Surgical Endoscopy and Other Interventional Techniques

https://doi.org/10.1007/s00464-020-07536-1

What influences conversion to open surgery during laparoscopic

colorectal resection?
Caitlin Stafford1 · Todd Francone1 · Patricia L. Roberts2 · Peter W. Marcello2 · Rocco Ricciardi1

Received: 7 February 2019 / Accepted: 31 March 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Introduction  We analyzed the risk of morbidity and mortality in laparoscopic (Lap) conversion for colorectal surgery across
a group of subspecialist surgeons with expertise in minimally invasive techniques.
Methods  We reviewed prospective data patients who underwent abdominopelvic procedures from 7/1/2007 to 12/31/2016
at a tertiary care facility. We identified procedures that were converted from Lap to open (Lap converted). Lap converted
procedures were matched to Lap completed and open procedures based on elective versus urgent and surgeon. We also
abstracted patient demographics and outcomes at 30 days using the American College of Surgeons National Surgical Quality
Improvement Program defined adverse event list. We analyzed outcomes across these groups (Lap converted, Lap completed,
open procedures) with x2 and t tests and used the Bonferroni Correction to account for multiple statistical testing.
Results  From a database of 12,454 procedures, we identified 100 Lap converted procedures and matched them to 305 open
procedures and 339 Lap completed procedures. In our dataset of abdominopelvic procedures, Lap techniques were attempted
in 49 ± 1%. We noted a higher risk of aggerate morbidity following open procedures (33 ± 10) as compared to Lap converted
(29 ± 17%) and the matched Lap completed procedures (18 ± 8%; p < 0.001). Converted cases had the longest operative time
(222 ± 102 min), compared to lap completed (177 ± 110), and open procedures (183 ± 89). There were no differences in mor-
tality, sepsis complications, anastomotic leaks, or unplanned returns to the operating room across the three operative groups.
Conclusions  Although aggregate morbidity of Lap converted procedures is higher than in Lap completed procedures, it
remains less than in matched open procedures. Compared to Lap completed procedures, the additional morbidity of Lap
converted procedures appears to be related to additional surgical site infection risk. Our data suggest that surgeons should
not necessarily be influenced by additional complications associated with conversion when contemplating complex laparo-
scopic colorectal procedures

Keywords  Laparoscopic · Colectomy · Conversion · Open

The use of minimally invasive surgical (MIS) techniques in why more complex procedures are performed in an open
colon and rectal surgery has increased slowly but steadily fashion including surgeon comfort, lack of perceived ben-
over the past two decades. Today, many colectomy proce- efits for MIS, and the potential perceived harms of conver-
dures are often performed with MIS techniques particularly sion. In fact, the risk of open conversion with MIS tech-
for right colectomy, as compared to more complex proce- niques is estimated to be between 7 and 25% [2]. Conversion
dures such as proctectomy [1]. There are numerous reasons increases as case complexity increases and is estimated to
be highest for more complex pelvic procedures. Ultimately,
however, the hesitation that leads a surgeon to choose open
* Caitlin Stafford instead of MIS would reduce the potential benefits of lapa-
cstafford2@partners.org
roscopic techniques to the patient [3].
1
Section of Colon & Rectal Surgery, Division of General There are multiple surgical conditions, patient factors,
and Gastrointestinal Surgery, Massachusetts General and disease complexity concerns that may lead surgeons to
Hospital, 15 Parkman Street, WACC 460, Boston, consider a more traditional open approach. Yet, improve-
MA 02114, USA
ments in equipment and increased surgeon experience are
2
Department of Colon & Rectal Surgery, Lahey Hospital & likely to have complementary effect on rate of adoption
Medical Center, Burlington, MA, USA

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 Surgical Endoscopy

of MIS techniques and reduced the risk of conversion in Indication for conversion

colorectal surgery. Although absolute contraindications
to MIS are limited, many surgeons may be weary of MIS We abstracted indication for conversion from the opera-
techniques in cases that are less straightforward, or in cases tive notes of all patients who underwent lap conversion.
where converting to open surgery would lead to undesir- The report was analyzed by the authors (RR, CS). We had
able outcomes for the patient. Ultimately, although there are general agreement for conversion into one of the following
numerous publications that indicate outcome advantages for categories:
MIS procedures, the risk of conversion is feared to outweigh
the potential benefits of MIS. Given the numerous gaps in 1. Adhesions
knowledge regarding conversion in MIS, we conducted an 2. Loss of Pressure Control
analysis of MIS cases in our 100% capture colorectal surgery 3. Bleeding
institutional database. In particular, we sought to identify 4. Anatomy
the surgical indications for conversion as well as the down- 5. Obesity
stream effect on patient outcome. In addition, we sought to 6. Other/Unknown
determine the association between MIS attempts and rate
of conversion.
Outcome variables

