Conversion to open surgery in laparoscopic cholecystectomy: Long term retrospective outcomes

Authors

Abstract

Aim Laparoscopic cholecystectomy (LC) is considered the gold standard in the surgical treatment of gallbladder diseases. However, conversion to open surgery may be necessary in certain situations. This study aims to retrospectively evaluate cases converted to open surgery among LC procedures performed at our center over 13 years.
Materials and Methods Adult patients who were scheduled for LC but required conversion to open cholecystectomy during surgery between January 1, 2008, and January 1, 2021, were included. Demographic data, clinical features, laboratory findings, reasons for conversion, and postoperative outcomes were analyzed.
Results Out of 9580 LC cases, 49 patients (0.5%) required conversion to open surgery. The most common reason for conversion was dense adhesions in Calot’s triangle (77.6%), followed by organ injury (14.3%). A history of previous abdominal surgery was significantly more common in patients with adhesions (p < 0.001), while a history of cholecystostomy was more frequent in those converted due to severe inflammation (p = 0.016). Patients with organ injuries had significantly lower hemoglobin levels (p = 0.006) and a higher rate of reoperation (p = 0.01).
Discussion In our study, the rate of conversion from LC to open surgery was notably lower than rates reported in the literature. Advanced age, male gender, dense adhesions, and prior abdominal surgery were identified as major risk factors for conversion. Proper patient selection, surgical experience, and appropriate technical approaches can reduce conversion rates. In cases of anatomical difficulty or high complication risk, early conversion or alternative surgical strategies, such as partial cholecystectomy, should be considered.

Keywords

Introduction

Laparoscopic cholecystectomy (LC) is widely accepted as the “gold standard” in the surgical management of gallstone disease [1]. Compared with open cholecystectomy, LC results in reduced postoperative pain, improved cosmetic outcomes, and shorter hospital stays [2]. Contraindications to LC are primarily related to anesthesia considerations: hemodynamic instability, uncontrolled bleeding disorders, and diffuse peritonitis [3]. Suspected gallbladder carcinoma mandates open cholecystectomy [4]. Depending on the surgeon’s experience, previous abdominal operations, pregnancy, obesity, cholangitis, and significant comorbidities may also warrant open approaches [5].Major complications such as vascular injury, bowel perforation, mesenteric damage, and bile duct injury frequently necessitate emergency laparotomy. Previous studies report conversion rates from LC to open surgery ranging from 0.5% to 15%; a high rate should not be interpreted as a sign of surgeon failure [6, 7, 8]. Indications for conversion include [9]:
- hemorrhage,
- unidentifiable or abnormal anatomy,
- inability to proceed laparoscopically in a timely manner,
- bowel or bile duct injury,
- resectable gallbladder cancer,
- bile duct stones not removable by laparoscopic or endoscopic means (e.g., Billroth II anatomy, prior failed ERCP, or lack of experienced endoscopist)
Partial cholecystectomy in laparoscopic cases may reduce the likelihood of conversion to open surgery [10]. However, the risk of postoperative complications such as bilioma or abscess is higher with partial cholecystectomy compared to standard cholecystectomy [11]. Laparoscopic cholecystectomy provides numerous significant advantages for patients, surgeons, and healthcare costs [12]. Therefore, performing this surgical procedure laparoscopically whenever possible is a primary goal for both surgeons and patients. For this reason, analyzing the causes of conversion is of great importance. Although many previous studies have investigated the reasons for conversion from laparoscopic to open cholecystectomy [6], a considerable number of conversions still occur. This indicates a continuing need for further research in this area. The aim of this study is to retrospectively evaluate all laparoscopic cholecystectomy cases performed in our center to determine the conversion rate, identify the cases in which conversion occurred, and analyze the reasons behind these conversions.

Materials and Methods

This study included adult patients who were scheduled for laparoscopic cholecystectomy between January 1, 2008, and January 1, 2021, but required conversion to open cholecystectomy during the procedure. Inclusion criteria: Patients over 18 years of age who underwent laparoscopic cholecystectomy that was subsequently converted to open surgery. Exclusion criteria: Patients under 18 years of age, cases that were initiated as open cholecystectomy from the beginning, and cases where laparoscopic cholecystectomy was completed without conversion. For patients who underwent conversion, the following data were recorded: age, sex, comorbidities, history of ERCP, presence of cholecystostomy, laboratory parameters (including blood glucose, WBC count, hemoglobin, total bilirubin, ALT, AST, ALP), reasons for conversion, surgical indications, history of previous abdominal surgery, duration of symptoms, radiological findings, intraoperative and postoperative complications, ICU stay duration, pathological results, and mortality. Patients were categorized into subgroups based on the reason for conversion: dense adhesions in Calot’s triangle, severe inflammation, adhesions due to previous surgeries, organ injury, and anatomical variations. These subgroups were then compared based on the aforementioned parameters to complete the study.
Statistical Analysis
First, Kolmogorov-Smirnov and Shapiro-Wilk tests were used to assess the normality of the variables. Non-parametric methods were used for non-normally distributed variables. Subsequently, the Mann–Whitney U test was used to compare the variables obtained from the measurements between groups. Chi-square and Fisher’s exact tests were used to analyze the relationships or differences between groups regarding categorical variables. Multiple group comparisons were conducted using ANOVA analysis. Bonferroni and Tamhane-T2 tests were applied depending on whether the variances were homogeneous. Comparative results between groups based on demographic characteristics were presented as the ratio of qualitative variables. Quantitative variables were expressed as mean and standard deviation. Statistical Package for Social Sciences (SPSS), version 22.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. p-value <0.05 was considered significant.
Ethical Approval
This study was approved by the Ethics Committee of the University of Health Sciences, Hamidiye Scientific Research Ethics Committee (Date: 2021-03-31, No: 23694).

