Conversion to Hand Assistance May Prevent Conversion to an Open Procedure in Standard Laparoscopic Nephrectomy

Introduction

O ver the past two decades, laparoscopy has developed from a novel surgical approach into the standard of care for a large variety of urologic operations. Conversion to open surgery during laparoscopy may sometimes become necessary, especially during the early experience of the surgeon or during a technically challenging case. The reasons to convert may be various, and the threshold to convert is largely dependent on the experience of the surgical team.

Conversion should generally be viewed as a wise decision, rather than a complication. It is a deviation from the planned procedure, however, and thus may embrace an element of a feeling of failure for the surgeon and disappointment for the patient. Moreover, completing surgery with a large incision may potentially avert the classic postoperative advantages of laparoscopic surgery, such as decreased pain and faster recovery in the postoperative period.

Studies that specifically address conversion from standard laparoscopy are scarce and comprise only those reporting on conversion to open surgery. ^{1 –3} To the best of our knowledge, conversion from standard to hand-assisted laparoscopic surgery, ⁴ initially reported by Nakada, ⁵ has been reported in a few patients within some series; however, a specific publication on this topic is lacking. The theoretical advantages of a hand-assisted approach include the surgeon's ability to use his/her hand during the operation for tactile sensation, blunt dissection, retracting surrounding structures, and maintaining hemostasis. When a decision is made to convert from standard laparoscopy, conversion to hand-assistance may be a safe and potentially more advantageous alternative compared with conversion to open surgery. We consider this to be an underrated issue.

We retrospectively analyzed and report our data on conversion to hand assistance during laparoscopic nephrectomy in an effort to emphasize this matter.

Patients and Methods

We retrospectively reviewed the records of laparoscopic nephrectomies that were performed between July 2002 and December 2009. An Institutional Review Board approval was obtained. Demographic and perioperative data were collected prospectively at the time of surgery. Data that were evaluated included indications and the type of laparoscopic nephrectomy performed, duration of surgery, estimated blood loss (EBL), conversion from the planned surgery, and operative and perioperative complications. In each case, the operative reports were reviewed and the reason for conversion determined.

Operative time was the elapsed time from skin incision to skin closure. All procedures were performed via a transperitoneal approach by the senior author (ARK) or with his assistance. For standard laparoscopy, four ports were used on the left side, and an additional 5-mm port was used on the right side for liver retraction. When cutting trocars were used, all 10- to 12-mm ports were closed via the Carter Thomason device before exiting the abdomen. The specimen was removed intact within an impermeable bag for standard laparoscopy.

Hand-assisted laparoscopy was performed with various hand-assistance devices (Gelport, Lapdisc). An approximately 7-cm incision was made in the midline above the umbilicus on the left side or obliquely in the lower abdomen on the right side for the hand port device. Previously placed trocars were used along with the hand-assistance device. The primary technical modification in obesity was to displace the hand-assistance site and ports lateral and superior relative to the umbilicus, often using paramedian hand assistance. All specimens were extracted intact through the hand port device without using a bag.

Results

A total of 161 laparoscopic nephrectomies were performed within the study period. Conventional laparoscopy was initially planned in 150, and hand-assisted laparoscopy in 11. This comprises our initial experience and thus the learning curve for laparoscopy as well. Of the 150 patients who were scheduled for standard laparoscopy, 76 (50.5%) underwent radical nephrectomies that were performed for renal-cell carcinoma. Fifty-two (34.5%) underwent surgery for benign disease and are grouped under simple nephrectomies. Laparoscopic radical nephroureterectomy was performed for upper-tract urothelial carcinoma in 22 (14.5%). Hand-assisted laparoscopic surgery was initially planned and carried out (not conversion) in 11 patients who were undergoing radical nephrectomies (8), simple nephrectomies (2), and nephroureterectomy (1).

The operative time, American Society of Anesthesiologists (ASA) score, body mass index (BMI), EBL, specimen weight, and hospitalization period for various techniques are presented in Table 1.

Conversion from planned standard laparoscopy was deemed necessary in six patients. We converted from standard to a hand-assisted procedure in five patients, and surgery was successfully completed in all with hand-assisted laparoscopy (Table 2). Of these five patients, four were undergoing radical nephrectomy and one radical nephroureterectomy. The reason for conversion was failure to progress in three patients. Exertion was associated with handling a large kidney in two (2200 g and 1395 g specimen weights), and retraction with a hand in the abdomen facilitated surgery. In another patient, whose final pathology findings revealed sarcomatoid differentiation, difficulty in finding planes for dissection was the reason for conversion.

Control of bleeding was the motive to convert to a hand-assisted procedure in the remaining two elderly (85 and 88 years old) patients. Blood loss was more in the form of oozing in both, and the decision was that hemostasis would be achieved more easily and safely with conversion without risking hypotension and other cardiovascular complications. EBL was 450 and 800 mL in these patients. None of the conversions were conducted on an emergency basis.

Conversion to open laparotomy was performed in one patient at the initiation of the procedure, because of the patient's intolerance of pneumoperitoneum. He displayed severe signs of vagal reaction immediately after the instigation of insufflation. After a few unsuccessful insufflation trials, laparoscopic surgery was abandoned, and nephrectomy was performed via an open approach. Thus, none of the patients in the series required open conversion after the initiation of laparoscopic renal surgery. We have not had any conversions from standard laparoscopy since March 2007.

There were four patients in the series who needed blood transfusion (two of whom were in conversion to the hand-assistance group). Major complications were seen in two patients. Pulmonary embolism developed in one patient, who died on postoperative day 6. Biliary fistula developed in another patient after synchronous cholecystectomy performed by a general surgeon. She underwent endoscopic stent placement postoperatively. This patient had a prolonged hospital stay (6 days), and all other patients were discharged at an average of 3.7 days.

