medigraphic.com
ISSN 2594-1518 (Electronic)
ISSN 1405-0099 (Print)

2024, Number 3

<< Back Next >>

Cir Gen 2024; 46 (3)

Predictors of conversion from laparoscopic cholecystectomy to open cholecystectomy

Medina López, Jorge Luis1

Language: English/Spanish [Versi?n en espa?ol]
References: 33
Page: 143-152
PDF size: 387.00 Kb.


ABSTRACT

Introduction: cholecystitis is the acute inflammatory process of the gallbladder wall secondary to gallstones in 95 % of cases. Chronic cholecystitis is usually caused by repeated attacks of acute cholecystitis. Laparoscopic cholecystectomy can be the simplest procedure or it can become the most difficult laparoscopic procedure, conversion to open surgery has traditionally been a marker of difficult surgery and an anticipation of avoiding injury and decreasing in-hospital stay and complications. Objective: analyze predictive factors associated with the conversion from laparoscopic cholecystectomy to open cholecystectomy. Material and methods: an observational, retrospective, single-center cross-sectional analytical study was perfmormed, in a period of 2016-2018, all cholecystectomies performed were included, identifying ultrasound, sociodemographic, and serum laboratory variables, history of endoscopic retrograde cholangiopancreatography, surgeon experience, existence of anatomical variants, analyzed using χ2 in case of non-numerical variables, and using Student's T test for numerical variables. Risk factors were analyzed using a bivariate logistic regression analysis model. A p value of < 0.05 was considered statistically significant. Results: a total of 419 patients were studied, of which 57 were excluded, leaving a total of 362 participants divided into two groups, group 1 was made up of those patients in whom laparoscopic surgery was converted to open surgery and group 2 only cholecystectomy laparoscopic. Conclusion: this study demonstrated the incidence of conversion is 9.6%, and preoperative risk factors predictive of conversion from laparoscopic to open cholecystectomy were found: Age > 65 years, female sex, overweight, C reactive protein > 10 mg/Dl, Leukocytes > 10,000 mg/dl, bilirubin > 2 mg/dl. The study showed that the surgeon in training with three and four years of experience was a risk factor as well as the bile duct injury noted was a significant intraoperative risk factor for conversion.



ABBREVIATIONS:

  • OS = open surgery.
  • LC = laparoscopic cholecystectomy.
  • ERCP = endoscopic retrograde cholangiopancreatography.
  • USG = ultrasound scan.