Results

In this study, a retrospective analysis was performed on 49 cases converted to open surgery out of 9,580 patients who underwent laparoscopic cholecystectomy at our center between January 1, 2008, and January 1, 2021. The conversion rate in our clinic was found to be 0.5%.Thirty-eight patients (77.6%) underwent conversion to open surgery for this reason. The second most common reason was organ injury in 7 patients (14.3%). Other causes included adhesions from previous surgery (4.1%), severe inflammation (2%), and anatomic variations (2%).Of the 49 patients, 28 were male and 21 were female, with a mean age of 64.1 years. The majority of patients belonged to the ASA II risk group (55.1%). The most frequent indication for cholecystectomy was cholelithiasis (57.1%). A history of ERCP was present in 5 patients, prior abdominal surgery in 4 patients, and cholecystostomy in 4 patients (Table 1).When comparing subgroups based on reasons for conversion, no statistically significant differences were observed in terms of age, gender, ASA scores, surgical indication, or ERCP history. However, patients who were converted due to dense adhesions were significantly more likely to have a history of previous abdominal surgery (p < 0.001). Similarly, patients converted due to severe inflammation were more likely to have a history of cholecystostomy (p = 0.016) (Table 1). Ultrasonographic and laboratory findings were also compared among groups.
Hemoglobin levels were significantly lower in the group converted due to organ injury (p = 0.006). No significant differences were found in other parameters (Table 2). There were no statistically significant differences among groups regarding ICU stay, need for postoperative ERCP, or pathology results. However, the reoperation rate was significantly higher in the group converted due to organ injury (p = 0.01) (Table 3).

Discussion

According to the literature, the conversion rate from laparoscopic to open cholecystectomy ranges between 0.5% and 15%, with an average of approximately 6% [5, 13]. In our study, which included 9,580 patients at our clinic, the conversion rate was found to be significantly lower than the reported average, at 0.5%.Advanced age and male sex are known risk factors for conversion [14]. In line with the literature, the mean age of patients in our study was 64 years, and 57% were male. Other identified risk factors for conversion include a history of acute cholecystitis, diabetes, and obesity. Among our patients, the most common indication for cholecystectomy was cholelithiasis (57%), followed by acute cholecystitis (30%) and choledocholithiasis (8%). However, since our study focused solely on converted cases, we could not establish a statistically significant relationship between acute cholecystitis and conversion. A comprehensive comparison with non-converted cholecystitis patients would be required to evaluate this. No significant association was found between ASA scores (used by anesthesiologists to evaluate comorbidities) and conversion. A history of ERCP was present in 10% of patients, but this was not statistically significant, suggesting that a prior ERCP does not pose a risk factor for conversion. Therefore, laparoscopic cholecystectomy can be safely performed in patients with a history of ERCP. In 78% of cases, the reason for conversion was dense adhesions in Calot’s triangle. Organ injury accounted for 14% of conversions. In accordance with the literature, we found that a history of previous abdominal surgery was significantly associated with conversions due to dense adhesions. Prior surgeries are likely to increase the presence of intra-abdominal adhesions, which impair visibility during laparoscopy, prolong the procedure, and consequently raise the likelihood of conversion. Similarly, the presence of a cholecystostomy catheter, often placed in critically ill patients or those with severe inflammation, was found to significantly correlate with conversions due to intense inflammation in our study. Cholecystostomy contributes to fibrosis and adhesions around the gallbladder, increasing the difficulty of laparoscopic dissection and raising the likelihood of conversion [15].
Hemoglobin levels were significantly lower in patients who were converted due to organ injury. This anemia may reflect underlying chronic inflammation [16]. Additionally, patients with preoperative anemia may be more adversely affected by intraoperative bleeding, especially from the liver bed. Delayed bleeding control may increase the risk of conversion to open surgery. Organ injury was also identified as a significant risk factor for reoperation. The most critical injuries during cholecystectomy involve the duodenum and common bile duct. In patients where the gallbladder is densely adherent and fibrotic to surrounding structures like the duodenum, partial cholecystectomy may be a safer alternative to conversion [10]. In cases of postoperative bile leakage due to bile duct injury, if no signs of acute abdomen are present, ERCP may be considered before surgical reintervention.

Limitations

This study has some limitations. First, its retrospective and single-center design restricts the generalizability of the findings. Second, as only converted cases were analyzed, risk factors could not be compared with those of non-converted patients. Additionally, the small sample size in some subgroups may have reduced the statistical power. Finally, long-term outcomes were not assessed, limiting insight into the extended impact of conversion.

Conclusion

In this study conducted at our clinic, the evaluation of laparoscopic cholecystectomy cases revealed a conversion rate significantly lower than that reported in the literature. The most prominent risk factors for conversion to open surgery were advanced age, male gender, dense adhesions in Calot’s triangle, and a history of previous abdominal surgery. Organ injuries, while less frequent, require particular attention due to their association with both conversion and increased postoperative morbidity. Proper patient selection, surgical experience, and the application of appropriate technical strategies during laparoscopic cholecystectomy are essential in minimizing complications and reducing the likelihood of conversion to open surgery. When anatomical difficulties are encountered, an early decision to convert to open surgery should be considered, and alternative methods such as partial cholecystectomy may also be evaluated if necessary.

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