Frequency of Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy in a Low-Middle-Income Country

Laparoscopic Cholecystectomy (LC) is the most common minimally invasive procedure in general surgery and the preferred method of surgical intervention in patients with cholelithiasis due to shorter hospital stay times, fewer complications and improved cosmesis [3]. Open Cholecystectomy (OC) is preferred where LC is not available or if there is significant risk of iatrogenic injury especially to the common bile duct from LC. Both of these are safe in their own right but conversion from laparoscopic to open cholecystectomy can lead to injury, post-operative complications and a longer hospital stay [4]. The rate of conversion ranges from 4.6-20% [5].


Introduction
Worldwide, gallstones are a common disease with a prevalence of 10-15% in the developed world and 16% in Pakistan [1]. Risk factors for this condition are either genetic or environmental and lifestyle factors such as obesity and metabolic disease play a big role. Symptomatic gallstones can lead to complications hence usually prompt treatment, which is most often surgical [2].
Laparoscopic Cholecystectomy (LC) is the most common minimally invasive procedure in general surgery and the preferred method of surgical intervention in patients with cholelithiasis due to shorter hospital stay times, fewer complications and improved cosmesis [3]. Open Cholecystectomy (OC) is preferred where LC is not available or if there is significant risk of iatrogenic injury especially to the common bile duct from LC. Both of these are safe in their own right but conversion from laparoscopic to open cholecystectomy can lead to injury, post-operative complications and a longer hospital stay [4]. The rate of conversion ranges from 4.6-20% [5].
Risk factors for conversion in patients include maleness, obesity and history of previous abdominal surgery. Intraoperatively conversion is most frequently observed in patients with dense adhesions [6]. Patients selected for LC require preoperative assessment for identification of factors that may lead to conversion. This would minimize the need for conversion and help identify patients who should be selected for OC from the start. This study will seek to identify the frequency of conversion of LC into OC and the patient factors contributing to this pre-operatively and causes intra-operatively, and compare this to similar settings in the region in order to highlight changes needed to improve patient safety and to allow for better pre-operative decision making.

Materials and Methods
This descriptive, cross-sectional study was conducted at the Department of Surgery, Dr. Ruth K. M. Pfau Civil Hospital Karachi, from April 2021 till October 2021 for a period of six months. Willing patients of either gender in the age bracket of 18-70, presenting with symptomatic gallstones in the outpatient or emergency department indicated for LC, were included in this study. The exclusion criteria were gallbladder malignancies, polyps, or perforation and patients with a prior history of ERCP (endoscopic retrograde cholangiopancreatographys).
A standard pre-designed structured questionnaire was used to record the findings. Demographic data recorded included age, gender, residence, occupation, socioeconomic status. Anthropometric measurements included height (with shoes), weight (clothed) and body mass index. Clinical features included history of previous abdominal surgery, diabetes mellitus, Common Bile Duct (CBD) diameter, pre-operative alanine transaminase (ALT), alkaline phosphatase (ALP), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), total leucocyte count (TLC), total bilirubin, number of stones in the gallbladder, size of stones and presenting symptoms.
The study was conducted after approval from the College of Physicians and Surgeons Pakistan. Written informed consent was taken from all participating patients wherein the purpose, associated risks and benefits of the study and laparascopic cholecystectomy were briefed to them. Patient confidentiality was ensured throughout the study and their identity concealed.
Patients presenting to the OPD with symptomatic gallstones were recommended LC only after ultrasonographic confirmation, and were admitted a day before the planned procedure at which time their laboratory investigations (i.e. complete blood count and liver function tests) were conducted and documented. The decision to convert from LC to OC was upon the consultant general surgeon's discretion, the reasons for which were documented in the questionnaire.

Data Analysis
Data was entered and analyzed using SPSS version 21 (IBM). Qualitative data including gender, obesity, previous abdominal surgery, diabetes diagnosis, and hypertension were presented as frequency and percentage. Quantitative data including age, ALT, ALP, GGT, TLC, total bilirubin, number of stones, CBD diameter were presented as mean ± standard deviation. Effect modifying variables like age, gender, obesity, previous abdominal surgery, diabetes, hypertension, elevated ALT, ALP, AST, GGT, TLC, total bilirubin, number of stones were stratified and compared using chi square statistics. A p-value of <0.05 was considered significant.

