Minimally invasive colon surgery: Managing conversions

 

LAS VEGAS – Minimally invasive colon surgery has many advantages over an open procedure with respect to complications and patient recovery, but as surgeons are well aware, sometimes conversion cannot and should not be avoided. “It’s going to happen, and if you’re not converting any of your patients, then you’re probably not being aggressive enough,” said Bradley R. Davis, MD, FACS, at a talk he gave on the topic at the Annual Minimally Invasive Surgery Symposium (MISS) 2018 by Global Academy for Medical Education.

Dr. Davis discussed some of the most common reasons for conversion to open surgery and strategies to try to reduce the incidence. He is the chief of general surgery and the chief of rectal and rectal surgery at Carolinas Medical Center, Charlotte, N.C.

A 2017 survey of 41,417 left hemicolectomy and sigmoidectomy procedures revealed that 63.4% were attempted laparoscopically, and the rate of conversion to an open procedure was 13.4% (JSLS. 2017 Jul-Sep;21[3]:e2017.00036). “I think that if your conversation rate is between 5% and 15%, [it’s] perfectly acceptable,” said Dr. Davis.

He suggested that surgeons should be willing to consider an increasing number of cases for minimally invasive surgery, despite the risk of conversion. By taking some precautions and being aware of which cases are most likely to lead to conversion, surgeons can potentially reduce the conversion rate – or at least lessen the effects it can have on patients and on costs.

 

Dr. Davis started with a discussion of the surgeon factors that can affect conversion rates. Medial and lateral approaches seem to have similar learning curves. “You’ve got to just stick to one approach. There’s not going to be any difference in terms of [frequency of] conversions,” said Dr. Davis.

Vascular pedicle ligation is the easiest approach, he said. Flexure mobilizations can be challenging, but they aren’t necessarily easier in open surgery. “If you’re struggling to mobilize the flexure, that may be the time to keep struggling because often when we go to open surgery [it doesn’t] get any easier,” said Dr. Davis.

The transverse colon mesentery is most difficult. “If you’re early in your learning curve, that’s something that’s going to be a little more difficult. The learning curve is between 50 and 60 cases,” said Dr. Davis.

Adhesions are the most common cause of conversions, but Dr. Davis said he generally starts with an attempt at laparoscopy. When he has a questionable case, he notifies the operating room staff that it should be prepared for a conversion so they don’t open a lot of disposables.

Other causes of conversion include pedicle or solid organ bleeding, hollow viscus injuries, and anastomotic complications. “As you get more up on your learning curve, you’ll be more comfortable in managing a hole in the bowel laparoscopically. ... Often you can manage those through your extraction site, so you can temporize that with a stitch and then bring it out and look at it,” said Dr. Davis.

Air leaks while doing an anastomosis on the sigmoid can also lead to conversion. “If you have a Pfannenstiel incision, you can do it through the Pfannenstiel, but if you have no incision, you are probably going to want to do some kind of incision to take a peek at that,” said Dr. Davis.

 

In neoplasms, conversions are common to ensure negative margins, which can’t always be accomplished laparoscopically.

Severe diverticulitis is another case that can mean a conversion, but hand-assisted techniques can be employed to avoid conversion. In severe diverticulitis, ureteral catheters can be helpful. “We identified a lower incidence of ureteral injury [with the use of ureteral catheters] in diverticulitis and T4 cancers. If you have a big phlegmon or a big cancer, I would definitely consider ureteral catheters,” said Dr. Davis. He pointed out that an inability to pinpoint the ureter is daunting in these types of cases. “That’s another thing to plan on if you know you’re going into these tough cases – trying to maximize your chances of not having a conversion by giving yourself the best possible tools to and the best visualization possible,” he added.

Obesity and inflammatory bowel disease are other conversion risk factors, as is performing a left hemicolectomy versus a sigmoidectomy. “As you plan your surgery, if you know you’ve got an obese patient with bad diverticulitis, this might be someone you would schedule as a laparoscopic versus open, with minimum disposable equipment in the room, knowing that, if it’s just not going to happen, then you need to open,” said Dr. Davis.

