title: Laparoscopic cholecystectomy after a quarter century: why do we still convert?
abstract: BACKGROUND
  Laparoscopic cholecystectomy (LC) is the gold standard procedure for gallbladder removal. However, conversion to open surgery is sometimes needed. The factors underlying a surgeon's decision to convert a laparoscopic case to an open case are complex and poorly understood. With decreasing experience in open cholecystectomy, this procedure is however no longer the "safe" alternative it once was. With such an impending paradigm shift, this study aimed to identify the main reasons for conversion and ultimately to develop guidelines to help reduce the conversion rates.
  
  
  METHODS
  Using the National Surgical Quality Improvement Program (NSQIP) database and financial records, the authors retrospectively reviewed 1,193 cholecystectomies performed at their institution from 2002 to 2009 and identified 70 conversions. Two independent surgeons reviewed the operative notes and determined the reasons for conversion. The number of ports at the time and the extent of dissection before conversion were assessed and used to create new conversion categories. Hospital length of stay (LOS), 30-day complications, operative times and charges, and hospital charges were compared between the new groups.
  
  
  RESULTS
  In 91% of conversion cases, the conversion was elective. In 49% of these conversions, the number of ports was fewer than four. According to the new conversion categories, most conversions were performed after minimal or no attempt at dissection. There were no differences in LOS, complications, operating room charges, or hospital charges between categories. Of the six emergent conversions (9%), bleeding and concern about common bile duct (CBD) injury were the main reasons. One CBD injury occurred.
  
  
  CONCLUSIONS
  In 49% of the cases, conversion was performed without a genuine attempt at laparoscopic dissection. Considering this new insight into the circumstances of conversion, the authors recommend that surgeons make a genuine effort at a laparoscopic approach, as reflected by placing four ports and trying to elevate the gallbladder before converting a case to an open approach.
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
authors.forename: Balazs I
authors.initials: BI
authors.lastname: Lengyel
authors.forename: Dan
authors.initials: D
authors.lastname: Azagury
authors.forename: Oliver
authors.initials: O
authors.lastname: Varban
authors.forename: Maria T
authors.initials: MT
authors.lastname: Panizales
authors.forename: Jill
authors.initials: J
authors.lastname: Steinberg
authors.forename: David C
authors.initials: DC
authors.lastname: Brooks
authors.forename: Stanley W
authors.initials: SW
authors.lastname: Ashley
authors.forename: Ali
authors.initials: A
authors.lastname: Tavakkolizadeh
mesh_terms: D016063:Blood Loss, Surgical; D002763:Cholecystectomy / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; D017081:Cholecystectomy, Laparoscopic / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data; D003135:Common Bile Duct / Q000293:injuries; D004638:Emergency Treatment / Q000706:statistics & numerical data; D017722:Hospital Charges; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies