Year : 2003 | Volume
: 9 | Issue : 3 | Page : 124--128
Laparoscopic cholecystectomy: The outcome with minimal conversion rate: Experience in a district hospital
Abdulhameed Safar Al Ghamdi, Hussein Sami Khamis, Rida El Shawatfy El Said, Gamal Ahmed Khairy
Department of Surgery, King Fahad Hospital, Al Baha, Saudi Arabia
Gamal Ahmed Khairy
Faculty of Medicine, King Saud University, P.O. Box 7805, Riyadh 11472
Background: Since introducing laparoscopic cholecystectomy (LC) different centres have reported different conversion rate (CR) to open cholecystectomy (OC) and different reasons for conversion. Objective: To evaluate the role of LC in the treatment of symptomatic gallstones and establish the outcomes of this treatment modality in general, looking especially into the rate of conversion to OC, at a district hospital. Patients and methods: From July 1992-July 1998, 751 patients who underwent LC were retrospectively reviewed. All patients with symptomatic gallstones were offered LC with no exclusion criteria apart from anaesthetic opinion. No attempts were made at selection of patients for LC. Results: There were 751 patients with symptomatic gallstones (617 females, 134 males) underwent LC. Chronic cholecystitis represented the majority of cases (83%). The mean operative time was 65.52 minutes: pre-operation and main hospital stay was 2.46 days. Our total conversion rate was 0.9% and 0.4% if malignancy of the gallbladder is excluded. In comparison to the published data, there was obvious lower conversion rate, which was neither associated with increased morbidity nor mortality. Conclusion: Laparoscopic cholecystectomy is a reliable, safe and cost effective treatment modality for symptomatic gallstones. With growing experience in laparoscopic technique, proper settings and harmony of the operating team, it is possible to bring the conversion rate to OC to the minimum without any increment in mortality or morbidity
|How to cite this article:|
Al Ghamdi AS, Khamis HS, El Said RE, Khairy GA. Laparoscopic cholecystectomy: The outcome with minimal conversion rate: Experience in a district hospital.Saudi J Gastroenterol 2003;9:124-128
|How to cite this URL:|
Al Ghamdi AS, Khamis HS, El Said RE, Khairy GA. Laparoscopic cholecystectomy: The outcome with minimal conversion rate: Experience in a district hospital. Saudi J Gastroenterol [serial online] 2003 [cited 2021 Dec 3 ];9:124-128
Available from: https://www.saudijgastro.com/text.asp?2003/9/3/124/33353
The contraindications to LC in the early years following its introduction in 1987 by Mouret in France used to contain a long list of local and systemic conditions  . This list has progressively become shorter. Acute cholecystitis, previous scars, morbid obesity, common bile duct (CBD) stones and compensated cardiac and pulmonary diseases are no longer considered as contraindications to LC ,,,, .
Now LC has become the first-line surgical treatment of calculus gallbladder disease but conversion to OC is still substantial. Unfortunately, as more cases with no selection criteria are being operated laparoscopically, the number of difficult cases have increased. This will demand more experienced surgical teams, and probably longer operative time. In many centers this may be reflected on a higher conversion rate.
If a lower conversion rate is associated with increased incidence of complications, this would be a disadvantage. However, if a low conversion rate can be achieved without increment in either morbidity or mortality, then the undoubted benefits of minimal invasive surgery will be gained. In order to have a valid comparison between conversion rates, inclusion and exclusion criteria for LC should be considered.
The aim of this study is to establish the outcome of LC in treatment of symptomatic gallstones at a district hospital in Saudi Arabia.
Patients and methods
From July 1992-July 1998, a total of 751 LC were attempted by the same operating team at King Fahad Hospital, Al-Baha, Saudi Arabia. This constituted 93% of the total number of laparoscopic procedures performed in our hospital during this period. All patients with symptomatic gallstones were offered LC with no exclusion criteria except; anaesthetic opinion in some American Society of Anaesthesia (ASA) Class 4 patients. Retrospective evaluation of all patients who underwent LC by the specialists (authors) was carried out. One dose of third generation, cephalosporin was given to each patient as prophylactic antibiotic. In few patients antibiotics were continued for 1-2 days postoperatively if perforation and leakage of bile or stone occurred in empyema or gangrene of the gallbladder.
Preoperative ERCP was required in 46 patients (6.12%) as indicated by abnormal liver function tests (LFTs) and ultrasound (U/S) findings. Peroperative cholangiogram was performed in ten (1.33%) of the patients due to failed ERCP or according to operative findings of unclear anatomy. Another 5mm port was inserted at the right upper quadrant for this procedure. The operating team consisted of three of the authors in all operations. A standard technique of LC was practiced using reusable and occasionally disposable instruments. Nasogastric tube or urinary catheter were not introduced routinely. If the gallbladder was found to be tense, it was aspirated by puncturing at the fundus. The gallbladder was extracted through the epigastric port, which was extended if necessary.
