Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 51, Num. 1, 2005, pp. 21-21

Journal of Postgraduate Medicine, Vol. 51, No. 1, January-March, 2005, pp. 21

Expert's Comments

Conversion to an open approach during video-laparocholecystectomy

ValentinoTiziano Pio

University of Foggia, Department of Surgical Sciences, Division of General Surgery, Polyclinic of Foggia, Foggia

Correspondence Address:University of Foggia, Department of Surgical Sciences, Division of General Surgery, Polyclinic of Foggia, Foggia, tizpv@tiscali.it

Code Number: jp05006

The conversions during video-laparocholecystectomy are due to two reasons: first, the anatomic variations and the intraoperative complications, that are absolutely unpredictable and accidental; second, the acute cholecystitis, with clinical (right upper abdominal quadrant pain with positive Murphy′s sign and fever) and instrumental evidence (US signs of increase of the thickness of the gallbladder wall, presence of pericholecystic fluid material),[1] male gender,[2] hepatic cirrhosis,[3] portal hypertension and obesity, because of the greater adiposity of the hepato-duodenal ligament and so a greater difficulty in the recognition of the structures in the Calot′s triangle.[4],[5]

All this data are evident in the preoperative phase and are in part emendable. An important role is played by the first surgeon′s formation, ability and care, because the management of an intraoperative accident, the recognition of an anatomic anomaly or the execution of a difficult cholecystectomy can be evaluated and treated in different way, sometimes even without conversion to an open procedure.[6]

The development of a model that can show, surely, in the preoperative phase, the exact probability of conversion of a video-laparocholecystectomy to an open approach, is not a practicable idea, because there are a great number of variables, that are not all predictable and manageable; instead, it is right to maintain that must be considered some factors in the presence of which the generic probability of conversion can increase; this must be done with the aim of a good and precise conversation with the patient.

In presence of preoperative predictive factors of difficulty of the laparoscopic cholecystectomy, the surgeon′s experience will give the probability of the risk of conversion.

In conclusion we can propose two considerations: the first of ethical order and the second technical.

The decision of converting the intervention to an open traditional approach must be never considered a defeat by the surgeon. The laparoscopic approach is only a technical modality of executing the same intervention.

The decision of changing approach in order to improve the surgical performance does not damage the therapeutic program and has the aim to give the patient the best treatment. From a technical point of view, we recommend the partially antegrade laparoscopic cholecystectomy, that we execute as a routine.

REFERENCES

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