factors leading to conversion in laparoscopic cholecystectomy

OriginalArticleFACTORS LEADING TO CONVERSION INLAPAROSCOPIC CHOLECYSTECTOMYPERVEZ IQBAL, MOHAMMAD SADDIQUE, TUFAIL AHMED BALOCH*Department of Surgery (Unit VI), Dow University of Health Sciences & Civil Hospital, KarachiDepartment of Surgery, Sindh Government Lyari General Hospital, Karachi*ABSTRACTObjective: To determine the reasons for conversion of Laparoscopic Cholecystectomy to open surgery in our setup.Design & Duration: A case series from January 2000 to June 2007.Setting: Surgical Unit I & IV of Civil Hospital Karachi, Surgical Unit VIII of Lyari General Hospital and two privatehospitals of Karachi.Patients: A total of 340 patients who underwent Laparoscopic Cholecystectomy.Methodology: Detailed history, physical examination and investigations were carried out. Patients were operatedby a senior surgeon. Cases that required conversion from Laparoscopic to open surgery were analyzed and the factorsresponsible for such conversion were studied.Results: Out of 340 patients 32 (9.4%) required conversion to open procedure. Factors responsible for these conversionwere dense adhesions in 8(2.4%), empyema gall bladder in 4(1.2%), contracted gall bladder in 3(0.9%), haemorrhagein 3(0.9%), and CBD injury and carcinoma gall bladder in 2(0.6%) each. Instrument failure and repeated powerbreakdowns with backup failure were also recognized as important factors responsible for 10(2.9%) conversions.Conclusion: Conversion of Laparoscopic to open procedure may be life saving in difficult situations. Conversionrate can be reduced by addressing the preventable factors.KEY WORDS: Laparoscopic Cholecystectomy, Conversion, Instrument FailureINTRODUCTIONLaparoscopic Cholecystectomy (LC) has gradually replacedopen cholecystectomy for the treatment of symptomaticgall stone disease in almost all major hospitalsin Pakistan. Better cosmetic results, short hospital stay,early recovery and return to physical activity and workhave all contributed to the popularity of this technique,establishing it as the gold standard for the treatment ofcholelithiasis.In some cases conversion to open cholecystectomy isCorrespondence:Dr. Pervez Iqbal, Associate Professor,Surgical Unit VI, DUHS & Civil Hospital, Karachi.Phones: 4963228, 0345-2188611.E-mail: surgeonpervez@hotmail.comrequired for the safety of patients. The factors leadingto conversion may be patient related as in the case ofdistorted anatomy, surgeon related due to less experienceof difficult situations and equipment related as in thecase of instrument failure. A conversion rate of 1.5 to19% have been reported in different published series. 1The object of this study was to identify the factors responsiblefor conversion in our setup.PATIENTS & METHODSThis study was conducted in Surgical Unit I & IV ofCivil Hospital, Unit VIII of Lyari General Hospital andtwo private hospitals in Karachi. A total of 340 patientspresenting with symptomatic gall stone disease betweenJanuary 2000 to June 2007 were included in the study.Patients with history of jaundice, previous upper abdominalsurgery, palpable tender lump in right hypochondrium,deranged liver function tests, dilated CBD orCBD stones on ultrasound and those with medical comorbidswere not included in the study. All patientswere evaluated on the basis of history, physical exami-9Volume 24, Issue 1, 2008

Factors leading to Conversion in Lap. CholecystectomyP. Iqbal, M. Saddique, T. A. Balochnation, laboratory investigations and ultrasound abdomen,and underwent classical laparoscopic cholecystectomy.Details of patients who underwent conversion toopen operation were analyzed and the factors responsiblenoted.RESULTSAmongst the 340 patients admitted for laparoscopiccholecystectomy 80(23.5%) were male and 260(76.5%)female, with an average age of 39 years (range 16 yearsto 62 years). Thirty two patients (9.41%) required conversionto open procedure; in the remaining cases thelaparoscopic cholecystectomy was successfully completed.The reasons for conversion (Table I) included denseadhesions in the region of gall bladder and Calot’s trianglemaking dissection unsafe in 8(2.35%) cases,empyema gall bladder in 4(1.18%), failure to hold thecontracted thick-walled gall bladder in 3(0.88%) andhaemorrhage in 3(0.88%) patients. Two (0.59%) caseswith injury to the CBD recognized during surgery wereconverted to open procedure, as were 2(0.59%) patientswith incidental finding of carcinoma gall bladder. Instrumentfailure contributed to maximum number of conversionsi.e. 10(2.94%). Instrument failure (Table II) includedfailure of light source in four cases, failure of thecamera in two and insufflator also in two cases. Repeateddisruption of power supply with backup failure wasalso responsible for two conversions.DISCUSSIONWith growing experience of laparoscopic cholecystectomyand completion of the learning curve, the indicationsfor LC have been extended, approaching to thatof open cholecystectomy depending upon the expertiseof the operating team. Complications of LC have beenminimized to as low as 2-6%. 2 However, a substantialTable I. Reasons for Conversion (n=340)Reason for ConversionPresence of dense adhesionsEmpyema gall bladderContracted gall bladderHaemorrhageCBD InjuryCarcinoma gall bladderInstrument failureTotalNo.8433221032%2.351.180.880.880.590.592.949.41proportion of patients had to be converted from LC toopen operation because of technical difficulty or intraoperativecomplications. 3-5 The conversion rate of LChas been reported in different studies as ranging from2-15%. 6-8The importance of factors predisposing to conversionfrom laparoscopic to open cholecystectomy has beenemphasized in different studies 9-12 and studies havealso been conducted to address this important issue. 13The incidence of conversion due to adhesions, empyemagall bladder and contracted gall bladder in our study issimilar to that of other international studies. Singh andOhri 14 in their study reported adhesions as the cause ofconversion in 16.7% cases, empyema gall bladder in2.05% and contracted gall bladder in 1.4% cases.With more experience and technical advances, haemorrhageand CBD injuries are being increasingly managedlaparoscopically. Similarly advances in diagnostic modalitieshave resulted in increased preoperative diagnosisof carcinoma gall bladder. CBD stones can now alsobe managed by laparoscopic methods or ERCP.Conversion due to instrument failure has been reportedonly in earlier studies. 15 In our study it was an importantreason for conversion accounting for 10(2.9%) cases.Camera, insufflator and clip applicator failure has beendocumented in a local study. 16 Search in local and internationalliterature revealed that conversion due to repeatedpower breakdown with backup failure has not beendocumented in any study. This new factor, endangeringthe life of patients and threatening to damage the equipmenthas coincided with power generation problemswhich the country is facing for the last one year.CONCLUSIONDuring laparoscopic cholecystectomy operation conversionto open surgery under difficult situation andconditions should not be delayed for the safety of patient.However certain preventable factors like instrumentfailure and power breakdown can be addressed by areliable backup.Table II. Instrument Failure (n=10)Cause of FailureLight sourceCameraInsufflatorPower supplyNumber4222(%)1.180.590.590.5910Volume 24, Issue 1, 2008

