Original Article

INTRODUCTION

Laparoscopic cholecystectomy has become the goldstandard treatment of symptomatic gall stone since itsinception in 1987 [1]. With the increasing experience inlaparoscopic surgery, surgeon has started to take more andmore difficult, complex and high risk cases, which wereconsidered relative contradictions for laparoscopicremoval of gall bladder few year back.

But it is important to know the different clinical,radiological parameter and specific predictor that givesome prediction of difficult laparoscopic cholecystectomy,which not only helps in patient counselling but also helpthe surgeon to prepare better for intraoperative difficultiesexpected to be encountered. Laparoscopiccholecystectomy is associated with less morbidity thanopen cholecystectomy if it is done successfully,irrespective the of duration of surgery [2].

But with the growing experience and improvedtechnology more number of laparoscopiccholecystectomy, even in case of so called difficult cases,can be completed successfully and the need for conversionto open is gradually decreasing.

METHOD

We conducted this study at our hospital and includedall laparoscopic cholecystectomy done at our hospitalfrom May 2008 to January 2010. Detailed clinical historyand physical examination were carried out. Completeblood count, RBS, RFT, LFT, BT, CT, PT, Viral marker,Urine examination and USG was done in every case.Preoperative ERCP done in case of suspected CBDstones. Total time taken in surgery, conversion rate andcomplication rate were analysed. Factors making lapcholecystectomy difficult were also analysed.

We defined difficult laparoscopic cholecystectomywhen we found

(i) Dense fibrotic adhesion in and around calot’striangle

(ii) Gangeranous gall bladder

(iii) Empyema

(iv) Large stone impacted at neck of gall bladder

(v) Contracted gallbladder

(vi) Mirrizi’s syndrome

135 Apollo Medicine, Vol. 7, No. 2, June 2010

DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY- WHEN AND WHERE IS

THE NEED TO CONVERT?

Rajesh Sinha

Consultant, Department of Surgery, Apollo BSR Hospitals, Bhilai 490 020, India.e-mail:rajeshsinha1987@yahoo.co.in

Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. Withincreasing experience, surgeon has started to take more difficult cases which were considered relative contraindications for laparoscopic removal of gall bladder few years back.

We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May’08 toJanuary’10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors makinglaparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomywhen we found -dense fibrotic adhesions in and around Callot’s triangle, gangrenous gall bladder, empyma,large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi’s syndrome, h/o biliary pancreatitis,CBD stones, acute cholecystitis of <72 hrs duration.

Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases wereconverted to open.

With growing experience and technical advancement surgery can be completed in most of the difficult cases.This is important because recently it is shown in literature that laparoscopic cholecystectomy is associatedwith less morbidity than open method irrespective of duration of the surgery.

Key word: Laparoscopic cholecystectomy, Difficult laparoscopic cholecystectomy, Laparoscopy,Cholecystectomy.

Apollo Medicine, Vol. 7, No. 2, June 2010 136

Original Article

complition rate and low conversion rate in difficult caseswhen surgeons are experienced and technique is little bitmodified & operative team is same [3-6].

Conversion rates can be brought down to a very lowlevel, if surgeon is experienced enough and if theprocedure is modified accordingly in difficult cases [7].

The most common cause of conversion to opensurgery in literature is dense adhesion at Callot’s trianglefollowed Mirrizi’s syndrome [8].

Many studies also tried to find the method by whichprediction of the difficult laparoscopic cholecystectomycan be made preoperatively [9-12], with varied degree ofsuccess.

Some have also tried to come out with some sort ofscoring system [13,14] which can help in prediction ofdifficult lap cholecystectomy. Several clinical andradiological parameter have been identified, which canpredict the difficult laparoscopic cholecystectomy. Theclinical parameter, male sex [15-16], advanced age [14-17], prolonged history of gall stone, leucocytosis andsystemic signs of sepsis, elevated liver enzyme are relatedto difficulty encountered during the surgery.

