The Preoperative Factors for Conversion of Laparoscopic to Open Cholecystectomy for Treatment of Acute Cholecystitis

ABSTRACT

BACKGROUND: Since its introduction in 1987, the laparoscopic cholecystectomy has become the treatment of choice for most patients with symptomatic cholelithiasis. However, about 20% of the patients requiring a cholecystectomy present with acute cholecystitis, and the safety of a laparoscopic cholecystectomy in these patients has been questioned. With increasing experience, many studies have reported that a laparoscopic cholecystectomy in patients with acute cholecystitis is safe and cost effective. This study was to review retrospectively the results of laparoscopic cholecystectomies in patients with acute inflamed gallbladders. METHODS: From July 1993 through Fabruary 1997, laparoscopic cholecystectomies were attempted in 250 patients with or without symptomatic gallbladder disease. Acute cholecystitis, confirmed by clinical, laboratory, operative, and histological findings, was present in 61 patients. The preoperative factors that may be useful in predicting conversion to an open operation were analyzed. RESULTS: The frequency of conversion to an open operation was 19.7% for acute inflammation and 3.2% for chronic inflammation. Patients who had a laparoscopic cholecystectomy done within 72 hours of the onset of symptoms had a lower rate of conversion to open procedures. Patients who had a laparoscopic cholecystectomy done and who had a white blood cell count over 15 10(9)/L, persistant high fever (>38.0degrees C) over 3 days, and managed diabetes mellitus for over 3 years had a high rate of conversion to open procedures. There were no bile-duct injuries and no mortalites. CONCLUSIONS: Laparoscopic intervention appears to be a safe and beneficial option in the management of patients with acute cholecystitis. Surgeons should have extensive experience with both routine laparoscopic cholecystectomy and conventional open biliary tract surgery. A greater number of patients with inflammation require conversion to an open operation compared with the number of patients with no obvious inflammation who require conversion. Conversion to an open operation was frequent for patients with empyema, with symptoms that had lasted for longer than 72 hours prior to the operation, with white blood cell counts over 15 10(9)/L, with persistant high fever (>38.0degrees C) over 3 days and with managed diabetes mellitus for over 3 years, suggesting that once this diagnosis of acute cholecystitis is made, excessive time should not be spent in a laparoscopic trial dissection before conversion to an open operation.