Thompson M H, Benger J R
The Department of Surgery, Southmead Hospital, Bristol, United Kingdom.
HPB Surg. 2000 Aug;11(6):373-8. doi: 10.1155/2000/56760.
Faced with a difficult laparoscopic cholecystectomy the surgeon may feel that conversion to open operation would risk greater complications because of the laparotomy. Information on the effect of conversion is lacking. The purpose of this study is to measure the complications of laparoscopic cholecystectomy and observe the effect of the conversion rate.
A total of 957 patients were studied. There were three consecutive series of patients; the first undergoing open cholecystectomy (384 patients), the second laparoscopic cholecystectomy with a 5.8% conversion rate (412 patients) and the third laparoscopic cholecystectomy with a 1.3% conversion rate (161 patients). Data was collected prospectively using a continuous audit, and the complication rate compared on an intention to treat basis. In addition a panel of experienced surgeons was asked to score the complications depending on their severity and a composite complication score calculated. Comparison between the 3 groups was then undertaken.
Open cholecystectomy produced a post-operative complication rate of 6%. Initially this appeared to fall to 3.1% with the introduction of laparoscopic cholecystectomy, but when the complications occurring in the converted patients were included (i.e., on an intention to treat basis) the rate increased to 5.6% in the first group of laparoscopically-treated patients and 3.1% in the second. These differences were not statistically significant. A similar pattern emerged when scoring the severity of the complications as judged by the expert panel. The inclusion of intra-operative complications appears to remove any small advantage for laparoscopic cholecystectomy. The reduction in the conversion rate between the two laparoscopic groups from 5.8% to 1.2% was statistically significant.
When considered on an intention to treat basis laparoscopic cholecystectomy offers no advantage over open operation in terms of the frequency or severity of complications. Reducing the frequency of conversion from a laparoscopic to an open procedure also has no significant effect on the complications encountered. We conclude, therefore, that the complication rate is independent of the conversion rate and that the surgeon, when faced with difficulty at laparoscopic cholecystectomy, should not be deterred from converting to open operation for fear of the post-operative consequences.
面对困难的腹腔镜胆囊切除术时，外科医生可能会觉得转为开腹手术会因剖腹术而带来更高的并发症风险。目前缺乏关于转为开腹手术影响的相关信息。本研究的目的是衡量腹腔镜胆囊切除术的并发症，并观察中转率的影响。
共对957例患者进行了研究。患者分为连续的三组；第一组接受开腹胆囊切除术（384例患者），第二组接受腹腔镜胆囊切除术，中转率为5.8%（412例患者），第三组接受腹腔镜胆囊切除术，中转率为1.3%（161例患者）。采用连续审计前瞻性收集数据，并在意向性治疗的基础上比较并发症发生率。此外，邀请一组经验丰富的外科医生根据并发症的严重程度进行评分，并计算综合并发症评分。然后对三组进行比较。
开腹胆囊切除术的术后并发症发生率为6%。最初，随着腹腔镜胆囊切除术的引入，该发生率似乎降至3.1%，但当纳入中转患者发生的并发症时（即在意向性治疗的基础上），第一组腹腔镜治疗患者的发生率升至5.6%，第二组为3.1%。这些差异无统计学意义。在由专家小组判断并发症严重程度时也出现了类似的模式。纳入术中并发症似乎消除了腹腔镜胆囊切除术的任何微小优势。两个腹腔镜组之间的中转率从5.8%降至1.2%具有统计学意义。
在意向性治疗的基础上考虑，腹腔镜胆囊切除术在并发症的发生率或严重程度方面并不比开腹手术更具优势。降低从腹腔镜手术转为开腹手术的频率对所遇到的并发症也没有显著影响。因此，我们得出结论，并发症发生率与中转率无关，并且外科医生在腹腔镜胆囊切除术遇到困难时，不应因担心术后后果而不敢转为开腹手术。
