how to predict difficult Laparoscopic Cholecystectomy and when to convert?

Subhash Khanna
Within a short span of merely two decades since its introduction, Laparoscopic cholecystectomy has become widely accepted as the procedure of choice for symptomatic gall bladder disease. With their growing experience in this surgery, the surgeons have started taking up more complex cases and high risk patients, some of which were considered relative contraindications a couple of years back. Thus with wider application of laparoscopy for technically difficult and high risk patients it was expected that the complication rates would rise as also the rate of conversion to open cholecystectomy. Although 2% to 15% of patients require conversion to open cholecystectomy for various reasons (1,2,3,4) but irrespective of this morbidity and mortality statistics do still favour laparoscopic cholecystectomy over open cholecystectomy. We have tried to look at the various factors and conditions that would help a surgeon to predict a difficult cholecystectomy, which are essentially the same as those that increase the complexity of conventional open cholecystectomy. Pre-operative prediction of a difficult laparoscopic cholecystectomy not only helps patient counselling but also helps the surgeon to prepare better for the intraoperative risk and the technical difficulties expected to be encountered. Moreover, the patient safety may further be improved by involving an experienced surgeon both preoperatively in the decision making and also during the surgery. CLINICAL PARAMETERS It is evident from the literature that clinical, laboratory and radiological parameters have been studied extensively to analyze their effect on conversion rates.(4,5,6,7).Starting from a single variable, upto 34 parameters have been

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studied which include, patient demographics e.g. age, ASA classification, sex, body mass index(BMI)etc., alcohol or tobacco use, any concomitant medical condition, chronic obstructive lung disease, diabetes mellitus, cirrhosis, history of previous abdominal surgery etc. Clinical data studies included the presence of fever, tenderness and/ or palpable mass in the right upper quadrant, jaundice, evidence of pancreatitis, present preoperative clinical diagnosis and elective or nonelective surgery. Of the various preoperative variables, some were found to have statistically significant association with conversion rates. Several series have reported an association of advanced age with the need to convert (5, 8, 9, and 10). The strong association between age, conversion and systemic complications can probably be due to increasing comorbidities in older patients. Age probably cannot be taken as an independent risk factor for the need to conversion. On the other hand, a large sex difference was observed in a nationwide study of conversion obtained from National Hospital Discharge Database encompassing 2,916,470 entries for biliary tract disease from 1998 to 2001 (11). Of the laparoscopic cases only 27% were male, whereas for the open operations 42% were male. These findings of the male sex being identified as a significant risk factor for conversion are consistent with similar findings from several single institutions (1, 2, 8, 9, and 12) and also metaanalysis of the literature. (13) Initially laparoscopy was contraindicated in obese individuals mainly because of technical difficulties such as difficult access due to thick abdominal wall, cannula displacement, difficulties in obtaining a pneumoperitoneum, fat laden omentum and falciform



How to predict difficult Laparoscopic Cholecystectomy and when to convert?

ligament and a heavy fatty liver which was difficult to elevate. Although obesity has been considered a risk factor for increased conversion (14, 15), but several investigators have reported conversion rates similar to those in non obese patients.(1, 2, 12, 16). In general, conversion rates, mortality and complications excluding infection are not significantly different among obese and non obese individuals. Laboratory analysis preoperatively not only confirms the diagnosis but may also help to rule out the presence of a complicated gall bladder disease. Although no single specific criteria has been identified to predict the technically difficult Cholecystectomy, but various parameters have been analyzed in different studies which include white blood cell count, total serum bilirubin, alkaline phosphatase, asparate transaminase (AST), alanine transaminase(ALT) and amylase. Leucocytosis is indicative of acute cholecystitis, but if associated with systemic signs of sepsis, it is indicative of complicated cholecystitis such as empyema, perforation or gangrene. Elevated liver function tests are indicative of cholangitis or common bile duct stones and coagulopathy which needs correction prior to cholecystectomy. RADIOLOGICAL RISK FACTORS Abdominal Ultrasonography which is performed in the majority of patients has become a reliable, quick and noninvasive tool to diagnose gall stone disease (17). Apart from its value in establishing the diagnosis, it may also predict the degree of difficulty involved in the procedure. One of the important findings is maximal gall bladder wall thickness of >4.0mm which indicates a contracted fibrotic gall bladder which is difficult to grasp (18) . Apart from this the ultrasound may demonstrate a porcelain gall bladder, calcification of gall bladder wall and a gall bladder containing large stones; all of these are technically difficult due to inability to grasp and retract with standard laparoscopic instruments. Although a meta-analysis of diagnostic characteristics of ultrasonography published in1994 (13) has revealed a sensitivity and specificity of 94% and 78% respectively but little data is available to assess its diagnostic value for the presence and severity of gallbladder inflammation. Although multiple sonographic indicators of acute cholecystitis have been described including sonographic Murphys sign, pericholecystic fluid, gall bladder wall thickening and gall bladder distension (20,21), but the ability to predict acute cholecystitis and the ease or difficulty of Cholecystectomy appears to be limited (22), and it seems

