Clinical Relevance of Conversion Rate and Its Evaluation in Laparoscopic Hysterectomy

Literature Review Article

Clinical Relevance of Conversion Rate and Its Evaluation in Laparoscopic Hysterectomy. Twijnstra, ARH, Blikkendaal, MD, van Zwet, EW, Jansen, FW. J Minim Invasive Gynecol 2013; 20: 64-72. 

Review
John Parry, M.D.
 

The study characterizes how qualities of both patients and surgeons influence the likelihood of conversion from laparoscopic hysterectomy (LH) to open hysterectomy. This prospective cohort study of 79 gynecologists at 43 hospitals (75% of gynecologists performing LH in the Netherlands and 68% of Dutch hospitals) led to 1534 LH’s being performed between 2008 and 2010. 70 LH’s (4.6%) were converted to open procedures. Of these, 31.4% were reactive, which included uncontrolled bleeding (63.6%), internal organ lesions (13.6%), and equipment failure (13.6%). The remaining 68.6% were considered strategic, due to visibility (e.g. myomas or adhesions, 70.8%), risk for malignancy (the uterus was too large to remove intact, making morcellation contraindicated, 14.6%), and anesthesiologic problems in the setting of morbid obesity (10.4%). Risk factors for conversion included BMI >35 (OR, 6.5), age >65 (OR, 7), uterine weight 200 to 500g (OR 4.1), and uterine weight >500g (OR 30.9). Supracervical laparoscopic hysterectomy decreased the risk for conversion relative to total laparoscopic hysterectomy (OR, .32). LAVH was associated with a higher rate of conversion (OR 2.1), but this association was not statistically significant. Of interest, surgeon experience (<30 TH’s) was not found to increase the risk of conversion, which the authors attribute to standards of care in supervision and mentorship. However, there was a risk of conversion associated with the collective ability of the team performing the TH (OR, 2.8). The authors conclude that individual patient characteristics are important in predicting conversion rates, but that the experience of individual surgeons was less important than the collective ability of a clinical team.

Comments
Daniel B. Williams, M.D.
 

This prospective cohort study attempts to qualify the factors associated with conversion from laparoscopic hysterectomy (LH) to open hysterectomy among 79 gynecologists performing 1534 LH’s between 2008 and 2010. 70 LH’s (4.6%) were converted to open procedures. Of these, 31.4% were reactive, which included uncontrolled bleeding (63.6%), internal organ lesions (13.6%), and equipment failure (13.6%). The remaining 68.6% were considered strategic, due to visibility (e.g. myomas or adhesions, 70.8%), risk for malignancy (the uterus was too large to remove intact, making morcellation contraindicated, 14.6%), and anesthesiologic problems in the setting of morbid obesity (10.4%). Risk factors for conversion included BMI >35 (OR, 6.5, 95% CI 2.3-18.8), age >65 (OR, 7.0, 95% CI 1.8-28.3), uterine weight 200 to 500g (OR 4.1, 95% CI 1.8-8.8), and uterine weight >500g (OR 30.9, 95% CI 11.7-81.5). Supracervical laparoscopic hysterectomy decreased the risk for conversion relative to total laparoscopic hysterectomy (OR, 0.32, 95% CI 0.12-0.83). LAVH was associated with a higher rate of conversion (OR 2.1, 95% CI 0.8-5.4), but this association was not statistically significant. Surgeon experience (<30 TH’s) was not found to increase the risk of conversion, which the authors attribute to standards of care in supervision and mentorship. However, there was a risk of conversion associated with the collective ability of the team performing the TH (OR, 2.8). The authors conclude that individual patient characteristics are important in predicting conversion rates, but that the experience of individual surgeons was less important than the collective ability of a clinical team.

 

The above review and commentary on this article were written by SRS members. Publication of these summaries does not reflect endorsement of any particular procedure or treatment. Views expressed in these summaries do not necessarily reflect the views of SRS or ASRM.

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