Vijay, K (2013) Pre-Operative Prediction of Conversion of Laparoscopic Cholecystectomy to Open Surgery: A Multivariate Analysis of Pre-Operative Risk Factors in Rajiv Gandhi Government General Hospital. Masters thesis, Madras Medical College, Chennai.
|
Text
220100113vijay.pdf Download (1MB) | Preview |
Abstract
INTRODUCTION: Laparoscopic cholecystectomy has almost replaced open cholecystectomy as the therapeutic modality in the treatment of symptomatic gallstones. The difficult gallbladder is the most common 'difficult' laparoscopic surgery being performed by general surgeons all over the world and the potential one that places the patient at significant risk. A number of published clinical series emphasize the promising role laparoscopy is playing in treating benign gallbladder disease. In the beginning of Laparoscopic cholecystectomy, patients having acute cholecystitis, empyema, gangrenous gallbladder, cirrhotic patients, and Mirizzi syndrome were contraindication because of high risk of complications and conversion rate. Thus with wider application of laparoscopy for technically difficult and high risk patients it was expected that the complication rates would rise as also the rate of conversion to open cholecystectomy. Although 2% to 15% of patients require conversion to open cholecystectomy for various reasons but irrespective of this morbidity and mortality statistics do still favour laparoscopic cholecystectomy over open cholecystectomy. It is important to realize that the need for conversion to laparotomy is neither a failure nor a complication but an attempt to avoid complication and ensure patient safety. Conversion to open cholecystectomy has been associated with increased overall morbidity, surgical site and pulmonary infections, and longer hospital stays. Prediction of a difficult Laparoscopic cholecystectomy would allow the surgeon to discuss the likelihood of conversion with the patient and prepare him/her psychologically as well as planning their recovery and explaining their absence from work. Another benefit would be to allow more efficient scheduling of the operating lists and ensuring the availability of a more experienced laparoscopic surgeon for the procedure. Pre-operative prediction of a difficult laparoscopic cholecystectomy not only helps patient counselling but also helps the surgeon to prepare better for the intraoperative risk and the technical difficulties expected to be encountered. Moreover, the patient safety may further be improved by involving an experienced surgeon both preoperatively in the decision making and also during the surgery. The ability to accurately identify an individual patient’s risk for conversion based on preoperative information can result in more meaningful and accurate preoperative counseling, improved operating room scheduling and efficiency, stratification of risk for technical difficulty, and appropriate assignment of resident assistance, may improve patient safety by minimizing time to conversion, and helps to identify patients in whom a planned open cholecystectomy is indicated. My study was to predict the possibility of conversion of Laparoscopic cholecystectomy to open cholecystectomy before surgery using the clinical and ultrasonographic criteria by multivariate analysis in our Rajiv Gandhi Government General Hospital & Madras Medical College, Chennai. AIMS OF THE STUDY: The aims of the study is, 1. To evaluate the pre-operative risk factors and to predict the difficulty of Laparoscopic cholecystectomy and the possibility of conversion to open cholecystectomy before surgery. 2. To analyse the causes of conversion to open surgery. 3. Multivariate analysis of pre-operative risk factors of possible conversion to open surgery. PATIENTS AND METHODS: Design of Study: Prospective analysis on consecutive patients planned for elective laparoscopic cholecystectomy. Study Population: 101 patients planned for elective laparoscopic cholecystectomy and proceeded. My study was conducted in the Department of general surgery, Rajiv Gandhi Government General hospital, Chennai for a period of 9 months from April 2012 to November 2012. My study was to analyse the multiple possible risk factors for conversion of laparoscopic cholecystectomy to open surgery in our hospital as a multivariate analysis which helps to study on the per-operative prediction of laparoscopic cholecystectomy conversion to open surgery. One hundred cases of planned elective laparoscopic cholecystectomy was targeted and studied prospectively in our department. Selection of Subject: All consecutive patients planned for elective laparoscopic cholecystectomy for benign gallbladder disease in Department of general surgery, Rajiv Gandhi Government General Hospital were selected for the study. Exclusion Criteria: Patients with evidence of concomitant choledocholithiasis were excluded from the study pre-operatively. Patients who were planned for open cholecystectomy were also excluded. METHODS: The following materials were evaluated in each patient before surgery; 1. Clinical data, 2. laboratory data, 3. Ultrasonographic parameters. The following material were evaluated for the patients who had a conversion from laparoscopic cholecystectomy to open surgery on the operating table ; Per-operative Indicaton for conversion. Sixteen characteristics were evaluated including the following main characteristics for statistical analysis ; 1. Age, 2. Sex, 3. Body mass index, 4. Pre-operative diagnosis, 5. Total leucocyte count, 6. Serum alkaline phosphatase, 7. Serum albumin, 8. Gall bladder wall thickness, 9. Pericholecystic fluis, 10. Per-operative indication for conversion. CONCLUSION: Although our study has favorable characteristics to predict conversion from laparoscopic to open cholecystectomy, it has some limitations. Our results are based on prospective data alone. We did not assess the impact of symptom duration on conversion rate. We chose not to include this factor in our analysis because of its subjective nature and the inherent inaccuracies associated with estimating the time of symptom onset. However, the duration of symptoms may be associated with the degree of inflammation encountered at operation and thus would influence the conversion rate. We also did not evaluate the time from hospital admission to operation. Patients with longer hospital stays before operation may have more severe inflammation; however, the time from symptom onset to operation is likely to correlate with conversion rates. It is possible that the utility of this model is that its parameters more accurately predict the diagnosis of acute cholecystitis. For patients with a high predicted rate of conversion, it may be advantageous to proceed with open cholecystectomy. This would negate the potential for trochar injuries, problems due to pneumoperitoneum, and other complications specifically associated with laparoscopy. A high presumed risk for conversion was frequently cited as a reason for the use of a planned open approach. Because patients undergoing open cholecystectomy were not included in our analysis, the complication rate in patients who had conversion to open operation may be lower than would have been seen if all cholecystectomies were initially approached laparoscopically. Our results demonstrate that an accurate and easily derived estimation of risk for conversion from laparoscopic to open cholecystectomy can be obtained from readily available preoperative data. Recognizing when a patient is at increased risk for conversion would improve preoperative counselling and assist with appropriate allocation of resources in the operating room, may increase safety by limiting delay in conversion to open cholecystectomy, and can identify patients who might benefit from a planned open approach. If validated, this prediction system may improve patient outcomes by reducing unnecessary injuries related to laparoscopy that is unlikely to succeed.
| Item Type: | Thesis (Masters) |
|---|---|
| Uncontrolled Keywords: | Pre-Operative Prediction ; Conversion of Laparoscopic Cholecystectomy ; Open Surgery ; Multivariate Analysis ; Pre-Operative Risk Factors ; Rajiv Gandhi Government General Hospital, Chennai |
| Subjects: | MEDICAL > General Surgery |
| Depositing User: | Devi S |
| Date Deposited: | 26 Mar 2018 15:49 |
| Last Modified: | 26 Mar 2018 15:49 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/6598 |
Actions (login required)
 |
View Item |
