Surg Endosc (2009) 23:2454–2458 DOI 10.1007/s00464-009-0414-6
Conversion in laparoscopic surgery: does intraoperative complication influence outcome? Chunkang Yang Æ Steven D. Wexner Æ Bashar Safar Æ Sanjay Jobanputra Æ Heiying Jin Æ Vicky KaMing Li Æ Juan J. Nogueras Æ Eric G. Weiss Æ Dana R. Sands
Received: 25 April 2008 / Accepted: 11 February 2009 / Published online: 25 March 2009 Ó Springer Science+Business Media, LLC 2009
Abstract Background Conversion from laparoscopy to laparotomy can be expected in a variable percentage of surgeries. Patients who experience conversion to a laparotomy may have a worse outcome than those who have a successfully completed laparoscopic procedure. This study aimed to compare the outcomes of converted cases based on whether the case was a reactive conversion (RC, due to an intraoperative complication such as bleeding or bowel injury) or a preemptive conversion (PC, due to a lack of progression or unclear anatomy). Methods All laparoscopic colorectal procedures converted to a laparotomy were retrospectively reviewed from data prospectively entered into an institutional review board–approved database. Patients who underwent an RC were matched with patients who underwent a PC according to age, gender, body mass index (BMI), and diagnosis. Patients who underwent a laparoscopic colorectal resection (LCR) were taken as the control group. The incidence and nature of postoperative complications, the time to liquid or regular diet, and the length of hospital stay were recorded. Results Of 962 laparoscopic procedures performed between 2000 and 2007, 222 (23.1%) converted to a laparotomy were identified. The 30 patients who had undergone an RC were matched with 60 patients who had undergone a PC and 60 patients who had undergone an LCR. The reasons for RC were bleeding in 14 cases, bowel
C. Yang S. D. Wexner (&) B. Safar S. Jobanputra H. Jin V. K. Li J. J. Nogueras E. G. Weiss D. R. Sands Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA e-mail:
[email protected]
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injury in 6 cases, ureteric damage in 3 cases, splenic injury in 3 cases, and other complications in 4 cases. The patients who had undergone RC were more likely to have experienced a postoperative complication (50% vs 27%; p = 0.028), required longer time to toleration of a regular diet (6 vs 5 days; p = 0.03), and stayed longer in the hospital (8.1 vs 7.1 days; p = 0.080). Conclusion Preemptive conversion is associated with a better outcome than reactive conversion. Based on this finding, it appears preferable for the surgeon to have a low threshold for performing PC rather than awaiting the need for an RC. Keywords Conversion Laparoscopic Minimally invasive Preemptive conversion Retrospective
The minimally invasive approach for colorectal resections was introduced more than 15 years ago. Some of the benefits described for the laparoscopic approach include less blood loss, reduced stress because of the diminished surgical trauma, less postoperative pain, faster return of bowel activity, shorter hospital stay, and lower complication rates than with the open technique [1–6]. However, questions remain that have prevented a more generalized acceptance of laparoscopic colectomy. One of the more significant concerns is the possible worse outcome for patients requiring conversion to open surgery. Some series have suggested that the postoperative course after conversion may be associated with appreciably poorer results in terms of morbidity, mortality, convalescence, and postoperative hospital stay [7–9]. Conversion rates have varied widely in different series, ranging from 5.2% to 77% [7–10].
Surg Endosc (2009) 23:2454–2458
Many factors lead to conversion including bowel injury, bleeding, unclear anatomy, and lack of progression, but all may be classified into two categories: reactive conversion and preemptive conversion [11]. Reactive conversion (RC) is defined as one that follows an intraoperative complication such as bleeding or organ injury, whereas preemptive conversion (PC) is defined as one undertaken to avoid complication. The reasons for PC include poor progression caused by unclear anatomy, obesity, or adhesions; inability to identify the ureter; and other similar situations. The difference in outcome between these two indications for conversion has been poorly studied. The current study aimed to compare the outcomes of converted cases between RC and PC.
