Series ◽

Calculous Cholecystitis ◽

Gallbladder Ultrasound

Evaluation of patients with signs and symptoms of biliary tract disease usually includes ultrasound assessment of the gallbladder. Does measurement of the thickness of the gallbladder wall yield any significant information to the clinical surgeon? The records of all my patients undergoing cholecystectomy since 1990 were reviewed. The entire series consists of 401 consecutive patients, in whom 388 procedures were completed laparoscopically, with 14 patients requiring conversion to an open cholecystectomy. Each patient's preoperative evaluation included a gallbladder ultrasound, which included measurement of the diameter of the gallbladder wall. The entire series of cholecystectomies was evaluated according to the ultrasound measured diameter of the gallbladder wall. A thin gallbladder wall was less than 3 mm in diameter. A thick gallbladder wall was 3 mm or greater in diameter. Of the 401 consecutive patients who underwent cholecystectomy for symptomatic gallbladder disease, 86 (21.5%) were removed laparoscopically for acalculous disease. Eleven per cent of patients with acalculous cholecystitis had acute cholecystitis and 89 per cent had chronic cholecystitis. Every patient with either a thin or thick gallbladder wall with acalculous cholecystitis had a successful laparoscopic cholecystectomy. Three-hundred fifteen patients had a laparoscopic cholecystectomy for calculous cholecystitis. In patients with calculous cholecystitis, 28.3 per cent had acute cholecystitis and 71.7 per cent had chronic cholecystitis. The gallbladder wall was found to be greater than 3 mm in 38 per cent of patients with acute calculous cholecystitis and greater than 3 mm in 41 per cent of patients with chronic calculous cholecystitis. One-hundred, forty-two patients, out of a series total of 401, had a gallbladder wall thickness greater than 3 mm by preoperative sonography and 14 of these patients (10%) required conversion to an open cholecystectomy. A preoperative gallbladder ultrasound evaluation for symptomatic cholecystitis, which documents a thick gallbladder wall (≥3 mm) with calculi, is a clinical warning for the laparoscopic surgeon of the potential for a difficult laparoscopic cholecystectomy procedure which may require conversion to an open cholecystectomy procedure.

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Predictive factors for conversion from laparoscopic to open cholecystectomy: an institutional study

International Surgery Journal ◽

10.18203/2349-2902.isj20183210 ◽

2018 ◽

Vol 5 (8) ◽

pp. 2894

Author(s):

Digvijoy Sharma ◽

Kunduru Nava Kishore ◽

Gangadhar Rao Gondu ◽

Venu Madhav Thumma ◽

Suryaramachandra Varma Gunturi ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Gall Bladder ◽

Acute Cholecystitis ◽

Wall Thickness ◽

Open Cholecystectomy ◽

Bladder Wall ◽

Bladder Wall Thickness ◽

Calot’S Triangle ◽

Conversion To Open Cholecystectomy ◽

Gall Bladder Wall

Background: Laparoscopic cholecystectomy has become the gold standard treatment for symptomatic gallstones. However, a conversion to open surgery may be required to complete the procedure safely. The aim of this study is to identify the predictive factors of conversion from laparoscopic to open cholecystectomy in elective setting.Methods: A retrospective review of all patients underwent laparoscopic cholecystectomy electively for symptomatic gallstones from January 2016 to December 2017 was performed. Data considered for analysis were: demographic data, preoperative laboratory values of liver function tests, gall bladder wall thickness on ultrasound, preoperative ERCP, indication for surgery, history of acute cholecystitis, presence of intraoperative adhesions and frozen Calot's triangle. Conversion to open cholecystectomy was chosen as the dependent variable for both, univariate and multivariate analysis.Results: 546 patients underwent laparoscopic cholecystectomy. 333 were females (60.9%) and 213 (39.1%) males, with a mean age of 44.6 years. The most common indication for surgery was symptomatic cholelithiasis. Conversion to open cholecystectomy occurred in 48 cases (8.8%) and the most common reason for conversion was inability to define the Calot’s triangle anatomy due to inflammation/adhesions. Univariate and multivariate analyses of various variables demonstrated that male gender, gall bladder wall thickness >5 mm and presence of previous documented acute cholecystitis had statistically significant co-relation with higher rates of conversion (p<0.001).Conclusions: Presence of acute cholecystitis, gall bladder wall thickness >5mm on preoperative ultrasound and male gender were independent predictor factors for conversion from laparoscopic to open cholecystectomy. Such patients should be properly counselled about the increased risk for conversion and should be operated by surgeons experienced in laparoscopic procedures to reduce the rate of conversion and operative complications.

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Clinical Impact of Preoperative Relief of Jaundice Following Endoscopic Retrograde Cholangiopancreatography on Determining Optimal Timing of Laparoscopic Cholecystectomy in Patients with Cholangitis

Journal of Clinical Medicine ◽

10.3390/jcm10194297 ◽

2021 ◽

Vol 10 (19) ◽

pp. 4297

Author(s):

