Papandria Dominic, Lardaro Thomas, Rhee Daniel, Ortega Gezzer, Gorgy Amany, Makary Martin A, Abdullah Fizan
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Am Surg. 2013 Sep;79(9):914-21.
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.
微创手术已经影响了外科手术实践和患者期望。腹腔镜手术转为开放手术的风险常被提及,但量化模糊。本研究考察了三种常见手术,以确定腹腔镜手术转为开放手术(LCO)事件的风险因素。利用美国外科医师学会国家外科质量改进计划(ACS-NSQIP;2005年至2009年)进行横断面分析,确定了具有阑尾切除术、胆囊切除术和减肥手术腹腔镜手术编码的病例。主要结局是腹腔镜手术转为同等的开放手术。比较了腹腔镜组和LCO组的汇总统计数据,并使用逻辑回归分析来估计患者和手术转为开放手术的风险因素。在176,014例选定的腹腔镜手术中,2,138例(1.2%)转为开放手术。大多数患者为女性(68%)和白人(71.2%);平均年龄为45.1岁。LCO胆囊切除术的可能性显著更高(n = 1526 [1.9%]),LCO减肥手术的可能性较低(n = 121 [0.3%]);阑尾切除术居中(n = 491 [1.0%],P < 0.001)。与LCO相关的患者因素包括男性(P < 0.001)、30岁及以上(P < 0.025)、美国麻醉医师协会2至4级(P < 0.001)、肥胖(P < 0.01)、出血性疾病史(P = 0.036)或术前全身炎症反应综合征或脓毒症(P < 0.001)。LCO与术后并发症的发生率较高相关,包括死亡、器官腔隙手术部位感染、脓毒症、伤口裂开和返回手术室(P < 0.001)。参与ACS-NSQIP的医院中总体LCO发生率较低。转为开放手术的风险因素包括患者年龄、性别、肥胖、术前合并症以及所实施的手术。这些信息对于临床医生与患者讨论转为开放手术的风险应该是有价值的。