We extracted the morbidity and mortality of lap converted,

lap completed, and open procedures from our prospective
Methods
database starting on the day of surgery to 30 days post-oper-
atively. Our primary outcome variable was morbidity and
Data
mortality in lap converted colorectal procedures. Morbidity
was defined by the American College of Surgeons National
We conducted a chart review of all consecutive patients who
Surgical Quality Improvement Program defined adverse
underwent an abdominopelvic procedure from July 1st, 2007
event list. Morbidity was calculated at 30 days to include
through December 31st, 2016 at a tertiary care facility. First,
superficial incisional SSI, deep incisional SSI, organ space
all study protocols were reviewed and approved by the insti-
SSI, wound disruption, pneumonia, unplanned intubation,
tutional review board at Lahey Hospital & Medical Center.
PE, DVT, ventilator > 48 h, progressive renal insufficiency,
The database includes diagnostic codes, procedure codes,
acute renal failure, UTI, stroke, cardiac arrest, myocardial
patient characteristics, operative time, conversion history,
infarction, return to the operating room, and systemic sep-
and 30-day outcomes. Our MIS/laparoscopic (lap) cohort
sis. Readmission was reported separately and censored at
was abstracted from our institutions prospective 100% cap-
30 days from procedure date.
ture colorectal surgery database.

Lap attempt vs. conversion rate analysis

Matching
In our secondary analysis, we compared surgeon lap attempts
We included all lap converted procedures and matched them with conversion rate. The calculation was conducted at the
to successful lap completed procedures and open procedures surgeon level. Lap conversion was calculated as number of
based on elective versus urgent indications and surgeon of lap converted procedures as a function of all attempted lap
record in a 1 converted lap, to 3 lap completed, and 3 open cases (successful and converted). Lap attempts was calcu-
surgeries. lated as number of lap cases as a function of all abdomi-
nopelvic procedures. A regression was then performed to
identify trends between lap conversions and lap attempts
Covariates by individual surgeons. A trendline was constructed and
Pearson coefficient was calculated to determine significance
Next, we abstracted the covariates of age, sex, American based on the number of degrees of freedom.
Society of Anesthesiologist (ASA) score, body max index
(BMI), history of past abdominal procedures, diagnosis,
Statistical analysis
unplanned or emergent surgery as documented by the pri-
mary surgeon, surgical access (i.e., lap & robotic, or open),
Data were analyzed with SAS version 9.4 (SAS Institute,
stoma creation including ileostomy or colostomy, length of
Cary, NC). In our univariate analyses, we used Student’s t
procedure.

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Surgical Endoscopy

tests for continuous variables and chi-square tests for cat- Primary outcome
egorical variables. In our analysis of lap Missing data were
classified into an additional category and labeled “null.” Table 2 displays outcomes for the three cohorts of patients.
There was an additional 40 min in operative time between
lap conversion cases and lap completed cases. We found that
Results lap converted patients had an aggregate morbidity of 29%
(CI 21–38%) with an SSI rate of 17% (CI 10–25%). Aggre-
Cohort characteristics gate morbidity was higher in the lap converted (29% ± 17%,)
versus lap completed (18% ± 8), but lower than matched
There were 12,454 total procedures between July 1st, 2007 open cases (33 ± 10%). As expected, mortality rates were
through December 31st, 2016. From the group, we identified low across all surgical groups: open 3%, converted 3%, lap
100 lap converted to open surgery and matched 305 open attempt 0.6%. Of the total group, proportionally more con-
procedures and 339 non-converted lap completed procedures verted patients than lap completed patients had a post-op
(successful). complication of surgical site infection (17 ± 7% vs 9 ± 3%).