INTRODUCTION

Cholecystitis is the acute inflammatory process of the gallbladder wall secondary to lithiasis in 95% of cases. Chronic cholecystitis is usually caused by repeated acute (sudden) cholecystitis attacks. The clinical picture presents mainly with nausea, vomiting, and pain in the right upper quadrant.1 The diagnosis is based on the Tokyo 2018 criteria, considering as definitive diagnosis the concomitant presence of local inflammatory signs in the right upper abdominal quadrant, signs of systemic inflammatory response, and typical imaging findings.1 The diagnostic imaging study of the approach is an ultrasound scan, and it is based on the combination of ultrasound findings since there is no pathognomonic sign. The characteristic findings described in cholecystitis are the presence of an impacted gallstone, gallbladder fluid, and overdistension and thickening of the gallbladder wall. The clinical practice guidelines mention the following risk factors for chronic cholecystitis: age over 40 years, female sex, pregnancy, oral contraceptive pill use, and hormonal therapy, as well as obesity, rapid weight loss, parenteral nutrition, diabetes mellitus, and dyslipidemia.2 The incidence of gallbladder stones is 10-15% of the population of which will be symptomatic and will present biliary colic, acute cholecystitis, jaundice, and acute pancreatitis; laparoscopic cholecystectomy is the surgical treatment of choice for symptomatic cholelithiasis.2 Nowadays, 10-15% of the adult population in developed countries present biliary lithiasis; in these individuals, the annual risk of developing complications requiring surgical treatment, such as acute cholecystitis, is estimated at 1-2%. Laparoscopic cholecystectomy is a safe and effective method in about 85% of patients with acute cholecystitis. In the United States, it is estimated that 11.8 million people between 20 and 74 years of age have gallbladder stones; there are approximately 1-2% of patients who present asymptomatic gallbladder stones but will present symptoms eventually requiring treatment.3 Laparoscopic cholecystectomy can be the simplest procedure or it can become the most difficult laparoscopic procedure; conversion to open surgery has traditionally been a marker of difficult surgery and an anticipation to avoid injury and decrease in-hospital stay and complications.3 Pre- and perioperative factors such as a history of endoscopic retrograde cholangiopancreatography have not been sufficiently evaluated in patients with chronic cholecystitis in whom elective laparoscopic surgery will be performed.4 Conversion from laparoscopic cholecystectomy to open surgery has been associated with inflammation and fibrosis of Calot's triangle, which generates unclear anatomy and uncontrollable bleeding that could culminate in bile duct injury. The importance of predisposing factors for conversion from laparoscopic cholecystectomy (LC) to open surgery (OS) has been emphasized in numerous studies, many of which have shown that acute cholecystitis is a major risk factor for conversion surgery.5 It is important to evaluate the determination of preoperative factors that will affect elective laparoscopic cholecystectomy conversion for cholelithiasis, which could give the surgeon an idea of the complexity and intraoperative findings encountered in such surgery.6 Acute cholecystitis occurs in 15% of all patients with symptomatic cholecystitis, and laparoscopic cholecystectomy for acute cholecystitis is associated with higher conversion levels than elective laparoscopic cholecystectomy. Therefore, selecting a therapeutic strategy and right patient selection may decrease the conversion rate from laparoscopic to open surgery; the correlation between severity based on the Tokyo guidelines and conversion from laparoscopic to open cholecystectomy has not yet been demonstrated.6 The high conversion rate from laparoscopic to open surgery has prompted interest in the study to identify various predictors of surgical conversion.7 Patient selection is crucial for safe training and procedure in laparoscopic cholecystectomy.8 Universally, the conversion rate of emergency laparoscopic cholecystectomy varies between 5 and 40% and is related to difficulty in identifying the anatomy, severe inflammation, hemorrhage, and adhesions, among other causes. In Latin America, different studies indicate that the conversion rate ranges between 0.8 and 11%.9 Laparoscopy for cholecystectomy was introduced in the 1980s, originally for elective surgery, but soon became the gold standard for elective and acute cholecystectomy surgery. Laparoscopic cholecystectomy is associated with decreased costs, shorter in-hospital stay, decreased postoperative pain, and a lower risk of deep infections when compared to open surgery. The conversion rate of laparoscopic versus open surgery ranges from 1.9-11.9%.10 Laparoscopic cholecystectomy is a common surgery in the Western world, usually electively scheduled with low morbidity and mortality. Conversion from laparoscopic to open surgery has been reported in 1.8-27.7%, and conversion of cases has been associated with an increased number of wound infections and postoperative complications, increased additional procedures, and risk of readmission at 30 days. Identifying variables in patients in the preoperative period could help identify those at risk for conversion from laparoscopic to open surgery.11 When comparing open cholecystectomy with laparoscopic cholecystectomy, it can be seen that the latter presents a lower morbidity and mortality rates [morbidity: open cholecystectomy (18.7%) versus laparoscopic cholecystectomy (4.8%) p < 0.0001; mortality: open cholecystectomy (4%) versus laparoscopic cholecystectomy (2.8%), p < 0.0001]. Although the surgeon's clinical judgment indicates when and why to perform a conversion to laparotomy, the conversion rate represents a quality indicator, which should be periodically evaluated in the surgical services.12

