Risk Factors and Outcomes of Open Conversion During Minimally Invasive Major Hepatectomies: An International Multicenter Study on 3880 Procedures Comparing the Laparoscopic and Robotic Approaches
Roberto Montalti # 1 , Mariano Cesare Giglio # 1 , Andrew G R Wu 2 , Federica Cipriani 3 , Mizelle D'Silva 4 , Amal Suhool 5 , Phan Phuoc Nghia 6 , Yutaro Kato 7 , Chetana Lim 8 , Paulo Herman 9 , Fabricio Ferreira Coelho 9 , Moritz Schmelzle 10 , Johann Pratschke 10 , Davit L Aghayan 11 , Qiu Liu 12 , Marco V Marino 13 , Andrea Belli 14 , Adrian K H Chiow 15 , Iswanto Sucandy 16 , Arpad Ivanecz 17 , Fabrizio Di Benedetto 18 , Sung Hoon Choi 19 , Jae Hoon Lee 20 , James O Park 21 , Mikel Prieto 22 , Yoelimar Guzman 23 , Constantino Fondevila 23 24 , Mikhail Efanov 25 , Fernando Rotellar 26 , Gi-Hong Choi 27 , Ricardo Robles-Campos 28 , Xiaoying Wang 29 , Robert P Sutcliffe 30 , Chung Ngai Tang 31 , Charing C Chong 32 , Mathieu D'Hondt 33 , Bernardo Dalla Valle 34 , Andrea Ruzzenente 34 , T Peter Kingham 35 , Olivier Scatton 8 , Rong Liu 12 , Alejandro Mejia 36 , Kohei Mishima 37 , Go Wakabayashi 37 , Santiago Lopez-Ben 38 , Franco Pascual 39 , Daniel Cherqui 39 , Fabio Forchino 40 , Alessandro Ferrero 40 , Giuseppe Maria Ettorre 41 , Giovanni Battista Levi Sandri 41 , Atsushi Sugioka 7 , Bjørn Edwin 11 , Tan-To Cheung 42 , Tran Cong Duy Long 6 , Mohammad Abu Hilal 43 5 , Luca Aldrighetti 3 , David Fuks 44 , Ho-Seong Han 4 , Roberto I Troisi # 45 , Brian K P Goh # 46 47 ; International Robotic and Laparoscopic Liver Resection Study Group Investigators
Introduction: Despite the advances in minimally invasive (MI) liver surgery, most major hepatectomies (MHs) continue to be performed by open surgery. This study aimed to evaluate the risk factors and outcomes of open conversion during MI MH, including the impact of the type of approach (laparoscopic vs. robotic) on the occurrence and outcomes of conversions.
Methods: Data on 3880 MI conventional and technical (right anterior and posterior sectionectomies) MHs were retrospectively collected. Risk factors and perioperative outcomes of open conversion were analyzed. Multivariate analysis, propensity score matching, and inverse probability treatment weighting analysis were performed to control for confounding factors.
Results: Overall, 3211 laparoscopic MHs (LMHs) and 669 robotic MHs (RMHs) were included, of which 399 (10.28%) had an open conversion. Multivariate analyses demonstrated that male sex, laparoscopic approach, cirrhosis, previous abdominal surgery, concomitant other surgery, American Society of Anesthesiologists (ASA) score 3/4, larger tumor size, conventional MH, and Institut Mutualiste Montsouris classification III procedures were associated with an increased risk of conversion. After matching, patients requiring open conversion had poorer outcomes compared with non-converted cases, as evidenced by the increased operation time, blood transfusion rate, blood loss, hospital stay, postoperative morbidity/major morbidity and 30/90-day mortality. Although RMH showed a decreased risk of conversion compared with LMH, converted RMH showed increased blood loss, blood transfusion rate, postoperative major morbidity and 30/90-day mortality compared with converted LMH.
Conclusions: Multiple risk factors are associated with conversion. Converted cases, especially those due to intraoperative bleeding, have unfavorable outcomes. Robotic assistance seemed to increase the feasibility of the MI approach, but converted robotic procedures showed inferior outcomes compared with converted laparoscopic procedures.
CITA DEL ARTÍCULO Ann Surg Oncol. 2023 May 18. doi: 10.1245/s10434-023-13525-0