Risk Factors for Conversion to Laparotomy during Gynecologic Laparoscopy

Study Objective. To identify risk factors and short-term outcomes associated with conversion from laparoscopic surgery to laparotomy. Design. Case control study (Canadian Task Force classification II-2). Setting. Large urban, academic medical center. Subjects. All 2530 gynecologic laparoscopies, including those converted to laparotomy. Intervention. Laparoscopic surgery. Measurements and Main Results. Statistical analysis was performed to compare risk factors in converted versus nonconverted cases. Multiple logistic regression analysis was performed using variables found to be significant on univariate analysis. Of 2530 laparoscopies identified, 159 (6.3%) were converted to laparotomy; 323 were selected by random number assignment from the remaining cases for the control group. The following factors were significantly associated with unintended laparotomy (OR; 95% CI): surgeon inexperience (2.43; 1.38, 4.17), level of laparoscopic complexity (3.19; 1.20, 5.10), body mass index greater than 30 kg/m² (2.45; 1.40, 4.41), suspicion of malignancy (17.45; 7.32, 43.57), history of laparotomy (1.34; 1.02, 1.78), presence of adhesions (2.30; 1.37, 3.76), and intraoperative technical difficulty (17.86; 7.32, 43.57). When stratified by level of complexity, experience in laparoscopy does not appear to confer protection during level 1 laparoscopic procedures (0.42; 0.12, 1.37) but does significantly reduce the frequency of conversion during level 2 procedures (0.39; 0.72, 0.93). Age, parity, bowel injury, vascular injury, and history of pelvic inflammatory disease and endometriosis did not increase the risk of conversion. Compared with controls, patients who were converted experienced significantly greater blood loss (p <0.001), longer operating room time (p <0.001), and longer hospital stay (p <0.001). Conclusion. All women undergoing laparoscopy should be counseled that unintended laparotomy is a known risk and has additional morbidity over laparoscopy alone. Less-experienced surgeons attempting complicated procedures significantly increase the risk of conversion.