Characterization of Patients with Minimally Invasive Surgery Converted in a Pediatric Hospital

Abstract

Introduction:

Minimally invasive surgery (MIS) in pediatric surgery is now the standard of care for various surgical conditions. We have seen an increase in MIS with some of the procedures requiring intraoperative conversion to open surgery.

Materials and Methods:

This is a single-institution retrospective study of patients who underwent MIS between 2009 and 2017 requiring conversion to open surgery. Preoperative characteristics, cause of conversion, and postoperative factors were recorded.

Results:

A total of 154 patients had converted to MIS, 89.6% underwent laparoscopic procedures. Mean age was 8.5 years, 53.9% were male. Primary cause leading to surgery was not oncologic (89.6%), dirty contaminated wound was found in 49.35%, inflammatory response markers were altered, and 38.9% of our patients were American Society of Anesthesiologists physical status classification 3. Principal causes of conversion were failure in progression (53.25%) and loss of anatomic reference (24.5%). A total of 44.16% of the patients required postoperative pediatric intensive care unit admission, 29.2% required reintervention, and mortality rate was 0.65%. We detailed data regarding thoracoscopic, appendectomy, and laparoscopic procedures.

Conclusion:

Conversion to MIS is a decision the surgeon must make in different scenarios. This study allowed us to characterize our population regarding converted MIS procedures. Male gender, age group, altered inflammatory markers, not oncologic pathology, and dirty wound were frequently found, but we cannot establish any of them as risk factors. Main cause for conversion to open surgery was failure in the progression of the procedure in our study according to reported literature. We intend to develop further studies to determine risk factors.

Introduction

The use of minimally invasive techniques in pediatric surgery has increased dramatically in recent years and is now the standard of care for various surgical conditions.^1–3 Some of the advantages are the development of fewer adhesions and scar tissue, lesser postoperative pain, and better esthetic results.^1,2

There was uncertainty at the beginning about minimally invasive procedures in pediatric surgery because instruments were designed for adults, lack of training, higher costs, and prolonged operative time.¹ However, technological advances and research demonstrated the advantages and safety of these new approaches.^3–5 Nowadays there are specific procedures for pediatric population and complicated surgical conditions can be treated with minimally invasive surgery (MIS).^2,3,6

Conversion to open surgery occurs because of the severity of the disease or whether intraoperative complications arise.^7–9 Conversion increases costs and operative times and the benefits of the laparoscopic approach are lost.^7–9 Therefore, it is useful to characterize the population that required conversion of procedures as a first step to determine risk factors.^10–19 Currently there are studies that neither characterize nor determine risk factors for conversion in our pediatric population, therefore, this study intends to describe the preoperative, intraoperative, and postoperative characteristics in the pediatric population who converted to MIS.¹⁹

Materials and Methods

The study was conducted at the department of Pediatric Surgery of Fundación Hospital Pediatrico la Misericordia (HOMI) in Bogotá, Colombia. Having prior approval by the ethics committee of our institution, we retrospectively reviewed the database of the Department of Pediatric Surgery to identify patients whose procedures required conversion from a minimally invasive approach to open surgery (including laparoscopy and thoracoscopy) between January 1, 2009, and December 31 2017. Information regarding preoperative characteristics, intraoperative cause of conversion, and postoperative factors were extracted from the patient chart.

Preoperative data included age, gender, disease leading to surgery (classified as benign/not oncologic, oncologic), American Society of Anesthesiologists (ASA) physical status classification, type of procedure either laparoscopic or thoracoscopic, and the specific procedure. Information regarding laboratories was also collected: leukocyte count, neutrophil count, platelets, C-reactive protein (CRP), international normalized ratio (INR), and albumin levels. Wound classification was also extracted and collected from the operative record.

The decision to convert to an open procedure was made by the individual surgeon and the reason for each conversion was extracted from the operative record.

Cause of conversion was classified in four groups: failure to progress, loss of anatomic reference, impossibility to control bleeding, and incidental injury without possibility to control in a minimally invasive approach.

Regarding the postoperative period, information was added about the length of hospital stay, intensive care unit (ICU) admission, reoperation, and mortality.

We used descriptive statistics to show the distribution of clinical and sociodemographic characteristics of patients included, and conversion causes.