Lap converted patients Surgeon volume and experience

Our cohort of lap converted patients contained proportion- Figure 1 demonstrations surgeon volume and individual con-
ally more men (62%) than women (38%). The median age version rates. There were 4730 abdominopelvic procedures,
was 64 ± 15 and 86 ± 5% of converted procedures were elec- of which 49% (16–65%) were attempted in a MIS manner.
tive (Table 1). Proportionally more patients with a diagnosis Surgeons attempted to perform MIS techniques 2329 times
of neoplasm were converted compared to patients with a with 100 conversions as described earlier (4.3%) lap con-
diagnosis of diverticulitis. The most common converted pro- verted. By surgeon, lap attempts ranged from 16 to 53%. By
cedures were ileocolic resection followed by colectomy and surgeon, the average lap conversion rate was 4% (1–8%).
anterior resection. The mean procedure time was 222 min A trendline revealed an inverse trend between lap attempts
(± 102) and the average ASA was 3. We found the most com- and lap conversion but the trendline revealed no statistically
mon reason for conversion was adhesions (n = 47) followed significant correlation between lap attempts and lap conver-
by surgeons account of a difficult patient anatomy (n = 35). sion (r = 0.25).

Matched lap completed cases

Discussion
Completed patients were male and female in equal propor-
tions (48% vs 52%), with a median age of 60 (± 15) and 91% In our analysis of a large, 100% capture, prospective colo-
of lap completed patients were elective. In addition, half of rectal surgery database, we found an overall conversion rate
the patients in the lap completed cohort were diagnosed with somewhat lower than that reported in similar large cohort
neoplasm, followed by diverticulitis and inflammatory bowel studies [4, 5]. There were numerous factors associated with
disease. The favored procedures were ileocolic resection, conversion, but the most common patient characteristic for
followed by subtotal colectomy and left colectomy. Mean lap converted cases was elevated BMI (Table 1). We and oth-
procedure time were 182 min (± 75), and the average ASA ers have noted that increased BMI was directly correlated to
was 2 (Table 1). an increase risk of conversion, as well as an increased risk of
post-operative morbidity [6, 7]. We also noted an increased
Matched open cases risk of conversion in male patients diagnosed with neoplasm
and those with prior abdominal surgery, which is consistent
Matched open patients were primarily female 61% (CI with the current literature [8, 9, 18]. Lastly, despite the antic-
55–69%) with average age of 62 (± 16) and 82% of open ipated correlation between lap attempts and lap conversions,
cases were elective. The diagnosis for open cases was much we were unable to demonstrate any significant relationship
like the matched lap completed and converted cohort with between these two variables. These data indicate that a more
the most common diagnosis of neoplasm, followed by aggressive approach for lap attempts is unlikely to lead to a
inflammatory bowel disease and diverticulitis. The most higher rate of lap conversions.
common procedure in the open cohort was ileocolic resec- There was a steady rate of conversion which did not
tion followed by left colectomy and anterior resection. The change during the entire study period. Despite the numer-
mean procedure time was 177 min (± 110), and the ASA was ous patient factors associated with conversion, we did not
almost evenly split between 2 and 3. identify any association between conversion and surgeon

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Table 1  Patient characteristics Converted Matched open Matched MIS Total cohort p value
(n = 100) (n = 301) (n = 343) n = (744)