clinical judgment is more important than ultrasound findings. Moreover, although the findings of air in the gall bladder wall, intraluminal membranes and marked irregularity of the gall bladder wall are features specific to gangrenous cholecystitis, these may also be present in severe form of acute disease without gangrene (23, 24). Plain abdominal radiography may occasionally be of some help in predicting a difficult cholecystectomy. A plain skiagram may identify a porcelain gall bladder (Fig.1), a large calcified gall stone and an emphysematous cholecystitis or aerobilia due to cholecystoenteric fistula; most of these conditions were earlier considered relative contraindications to laparoscopic surgery.

Fig. 1: Porcelain gall bladder seen in plain X ray

Computed Tomography and Magnetic Resonance Imaging are not done routinely, but, it may be of help in evaluating complicated gall bladder disease, especially in diagnosing an intraluminal mass (Fig.2), or pericholecystic abscess (Fig.3) and an associated intra abdominal disorder.

Fig. : An intraluminal mass seen on CT scan.

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cases and the highest risk of conversion is expected in gangrenous cholecystitis and empyema. Conversion rates and infectious complications are much higher after a delay of 48 hours, (30) therefore, patients admitted with acute cholecystitis should be investigated, hydrated and should be taken up for early cholecystectomy within 48 hours. Conversion rates rise very sharply after a delay of over 96 hours from the appearance of the first symptom.(30,31,32) It is now a well accepted fact that within 72 hours of admission or the attack of pain, cholecystectomy, both open and laparoscopic, may be performed safely (29,33,28).
Fig. 3: MR Imaging showing gall bladder perforaion with peri cholecystic abscess

EMPyEMA GALL BLADDER Twe percent to 31 percent of all cases of acute cholecystitis present preoperatively as empyema and gangrenous cholecystitis. (34, 35, 36) (Fig. 4, Fig. 5). The gall bladder becomes thick walled, distended and friable. However, despite the higher conversion rate, laparoscopic cholecystectomy when successful is associated with a better

A Radionucleotide hepatobiliary scan is one of the most sensitive tests to diagnose acute cholecystitis. Unfortunately, it is of limited value in predicting the degree of technical difficulty involved during the surgery. The rim sign characterized by nonvisualisation of the gall bladder and increased pericholecystic hepatic uptake is frequently associated with gangrenous cholecystitis (25), but is present in only small number of cases and thus is not of clinical benefit. SPECIfIC PREDICTORS Of DIffICULT LAPAROSCOPIC CHOLECySTECTOMy There are several conditions that make laparoscopic cholecystectomy a technically difficult procedure. These include acute cholecystitis, empyema gall bladder, gangrenous cholecystitis, porcelain gall bladder and intrahepatic gall bladder. Apart from these, there are various other conditions where laparoscopic cholecystectomy may be very challenging .These include previous laparotomy and postoperative adhesions, portal hypertension, cirrhosis of liver and surgery in a pregnant patient. ACUTE CHOLECySTITIS Patients presenting with acute cholecystitis with pain ,fever, leucocytosis and abnormal ultrasonography or scintiscan of the biliary tract were treated conservatively only two decades back, but several recent clinical studies have validated the safety and efficacy of early laparoscopic cholecystectomy in an acute setting (26,27,28). One of the most significant factors and independent predictors of conversion is the presence of or a previous attack of acute cholecystitis and some other proposed risk factors are related to this variable.(1, 19, 13, 15). The conversion rate ranges between 10% to 50% (1,29) in such

Fig. 4: Empyenma gall bladder with perforation

Fig. 5: Gangrenous Cholecystitis with a necrotic gall bladder.

