A FIVE YEARS ANALYSIS OF LAPAROSCOPIC CHOLECYSTECTOMY CONVERSION, WHEN AND WHY?

Contraindications to laparoscopic cholecystectomy diminished over the last decade but still conversion rate is about 56% in elective cases and higher in acute cholecystitis. The aim of this study is to analyze the reasons for conversion in all patients laparoscopically operated on for cholecystectomy in our surgical department and to create strategies for critical moments when conversion needed. From 2005 to 2010, the data sheets of all patients subjected for laparoscopic cholecystectomy had been analyzed regarding sex, age, intraoperative finding, the time and reason for conversion. Of the 899 patients who underwent laparoscopy cholecystectomy (83 male and 816 female), 3.8% [34 patients (21 women, 2.5% and 13 men, 15.61%)] were converted to open cholecystectomy. Difficulties with the anatomy in Calot's triangle (58.8%), difficulties in establishing pneumoperitoneum (8.8%) and bleeding (8.8%) have been the main reasons for conversion. In conclusion, the scene keys for conversion are difficulties in Calot's triangle, intra-abdominal adhesions, and the creation of the pneumoperitoneum. Conversion should not be regarded as a complication. INTRODUCTION ince the beginning of laparoscopic cholecystectomy (LC) more than 20 years ago, the patients scheduled for LC have been well selected to avoid complications. Previous abdominal operations and liver cirrhosis or portal hypertension were seen as contraindications. Nowadays, these contraindications have almost disappeared. However, up to 15% of all attempted elective LC end up as open procedures and the percentage in acute cholecystitis is definitively higher depending on surgeons experience, patient's clinical findings, and surgeon's threshold for conversion. The right moment for conversion is difficult to determine through guidelines or scoring systems. During LC, several key scenarios might appear which should lead to conversion before harming the patient. The aim of this study is to analyze data of our patients, in a 5 year period, which underwent LC regarding the reason and timing for conversion from laparoscopic to open cholecystectomy (CC) and also developing strategies for critical moments in case of conversion. PATIENTS AND METHODS From January 2005 to January 2010, a total of 899 laparoscopic cholecystectomies have been performed in the surgical department, Basrah Teaching Hospital. The patients were analyzed regarding sex, age, intraoperative findings, time and reason for conversion. For the statistical evaluation, we used the nonparametric Chi-square test was used to analyze the differences in conversions between the females and the males group. P<0·05 was considered statistically significant. Operation technique Laparoscopic cholecystectomy is performed, by most of surgeons, using 4 trocars, with the patient in supine position and the surgeon at the patients left side while the monitor at the patient's right shoulder. The pneumoperitoneum is created using the Veress needle (VN) via an infraumbilical incision after preparation and elevation of the fascia. The double click test and the waterproof test are carried out routinely. All operations are performed with CO2 gas and 12 mm Hg pressure. The first trocar (10 mm) is placed after removing the needle infraumbilical; all others (10 mm epigastric and 2×5 mm in the right-sided mesochondrium) are placed under direct vision. In patients with previous median abdominal laparotomy, was placed the first trocar to the left side or right side subcostal after open an access to the abdominal cavity. The preparation of the gallbladder is done by use of the electric hook, scissors or dissecting forceps. The dissection in Calot's triangle is performed meticulously until both the cystic duct and the artery are freed from surrounding tissue and secured with 2 clips central and 1 clip peripheral (STORZ Company). After retrograde dissection S MJBU, VOL 28, No.1, 2010 10 of the gallbladder, the specimen is excorporated through the epigastric port site. Converted cholecystectomy (CC) was performed by a right subcostal or right paramedian approaches. RESULTS Of the 899 patients who underwent laparoscopy cholecystectomy, (83 male and 816 female), 34 patients (3.8%) were converted to open cholecystectomy. The age of the patients ranged from 13-80 year. The distribution of what over the 5year is shown in (Fig-1). Fig 1. Relation of laparoscopic Complete LC: (865 Patients) In all, 865 operations which completely performed by laparoscopy (96.2%), there were 70 male (70/83=84%) and 795 female (795/816=97.5%). Converted Patients: (34 Patients) Thirteen males (13/83=15.6%) and 21 female patients (21/816=2.5%) were in the group of patients where conversion had to be performed, which was significantly higher in male than female patients (P<0.05) (Table-1). Table 1. Sex distribution in patients underwent LC. Completed Lc % Cc % Total Male 70 84.4 13 15.6 83 Female 795 97.5 21 2.5 816 Total 865 34 899 Fig.1: Relation of LC to CC. 2005 2006 2007 2008 2009 Years 0 50 100 150 200 250 No. of cases