Open conversion for laparoscopically difficult cholecystectomy is still a valid solution with unsolved aspects
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(2019) 14:7
LETTER TO THE EDITOR
Open Access
Open conversion for laparoscopically difficult cholecystectomy is still a valid solution with unsolved aspects M. Mannino1, A. Toro2, M. Teodoro1, F. Coccolini3, M. Sartelli4, L. Ansaloni3, F. Catena5 and I. Di Carlo1*
Abstract The difficult laparoscopic cholecystectomy remains a surgical challenge for surgeons who must decide between laparoscopic continuation and open conversion. The balance between the lack of open surgery training of young surgeons and the risk of maintaining the laparoscopic approach in difficult laparoscopic cholecystectomy is still an unresolved problem. Furthermore, the time that must be spent in an attempt to complete laparoscopic surgery before conversion is still controversial. The authors in this letter discuss about these and other questions that still require an answer. Keywords: Open conversion, Difficult cholecystectomy, Laparoscopy
Background The multiple guidelines [1–4] that have tried in the past to solve the problem of difficult laparoscopic cholecystectomies have not solved the problem right now. Multiple aspects are unsolved such as when a procedure has to be converted, after how much, and when a patient has to be operated in open surgery. As no answers until now, the authors try with this letter to propose some questions that concern the problem in order to stimulate further studies that can help both surgeons and patients. Laparoscopic surgery has completely changed the clinical course of some surgical procedures. Among these procedures, laparoscopic cholecystectomy has had a revolutionary impact, changing the clinical management of related diseases forever. Although laparoscopy as a mandatory procedure has almost erased open surgery, difficult cholecystectomy due to acute cholecystitis still represents an actual challenge for surgeons performing laparoscopy. In these cases, the surgeon has to cure the patient and has to avoid complications that can worsen the patient’s quality of life forever. For this reason, the kind of procedure * Correspondence: [email protected] 1 Department of Surgical Sciences and Advanced Technologies “GF Ingrassia”, Cannizzaro Hospital, University of Catania, Via Messina, 829, 95126 Catania, Italy Full list of author information is available at the end of the article
that should be applied in cases of difficult acute cholecystitis is still undetermined. In fact, all the cases in which the Calot triangle cannot be approached safely due to the absence of a critical view of safety (CVS) require a different approach [1]. However, whether this approach has to be done by laparoscopy, by open surgery or by conversion during laparoscopy, as well as when to perform the approach, is still up for discussion. A couple of consensuses have been agreed upon (at minimum twice), establishing some of the points but not solving all of the issues [1, 2]. The most cited consensus is that of Tokyo (TG18), which has established guidelines. This manuscript states that the surgeons that persevere laparoscopically, in cases
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