Laparoscopic cholecystectomy for acute cholecystitis is associated with high rates of conversion to conventional surgery compared to elective surgery.13 In the early years of laparoscopic cholecystectomy conversion was influenced by multiple factors such as patient characteristics (high body mass index, previous abdominal surgeries), anatomical variations of the extrahepatic bile duct and gallbladder, and pathology (severe inflammation of the gallbladder and common bile duct).13 In early studies in the 1990s, older age, male gender, obesity, previous abdominal surgeries, previous endoscopic retrograde cholangiopancreatography, and ultrasound findings of inflammation were associated with conversion. Subsequent studies showed that gallbladder thickness on ultrasound is a strong predictor for conversion from laparoscopic to conventional cholecystectomy.14 C-reactive protein is an acute phase reactant secreted by the liver in response to interleukin-6 and other proinflammatory cytokines in inflammation, infection, trauma, malignancy, and infarcted tissue. The synthesis rate determines the concentration in the circulation as a reflection of the intensity of the pathological process and is a good indicator of severe inflammation.15 Injury or inflammation of the human body increases the concentrations of some serum proteins; the increase during the postoperative period of these proteins is associated with the regeneration and repair process as an act of restoration of the injured tissue. This injury has a positive correlation between serum protein concentrations, especially C-reactive protein, and inflammation severity. C-reactive protein is consistent in response to injury and is the most proof of certainty of acute phase proteins.16 C-reactive protein is a normal serum component significantly elevated by trauma or inflammation, with C-reactive protein levels beginning to rise 24-72 hours later and returning to normal within two weeks.17 When laparoscopic cholecystectomy is performed after endoscopic retrograde cholangiopancreatography, the conditions of adhesion, inflammation, and fibrosis around the gallbladder change the anatomy and increase the difficulty for the surgeon performing the surgery.18 The association with high levels of C-reactive protein is very notable, so incorporating C-reactive protein levels into patient care could serve to diagnose complications such as gangrenous cholecystitis and diagnose early technical difficulties in converting minimally invasive surgery to open surgery.19 The critical window of safety is a safe method for identifying anatomical structures in an LC, as described by Strasberg in 1995. The critical window is now accepted as the key point for safe cholecystectomy to prevent bile duct injury during laparoscopic cholecystectomy.20 Dissection becomes more difficult in acute cholecystitis, where frequent inflammatory reactions occur. It is more time-consuming than the laparoscopic approach, and it is also very complicated to distinguish different tissues. Hence, the range of conversion to open surgery is 15-25%, compared to elective cases, and research on predictors of conversion should be performed to complete an early LC in patients with acute cholecystitis.21 Sippey comments that literature indicates numerous risk factors that could be predictors for conversion to open surgery, including gender, older age, arterial hypertension, systemic inflammatory response syndrome, preoperative albumin, decreased hematocrit, leukocytosis, hyponatremia, elevated INR, and thickened gallbladder wall by ultrasound.22 Kevin P. mentions that the duration of symptoms is an important parameter to estimate the changes generated by inflammation in cholecystitis. Some surgeons consider laparoscopic cholecystectomy within 72 hours after the acute event.17 Narinder reports that the need for conversion from laparoscopic cholecystectomy to open cholecystectomy is 15-25% (five times the conversion rate in cholecystectomy performed for chronic cholecystitis).23 Due to the biliary tree anatomy, we believe it is necessary to predict factors that could contribute identifying technical difficulties.24 Currently the criteria of the Tokyo guidelines are recommended for the diagnosis of acute cholecystitis, standardizing the treatment for each type of exacerbation. According to the Tokyo guidelines, diagnostic criteria include physical examination, laboratory findings such as C-reactive protein and elevated white blood cells, and radiological evaluation.25 The high-risk conversion rates contribute to an interesting study of predictive risk factors, as well as the performance of prompt cholecystectomy in acute cholecystitis; identification of these risk factors leads to careful preoperative screening and prompt cholecystectomy.26 The National Institute of Health and Nutrition estimates 6.3 million men and 14.2 million women in the United States with gallbladder stone disease with a prevalence over 26%, with women being at higher risk than men.27 Patient demographics and imaging findings of calculous cholecystitis are predictors of risk in many large series and meta-analysis.28 Factors associated with complications of laparoscopic cholecystectomy have been associated with advanced age, comorbidities, and risk factors inherent to the underlying disease being treated.29 Fifteen percent of elective laparoscopic cholecystectomies convert to open surgery; in contrast to acute cholecystitis, the percentage is higher.