Discussion

Laparoscopic surgery has been widely embraced in the urologic community and is no longer limited to specific institutions. Nevertheless, there are many urologists worldwide who are still relatively new to the technique, and many others who are planning to incorporate laparoscopy into their armamentarium. It is well documented that mastering laparoscopy is not easy, with a long and steep learning curve. ^3,6,7

The risk of conversion is inherent to every laparoscopic procedure. There is a universal trend toward a lower conversion rate with growing experience. ¹ This substantial decrease in conversion rate with time is indicative of a learning curve. ¹ The challenge persists for the experienced laparoscopic surgeon as he tackles more complex cases. Differences in conversion rates may be partly related to surgeon preference and threshold for conversion.

The most common reasons for conversion are vascular injury, bowel injury, failure to progress, adhesions, and/or oncologic concern. ¹ Importantly, conversion to open surgery should not be considered as a complication but rather be viewed as a wise decision regarding patient safety. It is a deviation from the planned surgery and may have consequences, however. For the surgeon in the learning curve, it might be discouraging. For the patient, conversion to an open incision is likely to have an impact in multiple ways; ie, a larger incision may cause more pain and a longer convalescence period.

Hand assistance was developed as an alternative to standard laparoscopy. Laparoscopic hand-assisted radical nephrectomy in humans was initially reported by Nakada ⁵ in 1999, with the goal being to shorten the challenging and lengthy learning curve as well as the operative time. ⁸ It was introduced as an easier, yet still minimally invasive approach. ^5,8 Placement of the hand in the operative field may allow excellent maneuverability with retraction and dissection, and the potential for increased vascular control. Consequently, the hand-assisted approach may give the surgeon a comfortable transition from the open to the laparoscopic approach. ⁹

Hand-assisted laparoscopic nephrectomy may be an attractive minimally invasive option in the setting of significant complicating factors. ^{10 –12} It may facilitate successful laparoscopic completion of challenging cases that otherwise may have been approached through open surgery with reasonable operative times, blood loss, and complication rates. ¹⁰

Baldwin and colleagues ¹³ performed a retrospective comparison between standard, hand-assisted, and open radical nephrectomy in patients who were at high risk for perioperative complications. They concluded that both standard and hand-assisted laparoscopic surgery resulted in less pain medication and faster return to oral intake than in the open group. Malaeb and coworkers ¹⁴ reported that estimated blood loss, operative time, length of hospital stay, and postoperative parenteral narcotic use were all significantly less in the hand-assisted laparoscopic radical nephrectomy group compared with its open counterpart. These data would suggest that completing surgery with either conventional or hand-assisted laparoscopy is more beneficial for the patient in comparison with open surgery.

An important factor in determining the rate of conversion is the type of surgical procedure performed. A multi-institutional review of laparoscopic nephrectomy series revealed a conversion rate of 3% of patients who were undergoing simple nephrectomy compared with 16% of those who were undergoing radical nephrectomy. ¹⁵ We did not require conversion in any of the simple nephrectomies; four conversions were during radical nephrectomies (80%) and one during nephroureterectomy (20%).

In the urology literature, vascular injury is generally the most common indication for conversion. In a large series with more than 2000 patients and 68 conversions, the indications to perform open laparotomy were vascular injury (36.8%), failure to progress (14.7%), oncologic concern (8.8%,) visceral injury (8.8%), and other causes (30.9%). ¹ Our indications were difficulty to progress in three (60%) and concern with obtaining adequate hemostasis in two (30%).

Tumor size, age, ASA score, BMI, and previous abdominal surgery are all potential factors that affect conversion from planned laparoscopy. Patients who are over age 50 years have been reported to be 3.9 times more likely to require conversion. ¹ Age appeared to be one of the factors leading to conversion in our series. The age was 75 years or greater in four of five patients. We preferred not to risk patient well-being by prolonging surgery or increased blood loss in the elderly, and probably had a lower threshold for conversion.

Specimen weight also was an important cause for conversion in our experience. Hand assistance was suggested to be a safe, minimally invasive option in the management of large renal specimens. ¹⁰ We concur, and we were able to overcome failure to progress with standard laparoscopy in two patients with large renal specimens by converting to hand assistance.

Another patient whom we converted to hand assistance because of failure to progress had sarcomatoid differentiation revealed on the pathologic findings. Kalra and coworkers ¹⁰ reported on the efficacy and safety of hand-assisted laparoscopy in patients with sarcomatoid features. ¹⁰ Our numbers are too small to comment on the influence of ASA score, BMI, and previous abdominal surgery.

In the present series, the primary surgeon was able to overcome the learning curve for laparoscopic surgery without “open conversion.” Thus, we have established that conversion to hand assistance may prevent conversion to open surgery and denote a very reasonable and safe alternative for completing the surgery laparoscopically. Evidently, this necessitates experience with the hand-assisted method. We recommend having a hand-assistance device available in the operating room for all standard laparoscopy cases.

There are a few limitations to our study. It is a retrospective analysis of a relatively small cohort. We were unable to analyze and comment on various factors leading to conversion, and compare basic differences for the converted vs nonconverted patients because of a relatively small series with very few numbers of conversions. None of the patients in the series had significantly enlarged lymph nodes or vein involvement; therefore, the applicability of conversion to hand assistance in these circumstances remains to be investigated. All of the conversions in this series were elective; hence, we cannot draw conclusions on the applicability of conversion to hand assistance in emergency situations.