Establishment of an evaluation system for conversion to laparotomy in laparoscopic cholecystectomy and exploration of surgical grading management

doi:10.16139/j.1007-9610.2025.01.10

Abstract

Abstract:

Objective To develop and validate a scoring system to predict the possibility of laparoscopic cholecystectomy (LC) conversion to laparotomy based on preoperative clinical data, and to establish a grading management model of surgery. Methods A retrospective analysis was conducted on the clinical data of 9 414 patients who underwent LC at Renhe Hospital and Huashan Hospital from June 2013 to June 2018. The patients were divided into two groups: the LC group (9 246 patients who successfully underwent LC) and the conversion to laparotomy group (168 patients who required conversion to open surgery). The data of two groups were compared, and the risk factors affecting conversion to laparotomy were screened out by single factor analysis of Chi-square test. Then, the risk factors were analyzed by multiple Logistic regression, and the pre-coefficient of each variable of the risk factors was assigned according to the established conversion to laparotomy possibility function. After calculating the score of each case, the difference in the actual conversion rate of each group was compared. The area under receiver operating characteristic (ROC) curve was calculated to evaluate the performance of the scoring system. According to the scoring system, LC surgical grading management model was created and verified. Results The following factors were identified as significant risk factors for conversion to laparotomy (P < 0.001): body temperature ≥ 38.5℃, frequency of acute cholecystitis ≥3 times, maximum thickness of gallbladder wall ≥ 5 mm, gallbladder neck stone incarceration, diameter of common bile duct ≥8 mm, and surgical experience ≤50 cases were the risk factors for conversion to laparotomy (P < 0.001). A score >3 points was associated with a high risk of conversion to laparotomy. Conclusions The LC scoring system and surgical grading management are reliable and effective tools for predicting and reducing the conversion rate of LC to laparotomy.

Key words: Laparoscopy, Cholecystectomy, Conversion to laparotomy, Risk factor, Scoring system

CLC Number:

ZHANG Nannan, GUO Jinxing, WU Gang, YI Hui, ZHOU Yuanhang, LIAO Zhiwei, HUANG Qi, DONG Jian. Establishment of an evaluation system for conversion to laparotomy in laparoscopic cholecystectomy and exploration of surgical grading management[J]. Journal of Surgery Concepts & Practice, 2025, 30(01): 54-60.