Age 64 (± 15) 62 (± 16) 59 (± 15) 60

Median 65 63 59 (± 15)
Female sex 38 185 179 402 0.0002
(38 ± 19%) (61 ± 14%) (52 ± 10%) (54 ± 7%)
BMI 31.67 (± 7.6) 28.8 (± 7.6) 29.9 (± 9.5) 29.7 (± 8.6)
Past abdominal 30 83 43 156
surgery (30 ± 18) (27 ± 10%) (13 ± 15%) (21 ± 6%)
Procedure time 222 (± 102) 177 (± 100) 182 (± 75) 185 (± 101)
(min)
Elective 86 252 307 658 0.09
(86 ± 15%) (82 ± 9%) (91 ± 7%) (87 ± 4)
ASA 1 3 0 9 13 0.01
(3 ± 7%) (0–1%) (3 ± 3%) (2 ± 1%)
ASA 2 43 139 229 389 < .0001
(43 ± 19%) (46 ± 11%) (67 ± 10%) (53 ± 7%)
ASA 3 45 126 92 280 < .0001
(45 ± 18%) (43 ± 9%) (27 ± 9%) (38 ± 10%)
ASA 4 4 24 5 33 0.0003
(4 ± 8%) (8 ± 7%) (1 ± .2%) (4 ± 3%)
Procedure
 Adhesionlysis 6 33 10 49 0.0002
(6 ± 9%) (11 ± 4%) (3 ± 3%) (6 ± 4%)
 Anterior resection 14 45 56 115 0.8
(14 ± 14%) (15 ± 7%) (16 ± 8%) (15 ± 5%)
 APR 8 13 22 43 0.3
(8 ± 9%) (4 ± 5%) (6 ± 5%) (6 ± 3%)
 Colostomy 8 27 26 61 0.8
(8 ± 9%) (9 ± 7%) (8 ± 6%) (8 ± 4%)
 Ileocolic resection 35 98 122 255 0.7
(35 ± 19) (32 ± 11%) (35 ± 10%) (34 ± 6%)
 Ileocecetomy 2 0 8 10 0.3
(2 ± 1%) (0–1%) (2 ± 3%) (13 ± 17%)
 Diag. Lap 4 7 5 16 0.3
(4 ± 8%) (2 ± 4%) (1 ± 2%) (2 ± 2%)
 Left colectomy 16 50 65 131 0.8
(16 ± 14%) (17 ± 8%) (19 ± 9%) (18 ± 5%)
 Proctocolectomy 2 10 9 21 0.1
(2 ± 1%) (3 ± 4%) (2 ± 4%) (3 ± 3%)
 Subtotal colectomy 3 10 13 26 0.9
(3 ± 7%) (3 ± 4%) (38 ± 4%) (3 ± 3%)
 Takedown colectomy 2 8 7 17 0.8
(2 ± 1%) (3 ± 3%) (2 ± 3%) (3 ± 3%)
Diagnosis
 Diverticulitis 15 34 62 11 0.03
(15 ± 14%) (11 ± 7% (18 ± 8%) (15 ± 5%)
 IBD 21 42 45 108 0.0004
(21 ± 16%) (14 ± 8%) (13 ± 7%) (14 ± 5%)
 Neoplasm 41 112 196 349  < 0.0001
(41 ± 19%) (37 ± 11%) (57 ± 10%) (47 ± 7%)
 Stoma 1 3 1 5 0.4
(1 ± 5%) (1 ± 3%) (2 ± 0.95%) (0.6 ± 0.07%)
 Hernia 0 5 2 7 0.2
(0–1%) (2 ± 4%) (0.6 ± 1.9%) (1 ± 1.5%)
 Misc 22 105 37 164  < 0.0001
(22 ± 16%) (34 ± 10%) (11 ± 7%) (21 ± 6%)

Results include mean ± st dev for continuous variables and proportion ± 95% CI for categorical variables

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Surgical Endoscopy

Table 2  Patient outcomes Converted Matched Matched Total cohort p value

(n = 100) open (n = 301) MIS (n = 343) n = (744)

SSI 17 59 32 108 0.0008

(17 ± 15%) (20 ± 10%) (9 ± 7%) (15 ± 5%)
UTI 3 23 11 37 0.1
(3 ± 7%) (8 ± 6%) (3 ± 5%) (5 ± 4%)
Mortality 3 10 2 15 0.03
(3 ± 7%) (3 ± 4%) (.6 ± 1.9%) (2 ± 2%)
Aggregate morbidity 29 102 63 213  < 0.0001
(29 ± 17%) (33 ± 10%) (18 ± 8%) (28 ± 6%)
Re-hospitalization 10 42 28 80 0.1
(10 ± 12%) (14 ± 8%) (8 ± 5%) (11 ± 4%)
Unplanned OR 5 6 12 23 0.2
procedures (5 ± 6%) (2 ± 3%) (3 ± 4%) (3 ± 3%)
Sepsis 1 4 4 9 0.9
(1 ± 4.9%) (1 ± 2.5%) (1 ± 2.8%) (1 ± 1.4%)
Anastomotic leak 3 8 10 21 0.9
(3 ± 7%) (3 ± 4%) (3 ± 3%) (3 ± 3%)
Urinary retention 2 10 10 22 0.7
(2 ± 6.5%) (3 ± 4%) (3 ± 3%) (3 ± 3%)
Pneumonia 1 13 9 23 0.2
(1 ± 4.9%) (4 ± 5%) (3 ± 4%) (3 ± 3%)
DVT 1 12 1 14 0.1
(1 ± 4.9%) (4 ± 5%) (3 ± 1.9%) (2 ± 2%)
PE 3 7 0 10 0.01
(3 ± 7%) (2 ± 4%) (0–1%) (1 ± 1.3%)
CVA 0 1 1 2 0.4
(0–1%) (0.3 ± 1.9%) (0.3 ± 1.9%) (0.003 ± .009%)

