Contributing Factors and Conversion Prevalence of Laparoscopic Cholecystectomy to Open Surgery

Back ground: The application of laparoscopic technique for cholecystectomy is expanding very rapidly and now performed in almost all major cities and tertiary level hospitals in our country. The laparoscopic approach brings numerous advantages at the expense of a new set of diffi culties leads to open conversion especially in training facilities. Objective: To determine the rate and associated causative factors of conversion to open cholecystectomy in case of laparoscopic cholecystectomy in our surgical practice. Methodology: 364 & 387 patients of laparoscopic cholecystectomy in BIRDEM General Hospital, Dhaka, Bangladesh and Khulna Medical College Hospital, Bangladesh were included in this prospective study on the basis of convenient purposive sampling from a period of 30.06.14 to 30.09.16 & 01.01.11 to 30.09.16 respectively. Result: Among the patients of BIRDEM, 25.5% cases were male and 74.5% patients were female. Mean±SD of age were 43±1.4 and 42±1.7 respectively, whereas among the KMCH patients, 26.1% were male and 73.9% were female. Mean±SD of age were 46±1.3 and 43±1.9 respectively. Among the total 364 cases in BIRDEM, in case of 277 (76.1% approximately), laparoscopic cholecystectomy was done due to chronic cholecystitis whereas in case of KMCH it was 83.2%. The overall conversion rates were 5.2% in BIRDEM and 7.0% in KMCH. Diffi culties to defi ne the anatomy of Calot’s triangle is the most important reason for open conversion which were 42.1% and 33.3% in the respective groups. Other important causes were suspicion of CBD injury, bowel injury, cystic artery bleeding, bile duct injury and suspicion of gall bladder cancer. The prevalence rates are relatively higher in male sex, age ≥60 years, in presence of comorbidities, upper abdominal surgery, acute cholecystitis, history of jaundice, obesity, thickened gall bladder wall on ultrasound and preoperative ERCP which are approximately 8.6%, 9.1%, 6.4%, 9.1%, 8.1%, 9.5%, 8.2%, 7.6% & 7.7% respectively in BIRDEM, whereas these were 8.9%, 7.7%, 7.5%, 10.5%, 10.8%, 9.7%, 9.2%, 8.4% & 9.7% respectively in KMCH. Conclusion: An appreciation for these predictors of conversion will allow appropriate planning and patient selection by the operating surgeon. Research Article Contributing Factors and Conversion Prevalence of Laparoscopic Cholecystectomy to Open Surgery Faruquzzaman* MS Part 3 (Thesis) Course Student, BIRDEM General Hospital, Dhaka, Bangladesh Dates: Received: 14 February, 2017; Accepted: 19 May, 2017; Published: 22 May, 2017 *Corresponding author: Faruquzzaman, Doctor, MS Part 3 (Thesis) Course Student, BIRDEM General Hospital, Dhaka, Bangladesh, E-mail:


Introduction
Gall stone disease is a common disease affecting human beings. Langenbach in 1892 done the fi rst cholecystectomy conversion from LC to open cholecystectomy [3]. The conversion from LC to open cholecystectomy results in a signifi cant change in out-come for the patient because of the higher rate of postoperative complications and the longer hospital stay in addition to the effect and the long term sequel of the cause of conversion itself as in bile duct injury [4]. Conversion to open cholecystectomy is occasionally necessary to avoid or repair injury, delineate confusing anatomic relationships, or treat associated conditions [5]. Therefore, aim of this study is to determine the rate of conversion to open cholecystectomy and associated factors.

Results
The age and sex distribution of the study population of BIRDEM General Hospital, Dhaka is presented in table 1 which suggest that majority of the patients were female (74.5%).
Mean±SD of age was 43±1.4 and 42±1.7 in case of male and female patients respectively (Table 1). On the other hand, the demographic distribution of the study population of KMCH, Khulna is presented in table 2 which suggest that majority of the patients were female (73.9%). Mean±SD of age was 46±1.3 and 43±1.9 in case of male and female patients respectively.
Majority of the patients of laparoscopic cholecystectomy in BIRDEM were due to chronic cholecystitis (76.1%) followed by 17.0% due to acute cholecystitis. In case of KMCH, these were 83.2% & 9.6% respectively ( Table 3).
The results of this study suggests that (Table 4) (Table 5).

Discussion
Laparoscopic cholecystectomy has become the procedure of choice for management of symptomatic gall bladder stone disease [6][7][8][9][10]. The advantages to the patient and the economic benefi ts to society have been reported [11]. However the risk of conversion to open surgery is always present. The actual rates of conversion reported in the literatures are quite variable [6][7][8][9][10], ranging from 0% to 20%. In our study the conversion rate was 7.3% of the 261 attempted Laparoscopic cholecystectomies.
Although conversion to open surgery is not a complication, laparotomy is associated with greater morbidity and prolonged convalescence than laparoscopy. Therefore, understanding the risk of conversion allows the patient to make a better informed decision about surgery.
In this study among the patients of BIRDEM, 25.5% cases were male (out of total 364 patients) and 74.5% patients were female. In male group, most of the patients (11.8%) were in 41-50 years of age group followed by 6.3% were in 51-60 years age     (Table 3). In another study, the conversion rate was 13% in the initial 200 patients and 2.1% in the remaining 1400 patients. Most of the conversions the reason was anatomic diffi culty related to inexperience of the surgeon. Early in a surgeon experience with laparoscopic cholecystectomy, patient selection is likely to be more restricted. In these early cases, surgeon would benefi t from having a good idea preoperatively about predictors of an "easy case" as compared with a case more likely to require conversion [12].
The decision about when to convert to laparotomy is an individual one, often subjective, made by the surgeon in the course of the procedure. In another study, the main reason for conversion was inability to defi ne the anatomy clearly (42 from 56), this fi nding was noted in similar studies [13][14][15]. The   (Table 4).
Acute cholecystitis is accompanied by increased vascularity and dense adhesions that interfere with good visualization, whereas thick walled gall bladder often is shrunken and contracted. In both presentations the cystic duct becomes foreshortened, and the gall bladder may be adherent to the common bile duct, making it diffi cult to grasp the gall bladder for retraction or to dissect the gall bladder from the common bile duct.