Predictors for Conversion to Open Appendectomy in Patients Undergoing Laparoscopic Appendectomy Based on Clinical Presentations on Ultrasonography Findings and Tzanaki's Scoring

Abstract

Background: Laparoscopic appendectomy (LA) may need to be converted to open appendectomy (OA) if intraoperative complications or severity of the disease hinders with a safe laparoscopic intervention. This may be in the form of abnormal position of appendix, adhesion due to previous inflammations, appendix mass, abscess, perforated appendix and diffuse peritonitis or other pelvic or right iliac fossa pathologies or technical problems, and lack of space for dissection. Even though these pathologies can be dealt with minimal access surgery, conversion to open surgery may become mandatory in a small number of cases. The presence of comorbidities is the independent factor related to conversion during laparoscopic appendicectomy. 1 Materials and methods: The study was carried out in PG Department of Surgery, SRN Hospital associated with MLN Medical College, Prayagraj from September 2018 to September 2019 after approval from the ethical committee and after obtaining written and informed consent either from patient or their legal heir. The study was conducted on the patients admitted in the Department of Surgery, SRN Hospital, MLN. Medical College between September 2018 and September 2019 who underwent conversion appendicectomy. Patients were evaluated and their complete biodata were recorded after taking detailed history. Based on history, clinical examination, laboratory investigations, and ultrasound of abdomen and pelvis, appendicitis diagnosed. The parameters studied include age, sex, previous history of acute appendicitis any lower abdominal surgeries in the past, symptoms, duration of symptoms, sign, white blood cell (WBC) count, ultrasound abdomen and pelvis findings, American Society of Anesthesiologists (ASA) grading, and intraoperative findings including reasons for conversion. Results: Multivariable analysis incorporating these factors available to the surgeon preoperatively identified advanced age, ASA score > 2 points, severity of adhesion in ultrasonography (USG), significantly associated with conversion. These results highlight the complex nature of the decision to convert, in as much as baseline patient characteristics, disease severity, and surgeon factor each independently impact the probability of the successful laparoscopic procedure. Conversion in our study was significantly associated with comorbidities as out of 11 patients with comorbidities [6 hypertension (HTN), 4 diabetes mellitus (DM), 1 asthma], 10 (90.90%) were converted to OA with significant p value ( p = 0.00001). Among nine patients with ASA grade > 2 points, eight were converted to OA. Total leukocyte count was > 12,000 in 25 patients (41.67%) out of which 9 patients (36%) were converted to OA. In this study, 21 patients (35%) had score ≤ 9, while 39 patients (65%) had score ≥ 10. Eleven patients (52.38%) were converted to OA out of 21 having score ≤ 9 in comparison to 1 patient (2.56%) out of 39 patients having score ≥ 10. Conclusion: W e identified preoperatively, predictors for conversion of LA to OA consisting of age ≥ 40, comorbidity, ASA grade > 2 point, leukocytosis, right iliac fossa lump and Tzanaki’s score < 9 point. By using this, we proceed directly to OA under these circumstances may reduce operative time and expenses by conversion to OA.