Risk factors for conversion of laparoscopic to open cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the treatment of choice for symptomatic gallstones; however conversion to open cholecystectomy (OC) remains a possibility. Unfortunately, preoperative factors indicating risk of conversion are unclear. Therefore, we aimed to identify risk factors associated with conversion of LC to OC. PATIENTS AND MATERIALS: Records of 564 patients undergoing LC in 1995 and 1996 were reviewed. Patients were assigned to one of two groups: (1) acute cholecystitis defined by the presence of gallstones, fever, leukocyte count >10(4), and inflammation on ultrasound or histology; (2) chronic cholecystitis that included all other symptomatic patients. Demographics, history, and physical, laboratory, and radiology data, operative note, and the pathology report were reviewed. RESULTS: 161 of 564 patients, had acute and 403 patients had chronic cholecystitis; 16 acute cholecystitis patients (10%) were converted from LC to OC and 17 chronic cholecystitis patients (4%) had LC converted to OC. Patients having open conversion were significantly older, had greater prevalence of cardiovascular disease, and were more likely to be males. LC conversion to OC in acute cholecystitis patients was associated with a greater leukocyte count; in gangrenous cholecystitis patients, 29% had open conversion. CONCLUSIONS: Importantly, these risk factors-older men, presence of cardiovascular disease, male gender, acute cholecystitis, and severe inflammation-are determined preoperatively, permitting the surgeon to better inform patients about the conversion risk from LC to OC. While acute cholecystitis was associated with more than a twofold increased conversion rate, only 10% of these patients could not be completed laparoscopically. Therefore, acute cholecystitis alone should not preclude an attempt at laparoscopic cholecystectomy.     

Laparoscopic cholecystectomy in acute cholecystitis

BACKGROUND: The aim of this prospective study was to compare the outcome of laparoscopic cholecystectomy (LC) in patients with acute cholecystitis versus those with chronic cholecystitis and to determine the optimal timing for LC in patients with acute cholecystitis. METHODS: From January 1991 to July 1998, 796 patients (542 women and 254 men) underwent LC. In 132 patients (67 women and 65 men), acute cholecystitis was confirmed via histopathological examination. These patients were divided into two groups. Group 1 (n = 85) had an LC prior to 3 days after the onset of the symptoms of acute cholecystitis, and group 2 (n = 47) had an LC after 3 days. RESULTS: There were no mortalities. The conversion rates were 38.6% in acute cholecystitis and 9.6% in chronic cholecystitis (p<10(-8)). Length of surgery (150.3 min vs. 107.8 min; p<10(-9)), postoperative morbidity (15% vs. 6.6%; p = 0.001), and postoperative length of stay (7.9 days vs. 5 days; p< 10(-9)) were significantly different between LC for acute cholecystitis and elective LC. For acute cholecystitis, we found a statistical difference between the successful group and the conversion group in terms of length of surgery and postoperative stay. The conversion rates in patients operated on before and after 3 days following the onset of symptoms were 27% and 59.5%, respectively (p = 0.0002). There was no statistical difference between early and delayed surgery in terms of operative time and postoperative complications. However, total hospital stay was significantly shorter for group 1. CONCLUSIONS: LC for acute cholecystitis is a safe procedure with a shorter postoperative stay, lower morbidity, and less mortality than open surgery. LC should be carried out as soon as the diagnosis of acute cholecystitis is established and preferably before 3 days following the onset of symptoms. Early laparoscopic cholecystectomy can reduce both the conversion rate and the total hospital stay as medical and economic benefits.     

