Conversion in Laparoscopic Colorectal Surgery: From Preoperative Risk Assessment to Intraoperative Strategies

Title

Design

Year

Study Comparison

# of institutions

Pnts # (Op/Lap)

Conversion rate (%)

Complications

LOS (Days)

Rectal procedure studies

CLASICC trial [15, 19]

RCT

2007

Laparoscopic vs. open survival and recurrence

737 (253/484)

34%

13%

–

COREAN trial [20]

RCT

2014

Laparoscopic vs. open survival outcomes

340 (170/170)

–

A randomized trial of laparoscopic versus open surgery for rectal cancer [7]

RCT

2015

Laparoscopic vs. open survival and recurrence

1044 (345/699)

16%

–

ACOSOG Z6051 [21]

RCT

2015

Laparoscopic vs. open pathological outcomes

462 (222/240)

11.3%

22%

ALaCaRT [22]

RCT

2015

Laparoscopic vs. open pathological outcomes

457 (237/238)

–

Colon studies

COST [16]

RCT

2004

Laparoscopic vs. open survival and recurrence

863 (428/435)

21%

COLOR [23]

RCT

2005

Laparoscopic vs. open clinical outcomes

1082 (546/536)

19%

21%

8.2

CLASICC trial [15, 19]

RCT

2007

Laparoscopic vs. open survival and recurrence

737 (253/484)

25%

–

Laparoscopically assisted vs open colectomy for colon cancer [24]

Meta-analysis

2007

Laparoscopic vs. open survival outcomes

1536 (740/796)

19%

Clinical outcomes and resource utilization associated with laparoscopic and open colectomy using a large national database [25]

Retrospective

2008

Laparoscopic vs. open clinical and economic outcomes

402

32,733 (21,689/11,044)

10.1%

26%

Elective open versus laparoscopic sigmoid colectomy for diverticular disease: A meta-analysis with the sigma trial [26]

Meta-analysis

2010

Laparoscopic vs. open clinical outcomes

10,898 (9360/1538)

8.4%

–

ALCCaS trial [27]

RCT

2018

Laparoscopic vs. open symptoms and QoL

Multicenter

425 (213/212)

15%

–

The practicing surgeon can easily determine his or her own laparoscopic conversion to open colectomy or proctectomy rate using his or her own institutional data. This rough estimate may allow self-assessment and aids in determining if the surgeon is providing a certain measure of quality care. The COST trial conversion rate for colectomy (excluding transverse colectomy) was 21%, and in the Z6051 trial , the laparoscopic conversion to open proctectomy rate for rectal cancer was 11%. Both trials involved expert surgeons with significant laparoscopic experience (>20 lifetime laparoscopic colectomies) and more importantly had undergone a credentialing process for the study where a video was reviewed for evaluation of surgical technique.

An important consideration when evaluating conversion rates is the impact of conversion on patient outcomes. While reactive conversion, for example, due to iatrogenic colotomy with gross fecal contamination is necessary and associated with worse outcomes with respect to infectious complications, other conversions may not have as much of a deleterious effect. Hence, the decision to attempt a laparoscopic approach should balance the benefits of a laparoscopic approach, and the risks of complications including consequences of conversion to open surgery with the understanding that a preemptive conversion, before complications or injury arises, may mitigate the impact of conversion on outcomes. Although a laparoscopic approach may be highly desirable in complex cases based on the clinical benefits incurred from avoidance of a laparotomy, early and preemptive conversion should be considered in the face of failure to progress or impending complications. When conversion is performed early, it may mitigate the morbidity incurred from reactive conversion in the face of a complication. When interpreting the literature on the negative impact of conversion on oncologic and infectious outcomes, surgeons should not become discouraged from attempting laparoscopy for fear of conversion but be prepared for this possibility and realistic with respect to when to convert. This clinical judgment is part of the laparoscopic learning curve and can only be finessed through experience gained when attempting complex cases. As a general rule, surgeons should consider diagnostic laparoscopy, with a low threshold to convert when the risk of injury and/or prolonged operative time outweighs the benefits of persisting with a laparoscopic approach.

High conversion rates for any given surgeon should prompt careful review of case logs, with specific focus on patient selection and risk factors for conversion, case volume, and experience with specific cases. This will in turn identify areas for improvement and strategies to mitigate the risk of conversion.

Preoperative Planning, Patient Work-Up, and Optimization

Patients undergoing laparoscopic colorectal surgery need a detailed medical history, physical exam, and colorectal cancer staging if the pathology is a colorectal malignancy. Particular attention should be paid to the number and type of previous abdominal surgeries and any history of abdominal infections, radiation, or surgical complications. The operative reports from previous abdominal surgeries should be reviewed. Patients can then proceed with standard preoperative blood work-up, electrocardiogram, and chest X-ray as indicated. A focused physical abdominal exam will appreciate previous surgical scars, the approach to previous surgeries (Pfannenstiel vs. midline laparotomy), and the presence of incisional hernias. The most important findings on history and physical are related to cardiopulmonary debilitation. A patient with poor functional status and non-optimized cardiac and pulmonary comorbidity often needs further specialty care through cardiology and pulmonology before surgery. Increases in preoperative activity and smoking cessation, prehabilitation, are of proven benefit in surgical outcomes.

When considering segmental colectomy for malignant polyps or tumors, localization of the tumor is key and achieved through a combination of cross-sectional imaging and endoscopy. Colonoscopy reports are valuable, as endoscopic tattoo placement or clipping may be crucial to localizing the pathology and planning your resection during the procedure. Preoperative planning entails reviewing all images prior to surgery. A CT scan is not only useful to localize disease but is also helpful to assess the thickness of the abdominal wall, location of the top of the splenic flexure, and other important surgical landmarks, which can help in port planning.

Patient Risk Factors for Conversion (Table 31.2)

Studies on the patient-related risk factors for conversion have almost exclusively retrospective single institution case series but are still worth considering for anyone adopting laparoscopy into his or her practice. Patient-related factors that have been shown to increase risk of conversion include advanced age, obesity, gender, ASA classification, previous surgery, and cardiopulmonary comorbidity. For patients undergoing colectomy, those older than 80 have a 73% higher chance of conversion compared to patients younger than 50 [8]. Male gender is also associated with a higher risk of conversion in colectomy [9, 10]. Obese patients (BMI >30 kg/m²) showed increasing the chance of conversion by 31% compared to patients with normal BMI [8]. While there is an increasing epidemic of obesity in the USA , the technical difficulty of performing laparoscopic colorectal resections increases with BMI, particularly in individuals with a BMI >40 or super obesity. In elective cases, we often council patients regarding weight loss strategies preoperatively, as this can significantly impact outcomes. Obesity contributes to difficulty with exposure as these patients often have a shortened mesentery and retraction of the small bowel can be difficult. Please refer to Chap. 32 on laparoscopic colorectal surgery in the obese and morbidly obese patient for more details on preoperative strategies and surgical techniques.

Table 31.2

Risk factors for conversion

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