Results

One hundred fifty-four patients were included in this study, general and demographic data are given in Table 1. We report 16 cases of thoracoscopic procedures converted (Table 2), 18.75% of which were performed in oncologic patients. Regarding primary disease being not oncologic, the most common procedure was pulmonary decortication followed by correction of patent ductus arteriosus. Majority of patients were under the age of 5 years (69%), 23% between 5 and 10 years, and 8%> 15 years old. Patients were predominantly male (69.2%) and classified as ASA 3 (53.8%). Leukocytosis (media 19,156), elevated neutrophil count (media 13,631) and C-reactive protein value (media 80) with hypoalbuminemia (media 3,02) and mildly prolonged INR (media 1.2) were documented. Postoperatively 92.3% of patients required ICU admission and the reintervention rate was 23.1%. In the oncologic group, 2 patients were in the age group between 11 and 15 years and 1 patient was between 5 and 10 years, 66.6% were female and predominantly classified as ASA 3 (66.6%). The most common procedure was pulmonary biopsy. Leukocyte and neutrophil count were normal, CRP was elevated (media 98), hypoalbuminemia (2.85) and prolonged INR (1.3) were also documented. One patient required postoperative ICU admission and none of them underwent reintervention. Most common cause of conversion was failure in progression in both groups.

Table 1.

General and Demographic Data

Variable/group	n (%)
Age
<5 years	41 (26.6)
5–10 years	44 (28.5)
11–15 years	55 (35.7)
>15 years	14 (9)
Gender
Male	83 (53.9)
Female	71 (46.1)
Procedure
Laparoscopic	138 (89.6)
Thoracoscopic	16 (10.3)
Primary disease leading to surgery
Nononcologic	138 (89.6)
Oncologic	16 (10.4)

Table 2.

Thoracoscopic Procedures and Cause of Conversion

Procedure	n	Cause of conversion
Pulmonary decortication	5	Failure in progression (3)
		Impossibility to control bleeding (1)
		Loss of anatomic reference (1)
Persistent ductus arteriosus	2	Impossibility to control bleeding
Persistent ductus arteriosus	2	Incidental injury
Mediastinal mass biopsy	1	Loss of anatomic reference
Pulmonary biopsy	1	Incidental injury
Bronchogenic cyst resection	1	Incidental injury
Esophagectomy and anastomosis (previous esophageal atresia)	1	Failure in progression
Pulmonary lobectomy	1	Failure in progression
Ascended colon remodeling and adhesion release	1	Failure in progression
Mediastinal mass biopsy^a	1	Incidental injury
Pulmonary biopsy^a	2	Failure in progression
Pulmonary biopsy^a	2	Loss of anatomic reference
Total	16	43.75% failure in progression, 25% incidental injury, 18.7% loss of anatomic reference,12.5% bleeding

Oncologic patients.

There were 138 procedures converted in the laparoscopic group; as most cases correspond to appendicectomy (n = 55), we detailed information regarding these patients in Table 3. Other procedures done by laparoscopy (n = 83) that required conversion are detailed in Table 4. Main cause of conversion (43.75%) in the overall group was failure in progression. Oncologic patients account 15.6% of laparoscopic cases. In the laparoscopic–oncologic group, there was a female predominance, mainly classified as ASA 3, and main cause of conversion was failure in controlling bleeding. Mean value of leukocyte, neutrophil count, and CRP was 15,235, 8697, and 43.9, respectively. Mean INR value was normal (1.1) and mean albuminemia was below normal (2.8). A total of 38.5% of patients required postoperative ICU admission, 1 patient was reoperated, and we had one fatal outcome (0.65% in the all series) attributed to ventilatory failure secondary to pneumonia in a patient with leukemia. In the nononcologic–laparoscopic group, there were 61.4% male patients, most patients were classified in the ASA 2 group (45.7%), mean laboratory values were leukocyte count = 16,009, neutrophil count = 9415, CRP = 103, INR = 1.3, and albumin = 2.9. Cause of conversion was failure in progression in the 57.1% of cases, 41.4% of patients were admitted in the ICU after the procedure and reintervention rate was 28.5%. None of the cases of cholecystectomy was associated with cholecystitis or pancreatitis.

Table 3.