Results
A total of 137 patients scheduled for laparoscopic cholecystectomy were included in this study. The majority of patients (67.88%) were between 18-45 years of age with a mean of 41.54 ± 9.07 years.
Females accounted for 60.58% and males 39.42% with a male to female ration of 1:1.6. The majority of patients (72.99%) had a BMI of ≥25 and the mean BMI was 27.53 ± 3.03 kg/m2. Conversion from LC to OC in patients presenting with cholelithiasis was seen in 13 (9.49%) patients out of 137, in the remainder the LC was continued to completion. As illustrated in the Table 1, the most common cause for conversion was intraoperative bleeding, which involved 6 (46.15%) patients, followed by adhesions in 4 patients (30.77%), suspicion of malignancy in 2 (15.38%) patients and gallbladder inflammation in 1 (7.69%) patient. Difficult anatomy did not spur conversion in our study.

Discussion
Laparoscopic cholecystectomy is now the gold standard for treatment of symptomatic cholelithiasis. This stems from its safety profile in emergent and elective situations along with a host of other benefits [3]. There remain circumstances in which conversion to open may be deemed necessary, and this is associated with increased morbidity [4].
Our primary goal was to ascertain reasons for conversion in a tertiary care government hospital setting in Pakistan, preoperatively and intra-operatively.
A total of 137 patients were enrolled in our study over a period of 6 months, among which a conversion rate of 9.49% was reported, which is well within the range reported in other studies [7]. This was similar to other Pakistani centers which reported 9.52% and 6.7% [1,8]. Among Low-Middle Income Countries (LMIC) in the region, rates were reported as 9.9% in Bangladesh, 9% in India, but 4.5% in Iraq [9][10][11]. The incidence of cholelithiasis is generally higher and LC more widely available in Pakistan which could account for the discrepancy [12].
Our study reports a younger population, mean age 41.54 ± 9.07 years; Awan et al reported mean age of 45.6±9.3 years whereas Agarwal et al reported 46.58±12.81 years [4,13]. The majority of patients, 67.88%, were between 18-45 years which was in line with Naeem, et al., but dissimilar to Agarwal, et al. [1,13].
Generally, the literature states that advancing age is associated with conversion [14]. Females made up 60.58% of the population and males 39.42%; Agarwal et al also reported similar figures as did Subhan, et al. [15].
In our study the most common reason for conversion was reported to be bleeding (46.15%), similar to Radunovic, et al. and Agarwal et al., whereas for Naeem, et al. this accounted for the second most common cause [1,13,16]. Adhesions around the gallbladder are a leading cause for conversion in the literature and in our study this was the second most common cause, which reflects the need to identify patients with significant gallbladder inflammation or previous abdominal surgery [4,10]. Contrasting with Amin et al and Awan et al, difficult anatomy was not a cause for conversion and this could reflect increasing surgeon expertise in dealing with obese patients in our region [4,5].
Obesity is a major patient factor which is known to be prevalent in patients who are eventually converted from LC to OC and our study reflected this as the majority (72.99%) of patients had a BMI above the norm, similar to Subhan, et al., Krishna, et al., and Chen G, et al. [15,17,18]. Obese patients require consideration and counseling beforehand so that they can be involved in decision making prior to choosing a treatment modality. Surgical centers in LMICs often do not have appropriate curricula and resources for training their minimally invasive surgeons. Careful dissection and consideration for anatomy in obese patients should be a part of minimally invasive surgical training in our region of the world especially with rising rates of obesity now known to be the trend [19,20]. Such patients need to be counselled adequately about the risk of conversion and involved in the decision about which procedure to carry out. This study recommends the use of scoring systems, which have shown great efficacy in other centers as a way of evaluating patients pre-operatively in order to reduce the rate of conversion of LC into OC and to ensure patient safety is kept paramount [21].

Conclusion
Laparoscopic cholecystectomy is a predominantly safe and effective procedure for patients with symptomatic gallstone disease even in LMIC. However, conversion to open cholecystectomy carries its risks and should be avoided. Efforts need to be made to reduce the conversion rate and bring it on par with the developed world and even better performing LMIC. Improvements in patient safety such as identification of patients at risk of conversion i.e. those with a higher BMI or those likely to bleed or have dense adhesions may help bridge this gap.