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Am Fam Physician. 2000;61(5):1500

Laparoscopic cholecystectomy (LC) is now widely used as surgical treatment of acute cholecystitis. In difficult cases, the surgery may require conversion to an open approach, with a consequent rise in morbidity and the rate of complications. Eldar and colleagues studied the factors associated with conversion from LC to open surgery. In particular, they investigated the impact of patient delay in presenting for medical attention and delay in diagnosis on the surgical outcome.

They studied 348 consecutive patients presenting with acute cholecystitis. Criteria for diagnosis included right upper quadrant pain, fever and leukocytosis. In more than 88 percent of cases, the diagnosis was supported by ultrasonography or another radiologic investigation. The laparoscopic approach was attempted in all patients. The patients ranged in age from 18 to 92 years of age (mean age: 54 years), and 62 percent were women. Approximately one half of the cases were uncomplicated, 26 percent were gangrenous, 10 percent had hydrops of the gallbladder and 12.5 percent had empyema of the gallbladder. Conversion to open cholecystectomy was required in 76 (22 percent) cases. The principal reason for conversion was technical (47 cases), followed by anatomic uncertainty (17 cases), uncontrolled bleeding (nine cases) and bile duct injury (three cases). Surgical complications occurred in 57 (16.5 percent) patients, but no patients died during the study.

Patients who delayed in seeking medical attention were significantly more likely to require open surgery than patients who sought medical assistance more promptly. A conversion rate of 29 percent was associated with delay of at least 48 hours, compared with 18 percent in patients presenting earlier for medical attention. Physician delay did not significantly influence the conversion rate. In statistical analyses, the factors significantly associated with conversion to open cholecystectomy were male gender, history of biliary disease and advanced or complicated cholecystitis. Older patients and men had higher rates of infectious complications than other patients.

The authors conclude that LC can be attempted safely for treatment of acute cholecystitis and that patient delay in presenting for medical attention is the most significant factor in the conversion of laparoscopic to open procedures.

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