The conversion rate depends on the patient's findings, the surgeon's skills, and the available laparoscopic equipment.30 Preoperative assessment of complexity factors is necessary for various procedures such as LC to identify complications and delays and ensure efficiency during surgery.31



MATERIAL AND METHODS

An observational, analytical, retrospective, and cross-sectional study was conducted in the General Hospital "Dr. Miguel Silva" of Morelia, Michoacán, from 2016 to 2018. The sample comprised all cholecystectomies performed in that period; the universe comprised the records of patients diagnosed with chronic calculous cholecystitis who underwent elective laparoscopic cholecystectomy. The variables are the following: conversion from laparoscopic to open cholecystectomy or not, age, sex nutritional status, ultrasonographic variables such as wall thickness > 4 mm, double rail imaging, C-reactive protein > 10 mg/l, leukocytosis > 10,000 mg/l, direct bilirubin >2 mg/dl, history of endoscopic retrograde cholangiography, whether the surgeon was in training, the academic degree of the resident, shift time in which the surgery was performed, whether there was an anatomical variant, bile duct injury detected, and days of in-hospital stay. All elective laparoscopic cholecystectomies performed from January 1, 2016, to December 31, 2018, were reviewed in the operating room registry; once the data were obtained, we went to the hospital archive and reviewed the files to assess those that were complete. Laparoscopic and open cholecystectomies were organized into two groups and the data were emptied into a collection sheet. Numerical variables were expressed as mean and standard deviation, while qualitative variables were expressed as n, proportion, and percentage. Two groups were formed: 1. Conversion from laparoscopic to open surgery and 2. Differences between groups that were analyzed by χ2 for non-numerical variables and Student's t-test for numerical variables. Risk factors were analyzed using a bivariate logistic regression analysis model; a p-value < 0.05 was considered statistically significant.



RESULTS

A total of 419 files presenting a diagnosis of chronic calculous cholecystitis were reviewed, of which 57 files were excluded, leaving a total of 362 participants with a mean age of 39.34 years, with the highest percentage (32.04%) of patients in the 21 to 30 years age group. We found that the highest percentage corresponded to the female sex with 78.17% (283), while the male sex obtained 21.82% (79%); according to nutritional status, normal weight predominated with 42.54% (154), followed by overweight with 41.71% (151), then grade I obesity with 9.67% (35), grade II obesity with 4.97% (18), underweight with 0.83% (3) and finally grade III obesity with 0.28%. Two groups of patient files were divided: group 1 consisted of those patients in whom laparoscopic surgery was converted to open surgery (9.67%) and group 2 consisted only of laparoscopic cholecystectomy (90.33%); 35 patients were included in the first group, and 327 patients in the second.