Methods All consecutive patients who underwent either elective or emergent laparoscopic colorectal surgery between January 2000 and April 2007 were identified from the institutional review board–approved prospective database. Patients whose procedures were converted to open surgery were identified. Preoperative variables including age, gender, weight, height, and body mass index (BMI) as well as intraoperative variables such as overall operating time, duration of laparoscopy, and reasons for conversion were recorded. The postoperative variables studied included mortality, postoperative complications, return of bowel function measured by time to first passage of flatus and stool as well as time to regular diet, and length of hospital stay. The patients were categorized into two groups according to whether they had experienced RC or PC. The patients who had undergone laparoscopic colorectal resections (LCR) were taken as the control group. Patient-controlled analgesia with parenteral opiates was used for all the patients. Routine chest physiotherapy was started on the first postoperative day. The patients were given clear liquids on the day of surgery, then gradually progressed to a solid diet as bowel function returned. The patients were mobilized as early as possible, then discharged as they regained independent mobilization, tolerated a regular diet, and had a solid bowel movement. Statistical analysis Continuous parametric data were analyzed using Student’s t-test. Normally distributed data are reported as mean ± standard error of the mean. Data not normally distributed are reported as median and range. Nonparametric data were analyzed using the chi-square test. A p value less than 0.05 was considered statistically significant.
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Results Between January 2000 and April 2007, 962 laparoscopic colorectal procedures were performed. A total of 222 laparoscopic procedures that had been converted to a laparotomy were identified. The total conversion rate was 23.1% (222/962). Of the 222 conversion patients, only 30 underwent an RC. We therefore chose 60 patients who had undergone PCs for a statistic match by age, gender, BMI, total operation time, and the underlying disease, and another 60 patients who had undergone LCR for control subjects. The conversion rates according to indication were as follows (Table 1): diverticulitis (29.8%), inflammatory bowel disease (21.0%), and neoplasm (18.5%). Conversions due to pathology such as severe adhesions or the presence of phlegmon and tissue friability were the most common reasons for conversion (Table 2). Problems such as unclear anatomy were the second most common reason for conversion, followed by intraoperative complications such as bleeding and bowel injuries. A total of 30 patients underwent conversion due to intraoperative complications (RC). These complications were bleeding in 14 cases, bowel injury in 6 cases, ureteric damage in 3 cases, splenic injury in 3 cases, and other complications (severely increased central venous pressure, hypotension, stapled air leak, and coagulopathy) in 4 cases. The 30 patients identified with RC were matched 60 patients with PC and 60 patients who underwent LCR. The patients were matched by diagnosis, age, BMI, and gender (Table 3). The reasons for conversion in the PC group were adhesions, phlegmons and tissue friability, and unclear anatomy. The indications for surgery are shown in Table 4. The most common indication for surgery in the three groups were neoplasm, followed by diverticulitis and Crohn’s disease. In-hospital complications occurred for 50% (15 patients) of the RC group, for 26.7% (16 patients) of the PC group (p = 0.028), and for 11.7% (7 patients) of the LCR group. Table 1 Rate of conversion in relation to diagnosis Diagnosis
Conversion rate % (n)
Diverticulitis
29.8 (78/262)
IBD
21.0 (34/162)
Neoplasm (cancer and polyp)
18.5 (72/389)
Others
25.5 (38/149)
Bowel obstruction
33.8 (22/65)
Fistula
23.5 (8/34)
Prolapse
20.0 (4/20)
Incontinence Constipation
14.3 (2/14) 12.5 (2/16)
IBD inflammatory bowel disease
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Table 2 Conversion due to intraoperative problems Categories
n (%)
Description
Limitations related to diseases
163 (73.4) Adhesions
n 78
Phlegmon and tissue friability
39
Abscess and inflammation Thickened and short mesentery
13 11
Locally advanced tumor 10 Large tumor
Technical problems
Intraoperative complications
5
Intestines ischemia
4
Obesity
3
29 (13.1) Unclear anatomy
25
Splenic flexure difficult 4 to mobilize 30 (13.5) Bleeding 13 Bowel injury
7
Splenic injury
3
Ureter damage
3 Others
4
The most common postoperative complication in the RC and PC groups was prolonged ileus, followed by pneumonia and wound infection, whereas in the LCR group, the only problems were prolonged ileus and atrial fibrillation (Table 5). Compared with the PC group, the patients in the RC group were more likely to require a longer time to toleration of a regular diet (6 vs 5 days; p = 0.033), and had a longer hospital stay (8.1 vs 7.1 days; p = 0.080). However,
comparison with the two conversion groups showed that the patients in the LCR group had a shorter length of hospital stay (5.3 days), a shorter time to flatus (3.2 days), a shorter time to toleration of a regular diet (4.4 days), and a lower postoperative complication rate (11.7%) (Table 6). No mortality occurred in any of the three groups.
