Papandria D, Lardaro T, Rhee D et al.: Risk factors for conversion from laparoscopic to open surgery: analysis of 2138 converted operations in the American College of Surgeons National Surgical Quality Improvement Program. Am Surg 79: 914-21
ABSTRACT Minimal access procedures have influenced surgical practice and patient expectations. Risk of laparoscopic conversion to open surgery is frequently cited but vaguely quantified. The present study examines three common procedures to identify risk factors for laparoscopic conversion to open (LCO) events. Cross-sectional analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP; 2005 to 2009) identified cases with laparoscopic procedure codes for appendectomy, cholecystectomy, and bariatric procedures. The primary outcome was conversion of a laparoscopic procedure to its open equivalent. Summary statistics for laparoscopic and LCO groups were compared and logistic regression analysis was used to estimate patient and operative risk factors for conversion. Of 176,014 selected laparoscopic operations, 2,138 (1.2%) were converted. Most patients were female (68%) and white (71.2%); mean age was 45.1 years. LCO cholecystectomy was significantly more likely (n = 1526 [1.9%]) and LCO bariatric procedures were less likely (n = 121 [0.3%]); appendectomy was intermediate (n = 491 [1.0%], P < 0.001). Patient factors associated with LCO included male sex (P < 0.001), age 30 years or older (P < 0.025), American Society of Anesthesiologists Class 2 to 4 (P < 0.001), obesity (P < 0.01), history of bleeding disorder (P = 0.036), or preoperative systemic inflammatory response syndrome or sepsis (P < 0.001). LCO was associated with greater incidence of postoperative complications, including death, organ space surgical site infection, sepsis, wound dehiscence, and return to the operating room (P < 0.001). Overall LCO incidence is low in hospitals participating in ACS-NSQIP. Conversion risk factors include patient age, sex, obesity, and preoperative comorbidity as well as the procedure performed. This information should be valuable to clinicians in discussing conversion risk with patients.
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ABSTRACT: Aim: To introduce a new strategy during complicated open appendectomy - converting open operation to laparoscopy. Methods: We retrospectively reviewed databases at two institutions between October 2010 and January 2013, identifying 826 patients who had undergone complicated appendectomy for histologically confirmed acute or chronic appendicitis. They included 214 complicated appendectomies: 155 lengthened-incision open appendectomies (LIA group) and 59 open appendectomies with conversion to laparoscopy (OACL group). Results: A total of 214 patients with complicated appendectomies were included in the study, including 155 cases of LIA and 59 cases of OACL. No major complication leading to death occurred in the study. Patient characteristics of the two groups were similar. Several parameters showed a significant difference between the two groups. For the OACL vs LIA groups they were, respectively: incision length (3.8 ± 1.4 cm vs 6.2 ± 3.5 cm, P < 0.05); time to flatus recovery (2.3 ± 0.6 d vs 4.2 ± 0.8 d, P < 0.05), drainage rate (61.0% vs 80.0%, P < 0.05); pain level (3.6 ± 1.8 vs 7.2 ± 2.4, P < 0.05); hospital stay (5.1 ± 2.7 d vs 8.7 ± 3.2 d, P < 0.05); complication rate (8.5% vs 14.7%, P < 0.05). Other factors showed no significant differences. Conclusion: Lengthened-incision open appendectomy increases the incidence of complications and prolongs the hospital stay. Conversion of open to laparoscopic appendectomy is feasible and efficient in complicated cases. It decreases the rate of incisional and abdominal infections, allows faster return of bowel movements, and shortens the hospital stay.World Journal of Gastroenterology 08/2014; 20(31):10938-43. DOI:10.3748/wjg.v20.i31.10938 · 2.37 Impact Factor
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ABSTRACT: Robotic single-site cholecystectomy (RSSC) has been shown to be a safe alternative to the laparoscopic approach in selected patients. Patient exclusion criteria have prevented RSSC as a surgical option in many obese patients. This study reports the feasibility of performing RSSC in obese patients (BMI ≥ 30).Methods Between November 2012 and February 2014, a total of 200 patients underwent RSSC at our institution. All patients were offered the robotic procedure regardless of their BMI, age, previous surgery and acuity of their disease with no exclusion criteria. All patients with BMI ≥ 30 were included in the study and were compared to non-obese patients for demographics, comorbidities and postoperative outcomes. Data were compared to RSSC performed in non-obese patients by the same surgeon, as well to published data for standard laparoscopic cholecystectomy (LC).ResultsA total of 112 cholecystectomies were successfully performed with the robotic approach in patients with BMI≥30 without conversion to open, laparoscopic or multiport procedures. The mean BMI was 39.5 (range 30.1-62.3). Twenty-eight patients had a BMI ≥ 40 (25%) and 13 patients had a BMI ≥ 50 (11.6%). Fifty-two patients (46.4%) had a history of prior abdominal surgery. Most procedures were non-elective (78.6%) with patients presenting with acute symptoms. Pathology showed chronic cholecystitis and cholelithiasis in 79 patients (70.5%), acute cholecystitis in 26 patients (23.3%), cholelithiasis in 4 patients (3.5%), and gangrenous cholecystitis in 3 patients (2.7%). Total mean operative time was 69.8(26) minutes for obese patients compared to 59.2(19.7) minutes in the non-obese, which was found to be statistically significant (p=0.0012). After a mean follow-up of 6 months, there were no major complications recorded including bile leak, hematoma, or ductal injury. There was one umbilical (incisional) hernia (0.9%) reported and zero wound infections. When comparing RSSC performed in obese patients, RSSC in non-obese patients, and published data for standard LC, we found no difference in operative time, with less conversion to open.Conclusions Robotic single-site cholecystectomy is a feasible option in the obese patient population with excellent short-term outcomes. Patients should not be excluded based on their high BMI although further study is needed to determine long-term outcomes.Surgery for Obesity and Related Diseases 11/2014; 11(4). DOI:10.1016/j.soard.2014.11.016 · 4.07 Impact Factor
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ABSTRACT: It has recently been shown that micropauses during long surgical procedures can be beneficial for surgeons' precision and fatigue. The aim of the study was to evaluate the impact of micropauses on surgical precision measured by a simple smartphone application. Two surgeons performed 40 simple laparoscopic procedures (appendectomy and cholecystectomy) with or without micropauses. After the operation the precision of surgical movements was measured by a simple smartphone application in which the number of successful trials and their mean time were used as a precision surrogate. Mean number of successful trials was significantly higher for appendectomy than for cholecystectomy (5.59 vs 4; p = 0.032). There was a difference between participating surgeons both in terms of number of successful trials (5.80 vs 3.55; p = 0.01) and a mean time of all successful trials (10.03 vs 6.28; p = 0.001). No other statistically significant differences were identified. Micropauses had no influence on surgical precision as evaluated after short laparoscopy procedures. The only differences were surgeon-dependent and intervention-dependent.Polish Journal of Surgery 03/2015; 87(3):116-20. DOI:10.1515/pjs-2015-0029