Laparoscopic cholecystectomy – review over 20 years with attention on acute cholecystitis and conversion*

BACKGROUND: The first laparoscopic cholecystectomy (LC) in Austria was performed on March 22nd, 1990 at the General Hospital Linz. As the experience increased during time the scope of contraindications has been narrowed and the rate of conversion has been decreased. However, acute cholecystitis still leads to a higher conversion rate. METHODS: We retrospectively analysed all cholecystectomies from 1990 till 2010. All acute cholecystectomies have been carried out with regard to conversion, risk factors for conversion, morbidity and mortality. RESULTS: We performed 7541 cholecystectomies. 701 (9.3%) patients had primary open cholecystectomy (OC) and 452 (6%) had concomitant CHE without further evaluation for this study. From the remaining 6139 patients with LC 1775 (male 885 [36%], female 890 [21%]) have been operated due to acute cholecystitis. 141 (7.9%, 78 male, 63 female, median age 66 years, range 20–94) of them led to conversion. The acute inflammation itself including difficulties in Calot's triangle was the most common cause for conversion (56%) followed by adhesions (19.1%). Two patients have been converted due to common bile duct lesion (1.4%) In case of acute operation and conversion the mortality was 5%, morbidity was 20%. Out of the 4364 patients with elective LC 200 had to be converted (4.6%). The overall conversion rate was 5.5%. The Reoperation rate after conversion was 6.3% (n = 9). CONCLUSIONS: Acute cholecystitis leads significantly more often to conversion as in elective LC. Male patients present at the clinic more frequent than female with acute cholecystitis, but in the acute situation the conversion rate is equal.     

腹腔镜胆囊切除术中转开腹的影响因素

目的：分析腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中转开腹的影响因素并探讨其防治措施。方法：对2000年1月至2006年1月1 170例LC术中97例（8.29%）中转开腹情况进行回顾性分析。结果：急性炎症期胆囊炎51例,占中转开腹的52.6%;术中出血25例（25.8%）;怀疑胆总管结石12例（12.4%）;胆囊癌5例（5.15%）;过度肥胖患者4例（4.12%）,开腹手术均获成功,均痊愈出院。结论：熟悉胆道系统解剖及变异、熟练的腹腔镜操作技术是减少LC中转开腹的关键,但适时中转开腹是防止LC严重并发症的最佳选择。     

Does the complication rate increase in laparoscopic cholecystectomy for acute cholecystitis?

BACKGROUND: Laparoscopic cholecystectomy (LC) has replaced open cholecystectomy for the treatment of gallbladder disease. Despite the well-accepted success of LC in chronic cholecystitis, the efficacy of this technique has been subject to some debate in acute cholecystitis (AC). This study was designed to evaluate our institution's experience with LC for AC and chronic symptomatic calculous cholecystitis (CC), based on complication and conversion rates to open surgery. PATIENTS AND METHODS: The records of 1158 patients with LC from September 1991 to December 2001 were analyzed. The parameters of age, gender, early and late complication rates, and conversion rates from LC to open cholecystectomy were compared in patients with AC and CC. RESULTS: During the study period, LC was performed in 1158 patients. Of these, 162 patients had AC (group 1) and 996 patients had CC (group 2). The conversion rates were 4.3% (7/162) in group 1 and 2.4% (24/996) in group 2. The complication rates were not significantly different (5.6% in group 1, 5.1% in group 2, P > 0.05). Difficulty in dissection around Calot's triangle and obscure anatomy were the main reasons for conversion to conventional open surgery. The mortality rate was 1.2% in group 1 and 0.01% in group 2. CONCLUSION: LC appears to be a reliable, safe, and effective treatment modality for AC and CC. The surgical approach should be performed carefully because of the spectrum of potential hazards of the laparoscopic procedure. Conversion and complication rates are similar in both AC and CC groups, and improve as surgeons gain experience.     

The laparoscopic challenge of cholecystitis.

OBJECTIVE: To evaluate the efficacy of laparoscopic cholecystectomy (LC) in acute and chronic cholecystitis and compare it with the open procedure. METHODS: This is a 5-year retrospective analysis performed at our hospital. Surgical treatment of gallbladder disease was performed in 1003 patients. Acute cholecystitis was present in 120 (11.9%) patients, and chronic cholecystitis was present in 830 (88.1%). Acute patients underwent surgery within 72 hours of symptom onset. The patients selected for LC or open cholecystectomy (OC) depended on the severity of disease, comorbid factors, and surgeon's preference. We reviewed age, sex, operating time, length of stay, perioperative complications, conversion rates, and cost. RESULTS: Patients chosen to undergo LC for acute cholecystitis tended to be younger females. Patients treated with LC for acute or chronic cholecystitis on average had a shorter operating time and length of hospital stay when compared with patients treated with OC (P < 0.005 by ANOVA with Bonferroni). Conversion rates (CR) for all LC decreased considerably from the first to the fifth year: 9% in 1995 (10/103), 9% 1996 (22/232), 4% in 1997 (8/188), 2% in 1998 (5/226) and 2% in 1999 (5/193). CONCLUSIONS: LC appears to be a reliable and cost-effective procedure for acute and chronic cholecystitis; however, the surgical approach should be chosen with caution because of the potential spectrum of technical difficulties. CR is also improving as surgeons' experience broadens.     

