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ASSESMENT OF RISK FACTORS DIAGNOSTIC APPROACH AND MANAGEMENT IN CASES UNDERGOING DIFFICULT CHOLECYSTECTOMIES

BACKGROUND: Laparoscopic cholecystectomy is the standard of care for the treatment of symptomatic gallbladder disease and one of the most common procedures being performed by the general surgeons all over the world. With more and more endeavors being made in the field of laparoscopy, more and more complicated cases which were relatively contraindicated a few years ago, are now being tackled laparoscopically. AIM: Aims of this study is assessment of risk factors, diagnostic approach and management of cases undergoing difficult cholecystectomies on basis of clinical, USG, preoperative, intra operative findings, duration of surgery, rate of conversion, post op complications and duration of stay in hospital. MATERIAL & METHODS: Prospective study done from June 2012 to Nov. 2014, 192 cases undergoing laproscopic cholecystectomy included in study at tertiary care hospital. RESULT: Cholecystitis or pancreatitis and thickened GB wall, PREOP ERCP are found to be significantly associated with increased risk of conversion. Obesity (BMI≥30 kg/m) was significantly associated with difficulty in access to the peritoneal cavity. Various factors. CONCLUSION: clinical factors like male sex, previous acute cholecystitis or pancreatitis and ultrasonographic finding of gall bladder wall thickness ≥4 mm can help to predict difficult laparoscopic cholecystectomy and likelihood of conversion of laparoscopic cholecystectomy to open cholecystectomy.

All patients undergoing laparoscopic cholecystectomy were included in the study.  Akoglu M et.al (2010) in their study, performed preoperative ERCP was done in 32.5% patients and according to their study preoperative ERCP appeared to be related to scleroatrophic gall bladder and that that scleroatrophic gallbladders present more difficulties for laparoscopic cholecystectomy and are associated with a higher conversion rate.
Costantini R et.al. (2011). 5 The execution of ERCP before surgery proved to be significantly associated with the risk of conversion (p<0.01) and hence the difficulty of procedure. 4. In this study, two variables were analyzed in relation to difficulty in access which were obesity and history of previous abdominal surgery. (Table no. 5) In this study it was found that obese patients had significantly higher difficulty in access as compared to non-obese patients. (p<0.001).
Similar finding has been noted in many other studies. Jagadish Nachnani et.al. (2005) 6 in his study concluded that difficulty in access was encountered significantly more often in obese patients (p<0.05) and patients with past history of upper abdominal surgery. (p<0.01). 5. In our study, Difficulty in GB dissection was studied in relation to 4 variables that were presence or absence of local signs of cholecystitis, number of stones, GB wall thickness and status of liver, preoperative ERCP. (Table no.6).
Out of these, cases with local signs of cholecystitis, GB wall thickness 4 mm or more and those in which preoperative ERCP was done had significantly higher difficulty in GB dissection (p<0.001), (p<0.001) and (p<0.001) respectively. Jagadish Nachnani et. al. (2005) 6 in his study concluded that dissection of GB bed was more difficult in patients with past history of acute cholecystitis/pancreatitis (p<0.01) and in those with GB wall thickness exceeding 3mm(p<0.05). 6. In our study, presence of dense adhesions during surgery was correlated with various variables (Table No. 7) out of which history of local sign of cholecystitis was significantly associated with presence of dense adhesions(p<0.001). Preoperative ERCP, past history of acute cholecystitis or acute pancreatitis and GB wall thickness 4mm or more were also positively associated with presence of dense adhesions intra operatively, (p<0.003, p<0.012and p<0.021 respectively). Jagadish Nachnani et.al. (2005) 6 in his study commented that past history of abdominal surgery, past history of acute cholecystitis/pancreatitis and thickened GB wall were associated with difficulty in defining the anatomy 7. Significant intra operative bleeding was correlated with various variables (Table No.9) out of which there was significant correlation observed between thickened GB wall and bleeding(p<0.001) and presence of acute cholecystitis/pancreatitis and bleeding (p<0.025).
Jagadish Nachnani et.al. (2005) 6 concluded that bleeding occurred more commonly in patients with having GB wall thickened (p<0.01) and those with history of acute cholecystitis/pancreatitis (p<0.01).
Abdel Baki et. al. (2006) 7 in their study demonstrated that patients with thickened GB wall had high incidence of bleeding resulting in significant increase in duration of surgery. (Table no. 10) mean operative time required for laparoscopic cholecystectomy is 62.2min; while mean time required for difficult cases is 90.56 minutes whereas mean operating time for converted procedures is 121.58 min which is significantly higher as compared to non-converted cases. 9. In our study, in presence of local signs of cholecystitis and thickened GB wall ≥4mm, pre op ercp, duration of surgery was significantly higher. (p<0.001).

Operative time
Abdel Baki et. al. (2006) 7 in their study commented that patients with local signs of cholecystitis, single impacted stones, thickened GB wall and liver fibrosis had significantly higher operative time (p<0.05). 10. The present study, (Table No. 13) the reasons for conversion were as follows -dense adhesions (10 cases), bleeding (4 cases), GB perforation (2 cases), and Duodenal perforation (1 case). Duca S et al (2003) 8 in their study over 9542 patients found following results -The rate of conversion was 1.9%.The causes of conversion were -CBD injury was the cause of conversion in 11 cases, right hepatic duct injury in 2 cases, bleeding in 9 cases, pericholecystitis in 124 cases, perforated GB in 2 cases, adhesions of previous laparotomy in 6 cases and instrument failure in 5 cases. Jagadish Nachnani et.al. (2005) 6 in their study found that 12 patients (11.4%) required conversion because of the following reasons: inability to delineate anatomy (66.7%), bleeding (25%), suspected CBD injury (8.3%).
The common reasons for conversions are dense adhesions, bleeding which hamper surgeons visibility other factors like viscus injury, aberrant anatomy, instrument failure also play role. 11. In our study, (Table No.14) a gallbladder wall thickness of 4mm or more was significantly associated with difficult surgical preparation leading to conversion and with the histopathologic report of chronic or acute inflammation (p value <0.001).
Avinash 12. In present series we found significant association with male sex and conversion to open cholecystectomy (p value 0.006). In present series, mean operative time required for difficult laparoscopic cholecystectomy is 89.92 min; while mean time required for converted procedures is 121.58 min which is highly significant as compared to operative time for non-converted cases which is 68.75 minutes. Significant bleeding occurred more often in patients with past history of acute cholecystitis or pancreatitis and those patients having gall bladder wall thickness ≥4m. The common reasons for conversion in present study were as follows-dense adhesions (57.9%), bleeding (21.1%), GB perforation (10.5%) and intra operative viscus perforation (10.5%).As more and more number of cases were performed laparoscopically, conversion rate was significantly reduced. The conversion rate of laparoscopic cholecystectomy to open cholecystectomy is 9.64% overall and 29.69 % in difficult cases which is slightly higher in our study and can be explained on the basis of less experience in difficult cases, early phase of learning curve and lack of technological advances.
Patients with a high predicted risk of conversion could be operated on either by or under the supervision of a more experienced surgeon. Also, a high predicted risk of conversion may allow the surgeon to take an early decision to convert to OC when difficulty is encountered during dissection; this may significantly shorten the duration of surgery and decrease the associated morbidity.