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\title{The Enormous Size of the Gallblader-A Reason for Conversion to Open Surgery in Acute Cholecystitis}
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             \author[1]{Rexhep  Selmani}

             \affil[1]{  University Clinic of Digestive Surgery}

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\date{\small \em Received: 12 April 2013 Accepted: 1 May 2013 Published: 15 May 2013}

\maketitle


\begin{abstract}
        


Introduction: Laparascopic cholecystectomy is considered the treatment of choice for cholelithiasis. Laparosopic cholecystectomy can be safely performed in patients with acute cholecystitis, but there is a difference between conversion rates in patients operated within 72 hours from the onset of the symptoms and those after. The main reason for conversion on early laparoscopic cholecystectomy is the inflammation that interferes and makes the anatomy of the Calot?s triangle less visible, while other factors for the conversion of laparoscopic cholecystectomy in acute cholecystitis are the timing of the operation, age, BMI, CRP, white blood cell count (WBC), fever, tenderness in the right upper abdomen and ultrasonographic finding of  extremely thickened gallbladder wall, close relation of the Hartmann?s pouch with hepaticoduodenal ligament, the gallbladder size and the number and size of stones. Case presentation: Here we present a case of 74 year old female patient, who presented at our institution with 6 day history of abdominal pain, nausea and fever, with physical, laboratory and ultrasound signs of acute cholecystitis. She underwent an laparoscopic exploration of  abdominal cavity in order to perform laparoscopic cholecystectomy. Because of  extremely large and thickened gallbladder wall and short xyphoid-umbilicus distance, conversion was mandated. Conclusion: The enormous size of gallbladder in patients with acute cholecystitis, accompanied with short xyphoid-umbilicus distance can be a reason for conversion to open surgery during laparoscopic cholecystectomy.

\end{abstract}


\keywords{acute cholecystitis, laparoscopic cholecystectomy, size of the gallbladder, conversions.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction ouret introduced laparoscopic cholecystectomy in 1987. It has rapidly replaced open cholecystectomy as the standard treatment (1).}]{Introduction ouret introduced laparoscopic cholecystectomy in 1987. It has rapidly replaced open cholecystectomy as the standard treatment (1).}\par
Laparascopic cholecystectomy is considered the treatment of choice for cholelithiasis. It has advantages over traditional open cholecystectomy in terms of minimal post operative pain, shorter hospital stay, better cosmesis and earlier recovery (2,3). With growing experience and overcoming the learning curve, a selection criterion has become more liberal. Most of the previous contraindications such as morbid obesity, previous upper abdominal surgery and acute cholecystitis are no longer absolute. Attempts can be made in all cases of gall stone diseases with laparoscopic procedure except for patients with bleeding diathesis, carcinoma gallbladder and patient not fit for general anaesthesia(4). However, of all LC 1-13\% requires conversion to an open if the anatomy of Calot's triangle is not clear or an uncontrolled bleeding occurs (5).\par
Laparoscopic cholecystectomy can be safely performed in patients with acute cholecystitis; however, the rate of conversion remains higher when compared with patients having chronic cholecystitis(6,7), but without statistically significant difference \hyperref[b0]{(8)}. However, there is a difference between conversion rates in patients operated within 72 hours from the onset of the symptoms and those after \hyperref[b0]{(8)}. Adhesions are amongst the common reasons for conversion of laparoscopic cholecystectomy \hyperref[b1]{(9)}. The main reason for conversion on early laparoscopic cholecystectomy is the inflammation that interferes and makes the anatomy of the Calot's triangle less visible \hyperref[b0]{(8,}\hyperref[b2]{10)}. Thus, for surgeons it would be helpful to establish criteria that would assess the risk of conversion preoperatively. The preoperative predictive factors for the conversion of laparoscopic cholecystectomy in acute cholecystitis are the timing of the operation, age, BMI, CRP, white blood cell count (WBC), fever, tenderness in the right upper abdomen and ultrasonographic finding of extremely thickened gallbladder wall, close relation of the Hartmann's pouch with hepaticoduodenal ligament, the gallbladder size and the number and size of stones (5,8). Here we present a case of 74 year old female (Figure  {\ref 1}), with fluid supra-and sub-hepatically. Free air within the gallbladder wall was not seen. She was admitted to our hospital with the diagnosis of acute cholecystitis. 
\section[{II.}]{II.} 
\section[{Case Presentation}]{Case Presentation}\par
Figure  {\ref 1 :} . Although 6 day of history of abdominal pain the laparosopic cholecystectomy was considered the treatment of choice. After short preoperative preparation the patient was sent to operating theatre. The laparoscopy revealed enormously large, strongly dilated and empyematic gallbladder extending down to the right iliac fossa, with thickened wall very difficult for grasping. We punctuate the gallbladder and evacuated more than 150 ml of fluid to be able to grasp the gallbladder. Because of extremely large gallbladder and patient's relatively short xiphoid-umbilicus distance of 12,7 cm, grasping the the cephalic traction over the surface of the liver and handling with laparosopic instruments was practically impossible.   
\section[{Discussion}]{Discussion}\par
Conversion rates of 2.6\% to 14\% had been described in literature (6,11). During the first 3 days of the onset of symptoms the conversion rate is significantly lower than in patients operated after 72 hours of the beginning of the disease \hyperref[b0]{(8)}. The main reason for the conversion at early laparoscopic cholecystectomy is the inflammation that covers the view to triangle of Callot(  {\ref 12}), while at delayed cholecystectomy those are the fibrotic adhesions \hyperref[b4]{(12,}\hyperref[b5]{13)}. Severe inflammation accompanied with fibrosis leads to greater chance of billiary tract lesions \hyperref[b7]{(14)}.\par
Conversion was necessary because of abnormal anatomy in meaning of disproportion between the size of the gallbladder and the size and the configuration of the patient's abdomen making grasping and handling the tense and thickened gallbladder, practically impossible. The gallbladder measured 19,5 cm, with very thick gallbladder wall, which was stiff, with fibrotic changes. Patients with enormous gallbladder size and acute cholecystitis tend to impose technical difficulties during laparoscopic cholecystectomy. In around 87\% of the patients with gallbladder wall thickening (>4 millimeter) surgeons encountered surgical difficulties \hyperref[b9]{(15,}\hyperref[b10]{16)}.  The additional difficulty for the conversion in our case was very short xiphoid-umbilicus distance of 12.7 cm only, including the enormous gallbladder size, creating the difficulty in positioning of the trocars and their angulation which led to poor visualization of the operative field. umbilicus in cadaveric study, was reported to be 18.2 ± IV. 
\section[{Conclusion}]{Conclusion}\par
Apart from the most common and well known reason for conversion to open surgery of laparoscopic cholecystectomy in patients with acute cholecystitis, the enormous size of the gallbladder can also be the reason. The additional difficulty in conversions with enormous size of gallbladder can be the short xiphoidumbilicus distance.\par
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\begin{longtable}{P{0.7459183673469387\textwidth}P{0.0067460317460317455\textwidth}P{0.03469387755102041\textwidth}P{0.008673469387755102\textwidth}P{0.0067460317460317455\textwidth}P{0.04047619047619047\textwidth}P{0.0067460317460317455\textwidth}}
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\end{bibitemlist}
 			 		 	 
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