Technical factors that can contribute to conversion include failures of staplers, clips, and energy devices. When bleeding occurs as a result of an energy device, he doesn’t repeat its use. “If the energy has failed, I go right to an endoloop,” said Dr. Davis.

 

Bleeding in general needs to be controlled quickly or converted to open. “If you can’t get control of bleeding, that’s when you want to make a quick decision to open. You don’t want to lose two liters of blood trying to be fancy,” said Dr. Davis.

“Cautery injuries will happen, and it doesn’t take much to cause a full-thickness injury. It’s important to address it immediately, rather than move on, since it can be difficult to find after you’ve moved on to something else. Serosal injuries should also be dealt with right away,” he said.

A staple misfire can sometimes be repaired laparoscopically, but if it can’t, the patient should be opened up. “It’s just not worth the leak to prevent an incision,” said Dr. Davis.

Finally, body mass index is a strong predictor of conversion because of the difficulties it presents. “These aren’t cases that are fun to do open, either, but it’s going to be something that we’ll have to get better and better at as we see more of these patients,” said Dr. Davis.

Global Academy for Medical Education and this news organization are owned by the same parent company.

 

 

 

LAS VEGAS – Minimally invasive colon surgery has many advantages over an open procedure with respect to complications and patient recovery, but as surgeons are well aware, sometimes conversion cannot and should not be avoided. “It’s going to happen, and if you’re not converting any of your patients, then you’re probably not being aggressive enough,” said Bradley R. Davis, MD, FACS, at a talk he gave on the topic at the Annual Minimally Invasive Surgery Symposium (MISS) 2018 by Global Academy for Medical Education.

Dr. Davis discussed some of the most common reasons for conversion to open surgery and strategies to try to reduce the incidence. He is the chief of general surgery and the chief of rectal and rectal surgery at Carolinas Medical Center, Charlotte, N.C.

A 2017 survey of 41,417 left hemicolectomy and sigmoidectomy procedures revealed that 63.4% were attempted laparoscopically, and the rate of conversion to an open procedure was 13.4% (JSLS. 2017 Jul-Sep;21[3]:e2017.00036). “I think that if your conversation rate is between 5% and 15%, [it’s] perfectly acceptable,” said Dr. Davis.

He suggested that surgeons should be willing to consider an increasing number of cases for minimally invasive surgery, despite the risk of conversion. By taking some precautions and being aware of which cases are most likely to lead to conversion, surgeons can potentially reduce the conversion rate – or at least lessen the effects it can have on patients and on costs.

 

Dr. Davis started with a discussion of the surgeon factors that can affect conversion rates. Medial and lateral approaches seem to have similar learning curves. “You’ve got to just stick to one approach. There’s not going to be any difference in terms of [frequency of] conversions,” said Dr. Davis.

Vascular pedicle ligation is the easiest approach, he said. Flexure mobilizations can be challenging, but they aren’t necessarily easier in open surgery. “If you’re struggling to mobilize the flexure, that may be the time to keep struggling because often when we go to open surgery [it doesn’t] get any easier,” said Dr. Davis.

The transverse colon mesentery is most difficult. “If you’re early in your learning curve, that’s something that’s going to be a little more difficult. The learning curve is between 50 and 60 cases,” said Dr. Davis.

Adhesions are the most common cause of conversions, but Dr. Davis said he generally starts with an attempt at laparoscopy. When he has a questionable case, he notifies the operating room staff that it should be prepared for a conversion so they don’t open a lot of disposables.

Other causes of conversion include pedicle or solid organ bleeding, hollow viscus injuries, and anastomotic complications. “As you get more up on your learning curve, you’ll be more comfortable in managing a hole in the bowel laparoscopically. ... Often you can manage those through your extraction site, so you can temporize that with a stitch and then bring it out and look at it,” said Dr. Davis.