USG finding of gall bladder wall thickness >4.0 mm[18], procaline gallbladder, calcification in gallbladder,large gallbladder stone can predict the difficultlaparoscopic cholecystectomy.

Predication of difficult laparoscopic cholecystectomy,preoperatively helps in patient counselling and also helpsthe surgeon to prepare both for intra operative risk and thetechnical difficulties expected to be encountered [19-20].

Finally many technical modifications have beenadvised for the successful completion of the laparoscopiccholecys-tectomy in difficult cases.

Our modification in difficult cases include puttingadditional trocar, use of fan shaped retractor, to retract thestomach & duodenum, aspiration of gall bladder in case ofmucocele and empyema, use of long and tooth grasper incase of thick walled gallbladder, blunt dissection with tipof suction cannula, subtotal and partial cholecystectomy,use of intra corporeal suturing in case of wide cystic duct,separate removal of large impacted stone in hartman’spouch which helps in grasping the gallbladder neck.

In spite of all these methods there are the instances,where a surgeon need to convert the surgery fromlaparoscopic to open – like (a) When surgeon isinexperienced (b) Anatomy is unclear (c) If no progress ismade in identifying the anatomy during the surgery [19-20].

(vii) H/o Biliary pancreatitis.

(viii) CBS stones.

(xi) Acute cholecystitis of <72 hrs duration.

We, as a policy do not operate in case of acutecholecystitis of >72 hrs duration at 1st admission and planfor surgery after 6-8 weeks.

RESULTS

We included 206 cases of laparoscopiccholecystectomy done at out centre between May 2008 toJan 2010. Out 206 cases 50 were male 156 were female.Out of 206 cases 56 cases were considered as difficultlaparoscopy cholecystectomy cases by our definition. Outof 56 difficult laparoscopic cholecystectomy cases, wewere able to complete the surgery by laparoscopic methodin 54 cases and only in two cases we converted it to open.In Both these cases the indication for conversion wasextremely friable gall bladder, which makes the gallbladder difficult to hold. There was no significantcomplication in cases where cholecystectomy wascompleted successfully by laparo-scopic method. In oneof two converted cases, wound infection occurred whichwas treated by dreessings & antibiotics. Average timetaken for the completion of surgery was 45 min. Averagetime taken in case of difficult cases was 1.35 hrs.

DISCUSSION

Laparoscopic cholecystectomy has almost replacedthe open cholecystectomy as a treatment option ofdiseased gall bladder, since Philip Mouret did the firstlaparoscopic cholecystectomy as in 1987 [1].Laparoscopic cholecystec-tomy has many advantage overthe open cholecystectomy like

(i) Minimal post operative pain

(ii) Fast recovery

(iii) Short hospital stay

(iv) Decreased morbidity

(v) Better cosmesis

(vi) Cost effectiveness.

These advantages are also there even in case ofdifficult laparoscopic cholecystectomy. It has been shownthat laparoscopic cholecsystectomy if completedsuccessfully, is associated with less morbidity than opencholecystectomy irrespective of total duration of thesurgery [2].

Many studies also indicates the reasonably high

Original Article

137 Apollo Medicine, Vol. 7, No. 2, June 2010

Also conversion should not be considered as a failureor complication of the surgery rather it is a demand of thesituation and when need arises surgeon should not hesitateto convert.

CONCLUSION

Laparoscopic Cholecystectomy is a gold standardtreatment now for the gall stone disease. The Techniquehas been standardized for the laparoscopiccholecystectomy. There are situations which give rise todifficult laparoscopic cheoleystectomy. With experience& little modification of technique & patience, we cansuccessfully complete the surgery by laparoscopic methodonly, because it is shown in literature that laparoscopiccholecystectomy is still better option than opencholecystectomy even in case of difficult cases. But thereare situation, where there is a need to convert the surgeryto open method & it should not be considerd as failure buta sound judgement by the surgeon.

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