Figures/Tables 6

Tab 1

Tab 2

Tab 3

Fig 1

Tab 4

Tab 5

References 20

[1]	LE V H, SMITH D E, JOHNSON B L. Conversion of laparoscopic to open cholecystectomy in the current era of laparoscopic surgery[J]. Am Surg, 2012, 78(12):1392-1395. pmid: 23265130
[2]	PHILIP ROTHMAN J, BURCHARTH J, POMMERGAARD H C, et al. Preoperative risk factors for conversion of laparoscopic cholecystectomy to open surgery-a systematic review and meta-analysis of observational studies[J]. Dig Surg, 2016, 33(5):414-423.
[3]	HUSSAIN A. Difficult laparoscopic cholecystectomy: current evidence and strategies of management[J]. Surg Laparosc Endosc Percutan Tech, 2011, 21(4):211-217. doi: 10.1097/SLE.0b013e318220f1b1 pmid: 21857467
[4]	BOURGOUIN S, MANCINI J, MONCHAL T, et al. How to predict difficult laparoscopic cholecystectomy proposal for a simple preoperative scoring system[J]. Am J Surg, 2016, 212(5):873-881.
[5]	陆昌友, 徐勇, 薛瑞丰, 等. 预防腹腔镜胆囊切除术中胆管损伤的单中心经验[J]. 肝胆外科杂志, 2022, 30(1):48-51.
	LU C Y, XU Y, XUE R F, et al. Pereventing bile duct injury in laparoscopic cholecystectomy: single-center experience[J]. J Hepatobiliary Surgery, 2022, 30(1):48-51.
[6]	INOUE K, UENO T, DOUCHI D, et al. Risk factors for difficulty of laparoscopic cholecystectomy in grade Ⅱ acute cholecystitis according to the Tokyo guidelines 2013[J]. BMC Surg, 2017, 17(1):114.
[7]	ABELSON J S, AFANEH C, RICH B S, et al. Advanced laparoscopic fellowship training decreases conversion rates during laparoscopic cholecystectomy for acute biliary diseases: a retrospective cohort study[J]. Int J Surg, 2015,13:221-226.
[8]	彭腊玲, 刘琳, 卜春花, 等. 急症腹腔镜胆囊切除术中转开腹的预警模型构建与验证[J]. 腹腔镜外科杂志, 2022, 27(6):447-453.
	PENG L L, LIU L, PIAO C H, et al. Construction and verification of an early warning model for switching to laparotomy during emergency laparoscopic cholecystectomy[J]. J Laparosc Surg, 2022, 27(6):447-453.
[9]	胡国治, 蔡国英, 郭永忠, 等. 508例急性胆囊炎行腹腔镜胆囊切除术的量化手术指征探讨[J]. 中国内镜杂志, 2007, 13(7):735-737.
	HU G Z, CAI G Y, GUO Y Z, et al. Study in the quan-tiatative operative indication of laparoscopic cholesystectomy in acute cholesystitis[J]. China J Endosc, 2007, 13(7):735-737.
[10]	JOSHI M R, BOHARA T P, RUPAKHETI S, et al. Pre-operative prediction of difficult laparoscopic cholecystectomy[J]. J Nepal Med Assoc, 2015, 53(200):221-226.
[11]	RAMAN J D, LIN Y K, SHARIAT S F, et al. Preoperative nomogram to predict the likelihood of complications after radical nephroureterectomy[J]. BJU Intern, 2017, 119(2):268-275.
[12]	吴品飞, 刘杰凡, 顾勇劲, 等. 腹腔镜胆囊切除术中转开腹200例危险因素分析[J]. 肝胆胰外科杂志, 2016, 28(4):329-331.
	WU P F, LIU J F, GU Y J, et al. Analysis of risk factors in 200 cases of laparoscopic cholecystectomy switching to laparotomy[J]. J Hepatopancreatobiliary Surg, 2016, 28(4):329-331.
[13]	仝仲凯, 郝志强, 王志斌. 急性结石性胆囊炎患者腹腔镜胆囊切除术中转开腹手术的影响因素分析[J]. 中国临床医生杂志, 2022, 50(12):1474-1476.
	TONG Z K, HAO Z Q, WANG Z B. Analysis of factors influencing conversion to open surgery in laparoscopic cholecystectomy of patients with acute calculous cholecystitis[J]. Chin J Clin, 2022, 50(12):1474-1476.
[14]	AL MASRI S, SHAIB Y, EDELBI M, et al. Predicting conversion from laparoscopic to open cholecystectomy: a single institution retrospective study[J]. World J Surg, 2018, 42(8):2373-2382. doi: 10.1007/s00268-018-4513-1 pmid: 29417247
[15]	邹细光, 朱芬如, 袁亚敏, 等. 急性结石性胆囊炎LC中转开腹影响因素分析[J]. 江西医药, 2022, 57(11):1832-1834.
	ZOU X G, ZHU F R, YUAN Y M, et al. Analysis of inf-luencing factors of LC transition to laparotomy in acute calculous cholecystitis[J]. Jiangxi Med J, 2022, 57(11):1832-1834.
[16]	TOSUN A, HANCERLIOGULLARI K O, SERIFOGLU I, et al. Role of preoperative sonography in predicting conversion from laparoscopic cholecystectomy to open surgery[J]. Eur J Radiol, 2015, 84(3):346-349. doi: S0720-048X(14)00574-9 pmid: 25579475
[17]	BEKSAC K, TURHAN N, KARAAGAOGLU E, et al. Risk factors for conversion of laparoscopic cholecystectomy to open surgery: a new predictive statistical model[J]. J Laparoendosc Adv Surg Tech A, 2016, 26(9):693-696. doi: 10.1089/lap.2016.0008 pmid: 27385483
[18]	JAMEEL S M, BAHADDIN M M, MOHAMMED A A. Grading operative findings at laparoscopic cholecystectomy following the new scoring system in Duhok governorate: cross sectional study[J]. Ann Med Surg (Lond), 2020, 23(60):266-270.
[19]	董汉华, 武齐齐, 陈孝平. 急性胆道感染东京指南(2018版)更新解读[J]. 临床外科杂志, 2019, 27(1):5-9.
	DONG H H, WU Q Q, CHEN X P. Tokyo guidelines for acute biliary tract infections (2018) updated interpretation[J]. J Clin Surg,2019, 27(1):5-9.
[20]	满高亚, 党同科, 吴清松. Rouviere沟引导胆囊后隧道解剖用于困难腹腔镜胆囊切除术[J]. 外科理论与实践, 2022, 27(3):239-243.
	MAN G Y, DANG T K, WU Q S. Rouviere’s sulcus guided retro-gallbladder tunnel dissection in difficult laparoscopic cholecystectomy[J]. J Surg Concepts Pract, 2022, 27(3):239-243.

