title: Laparoscopic cholecystectomy for acute cholecystitis: safe implementation of successful strategies to reduce conversion rates.
abstract: BACKGROUND
  A higher rate of conversion to open surgery is a well-known problem in patients with acute cholecystitis undergoing laparoscopic cholecystectomy. The aim of this study is to analyze factors which may impact on conversion rates, and to analyze our outcomes following implementation of a departmental strategy in reducing conversion rates.
  
  
  METHODS
  122 patients with acute cholecystitis were considered for laparoscopic cholecystectomy from July 2003 to July 2007. An audit of the results of laparoscopic cholecystectomy was done in July 2005 and a departmental strategy aimed at reducing the conversion rates was introduced. The strategies included early laparoscopic cholecystectomy (within 72 hours of admission), performed or supervised by specialist hepatobiliary surgeons, and modifications of operative techniques. This study compares the conversion rates before and after that audit. Forty-eight patients (group A) were from the preaudit period and the remaining 74 (group B) were from the postaudit period. A multivariate analysis was performed to identify risk factors for conversion to open surgery and whether the strategies implemented resulted in decrease in conversion rates.
  
  
  RESULTS
  In the group A patients, there was a conversion rate of 29.2%. Gallbladder wall thickness of greater than 5 mm was found to be a statistically significant (p = 0.028) risk factor for conversion to open surgery. In group B patients, the conversion rates were significantly lower at 6.75% (p = 0.001). Analyzing both groups of patients, using multivariate analysis, gallbladder wall thickness, increasing age, and preaudit operative period were found to be independently associated with conversion to open surgery.
  
  
  CONCLUSIONS
  This study demonstrated that, with specific strategies to decrease conversion and with technical improvements, the conversion rates can be decreased with no demonstrable difference in postoperative complications. Gallbladder wall thickness and increasing age are risk factors for conversion to open surgery.
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery Yong Loo Lin School of Medicine, National University Hospital, Singapore, 119074, Singapore.
authors.forename: Shiong-Wen
authors.initials: SW
authors.lastname: Low
authors.forename: Shridhar Ganpathi
authors.initials: SG
authors.lastname: Iyer
authors.forename: Stephen K-Y
authors.initials: SK
authors.lastname: Chang
authors.forename: Kenneth S W
authors.initials: KS
authors.lastname: Mak
authors.forename: Victor Tswen Wen
authors.initials: VT
authors.lastname: Lee
authors.forename: Krishnakumar
authors.initials: K
authors.lastname: Madhavan
mesh_terms: D000368:Aged; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000379:methods*; D041881:Cholecystitis, Acute / Q000175:diagnosis / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007813:Laparotomy / Q000379:methods / Q000706:statistics & numerical data; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D010149:Postoperative Pain / Q000503:physiopathology; D011183:Postoperative Complications / Q000175:diagnosis / Q000601:surgery*; D011336:Probability; D012189:Retrospective Studies; D018570:Risk Assessment; D017751:Safety Management; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome