The American Journal of Surgery (2009) 197, 781-784

Clinical Surgery-American

Surgical outcomes of open cholecystectomy in the

laparoscopic era
Andrea S. Wolf, M.D., Bram A. Nijsse, B.S., Suzanne M. Sokal, M.S.P.H.,
Yuchiao Chang, Ph.D., David L. Berger, M.D.*

Department of Surgery, Massachusetts General Hospital, Boston, MA, USA

KEYWORDS: Abstract
Cholecystitis; BACKGROUND: Although laparoscopic cholecystectomy has become the standard of care for
Cholelithiasis; symptomatic cholelithiasis and cholecystitis, 10% to 30% of cholecystectomies are still performed in
Laparoscopic open fashion. Because the total number of cholecystectomies is increasing with time, the average
conversion to open patient undergoing open cholecystectomy in the laparoscopic era is older and has more comorbidities.
procedure; METHODS: The records of 1629 consecutive patients who underwent cholecystectomy from July
Laparoscopy; 1997 to September 2006 were evaluated. Analysis of variance, chi-square test, logistic regression, and
Open cholecystectomy linear regression were used to compare the following outcomes: length of procedure, length of stay,
readmission (within 15 days and within 31 days), reoperation, and complication.
RESULTS: Major complications (death, bile duct injury, bile leak, or bleeding requiring reoperation
or transfusion) occurred more frequently in laparoscopic cholecystectomy patients who were coverted
to open procedure (5.9%) than in those who underwent open cholecystectomy (4.4%). Mortality rates
were 2.9%, 1.5%, and 0% for open, converted, and laparoscopic cholecystectomy, respectively.
CONCLUSIONS: Older patients, male patients, and patients with previous upper abdominal surgery are
at higher risk for mortality. They should be considered for open cholecystectomy given their increased
likelihood of major complications when laparoscopic cholecystectomy is converted to open surgery.
2009 Elsevier Inc. All rights reserved.

The introduction of laparoscopic cholecystectomy revolu-
tionized the management of symptomatic cholelithiasis and
cholecystitis.13 Although both laparoscopic and open chole-
cystectomy are safe and effective procedures, laparoscopic
cholecystectomy has become the standard of care.1,4 6 Never-
theless, because of a host of preoperative factors and unantic-
ipated conversions, 10% to 30% of cholecystectomies are still
performed in an open fashion.711 The laparoscopic technique
has been of great interest to general surgeons around the world
since its introduction in the late 1980s. The learning curve
* Corresponding author: Tel.: 617-724-6980; fax: 617-724-0067.
E-mail address: dberger@partners.org
Manuscript received January 14, 2008; revised manuscript May 22,
2008
associated with the new technique and the long-term advan-
tages of laparoscopic cholecystectomy have been studied and
reported in many series during the past 2 decades.1214
The advent of laparoscopy led to an increase in the total
number of cholecystectomies being performed, making the
average patient undergoing cholecystectomy (mostly lapa-
roscopic) younger and healthier. However, the average pa-
tient undergoing open cholecystectomy now has become
relatively older and sicker.15,16 As the subpopulations un-
dergoing laparoscopic and open cholecystectomy have
changed with time, it is no longer appropriate to compare
current patients with those from the past.13,13,17 This study
sought to define the characteristics and outcomes of patients
undergoing laparoscopic, open, and converted cholecystec-
tomy in the laparoscopic era.

0002-9610/$ - see front matter 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2008.05.010
782 The American Journal of Surgery, Vol 197, No 6, June 2009

Table 1 Patient characteristics

Characteristics Group 1 (open) Group 2 (conversion) Group 3 (laparoscopic) All groups

Age ( SD) 68.1 14.4* 62.7 12.9 49.3 15.4 51.7 16.4
Male sex (%) 51* 37 25 28
BMI 26.8 6.5 29.3 6.6 29.5 6.7 29.2 6.7
ASA (%)
I 2.2 2.9 22.1 19.3
II 41.2 67.6 66.4 64.0
III 51.5* 25.0 9.5 14.3
IV 4.4%* 2.9 .5 1.0
History of abdominal surgery (%)
None 44.1 48.5 60.8 58.6
Lower 31.6 41.2 37.1 36.8
Upper 9.6* 5.9 1.2 2.2
Both 14 4.4 .8 2.3
BMI body mass index.
*P .001 when compared with group 2.
There was no statistically significant difference in BMI among the 3 groups.

