Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?

Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications 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 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when 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 were converted 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 associated with less morbidity than open method irrespective of duration of the surgery.

1. Difficult Laparoscopic Cholecystectomy-When and Where
is the Need to Convert?

2. Original Article
INTRODUCTION
Laparoscopic cholecystectomy has become the gold
standard treatment of symptomatic gall stone since its
inception in 1987 [1]. With the increasing experience in
laparoscopic surgery, surgeon has started to take more and
more difficult, complex and high risk cases, which were
considered relative contradictions for laparoscopic
removal of gall bladder few year back.
But it is important to know the different clinical,
radiological parameter and specific predictor that give
some prediction of difficult laparoscopic cholecystectomy,
which not only helps in patient counselling but also help
the surgeon to prepare better for intraoperative difficulties
expected to be encountered. Laparoscopic
cholecystectomy is associated with less morbidity than
open cholecystectomy if it is done successfully,
irrespective the of duration of surgery [2].
But with the growing experience and improved
technology more number of laparoscopic
cholecystectomy, even in case of so called difficult cases,
can be completed successfully and the need for conversion
to open is gradually decreasing.
METHOD
We conducted this study at our hospital and included
all laparoscopic cholecystectomy done at our hospital
from May 2008 to January 2010. Detailed clinical history
and physical examination were carried out. Complete
blood 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 CBD
stones. Total time taken in surgery, conversion rate and
complication rate were analysed. Factors making lap
cholecystectomy difficult were also analysed.
We defined difficult laparoscopic cholecystectomy
when we found
(i) Dense fibrotic adhesion in and around calot’s
triangle
(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:[email protected]
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With
increasing experience, surgeon has started to take more difficult cases which were considered relative contra
indications 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 to
January’10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making
laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy
when 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 were
converted 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 associated
with less morbidity than open method irrespective of duration of the surgery.
Key word: Laparoscopic cholecystectomy, Difficult laparoscopic cholecystectomy, Laparoscopy,
Cholecystectomy.

3. Apollo Medicine, Vol. 7, No. 2, June 2010 136
Original Article
complition rate and low conversion rate in difficult cases
when surgeons are experienced and technique is little bit
modified & operative team is same [3-6].
Conversion rates can be brought down to a very low
level, if surgeon is experienced enough and if the
procedure is modified accordingly in difficult cases [7].
The most common cause of conversion to open
surgery in literature is dense adhesion at Callot’s triangle
followed Mirrizi’s syndrome [8].
Many studies also tried to find the method by which
prediction of the difficult laparoscopic cholecystectomy
can be made preoperatively [9-12], with varied degree of
success.
Some have also tried to come out with some sort of
scoring system [13,14] which can help in prediction of
difficult lap cholecystectomy. Several clinical and
radiological parameter have been identified, which can
predict the difficult laparoscopic cholecystectomy. The
clinical parameter, male sex [15-16], advanced age [14-
17], prolonged history of gall stone, leucocytosis and
systemic signs of sepsis, elevated liver enzyme are related
to 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 difficult
laparoscopic cholecystectomy.
Predication of difficult laparoscopic cholecystectomy,
preoperatively helps in patient counselling and also helps
the surgeon to prepare both for intra operative risk and the
technical difficulties expected to be encountered [19-20].
Finally many technical modifications have been
advised for the successful completion of the laparoscopic
cholecys-tectomy in difficult cases.
Our modification in difficult cases include putting
additional trocar, use of fan shaped retractor, to retract the
stomach & duodenum, aspiration of gall bladder in case of
mucocele and empyema, use of long and tooth grasper in
case of thick walled gallbladder, blunt dissection with tip
of 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’s
pouch 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 from
laparoscopic to open – like (a) When surgeon is
inexperienced (b) Anatomy is unclear (c) If no progress is
made 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 acute
cholecystitis of >72 hrs duration at 1st admission and plan
for surgery after 6-8 weeks.
RESULTS
We included 206 cases of laparoscopic
cholecystectomy done at out centre between May 2008 to
Jan 2010. Out 206 cases 50 were male 156 were female.
Out of 206 cases 56 cases were considered as difficult
laparoscopy cholecystectomy cases by our definition. Out
of 56 difficult laparoscopic cholecystectomy cases, we
were able to complete the surgery by laparoscopic method
in 54 cases and only in two cases we converted it to open.
In Both these cases the indication for conversion was
extremely friable gall bladder, which makes the gall
bladder difficult to hold. There was no significant
complication in cases where cholecystectomy was
completed successfully by laparo-scopic method. In one
of two converted cases, wound infection occurred which
was treated by dreessings & antibiotics. Average time
taken for the completion of surgery was 45 min. Average
time taken in case of difficult cases was 1.35 hrs.
DISCUSSION
Laparoscopic cholecystectomy has almost replaced
the open cholecystectomy as a treatment option of
diseased gall bladder, since Philip Mouret did the first
laparoscopic cholecystectomy as in 1987 [1].
Laparoscopic cholecystec-tomy has many advantage over
the 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 of
difficult laparoscopic cholecystectomy. It has been shown
that laparoscopic cholecsystectomy if completed
successfully, is associated with less morbidity than open
cholecystectomy irrespective of total duration of the
surgery [2].
Many studies also indicates the reasonably high

4. Original Article
137 Apollo Medicine, Vol. 7, No. 2, June 2010
Also conversion should not be considered as a failure
or complication of the surgery rather it is a demand of the
situation and when need arises surgeon should not hesitate
to convert.
CONCLUSION
Laparoscopic Cholecystectomy is a gold standard
treatment now for the gall stone disease. The Technique
has been standardized for the laparoscopic
cholecystectomy. There are situations which give rise to
difficult laparoscopic cheoleystectomy. With experience
& little modification of technique & patience, we can
successfully complete the surgery by laparoscopic method
only, because it is shown in literature that laparoscopic
cholecystectomy is still better option than open
cholecystectomy even in case of difficult cases. But there
are situation, where there is a need to convert the surgery
to open method & it should not be considerd as failure but
a sound judgement by the surgeon.
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