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How to predict difficult Laparoscopic Cholecystectomy and when to convert?

outcome (36). Perforation of the gall bladder is common and occurs in around 15-20% of cases (37). Usually these cases can be managed and the morbidity is not increased, provided the peritoneal cavity is thoroughly irrigated and sucked dry (Fig.6). Preoperative factors that may help us to determine which patient may require conversion to open cholecystectomy are yet to be clearly defined. The threshold for conversion must be very low.

Some of the studies have mentioned previous abdominal surgery as a risk factor for increased conversion rates. (7, 14, 39) . Surgery of the stomach and duodenum may make laparoscopic biliary surgery more difficult (40), particularly with dense adhesion in the triangle of Calot (1). Previous abdominal surgery is not a contraindication to laparoscopic surgery, but the patient should be warned of increased risk of bowel injury and the greater chance of conversion. PATHOLOGICAL ANATOMy Of BILIARy TRACT AND LIVER Apart from access problems due to postoperative adhesions and obesity, a difficult local dissection may be anticipated in some of the pathological conditions of the biliary tract. An evidence of gall bladder calcification or a porcelain gall bladder may be diagnosed on a plain x ray abdomen. Due to reported high incidence (12% to 60%) of gall bladder cancer (40) and the technical difficulty in grasping such calcified gall bladders, one must consider these and take appropriate measures (Fig. 8).

Fig. 6: Bile peritonitis in a case of perforated gall bladder

PREVIOUS ABDOMINAL SURGERy Patients with previous abdominal surgery may have no impact on a planned procedure; on the other hand there might be presence of gross adhesions and the laparoscopic procedure may fail. Postoperative adhesions pose problems in creating a pneumoperitoneum and also present the need for adhesiolysis before the gall bladder is visualized (Fig. 7). Preoperative sonography mapping can be done to detect the adhesions (38).Pneumoperitoneum should be created by placing the Veress needle at a site far away from previous scar, or by open Hassan technique.
Fig. : Porcelain gall bladder seen on laparoscopy

Fig. 7: Gross post operative adhesions seen on laparoscopy

Cholecystoenteric fistula may be diagnosed preoperatively by the presence of pneumobilia in a plain x ray, and can also be confirmed by a good ultrasonography or CT scan where a fistulous tract communicating with the stomach, duodenum or colon can be seen. Technically these may be slightly difficult to manage as the fistula needs repair, but it is no longer considered a contraindication. (41, 42)(Fig.9). An ERCP is the most reliable method for revealing the presence of bilioenteric fistula (43). An unexpected encounter which at times makes a simple cholecystectomy difficult includes a haemangioma near or at the gall bladder fossa (Fig.10).

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Fig. 9: Cholecystoduodenal fistula seen prior to dissection

Fig. 11: Contracted partially intraheptic gall bladder

Fig. 10: A haemangioma near the gall bladder fossa

Fig. 1: Large Calculus at Hartmanns pouch

TRABECULAR, CONTRACTED AND INTRAHEPATIC GALL BLADDER A gall bladder may congenitally be partially or completely embedded in the liver parenchyma or may become buried due to recurrent episodes of inflammation. The problem relating to this abnormality is an inability to grasp the fundus of the gall bladder and an absence of avascular plane of dissection between the gall bladder and liver parenchyma, which makes it technically a challenging task (Fig.11). Patients with a small contracted gall bladder or a trabeculated gall bladder due to heavy stone load and multiple criss cross strictures in the gall bladder lumen, are also candidates at risk where the surgeon would have difficulty in holding the gall bladder. Mirizzis Syndrome A large calculus at the Hartmanns pouch (Fig.12) or a stone at cystic duct and common bile duct junction may press the common bile duct causing obstructive jaundice or create a fistula between the cystic duct and common

bile duct known as Mirizzis syndrome (Fig.13). With experience the fistula can be repaired, the stone extracted, and the large cystic duct repaired laparoscopically, or a bypass may be needed necessitating conversion. 0.1% of all patients with gall stone disease would have Mirizzis (44) . Extensive adhesions may make visualization of the biliary anatomy exceptionally difficult, consequently ligation or permanent injury of CBD may occur (45). Laparoscopic stapled cholecystofistulectomy; which avoids contamination of peritoneal cavity, may be performed in well equipped centres (42). CIRRHOSIS Of LIVER wITH PORTAL HyPERTENSION A heavy pathological liver seen in fatty liver and chronic hepatitis is also firm and is difficult to elevate and rotate [Fig.14]. Even a flabby left lobe or an enlarged quadrate lobe may necessitate slight modification of the technique, and an extra access epigastric cannula may be needed for introducing a retractor to elevate the quadrate lobe. The elevated portal venous pressure

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How to predict difficult Laparoscopic Cholecystectomy and when to convert?

