Risk Predictive Factors to Convert Laparoscopic Cholecystectomy into Other Procedures

Laparoscopic cholecystectomy (LC) is nowadays the procedure of choice for cholecystitis. The intraoperative finding can make this procedure quite tricky such as dense adhesions at calot’s triangle, fibrotic and contracted gallbladder, acutely inflamed or gangrenous gallbladder, cholcystoenteric fistula, etc. There are also risk factors which make laparoscopic surgery difficult like old age, male sex, obesity, previous abdominal surgery, thickened gallbladder wall, distended gallbladder, pericholecystic fluid collection, impacted stone, etc. Methods: This is a one cohort retrospective review of patients admitted to the hospital with acute cholecystitis who during LC were converted to intraoperative cholecystostomy tube placement (CCT) or to open cholecystectomy (OC). Preoperative risk factors to predict difficult cholecystectomy were evaluated. Results: Medical records were reviewed retrospectively from January 2010 through December 2016. IRB approval was obtained. LC was performed in 556 cases between 2010-2016, with 56 (10%) conversion: 39 CCT and 17 OC. The highest reason for conversion are Perioperative fluid around the gallbladder before surgery on the ultrasound (10%), preoperative thickness of the gallbladder (9%), Impacted stones (7%) are the predicting factor that have more changes to turn the LC into a different surgical approach. These three parameters are followed by Prior Hospitalization (3%) and presence of abdominal scar (5%). Essential factors to make a problematic surgery were postoperative perivasculitis (2%), obesity (8%), difficult liver mobilization (1%), acute and scleroatrophic cholecystitis (1%), “porcelain gallbladder” (2%). Causes of bleeding during our operation were: cirrhosis (2%), accidental adhesion tearing (0.5%) (Table 1). Conclusion: Problematic LC can be diagnoses before the surgery and make the OR team ready for different surgical approach.

be always applicable. Our study is based on the assumption that difficulty cholecystectomy can be defined before the surgery and give the opportunity to the surgical team to prepare for alternate surgeries option like Open Cholecystectomy (OC) or intraoperative Cholecystostomy Tube placement (CTT).

Methods
This is a retrospective review of patients admitted to the hospital who were diagnosed with acute cholecystitis who underwent an initial laparoscopic Cholecystectomy. The study was designed to find those patients who were converted in other iii. Absolute contraindications to LC like cardiovascular, pulmonary disease, coagulopathies, and end-stage liver disease.
Demographic symptoms sings of presentations were evaluated to find if those were impacting on our surgeries and addresses the activities of the cholecystectomy. The evaluated risk were the following: history os hospitalization, palpable gallbladder, thicken gallbladder, peri-cholecystitis fluid, impacted stones at the neck, abdominal scar. The characteristic of the patients was reported in Table 1.

Pre And Intraoperative
A detailed proforma was in place before the surgery to record information regarding patient history, physical examination, laboratory parameters, ultrasonography (USG) findings and intraoperative details.

Operative Technique
After obtaining an informed consent including an option for CCT and OC the patient was taken to the operating room placed under general anesthesia and prep in the usual fashion. The first incision was done in the left upper quadrant with a knife and a trocar, and a camera was advanced through the tissue under direct vision. Once in the abdomen, we obtained a pneumoperitoneum of 15mmHg.
We place 2 five mm trocars in the right upper quadrant, one at the level of the belly button of 5 mm. The initial trocar was switched to a 12mm trocars. Evaluation of the Right upper quadrant and the gallbladder was made.

Critical Factors
The crititical factor evaluated to continue the LC or turned into CCT or OC: 1) a change of the color of the gallbladder (green etc), 2) multiple adhesion which could not be taken out, 3) inability to grab the gallbladder after aspirating with the needle, 4) failure to see after the body of the gallbladder and define the neck of the gallbladder without good vision of the area of the common bile duct.