Results include mean ± st dev for continuous variables and proportion ± 95% CI for categorical variables

considered in the context of fairly robust MIS experience

across our group and the higher sample sizes that would
be needed to conduct such an analysis.
We also noted a fairly high rate of morbidity follow-
ing lap conversion. Outcomes following lap conversion
revealed higher aggregate morbidity then lap completed
cases. These findings are similar to what is reported in
the literature in which higher rate of morbidity was wit-
nessed after conversion [12] following rectal cancer sur-
gery. Yet aggregate morbidity was found to be lower in
converted patients as compared to planned open cases.
This was not the case in a study by Gorgan et al. where
lap converted had a slightly higher morbidity rate than
Fig. 1  Surgeon laparoscopic attempt versus conversion rate
those with planned open procedure [13]. Moghadamy-
eghaneh et al. also found that lap converted patients had
a higher morbidity rate as well as longer length of stay.
experience or surgeon likelihood of performing lap pro-
Ultimately, conversion in our patients did not portend
cedures. Therefore, an affinity for attempting lap cases did
higher adverse event rate than planned open procedures.
not impact the overall single surgeon lap conversion rate,
In addition, mortality rates were equal across all tech-
which is somewhat unexpected. These findings are contra-
niques, which once again is in contradiction of current
dictory to current literature, which links surgeon attributes
literature [14].
to decreased conversion rates [10, 11]. These data must be

