NEW ORLEANSIn patients undergoing laparoscopic procedures
for gynecologic lesions, complications and conversion to laparotomy can be
predicted based on several risk factors, according to the 10-year experience of
Memorial Sloan-Kettering Cancer Center investigators, presented at the 34th
Annual Meeting of the Society of Gynecologic Oncologists (SGO abstract 74).
Dennis S. Chi, MD, reported the findings from a retrospective
chart review of all 1,452 patients undergoing laparo-scopic procedures by the
gynecologic oncology service at Sloan-Kettering between 1991 and 2000.
Currently, more than 50% of abdominal and/or pelvic procedures on this service
are performed using a laparoscopic approach, Dr. Chi said.
The study evaluated the procedures according to the level of
surgical complexity and the seriousness of the complications that were
The four levels of surgical complexity, based on the degree of
difficulty of the planned procedure, were: I diagnostic; II operative
procedures on the uterus and/or adnexa; III second-look procedures for
malignancy; and IV lymphadenectomies and/or other radical operative procedures,
such as radical hysterectomy or splenectomy.
Complications occurring intraoperatively or within 30 days of
surgery were assessed by an institutional grading system from 1 (mild) to 5
(death). Grade 3 complications required introperative radiology or operative intervention for correction; grade 4 resulted in chronic
deficit, disability, or organ resection. Procedures converted to laparotomy as
part of the planned management of malignant disease were not included as
complications or conversions for technical difficulty.
In the 1,448 evaluable laparoscopic procedures, older age,
previous abdominal and/or pelvic radiation therapy, and malignant histology
were found to be significant risk factors for laparoscopic complications, while
prior abdominal surgery significantly increased the risk of conversion to
Overall, grade 1-5 complications occurred in 7% of patients,
with major (grades 3-5) complications seen in 2% of the entire group. There
were only three grade 5 complications, and these all occurred in patients with
malignancies who underwent diagnostic laparoscopies; one patient died of a
postoperative pulmonary embolus, one due to cardiac arrhythmia, and one due to
a bowel injury at the time of initial laparoscopic peritoneal access. This
procedure was converted to a laparotomy for bowel repair, after which the
patient developed uncontrollable sepsis leading to her death, he said.
On univariate analysis, the significant risk factors and
relative risk (RR) for major complications (grade 3-5) were older age (RR
1.42), previous abdominal surgery (3.04), prior radiotherapy (4.88), and
malignant histology (3.64). Higher body mass index, prior chemotherapy, and
higher surgical level were not significant risk factors.
On multivariate analysis, previous abdominal surgery did not
retain statistical significance, but older age, prior radiotherapy, and
malignant histology did.
"Focusing specifically on the issue of malignant
histology, we saw that while this did increase the rate of major complications,
the actual rate for complications in this subgroup was only 4%," he added.
Conversions for Technical Reasons
Technical difficulty and/or complications led to conversion to
laparotomy in 104 cases, or 7% of the cohort. The conversion rate actually
decreased according to the level of surgical complexity, falling from 10% for
diagnostic procedures (level I), to 8% for level II, 4% for level III, and only
1% for level IV, the most radical procedures, Dr. Chi reported. "This
lower rate of conversion for higher level procedures is perhaps due to patient
selection and/or increased laparoscopic expertise of the surgeons attempting
more complex procedures," he said.
On univariate analysis, prior abdominal surgery was a
significant risk factor for conversion to laparotomy (RR 2.94) while higher
surgical level was associated with decreased risk of conversion due to
technical difficulty (RR 0.11). On multivariate analysis, both previous
abdominal surgery and surgical difficulty retained significance.
"Both simple and complex laparosco-pic procedures can be
performed on a gynecologic oncology service with a low rate of complications
and an acceptable rate of conversion to laparotomy. Risk factors should be
taken into account in preoperative patient counseling and surgical
planning," Dr. Chi concluded.
The discussant for the paper, Robert S. Mannel, MD, professor
of obstetrics and gynecology, University of Oklahoma College of Medicine, noted
that this series is one of the largest reported in the literature for
gynecologic laparoscopic procedures and therefore adds useful and reliable
information. Dr. Mannel noted, however, that the wide range of procedures and
indications "makes the data hard to analyze."
For complications, he said, "the major risk factors found
in this study are also those typically found with open techniques, so the real
question is whether the laparoscopic approach led to an increased or decreased
risk of complications as opposed to an open technique." This is hard to
determine without a control group, he noted.
With regard to conversions to laparotomy, obesity is
universally recognized as a risk factor, but this does not emerge in this
study, he pointed out.
Regarding the low rates of complications and conversions, Dr.
Mannel said, "the possibilities are that the study is underpowered, which
does not appear to be the case; the surgeons are ‘awesome’ and they do not
have these problems; or selection bias may be a problem." ONI