Air leaks while doing an anastomosis on the sigmoid can also lead to conversion. “If you have a Pfannenstiel incision, you can do it through the Pfannenstiel, but if you have no incision, you are probably going to want to do some kind of incision to take a peek at that,” said Dr. Davis.

 

In neoplasms, conversions are common to ensure negative margins, which can’t always be accomplished laparoscopically.

Severe diverticulitis is another case that can mean a conversion, but hand-assisted techniques can be employed to avoid conversion. In severe diverticulitis, ureteral catheters can be helpful. “We identified a lower incidence of ureteral injury [with the use of ureteral catheters] in diverticulitis and T4 cancers. If you have a big phlegmon or a big cancer, I would definitely consider ureteral catheters,” said Dr. Davis. He pointed out that an inability to pinpoint the ureter is daunting in these types of cases. “That’s another thing to plan on if you know you’re going into these tough cases – trying to maximize your chances of not having a conversion by giving yourself the best possible tools to and the best visualization possible,” he added.

Obesity and inflammatory bowel disease are other conversion risk factors, as is performing a left hemicolectomy versus a sigmoidectomy. “As you plan your surgery, if you know you’ve got an obese patient with bad diverticulitis, this might be someone you would schedule as a laparoscopic versus open, with minimum disposable equipment in the room, knowing that, if it’s just not going to happen, then you need to open,” said Dr. Davis.

Technical factors that can contribute to conversion include failures of staplers, clips, and energy devices. When bleeding occurs as a result of an energy device, he doesn’t repeat its use. “If the energy has failed, I go right to an endoloop,” said Dr. Davis.

 

Bleeding in general needs to be controlled quickly or converted to open. “If you can’t get control of bleeding, that’s when you want to make a quick decision to open. You don’t want to lose two liters of blood trying to be fancy,” said Dr. Davis.

“Cautery injuries will happen, and it doesn’t take much to cause a full-thickness injury. It’s important to address it immediately, rather than move on, since it can be difficult to find after you’ve moved on to something else. Serosal injuries should also be dealt with right away,” he said.

A staple misfire can sometimes be repaired laparoscopically, but if it can’t, the patient should be opened up. “It’s just not worth the leak to prevent an incision,” said Dr. Davis.

Finally, body mass index is a strong predictor of conversion because of the difficulties it presents. “These aren’t cases that are fun to do open, either, but it’s going to be something that we’ll have to get better and better at as we see more of these patients,” said Dr. Davis.

Global Academy for Medical Education and this news organization are owned by the same parent company.

 

 

 

LAS VEGAS – Minimally invasive colon surgery has many advantages over an open procedure with respect to complications and patient recovery, but as surgeons are well aware, sometimes conversion cannot and should not be avoided. “It’s going to happen, and if you’re not converting any of your patients, then you’re probably not being aggressive enough,” said Bradley R. Davis, MD, FACS, at a talk he gave on the topic at the Annual Minimally Invasive Surgery Symposium (MISS) 2018 by Global Academy for Medical Education.

Dr. Davis discussed some of the most common reasons for conversion to open surgery and strategies to try to reduce the incidence. He is the chief of general surgery and the chief of rectal and rectal surgery at Carolinas Medical Center, Charlotte, N.C.

A 2017 survey of 41,417 left hemicolectomy and sigmoidectomy procedures revealed that 63.4% were attempted laparoscopically, and the rate of conversion to an open procedure was 13.4% (JSLS. 2017 Jul-Sep;21[3]:e2017.00036). “I think that if your conversation rate is between 5% and 15%, [it’s] perfectly acceptable,” said Dr. Davis.

He suggested that surgeons should be willing to consider an increasing number of cases for minimally invasive surgery, despite the risk of conversion. By taking some precautions and being aware of which cases are most likely to lead to conversion, surgeons can potentially reduce the conversion rate – or at least lessen the effects it can have on patients and on costs.

