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Introduction The utilization of laparoscopy in colorectal surgery is increasing. However, conversion to open surgery remains relatively high. Objective We evaluated (1) conversion rates in laparoscopic colorectal surgery; (2) the outcomes of converted cases compared with successful laparoscopic and open colorectal operations; (3) predictive risk factors of conversion of laparoscopic colorectal surgery to open surgery. Methods Using the National Inpatient Sample database, we examined the clinical data of patients who underwent colon and rectal resection from 2009 to 2010. Multivariate regression analysis was performed to identify factors predictive for conversion of laparoscopic to open operation. Results A total of 207,311 patients underwent intended laparoscopic colorectal resection during this period. The conversion rate was 16.6 %. Considering resection type and pathology, the highest conversion rates were observed in proctectomy (31.4 %) and Crohn’s disease (20.2 %). Using multivariate regression analysis, Crohn’s disease (adjusted odds ratio [AOR], 2.80), prior abdominal surgery (AOR, 2.45), proctectomy (AOR, 2.42), malignant pathology (AOR, 1.90), emergent surgery (AOR, 1.82), obesity (AOR, 1.63), and ulcerative colitis (AOR, 1.60) significantly impacted the risk of conversion. Compared with patients who were successfully completed laparoscopically, converted patients had a significantly higher complication rate (laparoscopic: 23 %; vs. converted: 35.2 % vs. open: 35.3 %), a higher in-hospital mortality rate (laparoscopic: 0.5 %; vs. converted: 0.6 %; vs. open: 1.7 %) and a longer mean hospital stay (laparoscopic: 5.4 days; vs. converted: 8.1 days; vs. open: 8.4 days); however, converted patients had better outcomes compared with the open group. Conclusions The conversion rate in colorectal surgery was 16.6 %. Converted patients had significantly higher rates of morbidity and mortality compared to successfully completed laparoscopic cases, although lower than open cases. Crohn’s disease, prior abdominal surgery, and proctectomy are the strongest predictors for conversion of laparoscopic to open in colorectal operations.

BackgroundThe aim of this study was to identify national utilization trends of robotic surgery for elective colectomy, conversion rates over time, and the specific impact of conversion on postoperative morbidity. Conversion to open represents a hard endpoint for minimally invasive surgery (MIS) and is associated with worse outcomes when compared to MIS or even traditional open procedures.MethodsAll adult patients who underwent either laparoscopic or robotic elective colectomy from 2013 to 2018 as reported in the American College of Surgeons Quality Improvement Program (ACS-NSQIP) database were included. National trends of both robotic utilization and conversion rates were analyzed, overall and according to underlying disease (benign disease, inflammatory bowel disease (IBD), cancer), or the presence of obesity (body mass index (BMI) ≥ 30 kg/m2). Demographic and surgical risk factors for surgical conversion to open were identified through multivariable regression analysis. Further assessed were overall and specific postoperative 30-day complications, which were risk adjusted and compared between converted patients and the remaining cohort.ResultsOf 66,652 included procedures, 5353 (8.0%) were converted to open. Conversion rates were 8.5% for laparoscopic and 4.9% for robotic surgery (p < 0.0001). A decline in conversion rates over the 6-year inclusion period was observed overall and for patients with obesity. This trend paralleled an increased utilization of the robotic platform. Several surrogates for advanced disease stages for cancer, diverticulitis, and IBD and prolonged surgical duration were identified as independent risk factors for unplanned conversion, while robotic approach was an independent protective factor (OR 0.44, p < 0.0001). Patients who had unplanned conversion were more likely to experience postoperative complications (OR 2.36; 95% CI [2.21–2.51]), length of hospital stay ≥ 6 days (OR 2.86; 95% CI [2.67–3.05], and 30-day mortality (OR 2.28; 95% CI [1.72–3.02]).ConclusionThis nationwide study identified a decreasing trend in conversion rates over the 6-year inclusion period, both overall and in patients with obesity, paralleling increased utilization of the robotic platform. Unplanned conversion to open was associated with a higher risk of postoperative complications.

