Early decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis

Although recent reports suggest an initial laparoscopic approach to acute cholecystitis, the risk factors and consequences of the failure of an attempt remained unknown.

A retrospective study of 557 laparoscopic cholecystectomies was undertaken to identify 70 patients (13%) with a clinical diagnosis of acute cholecystitis confirmed by ultrasonography. Patients who required conversion to laparotomy (conversion group) were compared to those with successful laparoscopic cholecystectomy (successful group).

Eight of 70 patients (11%) required conversion. The conversion group had significantly more elderly (< or =65 years) patients (88% vs 37%; P = 0.02) and larger gallstones as shown on ultrasonography (25 mm vs 15.5 mm; P = 0.03). Other preoperative factors associated with severe inflammation were not predictive. Conversion was associated with the intraoperative finding of severe adhesions and not with those of empyema of gallbladder or gangrenous cholecystitis. Conversion was made after a median laparoscopic surgery time of 50 minutes. The conversion group required more operation time, more analgesics, a longer recovery time, and a longer hospital stay. In addition, the postoperative complication rate was significantly higher (63% vs 16%; P = 0.009).

Patients who required conversion from laparoscopic to open cholecystectomy for acute cholecystitis are at risk for postoperative complications. In elderly patients with large gallstones, the surgeon should made an early decision to convert if severe adhesions are encountered.