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Predictive factors for conversion of laparoscopic cholecystectomy.

Abstract Reliable predictive factors for conversion of laparoscopic cholecystectomy (LC) would be extremely useful in the preparation and planning of admission for patients with symptomatic cholelithiasis. Data from 783 patients in whom LC was attempted in a university clinic from June 1990 to December 1995 were retrospectively analyzed. The aim of this study was to determine preoperative indicators that can be useful for predicting conversion to open cholecystectomy (OC). Conversion was required in 58 (7.4%) patients, of which 48 (83%) were elective and 10 (17%) emergency. Factors evaluated were age, sex, obesity, duration of gallstone disease, co-morbid factors, indication for surgery, previous abdominal surgery, fever, physical examination findings, white blood cell (WBC) count, liver function tests, ultrasound findings, and the experience of the surgeon. Acute cholecystitis, rigidity in the right upper abdomen, fever, thickened gallbladder wall on ultrasonography, elevated alkaline phosphatase (ALP), liver transaminases and the WBC count were significant predictors of conversion in the univariate analysis. Multivariate logistic regression analysis on these significant predictors showed that acute cholecystitis [odds ratio (OR) = 3.12], thickened gallbladder wall on ultrasonography (OR = 3.75), elevated ALP (OR = 2.23), and WBC count (OR = 3.69) were jointly significant.

Diagnostic laparoscopy: Reducing the number of normal appendectomies

A prospective, controlled study was conducted to determine whether a selective policy of diagnostic laparoscopy could reduce the number of unnecessary normal appendectomies in patients with acute right iliac fossa pain. The cohort consisted of patients admitted with acute right iliac fossa pain by the emergency department. Of 102 patients in the study group, 28 subsequently required a diagnostic laparoscopy when a definite diagnosis could not be reached after 8 to 12 hours of observation. Of these, only 18 had inflamed appendices, which were removed. In the rest of the patients (10), the appendices were normal and unnecessary laparotomies were avoided. In the control group, wherein equivocal cases were laparotomized after a similar period of observation, there was a normal appendectomy rate of 15.7 percent (P<0.05). There was no significant difference in the incidence of perforation between the control and study groups. Diagnostic laparoscopy in equivocal cases could thus significantly reduce the number of unnecessary appendectomies without compromising on the rate of perforation.

Technical modification to laparoscopic appendectomy

An alternative technique for laparoscopic appendectomy is described. The isolated appendix is exteriorized through the trocar wound, ligated, and resected. The cecum is then returned to the abdomen.