Discussion The term ‘‘conversion’’ (i.e., the changeover from a laparoscopic procedure to a traditional laparotomy) refers to the point at which the surgeon realizes that continuation of the operation as a laparoscopic procedure is no longer appropriate [12]. Conversion is therefore not a complication of laparoscopy but a limit to the feasibility of the technique. The conversion rate of 23.1% achieved in this study is consistent with the conversion rates of 15% to 38% recently reported in a literature review [8]. The most common reasons for conversion in the current study were directly related to inflammatory conditions. Diverticular mass, inflammatory adhesions, and complicated diverticulitis (abscess, perforation) were responsible for almost 50.5% (112/222) of all the conversions. The patients with diverticular disease had a higher risk of conversion (29.8%) if a segmental resection was performed due to diverticulitis. These results are in agreement with published data concerning laparoscopic surgery for diverticular disease, which show conversion rates ranging from 10% to 53% [13–15]. An important reason for conversion in our study was intraoperative complications, although the rate was only
Table 3 Demographics of patients in each groupa Characteristics
RC group (n = 30)
PC group (n = 60)
LCR group (n = 60)
Gender
Males 17, females 13
Males 35, females 25
Males 35, females 25
Age (years)
64.57 ± 9.69
65.52 ± 12.45
62.77 ± 12.4
BMI (kg/m2)
27.20 ± 4.83
27.18 ± 4.99
26.05 ± 5.13
RC reactive conversion; PC preemptive conversion; LCR laparoscopic colorectal resections a
p value [0.05 in each compared group
Table 4 Indications for surgerya Diagnosis
RC group (n = 30) n (%)
PC group (n = 60) n (%)
LCR group (n = 60) n (%)
Neoplasia
16 (53.3)
30 (50.0)
34 (56.7)
Diverticulitis
11 (36.7)
25 (41.7)
22 (36.7)
Crohn’s disease
2 (6.7)
4 (6.7)
2 (3.3)
Others
1 (3.3)
1 (1.7)
2 (3.3)
RC reactive conversion; PC preemptive conversion; LCR laparoscopic colorectal resections a
p value [0.05 in each compared group
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Table 5 Postoperative complicationa Complication
RC group (n = 30) n (%)
PC group (n = 60) N (%)
Prolonged ileus ([5 days)
8 (26.7)
8 (13.3)
Pneumonia
3 (10)
4 (6.7)
Wound infection
2 (6.7)
2 (3.3)
Intraabdominal hemorrhage
1 (3.3)
1 (1.7)
Respiratory failure
1 (3.3)
Pulmonary embolus
6 (10)
1 (1.7)
Atrial fibrillation Total
LCR group (n = 60) n (%)
1 (1.7) 15 (50.0)
16 (26.7)
7 (11.7)
RC reactive conversion; PC preemptive conversion; LCR laparoscopic colorectal resections a
RC group:PC group (p = 0.028), RC group:LCR group (p = 0.000), PC group:LCR group (p = 0.037)
Table 6 Outcome among the RC, RC, and LCR groups RC group (n = 30)
PC group (n = 60)
Lap group (n = 60)
Length of stay (days)
8.40 ± 2.75
7.15 ± 3.34
5.35 ± 2.62
Flatus (days)
5.40 ± 3.02
4.76 ± 1.43
3.20 ± 1.73
Liquid diet (days) Regular diet (days)
3.13 ± 1.73 6.03 ± 2.14
2.58 ± 1.21 5.10 ± 1.82
1.60 ± 0.72 4.43 ± 1.90
Postsurgery complications
15/30
16/60
7/60
Operation time (min)
239.93 ± 77.38
224.30 ± 90.32
183.50 ± 76.57
p Valuesa RC /PC
RC/LCR
PC/LCR
Length of stay
0.080
0.000
0.01
Flatus
0.087
0.000
0.000
Liquid diet time
0.084
0.000
0.000
Regular diet time
0.033
0.001
0.052
Postsurgery complications
0.028
0.000
0.037
Operation time
0.420
0.001
0.009
RC reactive conversion; PC preemptive conversion; LCR laparoscopic colorectal resections a