Following conversion predictors were analyzed: age, sex, nutritional status, wall thickness, double rail imaging, CRP greater than 10, leukocytes > 10,000/mm3, direct bilirubin greater than 2 mg/dl, and history of endoscopic cholangiopancreatography (ERCP) (Table 1). Group 1: a total of 35 patients were included with a mean age of 47.4 years; the age groups are shown in Table 2. Eighty percent (28) were female, 20% (7) were male, and only 6 (17.14%) were older than 65 years; in terms of nutritional status, we found a higher risk of conversion in patients who were overweight (40%). Group 2: 327 patients participated with a mean age of 38.47 years; the age groups are shown in Table 2; 77.98% (255) belonged to the female sex and 22.02% (72) to the male sex; only 17 (5.20%) were older than 65 years, and regarding nutritional status we found a higher percentage in patients with normal weight (43.12%) (Figure 1). When performing a bivariate analysis for sex and age over 65 years, we obtained statistical significance in both variables. When analyzing the rest of the predictors of conversion of patients in group 1, we observed that most did not have a wall thickness > 4 mm [24 (68.6%)]; double rail imaging was only present in 25.7% (9), CRP > 10 mg/l in 65.7% (23), leukocytes > 10,000/mm3 in 71.4% (25), direct bilirubin > 2 mg/dl in 11.4% (4), and history of ERCP in 14.29% (5). In group 2, on the other hand, most of them did not have wall thickness > 4 mm with 74.9% (246), double rail imaging was only present in 17.7% (58), CRP > 10 mg/l in 11.9% (39), leukocytes > 10,000/mm3 13.1% (43), direct bilirubin > 2 mg/dl in 2.5% (10), and history of ERCP in 7.03% (23). When analyzing the predictors of conversion with χ2, we found that for CRP, we obtained a value of 64.44, with a statistically significant p-value, leukocytes with 70.38/mm3 with a p-value with statistical significance. Subsequently, the intraoperative conversion risk factors were studied: surgery performed by a physician in training, surgeon's degree of training, shift time, anatomical variant, bleeding greater than 200 ml, and bile duct injury. Most of the patients were operated on by surgeons in training; this represents 65.7% (23), while 34.3% (12) were operated on by the attending physician (group 1). In group 2, most of the patients were operated on by surgeons in training, representing 74.92% (245), while the attending physician operated on 25.07% (82). The training grade that presented the most conversions in group 1 was the fourth grade, with 40% (14); for group 2, we noticed that the third-grade resident was the one who performed the highest number of interventions, with 44.64% (146), followed by the attending physician with 85 (25.99%). When analyzing with χ2 the degree of training of the physicians we obtained significance only in the surgeries performed by R3 and R4. The shift time in which most surgeries were converted, in group 1 was the morning shift with 74.3% (23). In group 2, the main shift was the morning shift, with 191 (58.4%), followed by the evening shift, with 118 (36.08%), the night shift with 11 (3.3%), and the weekends with only 7 (2.1%). No statistical significance was obtained for this variable. The surgeries that were converted presented hemorrhage > 200 mL in 45.7% and biliary tract lesion in 5.7%; in those that were not converted, hemorrhage > 200 ml manifested in 7.6%, with a variant of 0.3%. Finally, complications were studied: surgical wound infection, jaundice, and days of in-hospital stay. The surgeries that were converted presented minimal complications, which were surgical wound infection in 8.6% and jaundice in 5.7%; in group 2, surgical wound infection in 2.4% and jaundice in 1.5%; when analyzing with χ2 statistical significance was not obtained. The mean length of stay was 3.97 days since most patients had an in-hospital stay of three days (14.40%) even when the surgery was open. In group 2, the mean was 3.12 days, finding that 168 patients stayed only for two days in the hospital, 106 stayed three days, and 24 more than five days.