Laparoscopic appendectomy (LA) for treatment of acute appendicitis has gained acceptance with its considerable benefits over open appendectomy. LA, however, can involve some adverse outcomes: morbidity, prolonged length of hospital stay (LOS) and hospital readmission. Identification of predictive factors may help to identify and tailor treatment for patients with higher risk of these adverse events. Our aim was to identify risk factors for serious morbidity, prolonged LOS and hospital readmission after LA. A database compiled information of patients admitted for acute appendicitis from eighteen Polish and German surgical centers. It included factors related to the patient characteristics, peri- and postoperative period. Univariate and multivariate logistic regression models were used to identify risk factors for serious perioperative complications, prolonged LOS, and hospital readmissions in acute appendicitis cases. 4618 laparoscopic appendectomy patients were included. First, although several risk factors for serious perioperative complications (C-D III-V) were found in the univariate analysis, in the multivariate model only the presence of intraoperative adverse events (OR 4.09, 95% CI 1.32–12.65, p = 0.014) and complicated appendicitis (OR 3.63, 95% CI 1.74–7.61, p = 0.001) was statistically significant. Second, prolonged LOS was associated with the presence of complicated appendicitis (OR 2.8, 95% CI: 1.53–5.12, p = 0.001), postoperative morbidity (OR 5.01, 95% CI: 2.33–10.75, p < 0.001), conversions (OR 6.48, 95% CI: 3.48–12.08, p < 0.001) and reinterventions after primary procedure (OR 8.79, 95% CI: 3.2–24.14, p < 0.001) in the multivariate model. Third, although several risk factors for hospital readmissions were found in univariate analysis, in the multivariate model only the presence of postoperative complications (OR 10.33, 95% CI: 4.27–25.00), reintervention after primary procedure (OR 5.62, 95% CI: 2.17–14.54), and LA performed by resident (OR 1.96, 95% CI: 1.03–3.70) remained significant. Laparoscopic appendectomy is a safe procedure associated with low rates of complications, prolonged LOS, and readmissions. Risk factors for these adverse events include complicated appendicitis, postoperative morbidity, conversion, and re-intervention after the primary procedure. Any occurrence of these factors during treatment should alert the healthcare team to identify the patients that require more customized treatment to minimize the risk for adverse outcomes.

ObjectiveThe objectives were to determine factors associated with conversion to open surgery in patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE, including laparo-thoracoscopic and robotic) and the impact of conversion to open surgery on patient outcomes.MethodsWe included patients from the National Cancer Database with esophageal and gastroesophageal junction cancer who underwent MIE from 2010 to 2015. Patient-, tumor-, and facility-related characteristics as well as short-term and oncologic outcomes were compared between patients who were converted to open surgery and those who underwent successful MIE without conversion to open surgery. Multivariable logistic regression models were used to analyze risk factors for conversion to open surgery from attempted MIE.Results7306 patients underwent attempted MIE. Of these patients, 82 of 1487 (5.2%) robotic-assisted esophagectomies were converted to open, compared to 691 of 5737 (12.0%) laparo-thoracoscopic esophagectomies (p < 0.001). Conversion rates decreased significantly over the study period (ptrend = 0.010). Patient age, tumor size, and nodal involvement were independently associated with conversion. Facility minimally invasive cumulative volume and robotic approach were associated with decreased conversion rates. Patients whose MIEs were converted had increased 90-day mortality [Odds Ratio (OR) 1.49; 95% Confidence Interval (CI) 1.10, 2.02], prolonged hospital stay (OR 1.39; 95% CI 1.17, 1.66), and higher rates of unplanned readmission (OR 1.67; 95% CI 1.27, 2.20). No significant differences were found in surgical margins or number of lymph nodes harvested.ConclusionPatients undergoing attempted MIE requiring conversion to open surgery had significantly worse short-term outcomes including postoperative mortality. Patient factors and hospital experience contribute to conversion rates. These findings should inform surgeons and patients considering esophagectomy for cancer.

Background The purpose of this study was to review our experience with laparoscopic colectomy and fistula resection, evaluate the frequency of conversion to open, and to compare the perioperative courses of the complete laparoscopic and conversion groups. Methods This study is a retrospective analysis of 111 consecutive adult patients with diverticular fistulae diagnosed clinically or radiographically over 11 years at a single institution. Five patients were excluded for preoperative comorbidities. The remaining 106 consecutive patients underwent minimally invasive sigmoid colectomy with primary anastomosis. Preoperative, intraoperative, and postoperative variables were collected from the colorectal surgery service database. A retrospective cohort analysis was performed between laparoscopic and converted groups. Results Within the group, 47% had colovesical fistulas, followed by colovaginal, coloenteric, colocutaneous, and colocolonic fistulas. The overall conversion rate to laparotomy was 34.7% ( n  = 37). The most common reason for conversion was dense fibrosis. Mean operative time was similar between groups. Combined postoperative complications occurred in 26.4% of patients (21.4% laparoscopic and 37.8% converted, p  = 0.075). Length of stay was significantly shorter in the laparoscopic group (5.8 vs 8.1 days, p  = 0.014). There were two anastomotic leaks, both in the open group. There were no 30-day mortalities. Conclusions Laparoscopic sigmoid colectomy for diverticular fistula is safe, with complication rates comparable to open sigmoid resection. We identify a conversion rate which allows the majority of patients to benefit from minimally invasive procedures.