Most patients can be managed conservatively until the postpartum period, how ever nearly half the patients require repeated hospitalization and thus 40 percent of pregnant patients with symptomatic biliary disease need cholecystectomy during pregnancy (51, 50). Several studies have documented good results with laparoscopic cholecystectomy in the first two trimesters (52). Several technical modifications are required(53) in order to enhance the safety of both mother and fetus (Fig.15).

Fig. 13: Case of Mirizzis Syndrome with a calculus at cystic duct-CBD juncion

Fig. 15: Pregnant uterus (24wks) seen in a patient undergoing laparoscopic cholecysectomy

ABNORMAL HEPATO BILIARy AND ARTERIAL ANATOMy

Fig. 14: Nodular and Firm liver in Cirrhosis

and extensive collateral portosystemic shunts may cause troublesome bleeding during dissection of the cystic duct and artery. Although technically difficult, laparoscopy has become the preferred method of treatment in recent years(46, 47, 48, and 49) with the specific advantages of absence of wound infection, lower rate of postoperative hepatic failure and reduced risk of viral contamination of the surgical staff (41). It is feasible in most childs A and B patients with an acceptable conversion rate. Some modification of technique and subtotal cholecystectomy has also been advocated by specialised centres having large series with acceptable postoperative morbidity (49). LAPAROSCOPIC CHOLECySTECTOMy DURING PREGNANCy Biliary tract disease is the second most frequently encountered inflammatory problem encountered during pregnancy. Gall stones are present in 5 to 12 percent of all pregnancies.(50). The treatment of biliary tract disease is similar for pregnant and non pregnant patients.

The most dangerous and striking feature of the anatomy of the extra hepatic biliary tree is its variability. Variations of ducts, cystic artery, hepatic artery etc. are all common and even anomalies of the gall bladder are infrequently encountered. A congenital true duplication of the gall bladder, which has an incidence of 1 in 4000, may need special attention as it requires removal of both the lobes (Fig.16) and rarely one of these twins may be intrahepatic. Various anomalous positions of the gall bladder have been described, which includes left sided, transverse, floating, intrahepatic and retrodisplaced gall bladder. The left sided gall bladder may or may not be associated with situs inversus (Fig.17). Whereas the cystic duct joins the common hepatic duct in the usual position, it is expected that there would be associated ductal and vascular anomalies. Therefore while making special access ports one may consider intraoperative cholangiogram in case of any doubt regarding ductal anomalies. The hepatic artery crosses the hepatic duct posteriorly but in about 12% of cases, it may cross anteriorly.

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CONVERSION TO OPEN SURGERY When to Convert? Conversion to open surgery is at times perceived as a failure of the laparoscopic procedure, and surgeons enthusiasm to keep the conversion rate low may lead to unwanted biliary tract injuries and complications. Conversion is appropriate when the key technical points of the procedure are not possible and there is uncertainty about the patients anatomy, or if concern for injury exists. There is no clear cut guideline as to the extent to which a surgeon should struggle to complete the procedure laparoscopically and when to convert to open procedure. Although it has been suggested in recent studies (54) that laparoscopic cholecystectomy is associated with less morbidity than open cholecystectomy irrespective of the duration, in contrast, several studies have shown that for an additional interval of 30 minutes, the intraoperative, local and systemic post operative complications rise considerably. If laparoscopic cholecystectomy is extended for more than 2 hours, the risk of perioperative complications is four times higher than that with a surgery which lasts between 30 to 60 minutes(4). The duration of trial dissection may be different depending on the risk score of the patient. When operating on a high risk patient, the surgeon has to make an early decision to convert if dissection seems to be very difficult; early conversion shortens the operation time and decreases morbidity. (15,29). A policy of converting if there is no progress in dissection of Calots triangle within 15 to 30 minutes may be adopted for high risk patients(1), whereas in low risk patients, in general, if no progress is made in identifying the biliary anatomy within 1 hour, the procedure is converted to open, and if the structures are seen and the feasibility of dissection is there, the procedure is continued (55). SUMMARy The technique of laparoscopic cholecystectomy has been standardized and it has become a routine and safe operation. However, there are numerous conditions which make the operation difficult necessitating conversion to open surgery. Preoperative prediction of a difficult cholecystectomy and the risk of conversion is of great help both to the patient who can plan his work and the surgeon who can also schedule his time and team accordingly. There