Factors leading to Conversion in Lap. CholecystectomyP. Iqbal, M. Saddique, T. A. BalochREFERENCES1. Sikora SS, Kumar A, Saxena R, et al. LaparoscopicCholecystectomy - Can conversion be predicted?World J Surg 1995; 19: 858-60.2. Gadacz TR. Update on Laparoscopic Cholecystectomy,including a clinical pathway. Surg Clin NorthAm 2000; 80: 1127-45.3. Krahenbuhl L, Sclabas G, Wente MN, et al. Incidence,risk factors and prevention of biliary tract injuriesduring Laparoscopic Cholecystectomy in Switzerland.World J Surg 2001; 25: 1325-30.4. Merriam LT, Kanaan SA, Dawes LG, Angelos P,Prystowsky JB, Rege RV, et al. Gangrenous cholecystitis:Analysis of risk factors and experiencewith Laparoscopic Cholecystectomy. Surgery 1999;126: 680-6.5. Kumar A, Thombare MM, Sikora SS, Kapoor VK,Kaushik SP. Morbidity and mortality of LaparoscopicCholecystectomy in institutional setup. J LaparoendoscSurg 1996; 6: 393-7.6. Livingston EH, Rege RV. A nationwide study ofconversion from Laparoscopic to Open Cholecystectomy.Am J Surg 2004; 188: 205-11.7. Kama NA, Kologlu M, Doganay M, Reis E, AtliM, Dolapei M. A risk score for conversion fromLaparoscopic to Open Cholecystectomy. Am J Surg2001; 181: 520-5.8. Rosen M, Brody F, Ponsky J. Predictive factors forof conversion of Laparoscopic Cholecystectomy.Am J Surg 2002; 184: 254-8.9. Kologlu M, Tutuncu T, Yuksek YN, Gozalan U,Daglar G, Kama NA. Using a risk score for conversionfrom Laparoscopic to Open Cholecystectomyin resident training. Surgery 2004;135:282-7.10. Hannan EL, Imperato PJ, Nenner RP, Starr H. Laparoscopicand Open Cholecystectomy in New YorkState: Mortality complications, and choice of procedure.Surgery 1999; 125: 223-31.11. Peters JH, Krailadsiri W, Incarbone R, BremnerCG, Froes E, Ireland AP, et al. Reasons for conversionfrom Laparoscopic to open in an urban teachinghospital. Am J Surg 1994; 168: 555-9.12. Ross A, Gustafsson L, Krook H, Nordgren CE,Thorel A, Wallin G, et al. Laparoscopic Cholecystectomyversus Mini Laparotomy Cholecystectomy.Ann Surg 2001; 234: 741-9.13. Hammarstrom Lars-Erik. Prediction of unsuccessfulLaparoscopic Cholecystectomy. J Postgrad Med2005; 51: 21-2.14. Singh Kuldip, Ohri Ashish. Laparoscopic Cholecystectomy- Is there a need to convert? J Min AccessSurg 2005; 1: 59-62.15. Ihasz M, Hung CM, Regoly-Merei J, Fazekas T,Batorfi J, Balint A, Zaborszky A, Posfai G. Complicationsof Laparoscopic Cholecystectomy in Hungary:A multicentre study of 13833 patients. Eur JSurg 1997; 163: 267-74.16. Jaffary SAA, Shamim MS, Raza SJ, Dastgir A.Instrument Failure: A Preventable cause of conversionin Laparoscopic Cholecystectomy. Pak J Surg2007; 23: 92-5.11Volume 24, Issue 1, 2008