The aim of this study was to investigate the early and late outcomes of Open Surgical Conversion (OSC) following the failure of Endovascular Aneurysm Sealing (EVAS) endografts, regarding surgical technique, morbidity and mortality. A single center retrospective observational cohort of 46 patients undergoing OSC after EVAS failure. Primary endpoints were primary technical procedural success and 30-day mortality. Secondary endpoints were complications and primary prosthesis patency. Primary technical procedural success was 97.8% (45/46). Elective 30-day mortality for OSC was 10.9% (5/42) and 75% (3/4) for acute OSC procedures. Median survival after OSC was 4.2 years (IQR 1.0, 4.9 years). Four peri-operative and 17 post-operative complications were registered. Major complications included bleeding, myocardial infraction, acute renal failure and splenectomy. Primary prosthesis patency was 82.6% (38/46) at 30-days. At median follow-up of 4.7 years (IQR 3.9, 5.3 years) 69.6% (32/46) of the patients are still alive with patent vascular prostheses. Open surgical conversion achieved acceptable technical success rate for failed EVAS, with better outcomes in elective versus emergency procedures. Enhanced surveillance with timely interventions before rupture and careful patient selection through multidisciplinary evaluation are essential for optimizing surgical outcomes.

Background Laparoscopic conversion-to-open colorectal surgery is associated with worse outcomes when compared to operations completed without conversion. Consequences of robotic conversion have not yet been determined. The purpose of this study is to compare short-term outcomes of converted robotic colorectal cases with those that are completed without conversion, as well as with cases done by the open approach. Methods The ACS-NSQIP database was queried for patients who underwent robotic completed, robotic converted-to-open, and open colorectal resection between 2012 and 2015. Propensity scores were estimated using gradient-boosted machines and converted to weights. Generalized linear models were fit using propensity score-weighted data. Results A total of 25,253 patients met inclusion criteria—21,356 (84.5%) open, 3663 (14.5%) robotic completed, and 234 (0.9%) conversions. Conversion rate was 6.0%. Converted cases had significantly higher 30-day mortality rate, higher complication rate, and longer hospital length of stay than completed cases. Converted patients also had significantly higher rates of the following complications: surgical site infections, cardiac complications, deep venous thrombosis, postoperative ileus, postoperative re-intubation, renal failure, and 30-day reoperation. Compared to the open approach, converted patients had significantly more cardiac complications, postoperative reintubation, and longer operating times with no significant difference in 30-day mortality. Conclusions Unplanned robotic conversion-to-open is associated with worse outcomes than completed cases and outcomes that more closely resemble traditional open colorectal surgery. Patients should be counseled with regard to minimally invasive conversion rates and outcomes. The continued pursuit of technological advancements that decrease the risk for conversion in minimally invasive colorectal surgery is clearly warranted.

Background & aims Although laparoscopic liver resection (LLR) has been widely accepted and considered a safe alternative to open liver resection in patients with hepatocellular carcinoma (HCC), it is still inevitable that some patients will encounter difficulties during LLR and need to be converted to open liver resection (OLR). It is currently uncertain whether unplanned intraoperative conversion to open liver resection (UCOLR) during LLR in HCC patients has a negative impact on patient prognosis, and there are still no comparative studies between HCC patients who underwent successful LLR and those who underwent UCOLR. Therefore, the aim of this study was to compare the short- and medium-term outcomes of LLR and UCOLR for HCC between two matched groups. Methods We retrospectively studied patients with HCC who underwent LLR or UCOLR between November 2016 and November 2022 at West China Hospital, Sichuan University. After 1:4 propensity score matching (PSM) was performed to reduce selection bias, the short-term and medium-term oncological outcomes of LLR and UCOLR were compared. Results Out of 846 patients included in this study (806 in the LLR group and 40 in the UCOLR group), 150 patients in the LLR group and 40 patients in the UCOLR group were selected for further comparison after 1:4 PSM. Compared to those who underwent successful LLR, patients who experienced UCOLR during LLR had significantly more intraoperative bleeding (500 ml vs. 200 ml, p  < 0.001), required more blood transfusions ( p  < 0.001), had higher transfusion rates (47.5% vs. 6.0%, p  < 0.001), and experienced longer operative times (244 min vs. 210 min, p  = 0.042). Additionally, the overall complication rate was significantly greater in the UCOLR group than in the LLR group (45.0% vs. 20.7%, p  = 0.002). Further analysis revealed that patients in the UCOLR group had a significantly greater risk of pulmonary infections (37.5% vs. 15.3%, p  = 0.002), pleural effusion (27.5% vs. 7.3%, p  < 0.001), anemia (22.5% vs. 4.7%, p  < 0.001), and bile leakage (10.0% vs. 2.0%, p  = 0.017). Moreover, those who experienced conversion to UCOLR reported significantly more postoperative pain (62.5% vs. 7.3%, p  < 0.001) and longer hospital stays (6 days vs. 5 days, p  = 0.005). In terms of quality of life (QOL) assessment, the LLR group showed a trend toward better general health at 1 and 3 months after surgery. However, no significant differences were detected between the LLR and UCOLR groups in terms of 3-year disease-free survival (76.4% for LLR vs. 63.5% for UCOLR, p  = 0.075) or overall survival (82.2% for LLR vs. 71.7% for UCOLR, p  = 0.124). Conclusion Compared to patients who underwent successful LLR, patients in the UCOLR group experienced worse short-term outcomes, although medium-term survival outcomes at 3 years were comparable. Additionally, segment 7 or 8 lesions with high AFP have a greater chance of conversion and an increased rate of recurrence after unplanned conversion. We should be cautious while selecting patient for laparoscopic liver resection.

