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ADDITIONAL FACTORS FOUND AT OPEN CHOLECYSTECTOMY AND ON PATHOLIGIC EXAMINATION CONTRIBUTE TO THE NEED FOR CONVERTING TO OPEN CHOLECYSTECTOMY
Kenneth R. Sirinek*, Haisar Dao, Jason Kempenich, Juan Marcano, Wayne Schwesinger
Surgery, Univ of Texas Health Science Center at San Antonio, San Antonio, TX
Background:Although the laparoscopic (LC) approach is the gold standard for patients undergoing an elective/urgent cholecystectomy, some patients still require an open cholecystectomy (OC). Multiple reports have detailed the major factors: inflammation, adhesions, unclear anatomy, organ injury, and bleeding which prompted the surgeon to convert to an OC.
Objective:This 10-year study evaluates all intraoperative findings found both at LC and OC along with pathology findings that were contributing factors for conversion to OC in a large series of cholecystectomy patients.
Methods:Data were prospectively collected and retrospectively reviewed and analyzed.
Results:From 1/1/04 to 12/31/13, 7738 patients underwent cholecystectomy: initial OC (140), LC (7427), and 171 patients had LC→ OC for a conversion rate of 2.2%. These 171 patients (M/F, 73/98) with a mean age of 51.2 yrs (range 14-83) underwent 27 elective LC’s (15.8%) and 144 urgent LC’s (84.2%). 144 urgent ER patients had pre-hospital symptoms for a mean of 5.9 days and time from ER to operation (mean 5.1 days) was: within 24 hrs (44.6%), 2-7 days (48.9%, mean of 3.3 days) and > 7 days (6.5%). Majority of in-hospital delays occurred in patients with major comorbidities, biliary pancreatitis or who had preoperative MRCP and/or ERCP. In addition to the 5 major LC → OC factors, additional patients were found to have gangrenous cholecystits + perforation at LC. Factors at OC included: additional patients with gangrenous cholecystitis + perforation, Mirrizi syndrome + cholecystocholedochal fistula, hydrops, choledocholithiasis, cholecystoduodenal fistula, porcelain gallbladder, and cancer (Table). Pathologic exam confirmed gangrenous cholecystitis, adenocarcinoma, and porcelain gallbladder and added xanthogranulomatous cholecystitis (Table). These 171 LC → OC patients had multiple contributing factors leading to conversion to OC: one (38.6%), two (40.4%), three (15.2%), and four (5.8%) factors.
Conclusions:This study demonstrates that despite a high volume, one institution, cholecystectomy practice, some patients undergoing either an elective or urgent LC will still need to be converted to an OC. This study demonstrates the critical role that additional factors found during open cholecystectomy (ie cholecystoenteric and cholecystocholedochal fistulas, adenocarcinoma, etc) and at pathologic examination (ie xanthogranulomatous cholecystitis, etc.) contribute clinically to the risk for LC → OC conversion. Pre-hospital and in-hospital delays may have contributed to the progression from acute to severe acute or gangrenous cholecystitis + perforation obscuring biliary anatomy at the time of an attempted LC. Further reduction in the already low LC → OC conversion rate of 2.2% appears to depend upon earlier patient presentation and earlier surgical intervention after the onset of acute biliary symptoms.
326 Indications and Contributing Factors Leading to Conversion to Open Cholecystectomy in 171 Patients
| Reason | N(%) | | Severe Inflammation | 93 (54.4%) | | Adhesions (prior laparotomy) | 50 (29.2%) | | Unclear Anatomy | 39 (22.8%) | | Gangrenous Cholecystitis | 36 (21.1%) | | Perforated Gallbladder | 17 (9.9%) | | Mirrizi Syndrome | 12 (7%) | | Preoperative Cholecystostomy Tube | 11 (6.4%) | | Bile Duct Injury | 11 (6.4%) | | Bleeding | 10 (5.8%) | | Hydrops | 10 (5.8%) | | Choledocholithiasis | 9 (5.3%) | | Xanthogranulomatous Cholecystitis | 8 (4.7%) | | Bowel / Artery Injury | 6 (3.5%) | | Cancer / Porcelain Gallbladder | 5 (2.9%) | | Cholecystoduodenal Fistula | 5 (2.9%) | | Technical Difficulties | 4 (2.3%) | | | 316 in 171 Patients |
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