Of the 751 patients with symptomatic gallstones, there were 617 (82%) female patients and 134 (18%) male patients. The mean age was 41 years (range 10-100 years) with highest incidence in the age group 31-40 years. Chronic cholecystitis represented the majority of patients (83%), while acute cholecystitis represented 124 (17%). 142 patients (19%) in our series had previous abdominal operations and 49 (6.5%) were known to have diabetes mellitus.
The mean operative time was 65.52 minutes per operation and mean hospital stay was 2.46 days per patient. Forty-eight patients (6.4%) had complications, the majority of them were minor. None of the patients had CBD injury. [Table 1] illustrates the morbidity details.
Seven patients 0.93% out of 751 patients were converted to OC. The reason for conversion was the discovery of an additional pathology that was not diagnosed pre-operatively in four patients (0.53%). Details of incidental operative findings are shown in [Table 2]. Three patients (0.4%) were converted because of technical difficulties during dissection, (two male and one female) all with pre-operative diagnosis of acute cholecystitis. We had two mortalities out of 751 patients (0.26%), one of them was 100 years old and the other had a sudden collapse mostly due to pulmonary embolism.
Laparoscapic cholecystectomy has become the firstline surgical treatment of calculus gallbladder disease; however, conversion to OC remains a possibility  . Unfortunately, preoperative factors indicating risk of conversion rate are unclear  .
Our conversion rate to OC in 751 patients of LC was 0.93%. If the patients who were converted to OC because of incidental operative findings (carcinoma gallbladder and hydatid cyst of liver) were removed, the conversion rate would come down to only 0.4%. In comparison to published reports in this field, our conversion rate is considerably low, despite the fact that our series was performed in a district hospital. It is worth mentioning that two of the three conversions were due to technical difficulties that we faced in the early stages of our series (i.e. in 1992). [Table 3] compares our conversion rate with some major published similar works ,,,,, .
Several workers have tried to study the factors predicting conversion to OC ,,, . Male sex, ultrasound finding of contracted/thick wall gallbladder, wide CBD, age >65 years and early learning phase were all reported to be predictors of conversion to OC. Other more recent studies related higher CR to the associated medical problems (such as diabetis mellitus)  , acute and gangrenous cholecystitis ,, and non-selection criteria preoperatively  . In a recent study, male patients had higher conversion rate and significantly longer operating time than females  . Kaushik et al claimed that the commonest cause of conversion was frozen Calot's triangle, followed by injury to common bile duct and the higher conversion rate (7.06%) was due to adopting "no hesitation" policy in converting  . In other loco-regional experience, Kamal et al showed a conversion rate of 6.28% whereas Al-Hadi et al showed a conversion rate of 2.7% ,.
Many of the above mentioned factors were included in our patients and there was no preoperative selection criteria. However, the CR was significantly low in our series in comparison to published data. We believe that the above mentioned factors could predict difficulty of the operation and call for the presence of an experienced laparoscopic surgeon but do not necessarily increase the conversion rate. Although some workers believe that a low threshold for conversion to open seems to be an important factor in maintaining a low incidence of operative complications  , the mortality and morbidity in our group of patients were comparable to published data. In a recent publication, Sarli et al gave a morbidity rate of 7.4%, with a conversion rate of 8.7%. Our morbidity rate was 6.4% (48 patients in [Table 1]  . Forty-five of these patients were managed nonoperatively while only three patients required reoperation. The first of the three patients who required re-operation had a hernia at the site of the umbilical port, which was repaired surgically. The second patient had a small bowel injury during insertion of the 1st laparoscopic umbilical trocar and was converted to open surgery to deal with this complication, which occurred in the early stages of our series; currently such a complication can be repaired laparoscopically. The 3rd complication was a sub-hepatic abscess that required surgical drainage after failure of conservative treatment. We had two mortalities (0.26%) in 751 patients and none of them was related to the choice of surgical approach whether laparoscopic or open.
From the above discussion, and contrary to the opinions held by some previous workers, it is clear that a low conversion rate can be associated with a low complication rate. The factors that influence the conversion rate are probably related to the patient, the surgeon as well as the set up and instrumentation.
Laparoscopic cholecystectomy is a reliable, safe, and cost effective treatment modality for symptomatic gallstones. Avoiding conversion from LC to OC or keeping it to minimum is possible without any increase in mortality or morbidity. This requires growing experience of the operating team with proper settings and instrumentation. Safety of the procedure will not be compromised if a careful standardized technique is practiced. The advantages of laparoscopic approach outweigh the relatively longer operative time, which will be needed in certain difficult cases.