Characterization of Cases of Laparoscopic Appendectomy Converted

Diagnosis	Age, n (%)				Gender, n (%)		Cause of conversion, n = (%)				Laboratory data			Postoperative course n (%)
Diagnosis	<5 years	5–10 years	11–15 years	>15 years	Male	Female	Bleeding	Incidental injury	Failure in progression	Loss of anatomic reference	ASA	Leukocytes (neutrophil)	CRP (m)	ICU admission	Reintervention rate
Not perforated appendicitis (n = 13)	3 (23.1)	2 (15.3)	7 (53.9)	1 (7.7)	3 (23.1)	10 (76.9)	0	3 (23)	5 (38.5)	5 (38.5)	1 (38.5), 2 (23), 3 (23), 4 (15.4)	16,435 (12,977)	191	2 (15.4)	2 (15.4)
Not perforated appendicitis (n = 13)	m = 9.61				3 (23.1)	10 (76.9)	0	3 (23)	5 (38.5)	5 (38.5)	1 (38.5), 2 (23), 3 (23), 4 (15.4)	16,435 (12,977)	191	2 (15.4)	2 (15.4)
Perforated appendicitis with localized peritonitis (n = 11)	3 (27.3)	6 (54.5)	2 (18.2)	0	7 (63.6)	4 (36.4)	1 (9)	0	5 (45.5)	5 (45.5)	1 (27.3), 2 (45.5), 3 (27.3)	18,092 (15,800)	156	5 (45.5)	3 (27.3)
	m = 6.09				7 (63.6)	4 (36.4)	1 (9)	0	5 (45.5)	5 (45.5)	1 (27.3), 2 (45.5), 3 (27.3)	18,092 (15,800)	156	5 (45.5)	3 (27.3)
Perforated appendicitis with generalized peritonitis (n = 15)	2 (13)	3 (20)	8 (54)	2 (13)	7 (46.6)	8 (53.3)	0	2 (13.3)	11 (73.3)	13.3 (2)	1 (20), 2 (33.3), 3 (53.3)	11,300 (8900)	227	12 (80)	9 (75)
	m = 10.9				7 (46.6)	8 (53.3)	0	2 (13.3)	11 (73.3)	13.3 (2)	1 (20), 2 (33.3), 3 (53.3)	11,300 (8900)	227	12 (80)	9 (75)
Appendicular plastron (n = 16)	2 (12.5)	4 (25)	6 (37.5)	4 (25)	8 (50)	8 (50)	0	0	8 (50)	50 (8)	1 (62.5), 2 (18.75), 3 (18.75)	16,300 (13,130)	153	2 (12.5)	6 (37.5)
Appendicular plastron (n = 16)	m = 11.06				8 (50)	8 (50)	0	0	8 (50)	50 (8)	1 (62.5), 2 (18.75), 3 (18.75)	16,300 (13,130)	153	2 (12.5)	6 (37.5)

ASA, American Society of Anesthesiologists physical status classification; CRP, C-reactive protein; ICU, intensive care unit.

Table 4.

Laparoscopic Procedures and Cause of Conversion

Organ/system	Procedure	n	Cause of conversion	Organ/system	Procedure	n	Cause of conversion
Upper GI tract	Correction of hiatal hernia and Nissen procedure	1	Failure in progression	Gynecologic	Left ovarian cystectomy	1	Failure in progression
	Heller esophagomyotomy	1	Loss of anatomic reference		Salpingooforectomy+ovarian biopsy	1	Failure in progression
	Laparoscopic piloromyotomy	2	Incidental injury (1) Failure in progression (1)		Salpingooforectomy+ovarian biopsy^a	3	Failure in progression (2) Bleeding (1)
	LAPEG	1	Incidental injury	Others	Adherences liberation (Intestinal obstruction)	27	Incidental injury (6) Impossibility to control bleeding (1) Loss of anatomic reference (3) Failure in progression (17)
Small bowel	Mesenteric cyst resection and anastomosis	2	Impossibility to control bleeding (1) Loss of anatomic reference (1)		Drainage of hemoperitoneum (1 oncologic)	6	Loss of anatomic reference (1) Impossibility to control bleeding (5^a)
	Intussusception (1 oncologic^a)	5	Failure in progression (4^a)		Diagnostic laparoscopy: Fecal impactation Intestinal resection and anastomosis Devolvulation and intestinal resection and anastomosis Partial omentectomy	1 1 1 1	Failure in progression Failure in progression Loss of anatomic reference Loss of anatomic reference
	Intussusception (1 oncologic^a)	5	Loss of anatomic reference (1)		Resection of urachal cyst (1 infected)	2	Loss of anatomic reference (1) Failure in progression (1)
	Meckel diverticulum resection	3	Impossibility to control bleeding (1) Loss of anatomic reference (1) Incidental injury (1)		Reubication of ventriculoperitoneal catheter	1	Incidental injury
	Intestinal resection and anastomosis	2	Failure in progression (1) Loss of anatomic reference (1)		Peritoneal dyalisis catheter replacement	1	Failure in progression
	Resection of intestinal tract duplication	1	Loss of anatomic reference		Fistula closure	1	Failure in progression
Colon	Transverse colectomy	2	Failure in progression		Splenectomy	1	Incidental injury
	Hemicolectomy (right 1, left 1)	2	Failure in progression		Resection of mesenteric mass+incidental appendicectomy	1	Failure in progression
	Subtotal colectomy^a	1	Failure in progression		Resection of suprarenal mass^a	1	Impossibility to control bleeding
	Remodelation of colostomy	1	Failure in progression		Resection or retroperitoneal tumor^a	1	Impossibility to control bleeding
	Hepatic biopsy (1 oncologic^a)	3	Failure in progression (1) Bleeding (2^a)		Partial resection of retroperitoneal tumor^a	1	Failure in progression
Hepatobiliary	Resection of hepatic cyst	1	Failure in progression		Partial resection of retroperitoneal tumor^a	1	Failure in progression
Hepatobiliary	Cholecistectomy and splenectomy^a	2	Impossibility to control bleeding		Retroperitoneal mass biopsy^a	1	Impossibility to control bleeding