CCT
The fundus of the gallbladder was open with the Bovie. The fluid was aspirated, and the stones inside in the gallbladder were taken out by grasping with a laparoscopic Babcock after all the stones were cleaned and placed one by one in a separate bag inserted in the abdomen. The bag was closed. We then whased the gallbladder with saline, which also helps to mobilize hidden stones.
The camera was then advance inside the gallbladder and evaluated from inside visualize the cystic duct. Once we know they there no other stones obstructing, a 2/0 silk purse string was placed at the Prat ten French drainage was placed in the liver fossa and secure to the skin. The wound was closed in layers with one vycril and stapler for the skin. The patient was allowed fluid, they were placed on PCA pump and discharge home with home health care within 4 days.

Post OP Treatment of the CCT
The tube was left on biliary bag drainage, Cholangiogram is ordered between week 4 and 6. If no stones were found from the 113 cholangiogram the tube was pulled out in the office otherwise redo surgery was scheduled.

Discussion
With the help of accurate prediction, the high-risk patient may be informed beforehand regarding probability of conversion to OC or CCT. This discuss will also help the surgeon and the OR team to prepare the alternative surgeries. Surgeons should be aware of the possible complications that may arise in high-risk patients.

Risk Predictors Factors
Male sex makes surgery difficult as being reported in studies [10][11][12]. Conversion rate and significantly higher mortality [13,8] and found to be a significant factor. Subtotal cholecystectomy, an ultrasonographic finding of acute cholecystitis, and it was a significant factor in previous studies [16][17][18]. James Majeski [16], showed that a preoperative gallbladder ultrasound evaluation with a thick gallbladder wall (>3mm) and calculi, is a clinical warning for a problematic laparoscopic cholecystectomy procedure which may require conversion to an open cholecystectomy procedure [19].
But Carmody concluded that detailed preoperative ultrasound evaluation of the gallbladder in patients destined for laparoscopic cholecystectomy is of little value in screening for difficult or unsuitable cases. They found that there were no ultrasound features that can differentiate between the unsuccessful, confusing, or uneventful laparoscopic cholecystectomy [20]. In our study thickened gallbladder wall was present in all patients and outcome was found to be dependent on this variable by chi-square test (p = 0.001), and logistic regression analysis also ascertained the significance of this factor for prediction (p = 0.005). Pericholecystic fluid is an ultrasonographic finding of acute cholecystitis. This was found to be a significant factor in our study (p = 0.939), as well as palpable gallbladder (p = 0.05). Therefore, we agree with Randhawa [21] who also reported that presence of palpable gallbladder has a significant bearing on define difficult surgery.
Difficulty in gallbladder grasping was associated significantly with the conversion. A distended gallbladder or a gallbladder filled with stones is not easily grasped because it tends to slip away. Presence of inflammation around the gallbladder makes the wall friable and edematous, thus posing problems. These data were reported by Singh [22] who also found a significant association between difficulties in grasping a distended gallbladder and pericholecystic inflammation. Lal [23] have identified that presence of large stones in the gallbladder neck leads to distention and difficulty in grasping.

Cholecystostomy
Percutaneous Cholecystectomy (PCCT) is primarily indicated for accessing the gallbladder to manage cholecystitis or to serve as a portal to remove or dissolve gallstones [24,25].  Perioperative fluid around the gallbladder before surgery on the ultrasound (10%), preoperative thickness of the gallbladder (9%), Impacted stones (7%) are the predicting factor that have more changes to turn the LC into a different surgical approach. These three parameters are followed by Prior Hospitalization (3%) and presence of abdominal scar (5%) ( Table 1) and made high risk for performing another surgery but LLC. Other factor whoch can predict problematic surgery were: postoperative perivasculitis (2%), obesity (8%), difficult liver mobilization (1%), acute and scleroatrophic cholecystitis (1%), "porcelain gallbladder" (2%).

Conclusion
Problematic LC can be diagnoses before the surgery and make the OR team ready for different surgical approach. Conversion should be kept less than 20% of the cases in out experience was 10%. PCCT should be still considered in a critically ill patient who cannot stand general anesthesia.