|1||Mouret G. From the first Laparoscopic cholecystectomy to the Frontiers of Laparoscopic surgery: The future perspective. Dig. Surg 1991; 8: 124-5.|
|2||Wittgen CM, Andrus JP, Andrus CH, Kaminski DL. Cholecystectomy, which procedure is best for the high-risk patient? Surg Endosc, 1993; 7: 395-9.|
|3||Pezet D. Fondrinier E, Rotman N, Guy L, Lemesle P, Lointier P, and Chipponi J. Parietal seeding of carcinoma of the gallbladder after laparoscopic cholecystectomy. Br. J. Surg 1992; 79: 230.|
|4||Unger SW, Rosenbaum G, Unger HM, Edelman DS. A comparison of laparoscopic and open treatment of acute cholecystitis. Surg Endosc 1993; 7: 408-11.|
|5||Zucker KA, Flowers JL, Baily RW, Graham SM, Buell J, Imbembo AL. Laparoscopic management of acute cholecystitis. Am J. Surg 1993; 165: 509-14.|
|6||Unger SW, Scott JS, Unger HM, Edelman DS. Laparoscopic approach to gallstones in the morbidly obese patient. Surg Endosc 1991; 5: 116-7.|
|7||Al-Ghamdi AH, Khamis HS. Laparoscopic excision of hydatid cyst of the liver. Surg Endosc Endosurgery 1996; 4: 81-83.|
|8||Slater K, Strong R, Wall D, Lynch S. latrogenic bile duct injury: the Scourge of laparoscopic cholecystectomy. ANZ-J-Surg. 2002; 72: 83-8.|
|9||Kanaan A, Murayama M, Merriam T, Dawes G. Prystowsky B, Rege V, and Joehl J. Risk factors for conversion of laparoscopic to open cholecystectomy. J Surg Res. 2002; 106: 20-4.|
|10||Wherry DC, Rob CG, Marhon MR, Rich NM. An external audit of laparoscopic cholecystectomy performed in medical treatment facilities of the department of defense. Ann Surg 1994; 220: 626-34.|
|11||Richardson MC, Bell G, Fullarton GM, and the West of Scotland Laparoscopic cholecystectomy audit group. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: An audit of 5913 cases. Br J Surg 1996; 83: 1356-60.|
|12||Al-Hadi FH, Chiedozi LC, Salem MM, George TV, Desouky M, Pasha SM. Comparison of laparoscopic and open cholecystectomy at Prince Abdulrahman Al- , Sudairy Hospital, Saudi Arabia. East-Afr-Med-J, 1998; 75: 536-9.|
|13||Kamal G, Fouad A, Hussein H, Tareq M, Gazi R. Laparoscopic cholecystectomy for gallstones: A comparison of outcome between acute and chronic cholecystitis. Annals of Saudi Med, 2001; 21: 312-16.|
|14||Kaushik R, Sharma R, Batna R, Yadar T-D, Attri A, Kaushik SP. Laparoscopic cholecystectomy: An Indian experience of 1233 cases. J Laparoendosc Adv Surg Tech A. 2002; 12: 21-5.|
|15||Sinha R, Sharma N. Acute cholecystitis and laparoscopic cholecystectomy. JSLS 2002; 6: 65-8.|
|16||Liu CL, Fan ST. Lai EC, Lo CM, Chu KM. Factors affecting conversion of laparoscopic cholecystectomy to open surgery. Arc Surg. 1996: 131: 98-101.|
|17||Jansen S, Jorgensen J, Caplehorn J, Hunt D. Preoperative ultrasound to predict conversion in laparoscopic cholecystectomy. Surg Laparosc Endosc. 1997; 7: 121-3.|
|18||Alponat A, Kum CK, Kho BC. Rajnakova A, Goh PM. Predictive factors for conversion of laparoscopic cholecystectomy. World J Surg. 1997; 21: 629-33.|
|19||Brunt LM, Quasebarth MA, Dunnegan DL, Soper NJ. Outcomes analysis of laparoscopic cholecystectomy in the extremely elderly. Surg Endosc. 2001; 15: 700-5.|
|20||Bedirli A, Souzer EM, Yuksel O, Yilmaz Z. Laparoscopic cholecystectomy for symptomatic gallstones in diabetic patients. J Laparoendosc Adv Surg Tech A., 2001; 11: 281-4.|
|21||Chahin F, Elias N, Paramesh A, Saba A, Godziachviliv V, Silva YJ. The efficacy of laparoscopy in acute cholecystitis. JSLS 1999; 3: 121-5.|
|22||Eldar S, Sabo E, Nash E, Abrahamson J, Matter I. Laparoscopic cholecystectomy for the various types of gallbladder inflammation: A prospective trial. Surg Laparosc Endosc. 1998; 8: 200-7.|
|23||Bedirli A, Saknak O, Sozuer EM, Kerek M, Gubar I. Factors effecting the complications in the natural history of acute cholecystitis. Hepatogastroenterology. 2001; 48: 1275-8.|
|24||Bartlett A, Parry B. Cusum analysis of trends in operative selection and conversion rates from laparoscopic cholecystectomy. ANZ J Surg 2001; 71: 453-6.|
|25||Lein, Heing-Hui, Huang, Ching-Shui. Male gender: Risk factor for severe symptomatic cholelithiasis. World-J-Surg. 2002; 26: 598-601.|
|26||Bickle A, Rappaport A, Kanievski V, Vaksman I, Haj M, Geron N, Eitan A. Laprascopic management of acute cholecystitis - Prognostic factors for success. 1996; 10: 1045-9.|
|27||Sarli L, lusco D, Sgobba G, Roncoroni L. Gallstone cholangitis : A 10-year experience of combined endoscopic and laparoscopic treatment. Surg Endosc. 2002; 16: 975-80.|