Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy: An Analysis in a High Risk Group of Patients

1 Department of General Surgery, Sher-IKashmir Institute of Medical Sciences, Srinagar, India 2 Department of Biochemistry SGT Medical College, Hospital and Research Institute Gurugram Haryana 122505 3 Department of Anesthesiology, Sher-IKashmir Institute of Medical Sciences, Srinagar, India 4 Department of General and Minimal Invasive Surgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India


Introduction
Laparoscopic Cholecystectomy (LC) was first reported in Germany (1985) and France (1987) more than two decades ago [1,2]. Although not immediately universally adopted, laparoscopic cholecystectomy has revolutionized minimally invasive surgery [3,4]. The appeal of diminished pain and fatigue, early return to normal activities and superior cosmesis has made it a popular surgery [5]. By now laparoscopic cholecystectomy has emerged as new gold standard for treatment of symptomatic cholelithiasis and increasing number of procedures are done for acute cholecystitis [6][7][8]. Several complications related to anaesthesia, peritoneal access, pneumoperitoneum, surgical exploration, anatomical and pathological have been reported during Laparoscopic This Article is Available in: www.jusurgery.com

Journal of Universal Surgery ISSN 2254-6758
Cholecystectomy (LC), and these complications and several other factors can necessitate the conversion from Laparoscopic Cholecystectomy (LC) to open cholecystectomy (OC). Conversion should not be considered a technical failure but, rather, accepted as a better surgical practice by the patient and surgeon when indicated [9].Carbon Dioxide and elevated intraabdominal pressure due to pneumoperitoneum has potential harmful intraoperative circulatory and Ventilatory effects are assumed to be deleterious for high risk patients ASA III & IV [10]. Despite the tremendous impact of Laparoscopic cholecystectomy on the management of biliary pathology, however surgeons continue to face challenges in application of Laparoscopic cholecystectomy in daily practice. Laparoscopic cholecystectomy today can be as straightforward operation, but may also be an operative approach fraught with underlying complexities necessitating conversion, leading to longer operative time, longer hospital stay and more postoperative morbidity and higher hospital costs [11,12] Conversion rates reported in literature range from 0-20% [13,14].

Establishment of pneumoperitoneum
One of the critical components is to establish Pneumoperitoneum in Cardiopulmonary high risk patients. In our study Pneumoperitoneum was established in every patient with some specific considerations with slow rate of insufflation at rate of 3-4 Liter/minute, low average pressure pneumoperitoneum (PP) in range of 10-12 mmHg, minimising the time of pneumoperitoneum and intermittent Desufflation if time of pneumoperitoneum gets prolonged.

Discussion
Conversion to open surgery from laparoscopic cholecystectomy was encountered because of recurrent management of multiple episodes of acute cholecystitis and avoiding definitive surgery because of associated comorbidities. It is considered as a sound judgment to avoid complications and reduce morbidity [12,15].
The identification of the risk factors for conversion helps in predicting the rate of conversion and counselling the patients and their families accordingly. Elderly age is itself a high risk for laparoscopic cholecystectomy and conversion to open cholecystectomy. Patients above 60 years showed a higher tendency towards conversion [16,17].
Although the numbers of female patients were more than   the males [14], the significance difference in the gender for conversion could not be ascertained.
Hypertension was found to be contribution factor in conversion to open cholecystectomy [12,18].
During this study we had encountered multiple factors that resulted in conversion of laparoscopic cholecystectomy to open cholecystectomy with adhesion in calot's triangle dominated the intraoperative findings, followed by bleeding and acute inflammatory changes around gall bladder and intolerance to pneumoperitoneum [16,21,23].

Conclusion
The identification of the parameters as age, high risk comorbidities, American Society of Anaesthesiologist's status and others helps in predicting the conversion rate and counseling the patient about postoperative complications. Among the intraoperative findings that resulted in conversion adhesions dominated the scene fallowed by acute inflammatory changes and bleeding. Moreover, surgeons should lower their threshold for conversion to open cholecystectomy in these high-risk patients when laparoscopic difficulty begins to compromise patient safety, especially in patients with cardiopulmonary dysfunction.