Factors associated with conversion in laparoscopic surgery in a low-resource setting: a single-center prospective study

INTRODUCTION

Laparoscopy has a clear patient benefit related to postoperative morbidity but may not be as commonly performed in low-and middle-income countries. The decision to convert to laparotomy can be complex and involve factors related to the surgeon, patient, and procedure. The objective of this work is to analyze the factors associated with conversion in laparoscopic surgery in a low-resource setting.

METHODS

This is a single-center prospective study of patients who underwent laparoscopic surgery between May 1, 2018 and October 31, 2021. The parameters studied were age, sex, body mass index (BMI), intraoperative complication (e.g., accidental enterotomy, hemorrhage), equipment malfunction (e.g., technical failure of the equipment, break in CO2 supply line), operating time, and conversion rate.

RESULTS

A total of 123 laparoscopic surgeries were performed. The average age of patients was 31.2 years (range 11-75). The procedures performed included appendix procedures (48%), followed by gynecological (18.7%), gallbladder (14.6%), digestive (10.56%), and abdominal procedures (4%). The average length of hospitalization was 3 days (range 1-16). Conversion to laparotomy was reported in 8.9% (n = 11) cases. Equipment malfunction was encountered in 9.8% (n = 12) cases. Surgical complications were noted in 11 cases (8.9%). Risk factors for conversion were shown to be BMI > 25 kg/m2 (OR 4.6; p = 0.034), intraoperative complications (OR 12.6; p = 0.028), and equipment malfunction (OR 9.4; p = 0.002).

CONCLUSION

A better understanding of the underlying factors associated with high conversion rates, such as overweight/obesity, intraoperative complications, and equipment failure, is the first step toward surgical planning to reduce postoperative morbidity in low-resource settings.

Promoting a Culture of Safety in Cholecystectomy (COSIC) over a decade at a Philippine public regional hospital after the SAGES International Proctoring Course in Laparoscopic Cholecystectomy Course

BACKGROUND

The SAGES International Proctoring Course for Laparoscopic Cholecystecomy accepts applications from low to middle-income countries for SAGES faculty to train local surgeons. A regional public hospital in the 10th most populous city in the Philippines was one of the chosen sites for the 1-week course in 2010. Two SAGES surgeons and one nurse trained two local surgeons and four nurses identified by the hospital director.

METHODS

All patients seen in the out-patient clinic at the Zamboanga City Medical Center in the Philippines and scheduled for elective laparoscopic cholecystectomy from the first day of the course in August 2010 until December 2018 were entered into a prospectively collected database including demographics, pre-op diagnosis, operative findings, histopathologic diagnosis, conversion rates and 30-day complications including re-operations.

RESULTS

521 patients underwent laparoscopic cholecystectomy. Majority were female (63.7%) with a mean age of 45.9 years. Most procedures were completed laparoscopically with an open conversion rate of 3.3%. Three patients underwent laparoscopic subtotal cholecystectomy. Reported complications requiring reoperation included one stump necrosis, two incisional hernias and one retained stone. One serosal injury and one surgical site infection were also reported for an overall morbidity rate of 4.6%. Pathology showed chronic calculous cholecystitis in 92.8% of specimens. No 30-day mortality was recorded.

CONCLUSION

The SAGES International Proctoring Course for Laparoscopic Cholecystectomy has been shown to be a successful method for global surgery training. A focused 1-week direct proctoring model in the Philippines showed a sustained culture of safety in cholecystectomy with low 30-day morbidity, complication and conversion rates over a decade following participation in this program.