Abstract
Background
Laparoscopic cholecystectomy (LC) is the gold standard procedure for gallbladder removal. However, conversion to open surgery is sometimes needed. The factors underlying a surgeon’s decision to convert a laparoscopic case to an open case are complex and poorly understood. With decreasing experience in open cholecystectomy, this procedure is however no longer the “safe” alternative it once was. With such an impending paradigm shift, this study aimed to identify the main reasons for conversion and ultimately to develop guidelines to help reduce the conversion rates.
Methods
Using the National Surgical Quality Improvement Program (NSQIP) database and financial records, the authors retrospectively reviewed 1,193 cholecystectomies performed at their institution from 2002 to 2009 and identified 70 conversions. Two independent surgeons reviewed the operative notes and determined the reasons for conversion. The number of ports at the time and the extent of dissection before conversion were assessed and used to create new conversion categories. Hospital length of stay (LOS), 30-day complications, operative times and charges, and hospital charges were compared between the new groups.
Results
In 91% of conversion cases, the conversion was elective. In 49% of these conversions, the number of ports was fewer than four. According to the new conversion categories, most conversions were performed after minimal or no attempt at dissection. There were no differences in LOS, complications, operating room charges, or hospital charges between categories. Of the six emergent conversions (9%), bleeding and concern about common bile duct (CBD) injury were the main reasons. One CBD injury occurred.
Conclusions
In 49% of the cases, conversion was performed without a genuine attempt at laparoscopic dissection. Considering this new insight into the circumstances of conversion, the authors recommend that surgeons make a genuine effort at a laparoscopic approach, as reflected by placing four ports and trying to elevate the gallbladder before converting a case to an open approach.
Similar content being viewed by others
References
Begos DG, Modlin IM (1994) Laparoscopic cholecystectomy: from gimmick to gold standard. J Clin Gastroenterol 19:325–330
Sain AH (1996) Laparoscopic cholecystectomy is the current “gold standard” for the treatment of gallstone disease. Ann Surg 224:689–690
Livingston EH, Rege RV (2004) A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg 188:205–211
Kaafarani HM, Smith TS, Neumayer L, Berger DH, Depalma RG, Itani KM (2010) Trends, outcomes, and predictors of open and conversion to open cholecystectomy in Veterans Health Administration hospitals. Am J Surg 200:32–40
Lichten JB, Reid JJ, Zahalsky MP, Friedman RL (2001) Laparoscopic cholecystectomy in the new millennium. Surg Endosc 15:867–872
Low SW, Iyer SG, Chang SK, Mak KS, Lee VT, Madhavan K (2009) Laparoscopic cholecystectomy for acute cholecystitis: safe implementation of successful strategies to reduce conversion rates. Surg Endosc 23:2424–2429
Tang B, Cuschieri A (2006) Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome. J Gastrointest Surg 10:1081–1091
Ballal M, David G, Willmott S, Corless DJ, Deakin M, Slavin JP (2009) Conversion after laparoscopic cholecystectomy in England. Surg Endosc 23:2338–2344
Wolf AS, Nijsse BA, Sokal SM, Chang Y, Berger DL (2009) Surgical outcomes of open cholecystectomy in the laparoscopic era. Am J Surg 197:781–784
Wiseman JT, Sharuk MN, Singla A, Cahan M, Litwin DE, Tseng JF, Shah SA (2011) Surgical management of acute cholecystitis at a tertiary care center in the modern era. Arch Surg 145:439–444
Harboe KM, Bardram L (2011) The quality of cholecystectomy in Denmark: outcome and risk factors for 20,307 patients from the national database. Surg Endosc 25:1630–1641
Lengyel B, Panizales MT, Steinberg J, Ashley SW, Tavakkolizadeh A (2011) Laparoscopic cholecystectomy: what is the price of conversion? Surgery (in press)
Low A, Decker D, Kania U, Hirner A (1997) Forensic aspects of complicated laparoscopic cholecystectomy. Chirurg 68:395–402
Zhang WJ, Li JM, Wu GZ, Luo KL, Dong ZT (2008) Risk factors affecting conversion in patients undergoing laparoscopic cholecystectomy. ANZ J Surg 78:973–976
Jenkins PJ, Paterson HM, Parks RW, Garden OJ (2007) Open cholecystectomy in the laparoscopic era. Br J Surg 94:1382–1385
Johansson M, Thune A, Nelvin L, Stiernstam M, Westman B, Lundell L (2005) Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis. Br J Surg 92:44–49
Alponat A, Kum CK, Koh BC, Rajnakova A, Goh PM (1997) Predictive factors for conversion of laparoscopic cholecystectomy. World J Surg 21:629–633
Lo CM, Fan ST, Liu CL, Lai EC, Wong J (1997) Early decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis. Am J Surg 173:513–517
Chung RS, Ahmed N (2010) The impact of minimally invasive surgery on residents’ open operative experience: analysis of two decades of national data. Ann Surg 251:205–212
Chung R, Pham Q, Wojtasik L, Chari V, Chen P (2003) The laparoscopic experience of surgical graduates in the United States. Surg Endosc 17:1792–1795
Schulman CI, Levi J, Sleeman D, Dunkin B, Irvin G, Levi D, Spector S, Franceschi D, Livingstone A (2007) Are we training our residents to perform open gallbladder and common bile duct operations? J Surg Res 142:246–249
Acknowledgment
Balazs Lengyel was supported by NIH grant R25 CA089017.
Disclosures
A. Tavakkolizadeh has been a consultant for GlaxoSmith Klein and Novartis Pharmaceutical, as well as for Ethicon Inc. He is on the scientific advisory board of Avaxia Biologics, Inc. B. Lengyel, D. Azagury, O. Varban, T. Panizales, J. Steinberg, D. Brooks, and S. Ashley have no conflicts of interest or financial ties to disclose.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Lengyel, B.I., Azagury, D., Varban, O. et al. Laparoscopic cholecystectomy after a quarter century: why do we still convert?. Surg Endosc 26, 508–513 (2012). https://doi.org/10.1007/s00464-011-1909-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-011-1909-5