Cholecystectomy, conversion and complications

Faced with a difficult laparoscopic cholecystectomy the surgeon may feel that conversion to open operation would risk greater complications because of the laparotomy. Information on the effect of conversion is lacking. The purpose of this study is to measure the complications of laparoscopic cholecystectomy and observe the effect of the conversion rate.

A total of 957 patients were studied. There were three consecutive series of patients; the first undergoing open cholecystectomy (384 patients), the second laparoscopic cholecystectomy with a 5.8% conversion rate (412 patients) and the third laparoscopic cholecystectomy with a 1.3% conversion rate (161 patients). Data was collected prospectively using a continuous audit, and the complication rate compared on an intention to treat basis. In addition a panel of experienced surgeons was asked to score the complications depending on their severity and a composite complication score calculated. Comparison between the 3 groups was then undertaken.

Open cholecystectomy produced a post-operative complication rate of 6%. Initially this appeared to fall to 3.1% with the introduction of laparoscopic cholecystectomy, but when the complications occurring in the converted patients were included (i.e., on an intention to treat basis) the rate increased to 5.6% in the first group of laparoscopically-treated patients and 3.1% in the second. These differences were not statistically significant. A similar pattern emerged when scoring the severity of the complications as judged by the expert panel. The inclusion of intra-operative complications appears to remove any small advantage for laparoscopic cholecystectomy. The reduction in the conversion rate between the two laparoscopic groups from 5.8% to 1.2% was statistically significant.

When considered on an intention to treat basis laparoscopic cholecystectomy offers no advantage over open operation in terms of the frequency or severity of complications. Reducing the frequency of conversion from a laparoscopic to an open procedure also has no significant effect on the complications encountered. We conclude, therefore, that the complication rate is independent of the conversion rate and that the surgeon, when faced with difficulty at laparoscopic cholecystectomy, should not be deterred from converting to open operation for fear of the post-operative consequences.