 

Dr. Davis started with a discussion of the surgeon factors that can affect conversion rates. Medial and lateral approaches seem to have similar learning curves. “You’ve got to just stick to one approach. There’s not going to be any difference in terms of [frequency of] conversions,” said Dr. Davis.

Vascular pedicle ligation is the easiest approach, he said. Flexure mobilizations can be challenging, but they aren’t necessarily easier in open surgery. “If you’re struggling to mobilize the flexure, that may be the time to keep struggling because often when we go to open surgery [it doesn’t] get any easier,” said Dr. Davis.

The transverse colon mesentery is most difficult. “If you’re early in your learning curve, that’s something that’s going to be a little more difficult. The learning curve is between 50 and 60 cases,” said Dr. Davis.

Adhesions are the most common cause of conversions, but Dr. Davis said he generally starts with an attempt at laparoscopy. When he has a questionable case, he notifies the operating room staff that it should be prepared for a conversion so they don’t open a lot of disposables.

Other causes of conversion include pedicle or solid organ bleeding, hollow viscus injuries, and anastomotic complications. “As you get more up on your learning curve, you’ll be more comfortable in managing a hole in the bowel laparoscopically. ... Often you can manage those through your extraction site, so you can temporize that with a stitch and then bring it out and look at it,” said Dr. Davis.

Air leaks while doing an anastomosis on the sigmoid can also lead to conversion. “If you have a Pfannenstiel incision, you can do it through the Pfannenstiel, but if you have no incision, you are probably going to want to do some kind of incision to take a peek at that,” said Dr. Davis.

 

In neoplasms, conversions are common to ensure negative margins, which can’t always be accomplished laparoscopically.

Severe diverticulitis is another case that can mean a conversion, but hand-assisted techniques can be employed to avoid conversion. In severe diverticulitis, ureteral catheters can be helpful. “We identified a lower incidence of ureteral injury [with the use of ureteral catheters] in diverticulitis and T4 cancers. If you have a big phlegmon or a big cancer, I would definitely consider ureteral catheters,” said Dr. Davis. He pointed out that an inability to pinpoint the ureter is daunting in these types of cases. “That’s another thing to plan on if you know you’re going into these tough cases – trying to maximize your chances of not having a conversion by giving yourself the best possible tools to and the best visualization possible,” he added.

Obesity and inflammatory bowel disease are other conversion risk factors, as is performing a left hemicolectomy versus a sigmoidectomy. “As you plan your surgery, if you know you’ve got an obese patient with bad diverticulitis, this might be someone you would schedule as a laparoscopic versus open, with minimum disposable equipment in the room, knowing that, if it’s just not going to happen, then you need to open,” said Dr. Davis.

Technical factors that can contribute to conversion include failures of staplers, clips, and energy devices. When bleeding occurs as a result of an energy device, he doesn’t repeat its use. “If the energy has failed, I go right to an endoloop,” said Dr. Davis.

 

Bleeding in general needs to be controlled quickly or converted to open. “If you can’t get control of bleeding, that’s when you want to make a quick decision to open. You don’t want to lose two liters of blood trying to be fancy,” said Dr. Davis.

“Cautery injuries will happen, and it doesn’t take much to cause a full-thickness injury. It’s important to address it immediately, rather than move on, since it can be difficult to find after you’ve moved on to something else. Serosal injuries should also be dealt with right away,” he said.

A staple misfire can sometimes be repaired laparoscopically, but if it can’t, the patient should be opened up. “It’s just not worth the leak to prevent an incision,” said Dr. Davis.

Finally, body mass index is a strong predictor of conversion because of the difficulties it presents. “These aren’t cases that are fun to do open, either, but it’s going to be something that we’ll have to get better and better at as we see more of these patients,” said Dr. Davis.

Global Academy for Medical Education and this news organization are owned by the same parent company.