Background The aim of this study is to explore the impact of the approach on conversion in patients undergoing minimally invasive restorative total mesorectal excision within a single unit. Methods A retrospective cohort study was conducted. Patients with rectal cancer undergoing minimally invasive restorative total mesorectal excision between January 2006 and June 2020 were included. Subjects were classified according to the presence or absence of conversion. Baseline variables and short-term outcomes were compared. Regression analyses were conducted to assess the relationship between the approach and conversion. Results During the study period, 318 patients underwent a restorative proctectomy. Of these, 240 met the inclusion criteria. Robotic and laparoscopic approaches were undertaken in 147 (61.3%) and 93 (38.8%) cases, respectively. A transanal approach was utilised in 62 (25.8%) cases (58.1% in combination with a robotic transabdominal approach). Conversion to open surgery occurred in 30 cases (12.5%). Conversion was associated with an increased overall complication rate ( P  = 0.003), surgical complications ( P  = 0.009), superficial surgical site infections ( P  = 0.02) and an increased length of hospital stay ( P  = 0.006). Robotic and transanal approaches were both associated with decreased conversion rates. The multiple logistic regression analysis, however, showed that only a transanal approach was independently associated with a lower risk of conversion ( OR 0.147, 0.023–0.532; P  = 0.01), whilst obesity was an independent risk factor for conversion ( OR 4.388, 1.852–10.56; P  < 0.00). Conclusions A transanal component is associated with a reduced conversion rate in minimally invasive restorative total mesorectal excision, regardless of the transabdominal approach utilised. Larger studies will be required to confirm these findings and define which subgroup of patients could benefit from transanal component when a robotic approach is undertaken.

Purpose This study was designed to evaluate the impact of laparoscopic converted to open colectomy on short-term and oncologic outcomes and to identify risk factors for long-term survival in patients undergoing colectomy for non-metastatic colon cancer. Methods A prospective database of consecutive operations for non-metastatic colon cancer was reviewed. Patients were grouped as conversion (CONV) group, completed laparoscopic resection (LAP) group, or open resection (OPEN) group. The clinical and perioperative parameters, pathologic features, and oncologic outcomes were collected. Univariate analysis was performed for comparing these data. Patients without evidence of recurrence at last follow-up or still alive at the end of study period were censored. Kaplan-Meier curves were utilized to analyze survival. A multivariate analysis was performed to identify predictors of poor disease-free survival (DFS) and overall survival (OS). Results The conversion rate was 15.2 %. The most common reason for conversion was locally advanced cancer (45.5 %). Converted patients were associated with a longer operative time (188 ± 29.1 min, P  < 0.001), greater blood loss (147 ± 14 mL, P  < 0.001), and a higher rate of intra-operative complications (15.2 %, P  = 0.042) compared to the completely laparoscopic or open patients. Days to flatus, early ambulation, and length of hospitalization were significantly shorter in completed laparoscopic resection (LAP) group ( P  < 0.001); however, the outcomes were comparable between conversion (CONV) and open resection (OPEN) groups. The incidence of wound infection was significantly higher in the OPEN group than in the LAP group ( P  = 0.005), whereas there were no significant differences observed between the CONV group and the OPEN group ( P  = 1.000) or between the LAP group and the CONV group ( P  = 0.073). The 5-year DFS in CONV patients (46.5 %) was comparable to LAP patients (55.5 %, P  = 0.138) and OPEN patients (59.1 %, P  = 0.113). Moreover, there were no significant differences noted in terms of the 5-year OS in the CONV group (56.7 %) compared to the LAP group (67.3 %, P  = 0.317) or the OPEN group (66.3 %, P  = 0.420). The multivariate analysis showed that pT3–4 cancer ( P  < 0.001) and poor differentiation ( P  < 0.001) were independent predictors of both lower OS and lower DFS, whereas leakage ( P  = 0.008) and lack of adjuvant chemotherapy ( P  = 0.023) were independent risk factors only of lower DFS. Conclusion Conversion to open colectomy from an initial laparoscopic approach does not worsen the long-term survival in patients with non-metastatic colon cancer.