Materials and Methods National Surgical Quality Improvement Program, complica-

After obtaining Institutional Review Board approval, the
records of 1629 consecutive patients who underwent cholecys-
tectomy from July 1997 to September 2006 were evaluated.
All operations were performed by a single surgeon. Whether to
initiate the operation laparoscopically was entirely at the sur-
geons discretion. In general, open cholecystectomy was pre-
ferred in selected patients based on generalized assessment
involving such features as male sex, obesity, history of previ-
ous upper abdominal surgery, and signs of sepsis from chole-
cystitis. After excluding cholecystectomies performed during
other abdominal procedures, patients were divided into 3
groups: group 1 consisted of 136 open cholecystectomy pa-
tients; group 2 consisted of 68 patients who were converted
from laparoscopic to open cholecystectomy; and group 3 con-
sisted of 1210 laparoscopic cholecystectomy patients.
Medical records were reviewed retrospectively for the fol-
lowing variables: length of procedure, length of stay, readmis-
sion (within 15 days and within 31 days), reoperation, and
complications. Length of procedure was measured in minutes
from the time of incision until the time of skin closure. Length
of stay was measured from admission until discharge. As in the
tions that occurred after 31 days postoperatively were exclud-
ed.18 Similarly, readmissions, reoperations, and complications
that occurred outside this institution and readmissions and
reoperations that occurred after 31 days were excluded. Death,
bile duct injury, bile leak, and bleeding requiring reoperation or
transfusion were classified as major complications. All other
complications were classified as minor.
Analysis of variance and chi-square tests were used to
compare patient characteristics. Logistic regression models
were used to compare dichotomized outcomes (complications,
death, readmission, and reoperation), and linear regression
models were used to compare continuous outcomes (length of
stay and length of procedure in the log scale) controlling for
sex and American Society of Anesthesiologists (ASA) class.
Results
Patients
Patient characteristics are displayed in Table 1. Patients in
group 1 were older and more commonly had undergone pre-

Table 2 Main outcome measures

Outcomes Group 1 (open) Group 2 (conversion) Group 3 (laparoscopic) All groups

No. of complications (%) 46 (34)* 20 (29)* 77 (6.4) 143 (10)
No. of major complications 6 (4.4) 4 (5.9)* 14 (1.2) 24 (1.7)
Mortality 4 (2.9)* 1 (1.5)* 0 (0) 5 (.4)
Length of procedure (min) 41.3 19.2 57.3 22.8* 33.1 15.2 35.0 17.0
Length of stay (d) 6.9 7.6* 6.0 9.3* 1.3 2.7 2.0 4.4
15-day readmission (%) 6.6 10* 2.2 3.0
31-day readmission (%) 8.1 8.8 3.0 3.7
Reoperation (%) 0 4.4* .6 .7
*P .05 compared with group 3.
A.S. Wolf et al. Surgical outcomes of open cholecystectomy 783

Table 3 Major complications

Major Group 1 (open) Group 2 (conversion) Group 3 (laparoscopic) Total

complications n 136 n 68 n 1210 n 1414
No. bile leak (%) 2 (1.5) 1 (1.5) 11 (.9) 14 (1)
No. bleeding (%) 0 (0) 1 (1.5) 3 (.2) 4 (.3)
No. CBD injury (%) 0 (0) 1 (1.5) 0 (0) 1 (.07)
No. dead (%) 4 (0) 1 (1.5) 0 (0) 5 (.4)
Total (%) 6 (4.4) 4 (5.9) 14 (1.2) 24 (1.7)
CBD common bile duct.

vious upper abdominal surgery, and more than half of these
patients had an ASA score of III or IV (severe systemic
disease). Patients in group 3 were younger and rarely had
undergone previous upper abdominal surgery, and only 10% of
these patients were ASA score III or IV. The average age,
percentage of patients with previous upper abdominal surgery,
and percentage of patients with ASA classification of III or IV
in group 2 were in between those in groups 1 and 3. Interest-
ingly, average body mass index was not significantly different
among the 3 groups. The overall conversion rate was 4.8%,
decreasing from 6.3% in the first 350 cases to 3.3% in the last
364 cases.
group 2, and 11 in group 3. Four patients with postoperative
bleeds required reoperation for evacuation.
With only 5 deaths in a 10-year study period, overall
mortality was low (.4%). Mortality rates were 2.9%, 1.5%,
and 0% for groups 1, 2 and 3, respectively. Four deaths
occurred after open cholecystectomy; 4 of these patients
were 70 years and had ASA scores of III or IV. The only
death occurring after a laparoscopic procedure converted to
open procedure was in a 64-year-old man who was ASA
class IV and who developed postoperative pneumonia.
Comments