A 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis: is it safe?

BACKGROUND: In the era of open surgery, emergency open cholecystectomy has been shown for many reasons to be preferred to delayed surgery for acute cholecystitis. Despite the fact that elective laparoscopic cholecystectomy (LC) has become the gold standard for the treatment of symptomatic gallstone disease, the same procedure remains controversial for the management of acute cholecystitis because it is considered to be associated with more complications and an increased risk of common bile duct injuries than interval LC after resolution of the acute episode. The purpose of this report is to describe our experience with LC for acute cholecystitis during a 10-year period. METHODS: Patients undergoing laparoscopic surgery have been entered prospectively into a database since 1995. Those who underwent surgery before 1995 were added retrospectively to the same database. Patients were included in this study if they underwent emergency laparoscopic cholecystectomy for suspected acute cholecystitis. The diagnosis was based on clinical, laboratory, and echographic examinations. Analysis was performed to identify risk factors associated with conversion or morbidity. RESULTS: Of the 1,212 patients subjected to LC between 1990 and 1999, 268 (151 women and 117 men), with a mean age of 53 years, underwent surgery on an emergency basis for suspected acute cholecystitis. Their mean age (p = 0.002) and the proportion of men (p < 0.001) were higher than in the elective group. Delay before admission and surgery varied widely, but 72% of the patients underwent surgery within 48 h of admission. An intraoperative cholangiography, attempted in 218 patients, was successful in 207 (95%). Histologic examination confirmed acute cholecystitis in 82% of the patients. Conversion was necessary in 15.6% of the cases. It occurred more frequently in patients who underwent surgery later than 48 (p = 0.03) or 96 h (p = 0.006) after admission. No other predictor of conversion was found. Overall morbidity was 15.3%, and major morbidity was 4.4%. The only risk factor for morbidity was a bilirubin level greater than 20 mmol/l (p = 0.02). Three partial lesions of the common bile duct occurred. All were recognised and repaired immediately with no adverse effect. There was no difference in the overall rate of biliary complications between the patients operated for acute cholecystitis and those who underwent elective surgery. No reoperation was necessary, and there was no mortality. CONCLUSIONS: Although LC is safe and effective for acute cholecystitis, its associated morbidity and conversion rate are higher than for elective LC. The conversion rate decreases with experience. When surgery is performed within 2 or maximally 4 days of admission, in experienced hands, LC represents the treatment of choice for acute cholecystitis. Intraoperative cholangiography should be performed in every case because it helps to clarify the anatomy and allows for early diagnosis and repair of bile duct injuries.     

Predictive factors for the type of surgery in acute cholecystitis

BACKGROUND: Whereas early cholecystectomy is accepted as the optimal timing for surgery, the best treatment modality for acute cholecystitis (AC) is still under debate. In this series, we aimed to assess the current treatment of AC in a single institution. In addition, preoperative criteria were defined predicting the severity of inflammation. METHODS: From January 1995 to June 1999, 236 patients undergoing cholecystectomy for AC were prospectively evaluated. Outcome measures were the treatment modality, the severity of inflammation, white blood cell (WBC) count, C-reactive protein (CRP), morbidity, and hospital stay. RESULTS: There were 115 laparoscopic cholecystectomies (LC), 77 primary open cholecystectomies (OC), and 44 conversions (CON) to OC. Patients with LC were significantly younger, in better condition, with a shorter duration of symptoms and lower CRP levels and WBC counts compared with OC and CON (P <0.001). Postoperative complications, reinterventions, and mean hospital stay were significantly increased after OC and CON (P <0.001). Overall mortality was 2.5%. Advanced AC was predominantly found in OC and CON (P <0.001). Patients with advanced AC were significantly older, predominantly male, and had a prolonged duration of symptoms as well as increased CRP levels and WBC counts (P <0.001). The conversion rate increased from 10% for mild AC up to 48% for necrotizing AC. CONCLUSIONS: Based on laboratory (CRP, WBC), demographic (age, sex), and individual (American Society of Anesthesiologists classification, duration of symptoms) findings, it is possible to reliably predict the severity of inflammation. Therefore, an individualized surgical approach can be used for each patient and type of AC.     