DISCUSSION

Laparoscopic cholecystectomy is the most performed surgical procedure worldwide, so it is important to impact factors that could predict the risk before complications occur. The conversion rate in this study was 9.6%; this is comparable with the conversion rate ranging from 5 to 40% found in the study of Ergun et al.11 as well as in the study of Samer al Masri, where the conversion rate was 1.6%.31 Age > 65 years was the factor studied that represented statistical significance, as mentioned by Yoshikazu Morimoto in his paper, where he found a relationship between complications of surgery in patients above 65 years.32 In this study, female sex showed statistical significance in contrast to the international literature that mentions that a predictor of conversion is male sex, as reported by Antonio Gengeni in his paper Risk Factors for Open Conversion in minimally invasive Cholecystectomy33 where he also mentions that male sex is an independent risk factor for complications and a risk of conversion from laparoscopic to open cholecystectomy, this predictor factor presents a bias because the majority of the population studied in this hospital was of female gender.33 Leukocytes > 10,000/mm3 also proved a predictor since elevated levels at this cutoff point have been associated with conversion from laparoscopic to open cholecystectomy.33 Ultrasonographic data, such as wall > 4 mm and double-rail imaging of the gallbladder wall, in this study, did not present statistical significance in contrast to several articles, as mentioned by Samer al Masri and colleagues in their article where they report ultrasonographic data as statistically significant.31 This is probably because ultrasound is operator dependent and several ultrasounds are not performed in this institution, so we believe that this may be the reason. Bilirubin greater than 2 mg/dl is a predictor of conversion in this institution, which had not been studied in published articles; most studies mention total bilirubin levels below 1 mg/dl.31 The history of ERCP was not a risk factor in the present study, contrasting with what is mentioned in the literature. In our study, factors that could be risk factors were incorporated, such as the fact that the physicians in training performing the surgery was statistically significant. Likewise, the years that turned out to be risk factors were the third and fourth year of residency; the shift time did not prove to be a risk factor. As mentioned in several studies, the hemorrhage greater than 200 ml was not statistically significant and the anatomical variant was not a risk factor. Bile duct injury as a conversion factor turned out to be a risk factor; these variables had not been reported in the literature as risk factors for conversion of laparoscopic cholecystectomy, except for > 200 ml. Licciardello, in his work, mentions that bleeding > 200 ml, as well as leukocytes greater than 10,000/mm3, are risk factors for conversion from laparoscopic to open surgery. Male gender, age > 65 years, elevated leukocyte count, and ultrasonographic data were predictors; all these agreed with the findings of our study, and only the ultrasonographic factors were not statistically significant. In contrast, postoperative complications such as surgical wound infection, jaundice, and post cholecystectomy, were not risk factors in this study.



CONCLUSIONS

It is important to determine the risk factors that make us refer to a technically difficult surgery prior to surgery. Knowing these factors can prevent serious consequences. According to the surgeon's experience, conversion to open surgery is common when faced with technical difficulty; nowadays, most of the complications can be resolved laparoscopically.


REFERENCES

  1. Izquierdo YE, Díaz-Díaz NE, Muñoz N, Guzmán OE, Contreras-Bustos I, Gutiérrez JS. Factores prequirúrgicos asociados con dificultades técnicas de la colecistectomía laparoscópica en la colecistitis aguda. Radiologia. 2018; 60: 57-63.

  2. CENETEC. Diagnóstico y tratamiento de colecistitis y colelitiasis. Guía de evidencias y recomendaciones: Guía de práctica clínica. 2013. Disponible en: https://www.actuamed.com.mx/informacion-medica/diagnostico-y-tratamiento-de-colecistitis-y-colelitiasis

  3. Jessica Mok KW, Goh YL, Howell LE, Date RS. Is C-reactive protein the single most useful predictor of difficult laparoscopic cholecystectomy or its conversion? A pilot study. J Minim Access Surg. 2016; 12: 26-32.

  4. Mok KW, Reddy R, Wood F, Turner P, Ward JB, Pursnani KG, et al. Is C-reactive protein a useful adjunct in selecting patients for emergency cholecystectomy by predicting severe/gangrenous cholecystitis? Int J Surg. 2014; 12: 649-653.

  5. Asai K, Watanabe M, Kusachi S, Matsukiyo H, Saito T, Kodama H, et al. Risk factors for conversion of laparoscopic cholecystectomy to open surgery associated with the severity characteristics according to the Tokyo guidelines. Surg Today. 2014; 44: 2300-2304. doi: 10.1007/s00595-014-0838-z.

  6. Díaz-Flores A, Cárdenas-Lailson E, Cuendis-Velázquez A, Rodríguez-Parra A, Trejo-Ávila ME. C-reactive protein as a predictor of difficult laparoscopic cholecystectomy in patients with acute calculous cholecystitis: A multivariate analysis. J Laparoendosc Adv Surg Tech A. 2017; 27: 1263-1268. doi: 10.1089/lap.2017.0139.

