Conversion During Laparoscopic Surgery: Frequency, Indications and Risk Factors Lee Richstone,* Casey Seideman, Lauren Baldinger, Sompol Permpongkosol, Thomas W. Jarrett, Li-Ming Su, Christian Pavlovich and Louis R. Kavoussi From the North Shore-Long Island Jewish Health System (LR, CS, LB, LRK), New Hyde Park, New York, Department of Urology, Ramathibodi Hospital (SP), Bangkok, Thailand, George Washington University Hospital (TWJ), Washington, D. C., and The Brady Urological Institute (LMS, CP), Baltimore, Maryland Purpose: There are limited data on the indications for open conversion during laparoscopic surgery. The frequency of conversion for various procedures is poorly quantified and the degree to which this changes with time is not well understood. Risk factors for conversion are not defined. We addressed these issues in a large series of laparoscopic operations. Materials and Methods: We reviewed our database of 2,128 laparoscopic operations performed between 1993 and 2005, including radical nephrectomy in 549 patients, simple nephrectomy in 186, partial nephrectomy in 347, donor nephrectomy in 553, pyeloplasty in 301, nephroureterectomy in 106 and retroperitoneal lymph node dissection in 86. Open conversions were identified and the frequency of conversion for the total cohort and specific procedures was determined. Trends in conversion with time were assessed and indications analyzed. Clinicopathological features between patients requiring conversion and those who did not were compared. Results: We identified 68 patients (3.3%) who underwent conversion to open surgery (group 1) and 2,011 (96.7%) who did not (group 2). The frequency of conversion was greatest during nephroureterectomy (8.49%), followed by simple nephrectomy (5.91%), retroperitoneal lymph node dissection (4.65%), partial nephrectomy (4.32%), radical nephrectomy (2.91%), donor nephrectomy (2.53%) and pyeloplasty (0.33%). The absolute number of conversions and conversions/cases performed per year decreased significantly with time, reaching a nadir of less than 1% per year. Conversion was inversely related to case volume and cumulative experience. Indications included vascular injury in 38.5% of cases, concern with margins in 13.5%, bowel injury in 13.5%, failure to progress in 11.5%, adhesions in 9.6%, diaphragmatic injury in 1.9% and other in 11.5%. The distribution of indications remained similar with time. There were no differences in patient age, gender, surgical history, American Society of Anesthesiologists score or tumor stage between groups 1 and 2. In groups 1 and 2 mean operative time was 304 vs 219 minutes and estimated blood loss was 904 vs 255 cc (each p 0.0001). Conclusions: The rate of conversion during laparoscopic surgery is not uniform across procedures and it is important for patient counseling. The most common indication for conversion is vascular injury. Importantly the frequency of conversion is dynamic and likely related to case volume and cumulative experience. Key Words: kidney, nephrectomy, laparoscopy, laparotomy, intraoperative complications L aparoscopic surgery has evolved tremendously in the last 2 decades in the field of urology. Originally used for limited procedures, eg pelvic lymph node dissec- tion, laparoscopy is now used for the most challenging of urological operations, including prostatectomy, cystectomy, retroperitoneal lymph node dissection and partial/radical nephrectomy. Throughout this evolution the potential ben- efits and risks of the laparoscopic approach have been con- tinually evaluated. Almost all such factors have been noted to be dynamic, influenced by the steep learning curve of technically challenging procedures. However, there are limited data in the urological literature on the need for conversion to open laparotomy during planned laparoscopic procedures. Although conversion is not a compli- cation itself, it is an important component of the potential risks vs benefits of laparoscopy. Conversion to an open incision is likely to impact patients in multiple ways, including increased pain, operative time, length of stay and hospital costs. There is a risk of conversion inherent in every laparoscopic procedure. The ability to accurately quantify the risk of conversion is important for thorough preoperative patient counseling. Un- derstanding the indications for conversion and how they may change with time and with experience may have important medicolegal implications. Moreover, by defining risk factors for conversion physicians are better equipped to identify patients who are at greater risk for conversion. To our knowledge no prior studies in the urological liter- ature have identified such trends, risk factors and indica- tions for conversion. Our study is unique, in that we ana- lyzed our experience with more than 2,000 cases performed during more than 10 years, allowing the frequency and risk of conversion to be analyzed as a dynamic process reflective of surgeon experience. Submitted for publication January 18, 2008. * Correspondence: North Shore-Long Island Jewish Health Sys- tem, 450 Lakeville Rd., Suite M41, New Hyde Park, New York 11040 (telephone: 516-734-8558; FAX: 516-734-8535; e-mail: lrichsto@yahoo.com). 0022-5347/08/1803-0855/0 Vol. 180, 855-859, September 2008 THE JOURNAL OF UROLOGY ® Printed in U.S.A. Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2008.05.026 855