老年患者急性胆囊炎行腹腔镜胆囊切除术与开腹式胆囊切除术的疗效比较

【摘要】〓目的〓比较腹腔镜胆囊切除术(LC)与开腹式胆囊切除术(OC)治疗老年患者急性胆囊炎的安全性和有效性。方法〓选择从2007年1月至2012年12月收治的年龄超过70岁急性胆囊炎患者76例,分别采用LC(34例)与OC(42例)治疗。观察两组的手术时间、术中失血、术后住院时间和术后并发症。结果〓两组患者手术均顺利完成胆囊切除术,且LC组无中转开腹的病例。LC组的手术时间为95.2±19.7 min,OC组的手术时间为86.8±21.2 min,两者差异无统计学意义;LC组术中失血>500 mL的有2例(5.9%),OC组术中失血>500 mL的有8例(19.0%)(P<0.05);LC组的术后住院时间明显少于OC组(P<0.01)。总共有24例患者在术后出现了并发症(31.6%),其中LC组的术后并发症明显少于OC组(P<0.05)。结论〓急性胆囊炎老年患者行腹腔镜胆囊切除术治疗能缩短术后住院时间和减少术后并发症发生率。     

腹腔镜胆囊切除术中转开腹的原因分析及时机选择

目的:研究腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中转开腹的原因及时机。方法:将成功施行LC的胆囊炎合并胆囊结石患者归入LC组,中转行开腹胆囊切除术(open cholecystectomy,OC)的患者归入OC组,进一步根据中转开腹的时机分为主动中转组与被动中转组,以观察LC中转开腹的危险因素及术中、术后各项指标。结果:OC组上腹部手术史例数、急性胆囊炎发作例数、白细胞计数、胆囊壁厚度均大于LC组;主动中转组手术时间、术中出血量、输血例数、术后引流量、排气时间、下床时间、术后住院时间均明显优于被动中转组。结论:上腹部手术史、急性胆囊炎发作、白细胞计数偏高及胆囊壁厚度增加均是中转开腹的危险因素,根据术中探查情况选择合适的中转开腹时机具有积极的临床意义。     

Laparoscopic cholecystectomy for acute cholecystitis in geriatric patients

Although acute cholecystitis (AC) in many centers is routinely treated by laparoscopic cholecystectomy (LC), the outcome of LC for AC in geriatric patients (75 years or more) remains almost unstudied. All 32 geriatric patients undergoing a cholecystectomy for histologically proven AC in a teaching hospital during a six-year period were studied retrospectively. Median preoperative duration of symptoms was eight days and median preoperative hospital stay was six days. Preoperative ERCP was performed in 22 patients with successful sphincterotomy and common bile duct (CBD) stone retrieval in 11 patients. Overall twelve patients (37%) had CBD stones and 14 patients (44%) had gangrenous cholecystitis at operation. Twenty-seven patients underwent a LC with a conversion rate of 26%, a complication rate of 41% and a mortality rate of 3.7%. Five patients were judged unstable for a laparoscopic approach and underwent a straight open cholecystectomy. Although the latter were at higher risk (higher APACHE II scores), their outcome except for longer intensive care unit stays, was not different from laparoscopically treated patients. Lack of superiority of laparoscopic over open cholecystectomy in the present study seemed due to clinical characteristics of AC in geriatric patients which may lead to late diagnosis and treatment. Preoperative ERCP by further delaying surgery may contribute to loose any potential benefit of an early laparoscopic procedure. The place of preoperative ERCP and the timing of LC in geriatric patients with AC therefore may need to be redefined.     