  7. Ercan M, Bostanci EB, Teke Z, Karaman K, Dalgic T, Ulas M, et al. Predictive factors for conversion to open surgery in patients undergoing elective laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A. 2010; 20: 427-434. doi: 10.1089/lap.2009.0457.

  8. Kohli R, Bansal E, Gupta AK, Matreja PS, Kaur K. To study the levels of C-reactive protein and total leucocyte count in patients operated of open and laparoscopic cholecystectomy. J Clin Diagn Res. 2014; 8: NC06-NC08.

  9. Onoe S, Maeda A, Takayama Y, Fukami Y, Kaneoka Y. A preoperative predictive scoring system to predict the ability to achieve the critical view of safety during laparoscopic cholecystectomy for acute cholecystitis. HPB (Oxford). 2017; 19: 406-410. doi: 10.1016/j.hpb.2016.12.013.

  10. Yücel E, Filiz A, Kurt Y, Balta AZ, Okul O, Derici ST, et al. Predictive factors for conversion to open surgery during laparoscopic cholecystectomy. Cumhur Med J. 2013; 35: 510-517. doi: 10.7197/1305-0028.2010.

  11. Hirohata R, Abe T, Amano H, Hanada K, Kobayashi T, Ohdan H, et al. Identification of risk factors for open conversion from laparoscopic cholecystectomy for acute cholecystitis based on computed tomography findings. Surg Today. 2020; 50: 1657-1663. doi: 10.1007/s00595-020-02069-5.

  12. Wevers KP, van Westreenen HL, Patijn GA. Laparoscopic cholecystectomy in acute cholecystitis: C-reactive protein level combined with age predicts conversion. Surg Laparosc Endosc Percutan Tech. 2013; 23: 163-166. doi: 10.1097/SLE.0b013e31826d7fb0.

  13. Teckchandani N, Garg PK, Hadke NS, Jain SK, Kant R, Mandal AK, et al. Predictive factors for successful early laparoscopic cholecystectomy in acute cholecystitis: a prospective study. Int J Surg. 2010; 8: 623-627. doi: 10.1016/j.ijsu.2010.05.014.

  14. Lee R, Ha H, Han YS, Jung MK, Chun JM. Predictive factors for long operative duration in patients undergoing laparoscopic cholecystectomy after endoscopic retrograde cholangiography for combined choledochocystolithiasis. Surg Laparosc Endosc Percutan Tech. 2017; 27: 491-496. doi: 10.1097/sle.0000000000000461.

  15. Menon A. A comprehensive review of the factors predicting techincal difficulty in laparoscopic cholecystectomy. Int Surg J. 2017; 4: 1147-1153.

  16. Kabul-Gurbulak E, Gurbulak B, Akgun IE, Duzkoylu Y, Battal M, Fevzi-Celayir M, et al. Prediction of the grade of acute cholecystitis by plasma level of C-reactive protein. Iran Red Crescent Med J. 2015; 17: e28091. doi: 10.5812/ircmj.17(4)2015.28091.

  17. Beliaev AM, Booth M. Risk factors and predictive models for conversion of laparoscopic cholecystectomy to open surgery, and surgical quality outcome measures. In: Actual Problems of Emergency Abdominal Surgery. InTech; 2016.

  18. Romero JJG. Criterios de conversión de cirugía laparoscópica a cirugía abierta y complicaciones post colecistectomía una estadificion preoperatoria. Rev Mex Cir Endoscop. 2001; 2: 134-141.

  19. Cicero A. Factores que predicen la conversión de la colecistectomía laparoscópica: Cinco años de experiencia en el Centro Médico ABC. Rev Mex Cir Endoscop. 2005; 6: 66-73.

  20. Vargas RL, Agudelo SM, Lizcano CR, Martínez BM, Velandia BL, Sánchez HS, et al. Factors associated with conversion of laparoscopic colecistectomy to open colescytectomy. Rev Col Gastroenterol. 2017; 32: 20-23.