Main outcome measures Reports on patients undergoing open cholecystectomy

Outcomes for the 3 groups are displayed in Table 2. Overall
complication rates were 34%, 29%, and 6.4% for groups 1, 2,
and 3, respectively. Major complications, however, occurred
more frequently in group 2 (5.9%) than in group 1 (4.4%).
Fifteen-day readmission rates and reoperative rates were also
higher in group 2 than in group 1. Open procedures took less
time than converted procedures. Mean hospital length of stay
for open and converted procedures was not significantly dif-
ferent. As expected, complication rate, mortality, length of
procedure and length of stay were all significantly less in group
3 compared with groups 1 and 2.
Table 3 shows the distribution of specific major compli-
cations among the 3 groups. The only common bile duct
injury occurred during a laparoscopic case that was con-
verted to open in order to repair the injury successfully.
There was a total of 14 bile leaks: 2 in the group 1, 1 in
during the laparoscopic era are scarce. Studies comparing
laparoscopic and open cholecystectomy were performed
almost 2 decades ago.1,3,7,8,13,16,17
Table 4 compares the characteristics and outcomes of
open cholecystectomy from 1971 to 1990 with those from
1997 to 2006. Patients undergoing open cholecystectomy in
this study were older than those in previous studies. Previ-
ous studies of open cholecystectomy demonstrated that
older patients are at higher risk of complications and mor-
tality than their younger counterparts. In a large series from
1971 to 1990, Girard and Morin1 found that patients 70
years had a 13.8% complication rate and a 2.5% mortality
rate compared with 6.5 and .3%, respectively, for patients
age 50 to 70 years. In their review of 42,474 patients who
underwent open cholecystectomy, Roslyn et al3 found a
complication rate of 26% in patients 65 years and 10% in
those 65 years.3 The increased age and comorbidities of

Table 4 Outcomes of open cholecystectomy

Study No. of Patient Morbidity Major Mortality

Study period cases age (y) M:F Ratio LOP (min) LOS (d) (%) complications (%)
This study 19972006 135 68.1 1:1 41.3 6.9 34 4.4 2.9
Roslyn et al3 19881989 42,474 60 1:3 14.7 .2 .17
Girard and Morin1 19711990 10,471 48 3:7 5.1 .3 .4
Cox et al17 19851889 457 52.5 1:3 73 6 9 3.5 0
Sanabria et al13 1989 121 45.3 1:3 94 6.4 9.1 0
LOP length of procedure; LOS length of stay.
784
patients selected for open cholecystectomy in the present
series may have contributed to the higher rates of compli-
cation and mortality in this study relative to these earlier
studies. In contrast, length of stay has not increased, likely
because of discharge pathways and current strict efforts to
limit hospital length of stay.
As described previously, the patients in group 1 were older,
comprised a higher percentage of ASA class III or IV and were
more likely to have undergone previous upper abdominal sur-
gery. Therefore, it is not surprising that patients in group 1 had
a higher total complication rate, mortality rate, and length of
stay. Patients in group 2, however, had higher rates of major
complications, reoperation, and readmission, implying that pa-
tients who undergo laparoscopic cholecystectomy and who are
converted to open procedure are more likely to have a com-
plicated postoperative course.
Several studies have described risk factors for converting
laparoscopic to open cholecystectomy: age, male sex, ad-
hesions in the region of the gallbladder, acute cholecystitis,
and obesity.19 21 The distribution of age, sex, and previous
upper abdominal surgery among patients in groups 1 and 3
likely reflects the surgeons decision to pursue open versus
laparoscopic cholecystectomy in these patients based on
their preoperative risk for conversion. By these criteria, one
would expect the patients in group 2 (who began as group 3
patients before conversion) to have characteristics similar to
patients in group 3. Patients in group 2, however, were
older, more often male, and more likely to have undergone
previous upper abdominal surgery than patients in group 3.
This implies that some of the higher risk patients ap-
proached laparoscopically might have been better served
with a straight open approach.
This study has several weaknesses. It is limited by sam-
ple size, especially for open cholecystectomy and converted
cases, thereby limiting the clinical significance of the com-
plication and mortality rates in these groups. In addition,
there is a major confounding variable in the converted group
in the tendency to convert a laparoscopic cholecystectomy
to open procedure in order to treat a complication; this is
exemplified by the single common bile duct injury that was
repaired in open fashion after the surgery was initiated
laparoscopically. Finally, this study is based on the experi-
ence of a single surgeon at a single institution. Although
there is uniformity in case selection in such a study, it is also
prone to the influence of bias and the learning curve of one
person. Nevertheless, this is a large series during a 10-year
period, and the results are still useful for comparison with
other surgeons results.
Cholecystectomy is a safe procedure with few postoper-
ative complications. In this series, major complications,
length of procedure, and rates of readmission and reopera-
tion were highest after conversion from laparoscopic to
open cholecystectomy compared with straight laparoscopic
or straight open cholecystectomy. The key to successful
patient outcomes is in careful patient selection for laparo-
scopic and open cholecystectomy. Older patients, male pa-
The American Journal of Surgery, Vol 197, No 6, June 2009
tients, and patients likely to have adhesions in the region of
the gallbladder (either from previous surgery in that area or
from acute cholecystitis) should be approached with cau-
tion. They may be better served with open cholecystectomy
rather than laparoscopic cholecystectomy when conversion
to open procedure is likely because the occurrence of major
complications is greatest in this setting.
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