Gangrenous cholecystitis in the decade before and after the introduction of laparoscopic cholecystectomy.

BACKGROUND: Gangrenous cholecystitis is a severe form of acute cholecystitis with high morbidity. This study investigate the outcomes for patients undergoing cholecystectomy for gangrenous cholecystitis in the decade before and after the introduction of laparoscopic technology at our institution. METHODS: From 1982 to 2002, all patients undergoing cholecystectomy for gangrenous cholecystitis were prospectively entered into a database. Demographic data, method of surgery, and outcome variables were assessed and compared over time. RESULTS: Cholecystectomy was performed to treat gangrenous cholecystitis in 238 patients (mean age, 54 years). From 1982 to 1992, 98 patients underwent cholecystectomy for gangrenous cholecystitis, and from 1992 to 2002, 140 patients underwent the procedure. Ninety-seven patients underwent laparoscopic cholecystectomy, and 33 patients (34%) required conversion. The open and laparoscopic cholecystectomy group differed in the number of intensive care unit admissions (13% vs. 5%, P < 0.05), overall length of hospital stay (10 vs. 5.7 days, P < 0.001) and rate of intraabdominal abscesses (8% vs. 0.7%). CONCLUSION: Gangrenous cholecystitis remains a disease with high morbidity. Laparoscopic cholecystectomy shortened hospital stay and can be offered without increasing morbidity. Methods to decrease intraabdominal abscess formation in patients undergoing laparoscopic cholecystectomy for gangrenous cholecystitis are needed.     

Early laparoscopic cholecystectomy for acute gangrenous cholecystitis

Treatment of severe acute cholecystitis by laparoscopic cholecystectomy remains controversial because of technical difficulties and high rates of complications and conversion to open cholecystectomy. We investigated whether early laparoscopic cholecystectomy is appropriate for acute gangrenous cholecystitis. Pathologic diagnoses and outcomes were analyzed in patients who underwent laparoscopic or open cholecystectomy at our hospital, January 2002 to September 2005. Of 30 patients with acute gangrenous cholecystitis, 16 underwent early laparoscopic cholecystectomy, 10 underwent open cholecystectomy, and 4 were converted to open cholecystectomy (conversion rate, 20.0%). There was no significant difference in operation time or intraoperative bleeding. The requirement for postoperative analgesics was significantly lower (6.4+/-7.3 vs. 1.5+/-1.2 doses, P<0.05) and hospital stay significantly shorter (8.6+/-2.1 vs. 15.6+/-6.3 d, P<0.01) after laparoscopic cholecystectomy. There were no postoperative complications in either group. Thus, early laparoscopic cholecystectomy seems appropriate for acute gangrenous cholecystitis. Conversion to open cholecystectomy may be required in difficult cases with complications.     

Conversion of laparoscopic to open cholecystectomy

Background: Identifying patients who are at risk for conversion from laparoscopic (LC) to open cholecystectomy (OC) has proven to be difficult. The purpose of this review was to identify factors that may be predictive of cases which will require conversion to laparotomy for completion of cholecystectomy. Methods: We reviewed 581 LCs initiated between July 1990 and August 1993 at a university medical center and recorded reasons for conversion to OC. Statistical analysis was then performed to identify factors predictive of increased risk for conversion. Results: Of the 581 LC initiated, 45 (8%) required OC for completion. Reasons for conversion included technical and mandatory reasons and equipment failure. By multivariate analysis, statistically significant risk factors for conversion included increasing age, acute cholecystitis, a history of previous upper abdominal surgery, and being a patient at the Veterans Affairs Medical Center (VAMC). Factors not increasing risk of conversion included gender and operating surgeon. Conclusions: We conclude that no factor alone can reliably predict unsuccessful LC, but that combinations of increasing age, acute cholecystitis, previous upper abdominal surgery, and VAMC patient result in high conversion rates. Patients with the defined risk factors may be counseled on the increased likelihood of conversion. However, LC can be safely initiated for gallbladder removal with no excess morbidity or mortality should conversion be required.     

