Surgical decision-making: key factors influencing the shift from laparoscopic to open cholecystectomy

Abstract

Background: Recognizing the preoperatively and intraoperatively factors can aid surgeons in making timely decisions to shift from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC). This study aims to identify the main factors leading to LC conversion to OC among Iraqi patients. Methods: One-year prospective research was performed using cross-sectional design between 1st April, 2023, and 3oth March, 2024, at Alkalis General Public Hospital and Al Hayat Private Hospital, Diyala, Iraq. Pre and intraoperative data were collected from the planned LC surgeries including demographics, medical history, laboratory and Ultrasound findings. Descriptive and bivariate analysis was carried out to compare variables between patients undergoing LC and those requiring conversion to OC. Results: Out of 172 LC patients (mean age 48.28±12.62), 52.9% were female, 55.8% obese, 50.6% aged 49+, 23.3% diabetic, and 19.8% had emergency cholecystectomy; 15 (8.7%) required conversion to open surgery. The conversion group was mainly men (66.7% vs. 46.5%, P = 0.001) and older (73.3% vs. 48.4% aged 49+, P = 0.003). Obesity (60.0% vs. 55.4%, P = 0.005) and diabetes (53.3% vs. 20.4%, P < 0.001) were more common. Public hospital referrals were higher (86.7% vs. 52.2%, P < 0.001). Elevated total bilirubin, direct bilirubin, and alkaline phosphatase levels were significant predictors of conversion to OC. Adhesions in Calot's triangle (20.0% vs. 13.4%, P = 0.021) were more common in the conversion group, along with unclear anatomy, thick gallbladder wall, bleeding, stone and bile spillage, and cystic duct injury. Conclusion: In conclusion, out of 172 LC patients, 15 (8.7%) required conversion to open surgery, predominantly older men with higher obesity, diabetes, and elevated bilirubin and alkaline phosphatase levels, and more adhesions in Calot's triangle.