Department of Surgery, BIRDEM General Hospital, Dhaka, Bangladesh
cholecystectomy (LC) has virtually replaced conventional open cholecystectomy
(OC) as the standard procedure of treatment for cholelithiasis and cholecystitis.
However, OC sometimes becomes a necessity considering the feasibility and
safety of the surgical procedure. But the factors that demand conversion from
LC to OC differ widely. The present study aimed to determine the prevalence of conversion
from LC to OC and to assess the causes of conversion and risk factors related
Methods: The study was
conducted in a referral hospital – ‘Bangladesh
Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic
Disorder (BIRDEM)’ from September 2014 to September 2016. Cases of
cholelithiasis with or without cholecystitis, and other gall bladder pathology
were included in the study. A team of experienced surgeon performed LC of all
selected cases. The causes of conversion to OC were systematically recorded by
the surgical team and the risk factors (age, sex, obesity, history of previous
abdominal surgery, gallbladder thickness) related to conversion from LC to OC was
A total of 261 (M / F = 87 /174) patients were considered eligible for the
study. The mean age of all patients was 43 (±1.75) years. For the male and
female groups the mean ages were 44±1.9 and 42±1.6 years respectively. Of the
total 261 cases, 210 (80.5%) patients had cholelithiasis with chronic
cholecystitis, 47 (18.0%) had gallbladder stone plus acute cholecystitis and 4
(1.5%) had gallbladder polyp. Open conversion was required in case of 19
patients. Thus, overall conversion rate was 7.3%. The common causes of
conversion were a) difficulty in defining Calot’s triangle (42.1%), b) injury to cystic artery (21.1%) and c) injury to bile duct (15.8%). Both
male and female had equal risk for conversion. The investigated risk factors
like history of previous abdominal surgery, preoperative ERCP, acute
cholecystitis, obesity, increased gallbladder-wall thickness and older age showed
no significant association with conversion.
The study revealed that a very few patents (7.5%) needed conversion from LC to
OC. The commonest cause of conversion was difficulty in defining Calot’s triangle, injury to cystic artery
and bile duct. The risk factors like previous abdominal surgery, preoperative
ERCP, gallbladder wall thickness, obesity and old age were not found associated
with conversion to OC.
IMC J Med Sci 2017; 11(2): 32-35
for Correspondence: Dr. Tapash Kumar
Maitra, Associate Professor & Head, Department of Surgery, BIRDEM General
Hospital, 122 Kazi Nazrul Islam Avenue,
Shahbagh Dhaka, Bangladesh. Email: firstname.lastname@example.org
cholecystectomy (LC) has been accepted as the most common surgical procedure
for the treatment of cholelithiasis and associated surgical conditions . However,
there are factors
that have increased the risk ofopenconversion [1-3]. LC also
introduced a new spectrum of complications . It has been reported that conversion
from LC to OC is less common as consultant caseload increases . This indicates that
LC should be undertaken only by the experienced surgeons who perform operation
on a substantial number of cholelithiasis and or cholecystitis cases . Some
authors suggest that a history of preoperative endoscopic sphincterotomy and a
thickened gallbladder wall contribute to the likelihood of conversion .
This study was undertaken to determine the prevalence of conversion from LC to
OC and the risk factors related to conversion.
Study population and Methods
was conducted at BIRDEM hospital in Dhaka city for consecutive two years
starting from 30 September 2014 to 30 September 2016. All cases of
cholelithiasis with or without cholecystitis, and other gall bladder pathology
admitted in the hospital during the above period were included in the study. Detail
clinical history was recorded in a predesigned data sheet. Clinical history
included gender, age, previous abdominal surgery, preoperative ERCP, jaundice,
acute cholecystitis, obesity, gallbladder wall thickness. The relevant
biochemical and imaging investigations were performed on each case for the
diagnosis of cholelithiasis and associated pathology. An experienced team of
surgeon of BIRDEM hospital performed LC of all selected cases.
The data were
presented as mean±SD and percentages. Chi-sq tests were used to determine the
factors related to conversion.
and sex distribution of the study population is presented in Table-1 which
suggest that majority of the patients were female (66.7%). The mean (±SD) age
was 44±1.9 years and 42±1.6 years in case of male and female patients respectively.
Majority of the patients (80.5%) selected for laparoscopic cholecystectomy had
chronic cholecystitis and 18.0% had acute cholecystitis and 1.5% had other
pathology like gall bladder polyp (Table-2).
Table-1: Age and sex distribution of study population
Table-2: Diagnosis following laparoscopic cholecystectomy
total 261, the conversion from LC to OC was performed in 19 patients. Thus, the
conversion rate reached 7.3%. The causes for conversion are shown in Table-3.
The most common cause of conversion was a difficulty to define the anatomy of Calot’s
triangle, which comprised 42.1%. The other major causes were injury to cystic
artery (21.1%) and bile duct (15.8%).
The risk factors for association with conversion of LC to OC were shown in Table-4.
There was no significant association of gender, age, history of previous
abdominal surgery, preoperative ERCP and jaundice with conversion. Likewise, acute
cholecystitis, obesity, gallbladder wall thickness were also found not
Table-3: The causes for conversion from LC to OC
Table-4: Factors associated with conversion to open cholecystectomy
many years LC
has been the standard treatment for symptomatic gallbladder disease [2,3,5].
The identification of factors that reliably predict the likely need to convert
LC to an open procedure is important and beneficial
in terms of patients’ education and postoperative expectations . This study
did not consider the risk score as suggested by CholeS study group .
However, the conversion rate of this study is consistent with the other studies
[4,5,6]. A study in England reported the overall conversion rate as 5.2% . Ishizaki et
al observed the conversion rate from 5.3% to 10.6% . It may be mentioned
that Sippey M et al  found age, male gender, obesity, pre-operative
alkaline phosphatase level, white blood cell count were independently
associated with conversion to OC. In the present study age, gender and obesity
were investigated but found not significant. Alkaline phosphatase and white
blood cell count were not included in the study. Further study may be conducted
to reveal the association of these factors to conversion.
with chronic cholecystitis were found as the most common candidates undergoing
laparoscopic cholecystectomy. Very few patents required conversion from laparoscopic
to open cholecystectomy. The most common cause of conversion was a difficulty
in defining Calot’s triangle followed
by injury to cystic artery and bile duct. The other reported risk factors like
previous abdominal surgery, preoperative ERCP, gallbladder thickness, obesity
and old age were found not associated with conversion to OC.
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