Timing of laparoscopic cholecystectomy for acute cholecystitis: evidence to support a proposal for an early interval surgery

We evaluated the safety and feasibility of delayed urgent laparoscopic cholecystectomy (LC) performed beyond 72 hours to overcome the logistical difficulties in performing early urgent LC within 72 hours of admission with acute cholecystitis (AC), and to avoid earlier readmission with recurrent AC in patients awaiting delayed interval. Patients admitted with AC were scheduled for urgent LC. Patients who underwent early urgent LC were compared with those who had delayed urgent surgery. Fifty consecutive patients underwent urgent LC for AC within 2 weeks of admission. There were no conversions and no bile duct injuries. Delayed surgery (n=36) neither prolonged operating time (90 vs. 85 minutes), nor increased operative morbidity (9.7% vs. 7.7%) or mortality (2.4% vs. 7.7%) compared with early surgery (n=14). Although delayed surgery was associated with shorter postoperative hospital stay (1 vs. 2 days, P = 0.029), it prolonged total hospital stay (9 vs. 5 days, P < 0.0001). Delay of LC beyond 72 hours neither increases operative difficulty nor prolongs recovery. It might be more cost effective to schedule patients who could not undergo early urgent LC but are responding to conservative treatment for an early interval LC within 2 weeks of presentation with AC.     

Conversion in laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) has become the gold standard in the treatment of symptomatic cholelithiasis. Some patients require conversion to open surgery and several preoperative variables have been identified as risk factors that are helpful in predicting the probability of conversion. The aim of this study was to analyze the factors that make LC difficult and determine conversion to open approach: Our study includes: 6985 cases which underwent LC and 1430 cases with open cholecystectomy, between March 1993 and April 2005 in our clinic of general surgery. The overall conversion rate was 5.1% (deliberate conversion--299 cases, conversion of necessity--62 cases). The conversion rate has decreased from 17.5% in 1993 to 3.2% in recent years. The most conversion happen after a simple inspection or a minimal dissection caused by the existence of perforation (105 cases), the discovery of a difficult anatomic situation (63 cases) or of another pathology (14 cases); more rarely, the conversion was necessary in the principal time, doing to hemorrhage (26 cases), impossible dissection (41 cases), visceral injury (1 case) or even at the end of the operation, doing to hemorrhage, loss piece or stone (10 cases), and other situations (101 cases). Significant predictors of conversion were acute cholecystitis , choledocholithiasis, past history of acute cholecystitis, male gender, gall bladder wall thickness exceeding 6 mm. In conclusion, based on our experience, we suggest limiting OC to patients with proven contraindications to LC (i.e., Mirizzi syndrome or systemic illness incompatible with general anesthesia or pneumoperitoneum), attempting LC in all other cases. Decision to convert to open approach is a proven of surgical maturity. Conversion must be decided from the beginning, in the moment of the recognition of a difficult situation and not after the occurrence of a complication.     

腹腔镜胆囊切除中转开腹手术的原因分析

目的分析腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中转开腹的原因并探讨其防治措施。方法2005年10月-2007年10月共行LC手术405例,中转开腹37例（9.1%）。结果中转开腹的原因：慢性萎缩性胆囊炎5例、解剖变异3例、术中胆管损伤7例、胆囊动脉或肝右动脉损伤出血6例、胆囊三角解剖不清16例,开腹手术均获成功,均痊愈出院。结论熟悉各种解剖变异、规范操作、正确术前评估、熟练的操作技术是减少LC中转开腹手术的关键。     

An early review of 800 laparoscopic cholecystectomies at a university-affiliated community teaching hospital.