  21. Domínguez LC, Rivera A, Bermúdez C, Herrera W. Análisis de los factores de conversión durante colecistectomía laparoscópica a abierta en una cohorte prospectiva de 703 pacientes con colecistitis aguda. Cir Esp. 2011; 89: 300-306. doi: 10.1016/j.ciresp.2011.01.009.

  22. Ozdemir A, Karakaya A, Pergel A. Conversion from laparoscopic cholecystectomy to open surgery reasons and possible risks: a single center experience. J Exp Clin Med. 2022; 39: 781-785. doi: 10.52142/omujecm.39.3.36.

  23. Babu S, Km KK, Raviteja, Jagannath. Study of risk factors for conversion during laparoscopic cholecystectomy in a tertiary care teaching hospital. Int J Surg Sci. 2019; 3: 14-16. doi: 10.33545/surgery.2019.v3.i2a.05.

  24. Andrews S. Does concentration of surgical expertise improve outcomes for laparoscopic cholecystectomy? 9 year audit cycle. Surgeon. 2013; 11: 309-312. doi: 10.1016/j.surge.2013.06.005.

  25. Dua A, Dua A, Desai SS, Kuy S, Sharma R, Jechow SE, et al. Gender based differences in management and outcomes of cholecystitis. American Journal Surgery. 2013; 206: 641-646. doi: 10.1016/j.amjsurg.2013.07.011.

  26. Sugrue M, Sahebally SM, Ansaloni L, Zielinski MD. Grading operative findings at laparoscopic cholecystectomy- a new scoring system. World J Emerg Surg. 2015; 10: 14. doi: 10.1186/s13017-015-0005-x.

  27. Jameel SM, Bahaddin MM, Mohammed AA. Grading operative findings at laparoscopic cholecystectomy following the new scoring system in Duhok governorate: cross sectional study. Ann Med Surg (Lond). 2020; 60: 266-270. doi: 10.1016/j.amsu.2020.10.035.

  28. Szabo K, Rothe A, Shamiyeh A. Laparoscopic cholecystectomy – review over 20 years with attention on acute cholecystitis and conversion. Eur Surg. 2012; 44: 28-32. doi: 10.1007/s10353-012-0072-0.

  29. Bouarfa L, Schneider A, Feussner H, Navab N, Lemke HU, Jonker PP, et al. Prediction of intraoperative complexity from preoperative patient data for laparoscopic cholecystectomy. Artif Intell Med. 2011; 52: 169-176. doi: 10.1016/j.artmed.2011.04.012.

  30. Ramakrishna HK. Predictive factors for conversion of laparoscopic cholecystectomy. Indian J Surg. 2013; 75: 152. doi: 10.1007/s12262-012-0503-y.

  31. Al Masri S, Shaib Y, Edelbi M, Tamim H, Jamali F, Batley N, et al. Predicting conversion from laparoscopic to open cholecystectomy: a single institution retrospective study. World J Surg. 2018; 42: 2373-2382. doi: 10.1007/s00268-018-4513-1.

  32. Morimoto Y, Mizuno H, Akamaru Y, Yasumasa K, Noro H, Kono E, et al. Predicting prolonged hospital stay after laparoscopic cholecystectomy. Asian J Endosc Surg. 2015; 8: 289-295. doi: 10.1111/ases.12183.

  33. Gangemi A, Danilkowicz R, Bianco F, Masrur M, Giulianotti PC. Risk factors for open conversion in minimally invasive cholecystectomy. JSLS. 2017; 21: e2017.00062. doi: 10.4293/jsls.2017.00062.



AFFILIATIONS

1 Intensive Care Unit, Hospital de la Mujer, SSA. Morelia, Michoacán, México. General Surgery and Critical Medicine.



CORRESPONDENCE

Jorge Luis Medina López. E-mail: drjorgemedlop@gmail.com




Received: 03/08/2024. Accepted: 08/21/2024

2020     |     www.medigraphic.com