Oncologic patients.

GI, gastrointestinal; LAPEG, laparoscopic assisted percutaneous endoscopic gastrostomy.

Discussion

We have had an increase in the percentage of MIS in our institution through the years (3.07% in 2009 and 38.96% in 2018). Majority of patients in our MIS converted series were in the group of 11 to 15 years old (37.5%), with a male gender predominance (54%), both characteristics have been reported in the literature as risk factors for conversion.^10–14,18 Pathologies that motivated surgery were primary not oncologic and may correlate with a predominance of dirty wound in almost 50%. Most patients were classified as ASA 3 consistent with the fact that our institution is a reference center for complex diseases, had preoperative higher risk, and, therefore, relate with the percentage of postoperative requirement of ICU admission postoperatively.

With respect to thoracoscopic procedures, most common disease leading to surgery was not oncologic and most common procedure was decortication in the context of complicated pneumonia. Most patients were aged <5 years, specifically <1 year of age and mostly classified as ASA 3, these could per se imply more difficulty in the performance of thoracoscopic procedures but not risk factors. We also found predominance of the male gender, but there are no studies regarding thoracoscopic procedures converted in pediatric population to compare with.

Calling attention is that laboratory data in the overall group showed inflammatory response, hypoalbuminemia, and mildly prolonged INR with an elevated percentage of postoperative ICU admission. It is possible that severity of inflammatory disease was related to conversion, but it cannot be established as a risk factor due to lack of a comparison group and the fact that also in noninfectious diseases, failure in progression of the procedure was the leading cause of conversion. We had few cases of oncologic patients with converted thoracoscopic procedures and we lack a comparison group, both facts restrict the analysis.

Regarding appendectomies, the literature describes higher conversion rate in older patients within the pediatric population, in our series most patients belonged in the age group between 11 and 15 years.¹⁹ We could not establish differences between the classification of appendicitis and the rate to conversion because of the study design. For all types of appendicitis, principal causes for conversion were failure in progression and loss of anatomic reference. Leukocyte, neutrophil count, and CRP were altered in all age groups but did not correlate with the severity in the progression of appendicitis, which may suggest additional individual characteristics involved in the MIS conversion outcome. Besides that, it is worth to mention that leukocytosis has also been described as a risk factor for conversion.¹² ICU admission was more frequently reported in the generalized appendicitis group, probably secondary to the severity of the disease.

Regarding laparoscopic procedures converted, currently there are no studies in the pediatric population. Nononcologic patients were distributed almost equally in the age groups and were predominantly male, in contrast, oncologic patients were mostly grade schoolers with a female predominance. We were not able to describe age or gender-related risk factors due to heterogeneity of procedures and lack of comparison group. Conversion was mainly due to failure in progression in the nononcologic patient, but in the oncologic group, it was related to impossibility to control bleeding, which correlates with the kind of procedures done in this group. We found elevated inflammatory markers, which related to severity of inflammatory disease that has been recognized as a risk factor,^14–16 nevertheless there was also noninfectious-related procedures. Lastly hypoalbuminemia is found in all groups, more studies and a control group are needed to establish the role of malnutrition.

Procedures were performed by pediatric surgeons as well as pediatric surgery residents always supervised by an attending physician, but we lack comparison according to level of training.

We are aware of the limitations of our study, but we were able to characterize our population. We consider this as the first step to develop further research to describe risk factors, correlation between preoperative factors, and the impact of conversion of MIS in our pediatric population. We intend to develop a prospective study with a control group.

Footnotes

Acknowledgments

We thank our fellow residents who contributed to the surgical patient's database, without which we would not have been able to carry out this study.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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