Laparoscopic cholecystectomy (LC) was first performed at Georgia Baptist Medical Center (GBMC) in December 1989, subsequently becoming the treatment of choice for most patients with symptomatic gallbladder disease. Early in the authors' series, all patients evaluated for cholecystitis were treated laparoscopically, unless the third party refused reimbursement or the attending surgeon was not trained in LC. Indications for LC were no different than for standard open cholecystectomy (OC). Eight hundred patients from December 1989 to March 1991 had an attempted LC at GBMC. The procedure was completed in 782 patients (97.7%) and required conversion to OC in 18 patients, (2.3%) primarily because of technical difficulties such as dense adhesions or gangrenous changes. No patient sustained a trocar injury to the intra-abdominal viscera, bile ducts injury, or major vascular injury. Overall morbidity was 3.1 per cent and mortality 0.13 per cent. Selective cholangiography (SIOC) was used in 14 per cent. Endoscopic retrograde cholangiopancreatography (ERCP), choledochoscopy, and Fogarty catheter techniques were used for common bile duct stone management. Average hospitalization was 0.89 days, with 85 per cent discharged in less than 24 hours. Average operative time was 86 minutes (range: 25 to 353). Patients returned to full activities at home in 8.4 days. Savings on hospital charges to patients averaged $1,100 for inpatient LC and $2,500 for outpatient LC when compared to 1989 costs for OC. Laparoscopic cholecystectomy is the current surgical procedure of choice for most patients with cholecystitis and can be done at least as safely as standard open cholecystectomy. The morbidity appears to be significantly less with LC, but longer follow-up is needed to confirm these preliminary findings.(ABSTRACT TRUNCATED AT 250 WORDS)     

Laparoscopic cholecystectomy can be safely performed in a resource-limited setting: the first 49 laparoscopic cholecystectomies in Yemen.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard for gallstone disease. Many studies have confirmed the safety and feasibility of LC and have shown that it is comparable regarding complications to open cholecystectomy (OC). The aim of this study was to evaluate the outcomes of LC including safety, feasibility in a resource-poor setting like Yemen, and also to compare the outcomes of LC with those of OC. METHODS: This was a prospective, nonrandomized, comparative study of 112 patients who were admitted to Alburaihy Hospital with a diagnosis of gallstone disease and underwent cholecystectomy from July 1998 to March 2004. Hospital stay, duration of operation, postoperative analgesia, and morbidity due to wound infection, bile leak, common bile duct (CBD) injury, missed CBD stone, bleeding, subphrenic abscess, and hernia were evaluated. Patients were followed up on an outpatient basis. RESULTS: Forty-nine patients underwent LC and 63 patients underwent OC. The mean age of LC patients was 43.96 years and of OC patients was 44.63 years. The 2 groups were similar in terms of age (p=0.740) and sex (p=0.535). No significant difference was found in the incidence of acute cholecystitis between the 2 groups (p=0.000). The mean operative duration for LC was 39.88 minutes versus 56.76 minutes for OC (p=0.000), and the mean hospital stay was 1.63 and 5.38 days for LC and OC, respectively (p=0.000). A drain was used frequently in OC (p=0.000). LC patients needed less analgesia (p=0.000). The morbidity rate in LC was 12.2% versus 6.3% for OC, which was not statistically significant (p=0.394), (p>0.05). Wound infection and bile leak were more common with LC. No mortalities were reported in either group. CONCLUSION: An experienced surgeon can perform LC safely and successfully in a resource-limited setting. As in other studies, LC outcomes were better than OC outcomes.     

腹腔镜胆囊切除中转开腹手术的危险因素分析

目的：分析腹腔镜胆囊切除术中转开腹手术的危险因素。方法：回顾分析我院5年间2 850例LC临床资料,采用单因素分析至Logistic多元回归分析推算出LC中转开腹的危险因素。结果：LC中转开腹手术115例,中转率为4.03%。LC中转开腹的危险因素有近半年胆囊炎急性发作≥2次,胆囊炎病史>2年,伴有右上腹体征（右上腹压痛、肝区叩痛、Murphy′s征阳性）,胆囊壁厚度≥3 mm和胆囊积液。结论：中转开腹的危险因素有近期胆囊炎发作频数、胆囊炎病史、右上腹体征、胆囊壁厚度和胆囊积液。术前仔细询问病史和完善检查,选择适合的LC患者和提高术者手术技术是降低LC中转开腹率的有效措施。对于存在危险因素的患者应适时的选择开腹手术。