Gallstone disease is prevalent worldwide though its prevalence varies by region. In western countries it ranges from approximately 8% in men to 16.6% in women, whereas in Asian countries it is 3% to 15 %, and in African countries it is less than 5%. The women develop gallstone disease more than men which may largely be due to extraneous risk factors, such as pregnancy and sex hormones.1
Cholecystectomy is the treatment of choice for symptomatic gallstones. It comprises of open and laparoscopic approaches. Laparoscopic cholecystectomy has rapidly become the preferred technique since early 1990`s, and the traditional open cholecystectomy has been replaced by laparoscopic cholecystectomy which is now the gold standard.3
Recently male gender has been recognized as risk factor in some developed countries for predicting a more severe disease , with more technical difficulties at the time of surgery, increased morbidity in those with symptomatic cholelithiasis and also for an increased conversion rate of laparoscopic cholecystectomy.4,5,6,7 Compared with female gender, males are most likely to have severe disease at presentation, previous hospitalization for acute cholecystitis, suppurative cholecystitis pancreatitis and longer operative time6,7,8
In this retrospective study, the medical records of all 615 patients admitted in surgical Unit -1 from January 2006 to January, 2009 (males: 113 , females 502) with symptomatic cholelithiasis fulfilling inclusion criteria were evaluated. Patients were evaluated in terms of clinical, hematological, biochemical and ultrasonographic parameters. All cases were operated by experienced senior surgeons. The independent variables were measured to evaluate severity of disease at presentation i.e. gender of the patient, age of the patients, acute cholecystitis, suppurative cholecystitis (empyema), pancreatitis. The criteria taken for diagnosis of acute cholecystitis were right upper quadrant pain with tenderness, pyrexia more than 100 F, total leucocyte count of 9000 cu mm or more and ultrasonographic findings of pericholecystic fluid & thickness of gallbladder wall more than 3mm. The dependent variables measured were duration of surgery, conversion rate of laparoscopic to open surgery, and post operative length of stay in the hospital.
Cholelithiasis with cholecystitis in males presents in a more severe disease form than females.8,9 Male gender has also been recognized as an important factor for difficult and delayed surgery, for both open and laparoscopic cholecystectomy with an increased conversion rate of laparoscopic to open surgery.4 In our study majority (81.6%) of the patients presenting with symptomatic cholelithiasis and subjected to cholecystectomy were female which is consistent with the national study by Mufti TS from Pakistan
Laparoscopic cholecystectomy is accepted as the gold standard treatment for symptomatic cholelithiasis, but the risk of conversion to open cholecystectomy is always present particularly in severe form of disease and in male gender.7 In our study, the effect of gender on the severity of disease in symptomatic cholelithiasis assessed by variables of acute cholecystitis (p<.05), and suppurative cholecystitis ( empyema) (p<.05), were significantly higher in consistent to other studies 9,13,14,15
Prior acute cholecystitis results in dense fibrotic adhesions that render dissection difficult at surgery. Gallbladder wall thickness is related to the inflammation or fibrosis that follows previous attack of cholecystitis., and it also reflects difficulty during dissection in delineating anatomy at calots triangle.10, 11, 12 The reason for severe form of cholecystitis, higher conversion and difficult cholecystectomy in male patients remains unexplained, though male gender has been a significant risk factor in most series8, 9, 12
The need to convert laparoscopic to open cholecystectomy is neither a failure nor a complication, but an attempt to avoid complications. It may be helpful to determine the risk of conversion to open cholecystectomy prior to surgery. More often these findings are not anticipated preoperatively and otherwise the procedure would have been scheduled for open rather than laparoscopically.9, 7, 12
Review of international and national studies show a conversion rate of 2% to 15 %.3, 12, 17, 18. A study from Singapore by Salleh Ibrahim shows conversion of 15.12% in men and 7.38% in women. Another study by Zisma A from Israel show conversion rate of 21% in men and 4.5% in females. A study by Simopoulous C from Greece show conversion rate of 7.3% in male and 4.6% in females. Another study by Russel JC from Connecticut shows conversion in male 8.4% and females 4.0%. Whereas studies by Lim K R from Singapore and by Yol S from Turkey did show that conversion rate was higher in men but statistically not found to have significant risk on conversion.11,13In our study conversion rate of 25.88% in males, and 07.14% in females is statistically significantly higher @P<0.05 in males as compared with females.
In case of conversion from laparoscopic to open cholecystectomy, the operating time and post operative length of hospital stay also increases. A study by Ibrahim S from Singapore show the mean duration of operating time who had successful laparoscopic cholecystectomy was 56.88+/- 31.48 minutes and in converted to open cases 92.38+/- 55.04 minutes ( p<0.05. In our study the mean duration of operating time in group of patients who had successful open and laparoscopic cholecystectomy was 81.27 +/- 6.29 minutes in males and 62.09 +/- 3.28 minutes in females whereas in converted to open cases 135 +/-8.45 minutes in males and 88.90 +/-5.60 minutes in females ( p<0.05) .
Male gender is a risk factor in comparison to female gender for presentation of severe disease in symptomatic cases of cholelithiasis resulting in difficult surgery, a longer duration of procedure, increased rate of conversion from laparoscopic to open surgery and length of postoperative hospitalization and hence increasing morbidity. Surgeons need to counsel and advice male patients with symptomatic cholelithiasis to undergo early intervention, and also inform them about higher conversion rate to reduce the disappointment postoperatively of a larger open cholecystectomy wound and prolonged recovery.
