Venkata Subramanian, A (2013) A Study on factors for conversion from Laproscopic cholecystectomy to open cholecystectomy. Masters thesis, Madurai Medical College, Madurai.
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Abstract
INTRODUCTION: First performed in the year 1882 by Langenbuch, Open cholecystectomy has been the primary treatment of gallstone disease for most of the past century (Beal, 1984). The prevailing public perception of this operation as one that resulted in pain, disability, and a disfiguring scar engendered many attempts in the 1980s and 1990s at non-operative treatment of gallstones (Schoenfield & Lachin, 1981; Schoenfield et al, 1990). Despite successful removal or dissolution of gallstones with some of these techniques, each is limited by the persistence of a diseased gallbladder. In 1985, Mühe in Böblingen, Germany, performed the first laparoscopically assisted cholecystectomy (Mühe, 1986). Even though facing early skepticism from the surgical community, laparoscopic cholecystectomy was accepted rapidly and recognized as the new “gold standard” for the treatment of gallstone disease. An NIH Consensus Development Conference in 1992stated that laparoscopic cholecystectomy “provides a safe and effective treatment for most patients with symptomatic gallstones. Indeed it appears to have become the procedure of choice.” The advantages of laparoscopic cholecystectomy over open cholecystectomy were earlier return of bowel function, decreased postoperative pain, improved cosmesis, shorter hospital stay, earlier return to activity, and decreased overall cost. Surgeons should not hesitate to convert to open cholecystectomy if the anatomy is unclear, if complications arise, or if there is failure to make reasonable progress in a timely manner. It is “better to open one too many than to open one too few,” even if it means a longer hospital stay for the patient. Some complications requiring laparatomy are obvious, such as massive hemorrhage, bowel perforation, or major injury to the bile duct. Open laparatomy allows the additional tool of manual palpation and tactile sensation and should be performed when the anatomy cannot be delineated because of inflammation, adhesions, or anomalies. The demonstration of potentially resectable gallbladder carcinoma also dictates an open exploration. Finally, cases with CBD stones that cannot be removed laparoscopically and are unlikely to be extracted endoscopically should be converted to open operation without hesitation. AIMS AND OBJECTIVES: 1. To study the factors that lead to conversion from Laparoscopic cholecystectomy to open method inregard toage, sex, clinical presentation, laboratory values, Ultrasonogram and Operative findings. 2. To assess preoperative factors that might predict the chances of conversion 3. To assess the intra operative reason that results to conversion. MATERIALS AND METHODS: This study was conducted in the Department of General surgery and Department of Surgical Gastroenterology in Madurai Medical College and Government Rajaji Hospital, Madurai from October 2010 to September 2012 for a period of two years. Sample Size: 1. Total No. of patients who were posted for laparoscopic method. 2. No of patients converted to open cholecystectomy (study group). METHODOLOGY: This is a retrospective study done in the Madurai Medical College and Government Rajaji Hospital. The details of all the patients who underwent and attempted Laparoscopic cholecystectomy in the Department of General surgery and Department of Surgical Gastroenterology in Madurai Medical College and Government Rajaji Hospital, Madurai were collected from the Medical Records Department and entered in the proforma. (Annexure2). The details collected were collected from the case sheets and entered into the proforma: 1. Age, 2. Sex, 3. Clinical History, 4. Physical Examination findings, 5. Laboratory findings, 6. Ultrasound findings, 7. Procedure performed, 8. Intraoperative findings, 9. Reason for conversion, 10. Other treatments. Inclusion Criteria: Cases above age 15 years of age diagnosed as cholelithiasis /cholecystitis treated surgically by laparoscopic approach for cholecystectomy and in whom the laparoscopic procedure was abandoned and open conventional cholecystectomy resorted to for any intra operative reason. Exclusion Criteria: 1. Patients below 15 years of age. 2. Patients who were diagnosed as having choledocholithiasis preoperatively with or without biliary obstruction. 3. Patients who underwent a planned open cholecystectomy. SUMMARY: The most common reason for conversion was inability to define anatomy in patients with inflamed gallbladder. • Conversion is more common in males with features of acute cholecystitis than in females. • Conversion is still more common in uncontrolled diabetic patients with feautures of acute cholecystitis and Risk of empyma gall bladder and gangrenous gall bladder and its complications with early precipitation of sepsis are common. • Conversion is more common if surgery is delayed > 72 hours in the setting of acute cholecystitis from the onset of symptoms. • Degree of difficulty relates to disease process, patient stability and technical ability. • Safety measures for difficult cholecystectomy. • Selective open technique of pneumoperitoneum. • Surgeons should be familiar with the angled scope. • Intra operative cholangiography if needed to indentity biliary anatomy and Bile duct stone. • Adequate instrumentation. • Hydrodissection. • Preliminary decompression. • Additional parts for retraction & exposure. • Two hand technique of suturing & knotting capability. CONCLUSION: An appreciation of these factors would predict the conversion that will allow appropriate planning by the patient, the institution, and the surgeon. Of the 276 patients in whom laparoscopic cholecystectomy was attempted, 26(9.4%) required conversion to open surgery. The most common reason for conversion was inability to define anatomy in patients with inflamed gallbladder (n = 13). Significant predictive factors for conversion were male gender, previous abdominal surgery, associated dibetes, acute cholecystitis and thickened gallbladder wall with pericholecytitic collection on preoperative ultrasonography.These factors are of more of importance when these factors are associated with each other than its independent presence in predicting difficult cholecystectomy.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | conversion ; Laproscopic cholecystectomy ; open cholecystectomy. |
| Subjects: | MEDICAL > General Surgery |
| Depositing User: | Devi S |
| Date Deposited: | 02 Jun 2018 15:45 |
| Last Modified: | 04 Jun 2018 17:37 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/8100 |
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