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 Surgical Endoscopy

The difference in aggregate morbidity was likely second- with lap conversion. The data confirm both a low rate of
ary to surgical site infections which were lowest in mini- complications and low rate of conversion when experienced
mally invasive patients. Interestingly lap converted patients surgeons perform these complex procedures. We believe that
did have a slightly lower SSI rate than planned open cases the additional 40 min of operative time that lap converted
which is an outcome that is echoed in some, but not all stud- patients experienced led to minimal patient downstream
ies [15]. Despite the additional total operative time for lap effects in the way of complications. The lack of a corre-
converted cases as compared to open cases, the SSI rate for lation between lap attempts and lap conversion also is an
lap conversion cases was not higher than planned open cases. important consideration as surgeons build MIS skills. Ulti-
Total time for surgery might explain why other investigators mately, the strength of these data should drive lap attempts
have noted that lap conversion actually increased the rate of higher in the hands of those surgeons with the experience
superficial SSI [13, 14] as compared to open surgery. In a to perform these procedures without concern for additional
review by Slim et al. the investigators found a higher con- patient morbidity.
version rate of nearly 25%, along with an increased rate of
post-operative morbidity in converted patients, specifically
post-op anastomotic leak [2]. This increased leak rate for lap Funding  No funding support.
converted cases was also noted by Yamamtoto et al. finding
a leak rate of 18% in converted patients versus 7.2% in lap Compliance with ethical standards 
completed. Interestingly, our group did not demonstrate an
Disclosures  Ms Caitlin Stafford, Dr. Todd Francone, Dr. Peter Mar-
increase in leak rates in converted patients [6] yet should cello, Dr. Patricia Roberts, and Dr. Rocco Ricciaridi have no conflicts
be placed in the context of a fairly low leak rate across the of interest or financial ties to disclose.
board.
Our study is important as it indicates that lap conversion
to open surgery is not an event or consequence that is detri-
mental to patient outcome, besides the additional SSI. These References
finding may provide reassurance when deciding on surgi-
cal approach. Our data would suggest that surgeons should 1. Simorov A, Shaligram A, Shostrom V et al (2012) Laparoscopic
colon resection trends in utilization and rate of conversion to open
not necessarily be influenced by additional complications
procedure: a national database review of academic medical cent-
associated with conversion when contemplating complex ers. Ann Surg 256:462–468
laparoscopic colorectal procedures. There are a number of 2. Slim K, Pezet D, Riff Y et al (1995) High morbidity rate after con-
surgeon characteristics including surgeon lap volume and verted laparoscopic colorectal surgery. Br J Surg 82:1406–1408
3. Poon J, Law W, Wong I et al (2009) Impact of laparoscopic colo-
past experiences that might also lead surgeons to be dis-
rectal resection on surgical site infection. Ann Surg 249(1):77–81
inclined to chance conversion [16, 17]. Again, the surgeon 4. Thorpe H, Jayne DG, Guillou PJ et al (2008) Patient factors influ-
should do what is comfortable, but in our hands, it seems encing conversion from laparoscopically assisted to open surgery
that surgeons were fairly good at predicting the capacity for for colorectal cancer. Br J Surg 95:199–205
5. Schlachta C, Mamazza J, Gregoire R (2003) Predicting conversion
lap completion.
in laparoscopic colorectal surgery. Surg Endosc 17:1228–1291
Our study has several limitations because of the unran- 6. Yamamoto S, Fukunaga M, Miyajima N et al (2009) Impact of
domized nature of the assigned treatment, heterogeneous conversion on surgical outcomes after laparoscopic operation for
patient populations, and variable surgical and medical rectal carcinoma: a retrospective study of 1,073 patients. J Am
Coll Surg 208(3):383–389
expertise. Surgeon preference and experience may lead to
7. Pikarsky AJ, Saida Y, Yamaguchi T et al (2002) Is obesity a
the tendency to perform one procedure over another and bias high-risk factor for laparoscopic colorectal surgery? Surg Endosc
our results. Most importantly, the operative findings at the 16(5):855–858
time of surgery might have persuaded surgeons to perform 8. Vaccaro C, Gustavo R, Guillermo O et al (2014) Laparoscopic
colorectal resection: a simple predictor model and a stratification
one technique over the other and these data points might
risk for conversion to open surgery. Disease of the Colon and
not be completely disclosed in the patients’ chart. However, Rectum 57(7):869–874
our study has the benefit of large numbers and operative 9. Masoomi H, Moghadamyeghaneh Z, Mills S et al (2015) Risk
note detail that is missing from large datasets. In addition, factors for conversion or laparoscopic surgery to open surgery:
does conversion worsen outcome? World J Surg 39:1240–1247
the study has the advantage of representing results from a
10. Tekkis P, Senagore A, Delaney C (2005) Conversion rates in lapa-
colorectal specialty unit with extensive experience in lap roscopic colorectal surgery. Surg Endosc 19:47–54
techniques. 11. Tekkis P, Senagore A, Delaney C et al (2005) Evaluation of the
In conclusion, the value of MIS techniques in colorectal learning curve in laparoscopic colorectal surgery—comparison of
right sided and left sided resections. Ann Surg 242:83–91
surgery has been demonstrated in numerous publications.
12. Agha A, Furst A (2008) Iesalniesk I Conversion rate in 300 lapa-
Our study adds substantial insight to the literature regarding roscopic rectal resections and its influence on morbidity and onco-
the fairly low increased morbidity experienced by patients logical outcome. Int J Colorectal Dis 23:409–417

13
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13. Gorgun E, Benlice C, Abbas M (2016) Conversion in laparoscopic 17. Franko J, O’Connell B, Mehall J et al (2006) The influences of
colorectal surgery: are short-term outcomes worse than with open prior abdominal operations on conversion and complication rates
surgery? Tech Coloproctol 20:845–851 in laparoscopic colorectal surgery. JSLS 10:169–175
14. Moghadamyeghaneh Z, Masoomi H, Mills S et al (2014) Out- 18. Curet M (2000) Special problems in laparoscopic surgery: previ-
comes of conversion of laparoscopic colorectal surgery to open ous abdominal surgery, obesity, and pregnancy. Surg Clin North
surgery. JSLS. https​://doi.org/10.4293/JSLS.2014.00230​ Am 80(4):1093–1110
15. Kiran R, El-Gazzaz G, Vogel J et al (2010) Laparoscopic approach
significantly reduces surgical site infections after colorectal sur- Publisher’s Note Springer Nature remains neutral with regard to
gery. J Am Coll Surg 211:232–238 jurisdictional claims in published maps and institutional affiliations.
16. Moine M, Fabre J, Vacher C et al (2003) Factors and consequences
of conversion in laparoscopic sigmoidectomy for diverticular dis-
ease. Br J Surg 90:323

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