Fig. 16: Double gall bladder with two cystic ducts

Fig. 17: Left sided gall bladder with two cystic ducts

Caterpillar hump of right hepatic artery occurs in 6% to 16% of cases. After crossing the hepatic duct, the right hepatic artery often descends in the triangle of Calot to an area dangerously close to the cystic duct. This tortuous artery gives rise to multiple small branches supplying the gall bladder, which if severed inadvertently, may bleed profusely [Fig18].

Fig. 1: A rare anomaly of double caterpillar hump



How to predict difficult Laparoscopic Cholecystectomy and when to convert?

2004;188(3):205-11. 12. Sikora SS, Kumar A, Saxena;et al. Laparoscopic Cholecystectomy can conversion be predicted. World J surg 1995;19: 858-60. 13. Shea JA, Berlin JA, Escarce JJ. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med(1994) 154: 2573-2581. 14. Hutchinson CH, Traverso LW, Lee FT: Laparoscopic Cholecystectomy: Do preoperative factors predict the need to convert to open? Surg Endosc.1994; 8: 875 15. Liu CV, Fan ST, Lair ECS et al. Factors affecting conversion of laparoscopic cholecystectomy to open surgery. Arch Surg 1996;131: 98-101. 16. Philips H, Carroll BJ, Fallas MJ, et al. Comparison of laparoscopic Cholecystectomy in obese and non obese patients Am J Surg 1994; 60: 316 17. Prian GW, Norton LW, Evle J. Jr, Eiseman B. Clinical indications and accuracy of gray scale Ultrasonography in the patients with suspected biliary tract disease. Am J Surg(1977) 134:705-711 18. Cuschieri A, Berci G.; The difficult Cholecystectomy in Laparoscopic Biliary Surgery.Second Edition. Blackwell Scientific Publications, London; 1992:101-115 19. Shea JA, Healey MJ, Berlin JA, et al. Mortality and complications associated with laparoscopic cholecystectomy.A meta-analysis. Ann Surg 1996;224:609-20 20. Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gall bladder pathology. Radiol Clin North Am(2003); 41:1203-1216 21. Menu Y, Vuillerme MP. Non traumatic abdominal emergencies imaging and intervention in acute biliary conditions. Eur Radiol. 2002;12: 2397-2406 22. Bingener J, Schwesinger W, Chopra S et al. Does the correlation of acute Cholecystitis on ultrasound and at surgery reflect a mirror image? Am. Jr. Surg 2004;188(6): 23. Merriam LT, Kanaan SA, Dawes LC, et al. Gangrenous Cholecystitis diagnosed by ultrasound.Radiology 1983; 148:219-21 24. Teefey SA, Barron RL, Radke HM, et al. Gangrenous Cholecystitis new observations on sonography. J Ultrasound Med 1991;10:603-9 25. Hauashi AK, Soudry G, Dibos PE. Rim Sign. Radionuclide imaging in a patient with acute gangrenous Cholecystitis and Cholelithiasis after nonspecific Ultrasonography. Clin Nucl Med. 1997;22:338-9 26. Rattner DW, Ferguson C, Warshaw AL. Factors associated with successful laparoscopic Cholecystectomy for acute Cholecystitis Ann Surg 1993;217:233-6. 27. Bickel A, Rappaport A ,knievski V. Laparoscopic management of acute cholecystitis Surg Endosc 1996;10:1045-1045.

are various studies regarding the risk of conversion in laparoscopic surgery and many studies have made some prediction using some variables without using any scoring system. A scoring system needs to be designed urgently which would definitely help surgeons in making unbiased standard predictions. We would definitely be able to clearly state and define difficult cholecystectomy, prior to taking the patient to the operation theatre, and this would help the surgeon to provide better surgical care to the patient.

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