Is there a role for a strict incision length criterion for determining conversions during laparoscopic colorectal resection?

Technique of last resort: characteristics of patients undergoing open surgery in the laparoscopic era

BACKGROUND

The utilization rates for minimally invasive colorectal resection techniques (MICR) continue to increase. In some centers MICR methods are the preferred approach, however, open methods continue to be utilized for select patients. In this study, the profile and short-term outcomes of open colorectal resection (CR) and MICR patients are determined and compared.

METHODS

A retrospective review of patients who underwent elective CR over 11 years at two institutions was performed. The MICR group contained both laparoscopic-assisted and hand-assisted cases. The past medical and surgical histories, indications, operations performed, and short-term outcomes were assessed. The Charlson co-morbidity index (CMI) was used to assess risk.

RESULTS

During the study period 1080 patients underwent CR (Open, 141; MICR, 939). As judged by the CMI, there were more high-risk patients (score ≥2) in the Open group (34.38%) versus MICR (22.11%) p = 0.0029. Significantly more open patients had prior abdominal surgery and specifically CRs (Open, 15.60% vs. MICR, 2.13%, p < 0.001). Intraoperative transfusion (Open 25.7%; MICR 6.8%, p < 0.001) and diversion (25.53 vs. 11.50%, p < 0.001) were more common in the Open group. Not surprisingly, recovery of bowel function and length of stay were longer for the Open group. The overall complication rate was also higher for the Open patients (p < 0.001).

CONCLUSION

When MICR is the procedure of choice, patients selected for Open CR are higher risk and more complex as judged by the CMI and past operative history. Not surprisingly, this translates into a longer length of stay, higher rates of transfusion, diversion, and complications. This disparity in patients undergoing CRs makes direct comparison of MICR and Open resection outcomes not reasonable.

Achieving consensus on the definition of conversion to laparotomy: a Delphi study among general surgeons, gynecologists, and urologists

BACKGROUND

In laparoscopic surgery, conversion to laparotomy is associated with worse clinical outcomes, especially if the conversion is due to a complication. Although apparently important, no commonly used definition of conversion exists. The aim of this study was to achieve multidisciplinary consensus on a uniform definition of conversion.

METHODS

On the basis of definitions currently used in the literature, a web-based Delphi consensus study was conducted among members of all four Dutch endoscopic societies. The rate of agreement (RoA) was calculated; a RoA of >70% suggested consensus.

RESULTS

The survey was completed by 268 respondents in the first Delphi round (response rate, 45.6%); 43% were general surgeons, 49% gynecologists, and 8% urologists. Average ± standard deviation laparoscopic experience was 12.5 ± 7.2 years. On the basis of the results of round 1, a consensus definition was compiled. Conversion to laparotomy is an intraoperative switch from a laparoscopic to an open abdominal approach that meets the criteria of one of the two subtypes: strategic conversion, a standard laparotomy that is made directly after the assessment of the feasibility of completing the procedure laparoscopically and because of anticipated operative difficulty or logistic considerations; and reactive conversion, the need for a laparotomy because of a complication or (extension of an incision) because of (anticipated) operative difficulty after a considerable amount of dissection (i.e., >15 min in time). A laparotomy after a diagnostic laparoscopy (i.e., to assess the curability of the disease) should not be considered a conversion. In the second Delphi round, a RoA of 90% was achieved with this definition.

CONCLUSIONS

After two Delphi rounds, consensus on a uniform multidisciplinary definition of conversion was achieved within a representative group of general surgeons, gynecologists, and urologists. An unambiguous interpretation will result in a more reliable clinical registration of conversion and scientific evaluation of the feasibility of a laparoscopic procedure.