Using a risk score for conversion from laparoscopic to open cholecystectomy in resident training.

BACKGROUND

We previously developed a risk score for conversion from laparoscopic to open cholecystectomy (RSCLO). The aim of this study is to validate this scoring system in a new patient population and test its use in case selection for resident training.

METHODS

The data of 1,000 laparoscopic cholecystectomies (LC) that had been performed in our clinic between 1992 and 1999 were analyzed retrospectively, and RSCLO was developed. Scores take values between -20 and 41; values below -3 represent low risk, and values over -3 represent high risk. Analyses in this group of patients showed that at least 15 cases have to be performed for adequate LC training. The current study is a clinical prospective study based on data of the previous study and evaluates RSCLO in a new patient population of 400 LCs. All patients were scored preoperatively; surgeons who had performed 15 or fewer LCs previously operated only patients with a score below -3. Patients with high scores (>values of -3) were operated only by surgeons who had performed at least 16 LCs. Results of the first 1,000 cases and later 400 cases (new patient population of the current study) were compared in terms of conversion to open cholecystectomy, complications, and operation times.

RESULTS

Both in the first 1,000 patients and later in 400 patients, increasing scores resulted with higher conversion rates and complication rates and longer operation times (P<.05). In the later 400 patients, conversion rate (4.8% vs 3.0%, P=.08), complication rate (5.5% vs 3.5%, P=.07), and mean operation time (56.8 min vs 52.5 min, P=.004) were decreased when compared with the first 1,000 patients. In resident training cases, conversion and complication rates decreased to 0%, and mean operation time was shortened by nearly 10 minutes. In high-score difficult cases, conversion and complication rates decreased, and mean operation time was shortened by nearly 20 minutes.

CONCLUSIONS

This risk score can predict the difficulty of LC cases reliably. Scoring patients preoperatively can decrease the problems in training cases, and management of difficult cases may be left to experienced surgeons.