Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
Surg Endosc. 2012 Feb;26(2):508-13. doi: 10.1007/s00464-011-1909-5. Epub 2011 Sep 23.
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.
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.
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.
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.
腹腔镜胆囊切除术（LC）是胆囊切除的金标准手术。然而，有时需要转为开腹手术。外科医生决定将腹腔镜手术转为开腹手术的因素复杂且尚未完全理解。随着开腹胆囊切除术经验的减少，该手术不再像以前那样是“安全”的替代方案。在这种即将到来的范式转变中，本研究旨在确定主要的中转原因，并最终制定指南以帮助降低中转率。
作者使用国家外科质量改进计划（NSQIP）数据库和财务记录，回顾性分析了 2002 年至 2009 年在他们机构进行的 1193 例胆囊切除术，并确定了 70 例中转病例。两名独立的外科医生审查了手术记录，并确定了中转的原因。评估了中转时的端口数量和中转前的分离程度，并用于创建新的中转分类。比较了新分组之间的住院时间（LOS）、30 天并发症、手术时间和费用以及医院费用。
在 91%的中转病例中，中转是选择性的。在这些中转病例中，有 49%的中转病例端口数量少于四个。根据新的中转分类，大多数中转是在没有或很少进行分离尝试的情况下进行的。各组之间的 LOS、并发症、手术室费用或医院费用均无差异。在六例紧急中转病例（9%）中，出血和对胆总管（CBD）损伤的担忧是主要原因。发生了一例 CBD 损伤。
在 49%的病例中，中转是在没有真正尝试腹腔镜分离的情况下进行的。考虑到对中转情况的这种新认识，作者建议外科医生在进行中转之前，真正尝试腹腔镜方法，例如放置四个端口并尝试提起胆囊。
