Laparoscopic surgery for Crohn's disease: Reasons for conversion

Objective To examine factors influencing conversion from a laparoscopic to an open pr ocedure in patients requiring surgery for Crohn's disease. Summary Background Data Laparoscopic management of patients with complications of Crohn's produces better outcomes than traditional open approaches, but it is difficult to de termine before surgery who will be amenable to laparoscopic management. in this series, a laparoscopic approach was offered to virtually all patients to determine reasons for laparoscopic failure. Methods Data regarding patients who underwent attempted laparoscopic procedures for Crohn's (January 1993 to June 2000) were collected prospectively, The bowe l was mobilized laparoscopically and extracorporeal anastomoses were perfor med, Conversion to open surgery was defined as creation of an incision of m ore than 5 cm. Results One hundred ten patients (age 37 +/- 1.1 years, 58% female) underwent 113 a ttempted laparoscopic interventions. Indications for surgery included obstr uction (77%), failure of medical management (35%), fistula (27%), and perin eal sepsis (4%). Sixty-eight procedures (60%) were completed laparoscopical ly. Procedures completed laparoscopically included ileocecectomy (n = 46), small bowel resection (n = 22), fecal diversion (n = 7), intestinal strictu roplasty (n = 7), resection of prior ileocolonic anastomosis (n = 5), segme ntal colectomy (n = 1), and lysis of adhesions (n = 1). Forty-five procedur es (40%) were converted as a result of adhesions (n = 21), extent of inflam mation or disease (n = 9), size of the inflammatory mass (n = 7), inability to dissect a fistula (n = 5), or inability to assess anatomy (n = 3). Fact ors associated with conversion were internal fistula as an indication for s urgery, smoking, steroid administration, extracecal colonic disease, and pr eoperative malnutrition. In laparoscopic patients, mean times to passage of fiatus and first bowel movement were 3.6 +/- 0.2 days and 4.4 +/- 0.2 days , respectively. Mean time to discharge was 6 +/- 0.2 days. Conclusions Attempted laparoscopic management is safe and effective if there is an appr opriate threshold for conversion to an open procedure. Conversion factors i dentified in this study largely reflect technical challenge and severity of disease. Patients taking steroids and those with known fistulas or colonic involvement threaten laparoscopic failure, but many of these patients can be managed laparoscopically and have better outcomes. By understanding the reasons for conversion, it is hoped that the chances of laparoscopic succes s can be improved by modifying standard preoperative medical management or using additional technological capabilities (e.g., robotics).