Assessment of Risk Factors for Conversion from Difficult Laparoscopic to Open Cholecystectomy - A Hospital Based Prospective Study

Background: Laparoscopic cholecystectomy is the gold standard in the treatment of gallstones. It has proved to be an effective and safe procedure both in elective and emergency conditions; however, conversion to open surgery is inevitable in some cases. Hence the present study was carried out to identify various factors which can predict the difficult laparoscopic cholecystectomy so that an early conversion to open cholecystectomy can be considered. Material and Methods: A prospective study was conducted from 1st February 2011 to 31st January 2012 that included 63 patients of all age groups and both sexes who were found to have symptomatic gallstones and were scheduled for laparoscopic cholecystectomy at Nepalgunj Medical College and Teaching Hospital, Nepal. Age, sex, body mass index, previous abdominal surgery and past history of acute attack of cholecystitis of the patients were recorded. A pre-operative ultrasound was performed just prior to surgery, and three ultrasonographic parameters were analyzed, namely gall bladder wall thickness, number of stones and stone impacted in Hartmann's pouch. Intra-operative causes for difficult laparoscopic cholecystectomy like adhesions in Calot's triangle and gall bladder perforation with bile leak were also evaluated. Results: Total number of patients in this study was 63; out of which difficult laparoscopic cholecystectomy was seen in 25(39.7) patients and 7(11.1) patients required conversion to open cholecystectomy. Ultrasonography was good at predicting difficulty in each component with exception of gall bladder wall thickness which was not statistically significant. Conclusion: BMI, ultrasonographic finding of presence of multiple stone or stones impacted in Hartmann's pouch, adhesion in Calot's triangle and gall bladder perforations are predictors of difficult laparoscopic cholecystectomy.