ENDOUROLOGY & LAPAROSCOPY

Conversion during laparoscopic surgery: frequency, indications and risk factors
Richstone L, Seideman C, Baldinger L, Permpongkosol S, Jarrett TW, Su LM, Pavlovich C, Kavoussi LR
North Shore-Long Island Jewish Health System, New Hyde Park, New York, USA
J Urol. 2008; 180: 855-9

• Purpose: There are limited data on the indications for open conversion during laparoscopic surgery. The frequency of conversion for various procedures is poorly quantified and the degree to which this changes with time is not well understood. Risk factors for conversion are not defined. We addressed these issues in a large series of laparoscopic operations.
• Materials and Methods: We reviewed our database of 2,128 laparoscopic operations performed between 1993 and 2005, including radical nephrectomy in 549 patients, simple nephrectomy in 186, partial nephrectomy in 347, donor nephrectomy in 553, pyeloplasty in 301, nephroureterectomy in 106 and retroperitoneal lymph node dissection in 86. Open conversions were identified and the frequency of conversion for the total cohort and specific procedures was determined. Trends in conversion with time were assessed and indications analyzed. Clinicopathological features between patients requiring conversion and those who did not were compared.
• Results: We identified 68 patients (3.3%) who underwent conversion to open surgery (group 1) and 2,011 (96.7%) who did not (group 2). The frequency of conversion was greatest during nephroureterectomy (8.49%), followed by simple nephrectomy (5.91%), retroperitoneal lymph node dissection (4.65%), partial nephrectomy (4.32%), radical nephrectomy (2.91%), donor nephrectomy (2.53%) and pyeloplasty (0.33%). The absolute number of conversions and conversions/cases performed per year decreased significantly with time, reaching a nadir of less than 1% per year. Conversion was inversely related to case volume and cumulative experience. Indications included vascular injury in 38.5% of cases, concern with margins in 13.5%, bowel injury in 13.5%, failure to progress in 11.5%, adhesions in 9.6%, diaphragmatic injury in 1.9% and other in 11.5%. The distribution of indications remained similar with time. There were no differences in patient age, gender, surgical history, American Society of Anesthesiologists score or tumor stage between groups 1 and 2. In groups 1 and 2 mean operative time was 304 vs. 219 minutes and estimated blood loss was 904 vs. 255 cc (each p < 0.0001).
• Conclusions: The rate of conversion during laparoscopic surgery is not uniform across procedures and it is important for patient counseling. The most common indication for conversion is vascular injury. Importantly the frequency of conversion is dynamic and likely related to case volume and cumulative experience.
  
  
• Editorial Comment
  Conversion of laparoscopic to open surgery is not a complication in my view.
  The escalation of surgical technique during a difficult case may provide the safe outcome desired for the patient. This large series of laparoscopic cases demonstrate that the vascular injuries are responsible for the majority of the conversions. The longer the clinical experience the rate of conversion tends to decrease even in complex cases. The authors ought to be congratulated to demonstrate that conversion is beneficial for the well being of the patient encouraging novice surgeons to perform it when suited.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA
E-mail: fernando.kim@uchsc.edu