p value of outcomes among the RC, RC, and LCR groups
3.1% (30/962). The specific reasons included bleeding (1.4%, 13/962), bowel injury (0.7%, 7/962), ureteric damage (0.3%, 3/962), and splenic injury (0.3%, 3/962). The incidence of ureteric injury varies from 0.7% to 5.7% during the conventional Miles operation [16] and from 0.2% to 1.0% in laparoscopic surgery [17]. Bowel injury can occur during the insertion of cannulas or instruments or as a result of energy injury. Thus, prevention of this severe complication must include constant visualization of the instruments during the procedure and protection of the small bowel by moving it aside with the help of gravity. The major problem posed by conversion is the possible increased risk of postoperative morbidity and mortality. In a study by Slim et al. [18], the morbidity rate for patients who experienced conversion was 50% compared with 21%
for patients who had surgery through a laparotomy. In a multicenter series including 1,658 patients who underwent laparoscopic surgery for colorectal disease, Marusch et al. [7] demonstrated higher morbidity and mortality rates for converted operations (47.7% and 3.5%, respectively) than for successful laparoscopic procedures (26.1% and 1.5%, respectively). The result in the current study was similar to that of the RC or PC group compared with the laparoscopically completed case. Most of these studies compared conversions with laparoscopic surgery or a standard laparotomy, but no reports have addressed the outcome based on the reason for conversion. In the current study, we found that patients whose conversion was reactive due to intraoperative complication were more likely to have a postoperative complication (50% vs 27%; p = 0.02), to require a longer time to
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toleration of a regular diet (6 vs 5 days; p = 0.03), and to have a longer stay in the hospital (8.1 vs 7.1 days; p = 0.08) than patients who underwent a PC. Therefore, whereas RC was clearly associated with increased postoperative morbidity and prolonged hospital stay, PC was not. The increased risk of morbidity after conversion has been related to an increase in operating time, to the consequences of intraoperative complications, and to the severity of the underlying disease [7]. The current study was limited to patients who had a laparoscopy converted to a laparotomy. The patients were divided into two groups based on the reason for conversion. The two groups were well matched by age, gender, BMI, total operation time, and underlying disease. The only factor predictive of a worse outcome in the PC and RC groups was related to an intraoperative complication. Patients who underwent converted LCR with an intraoperative complication were more likely to have a postoperative complication, to require a longer time to toleration of a regular diet, and to have a longer stay in the hospital. Conversion should not be considered a complication. For a significant reduction in postoperative morbidity, early conversion before the onset of an intraoperative complication, is preferable to late conversion after complication.
Conclusion This study found that PC is associated with a better outcome than RC. Based on this finding, it is advisable for the surgeon to have a low threshold for performing a PC rather than awaiting the need for an RC.
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