Characteristic		LC group (n=9 246)	Transfer laparotomy group（n=168）	χ² value	P value
Gender: male		4 186（45.3）	69（41.1）	1.176	0.278
Age ≥ 65 years		2 192（23.7）	41（24.4）	0.044	0.833
BMI≥ 28 kg/m²		280（3.0）	6（3.6）	0.165	0.684
Diabetes		325（3.5）	10（6.0）	2.856	0.091
History of upper abdominal surgery		564（6.1）	15（8.9）	2.287	0.130
Body temperature≥38.5℃		1 524（16.5）	105（62.5）	244.173	<0.001
Murphy sign positive		2 775（30.0）	110（65.5）	97.634	<0.001
Frequency of acute cholecystitis ≥3 times		3 246（35.1）	96（57.1）	34.991	<0.001
Duration of acute cholecystitis ≤72 h		3 452（37.3）	68（40.5）	0.695	0.404
Total bilirubin ≥23 μmolL		1 235（13.4）	58（34.5）	62.393	<0.001
Maximum cross-section of gallbladder ≥5 cm×10 cm or ≤ 3 cm×4 cm		1 975（21.4）	32（19.0）	0.526	0.468
Maximum thickness of gallbladder wall ≥5 mm		1 885（20.4）	72（42.9）	50.593	<0.001
Gallbladder neck stone incarceration		1 025（11.1）	60（35.7）	98.149	<0.001
Diameter of common bile duct ≥8 mm		725（7.8）	62（36.9）	181.928	<0.001
Surgical experience	≤50 cases	835（9.0）	78（46.4）	280.787	<0.001
	51-200 cases	2 864（31.0）	55（32.7）
	>200 cases	5 547（60.0）	35（20.8）

Characteristic		Regression coefficient	Wald χ²	P value	OR	95% CI
Body temperature≥38.5℃		1.578	72.113	<0.001	4.847	3.367-6.978
Frequency of acute cholecystitis ≥3 times		0.754	19.266	<0.001	2.125	1.518-2.976
Maximum thickness of gallbladder wall ≥5 mm		1.195	46.175	<0.001	3.305	2.341-4.666
Gallbladder neck stone incarceration		1.667	76.388	<0.001	5.297	3.645-7.698
Diameter of common bile duct ≥8 mm		1.858	98.958	<0.001	6.414	4.447-9.249
Surgical experience	≤50 cases	2.09	80.443	<0.001	8.088	1.816-4.419
	51-200 cases	1.041	21.077	<0.001	2.833	5.122-12.771

Evaluate project		Scores
Body temperature≥38.5℃		1.5
Frequency of acute cholecystitis ≥3 times		0.5
Maximum thickness of gallbladder wall ≥5 mm		1
Gallbladder neck stone incarceration		1.5
Diameter of common bile duct ≥8 mm		2
Surgical experience	>200 cases	0
	51-200 cases	1
	≤50 cases	2

Surgical experience Objective factor scale evaluation score: X	X>3	2<X≤3	1<X≤2	X≤1
≤50 cases	high-risk	high-risk	high-risk	LC
51-200 cases	high-risk	high-risk	LC	LC
>200 cases	high-risk	LC	LC	LC

Item	Before use	After use	χ² value	P value
LC cases	9 414	620
Direct laparotomy	0	15
Conversion to laparotomy	168(1.78)	4(0.65)	4.482	<0.05