Kyu-Hyun Paik ◽

Yoon Suk Lee ◽

Won-Suk Park ◽

Yong Chan Shin ◽

Woo Hyun Paik

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Common Bile Duct ◽

Hospital Stay ◽

Conversion Rate ◽

Open Cholecystectomy ◽

Optimal Timing ◽

Endoscopic Retrograde ◽

Perioperative Morbidity ◽

Group 1

Background: About 10% of patients with gallbladder (GB) stones also have concurrent common bile duct (CBD) stones. Laparoscopic cholecystectomy (LC) after removal of CBD stones using endoscopic retrograde cholangiopancreatography (ERCP) is the most widely used method for treating coexisting gallbladder and common bile duct stones. We evaluated the optimal timing of LC after ERCP according to clinical factors, focusing on preoperative relief of jaundice. Methods: A total of 281 patients who underwent elective LC after ERCP because of choledocholithiasis and cholecystolithiasis from January 2010 to April 2018 were retrospectively reviewed. We compared the hospital stay, perioperative morbidity, and rate of surgical conversion to open cholecystectomy according to the relief of jaundice before surgery. These enrolled patients were divided into two groups: relief of jaundice before surgery (group 1, n = 125) or not (group 2, n = 156). Results: The initial total bilirubin level was higher in group 1; however, there were no significant differences in the other baseline characteristics including age, sex, American Society of Anesthesiologists score, previous surgical history, white blood cell count, C-reactive protein, and operative time between the two groups. There was also no significant difference in postoperative hospital stay between the two groups (4.5 ± 3.3 vs. 5.5 ± 5.6 days, p = 0.087). However, after ERCP, the waiting time until LC was significantly longer in group 1 (5.0 ± 4.9 vs. 3.5 ± 2.4 days, p < 0.001). There were no statistical differences in the conversion rate (3.2% vs. 3.8%, p = 0.518) or perioperative morbidity (4.0% vs. 5.8%, p = 0.348), either. Conclusions: LC would not be delayed until the relief of jaundice after ERCP since there were no significant differences in perioperative morbidity or surgical conversion rate to open cholecystectomy. Early LC after ERCP may be feasible and safe in patients with cholangitis and cholecystolithiasis.

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Risk factors influencing conversion of laparoscopic cholecystectomy to open cholecystectomy

International Surgery Journal ◽

10.18203/2349-2902.isj20174495 ◽

2017 ◽

Vol 4 (10) ◽

pp. 3354

Author(s):

Mohanapriya Thyagarajan ◽

Balaji Singh ◽

Arulappan Thangasamy ◽

Shobana Rajasekar

Keyword(s):

Diabetes Mellitus ◽

Risk Factors ◽

Laparoscopic Cholecystectomy ◽

Acute Cholecystitis ◽

Wall Thickness ◽

Open Cholecystectomy ◽

Gallbladder Wall ◽

Related Factors ◽

Previous Episode ◽

Factors Influencing

Background: Gall stone disease is a common disease affecting human beings. Over the past two decades, laparoscopic cholecystectomy has become gold standard for the surgical treatment of gallbladder disease. The advantages of laparoscopic cholecystectomy over open surgery are a shorter hospital stay, less postoperative pain, faster recovery, better cosmoses. This study was planned to identify the circumstances and the risk factors influencing the conversion of laparoscopic cholecystectomy to open procedure.Methods: This is a Prospective study conducted over a period of 24 months. A total of 50/500 patients who were electively posted for laparoscopic cholecystectomy and got converted into open cholecyctectomy were included in the study. The Factors recorded and analysed were Age and Sex of the patient, presence of diabetes mellitus, previous episode of Acute Cholecystitis, Body Mass Index, presence of abdominal scar, total count, Ultrasonagram Abdomen findings of Gallbladder wall thickness and presence of pericholecystic fluid.Results: In our study, it has been observed that Patient Related Factors - Age >50yrs, Male gender, Presence of Diabetes Mellitus, Obesity, previous Abdominal surgeries and Disease Related Factors - previous episode of Acute Cholecystitis, presence of Acute Cholecystitis, Gallbladder wall thickness >4mm, presence of Pericholecystic fluid were found to be significant risk factors in conversion of laparoscopic to open cholecystectomy.Conclusions: These risk factors help to predict the difficulty of the procedure and this would permit the surgeon to better inform patients about the risk of conversion from laparoscopic to open cholecystectomy.

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Comparative study between laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis

International Surgery Journal ◽

10.18203/2349-2902.isj20192943 ◽

2019 ◽

Vol 6 (7) ◽

pp. 2250

Author(s):

Mohamed Mohsen Salem ◽

Mohamed Emad Esmat ◽

Ahmed Mohamed Abdelaziz Hassan ◽

Yaser Amer ◽

Hisham Abdelaziz ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Common Bile Duct ◽

Endoscopic Retrograde Cholangiopancreatography ◽

Clearance Rate ◽

Common Bile Duct Exploration ◽

Prospective Clinical Study ◽

Endoscopic Retrograde ◽

One Stage ◽

Significant Difference

Background: Endoscopic retrograde cholangiopancreatography (ERCP) with consequent laparoscopic cholecystectomy (LC) has been the favored approach for the treatment of choledocholithiasis for a long time; however recently, laparoscopic common bile duct exploration (LCBDE) has been offered to patients with suspected choledocholithiasis. Objective and aim of this work was to compare the efficacy, safety, and the surgical outcomes of LCBDE with ERCP followed by LC and determine the most appropriate approach for patients with choledocholithiasis.Methods: A prospective clinical study was carried out from March 2017 to September 2018. It included 50 patients with cholecysto-choledocholithiasis who were divided into two groups: group A (25 patients) included patients who underwent transcystic LCBDE and stone extraction with LC in one stage, and group B (25 patients) included patients who underwent ERCP followed by LC in two stages. The common bile duct (CBD) stone clearance rate, postoperative bile leakage, postoperative morbidity, mortality, overall hospital stay, and patient satisfaction were analyzed.Results: LCBDE and ERCP+LC were similar in terms of clearance rate, operative time, postoperative complications, retained CBD stones, and postoperative length of stay, but there was a significant difference in number of procedures and patient satisfaction.Conclusions: Although both approaches have equivalent success rates, LCBDE is better in terms of fewer procedures, and better satisfaction compared with ERCP + LC. Our study suggests that one-stage management is the treatment of choice for patients with cholecysto-choledocholithiasis.

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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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