Comparative Analysis Of Conversion To Laparotomy During Laparoscopic Liver Resection

Part I Analysis of conversion to laparotomy during laparoscopic liver resectionObjective:A large number of clinical studies have demonstrated the safety and effectiveness of laparoscopic hepatectomy.However,while demonstrating its minimally invasive and safety,conversion to laparotomy,as a concomitant surgical method,has attracted the attention of more and more clinicians as well.It is reported that conversion to laparotomy during laparoscopic hepatectomy may lead to poor prognosis of patients.However,few researches has been conducted on the risk factors of conversion to laparotomy and the differences between conversion and laparoscopic group,and opinions are divided to some extent.The aim of this study is to illustrate the preoperative general states of patients converted to laparotomy and laparoscopic patients,and analyze preoperative conditions,in an attempt to explore the risk factors in conversion to laparotomy.Method:This study reviewed the clinical and pathological data of patients who underwent liver resection surgery in a single center from January 2013 to December 2018,including 1285 patients.All the patients involved have underwent laparoscopic hepatectomy,with part of the patients underwent conversion to laparotomy during laparoscopic hepatectomy.General information of all patients was collected and analyzed.Logistic regression was used for univariate and multivariate analysis to analyze the possible risk factors for patient who underwent conversion to laparotomy during laparoscopic hepatectomy.The data was analyzed by SPSS 20.0 statistical software,and P<0.05 was statistically significant.Result:This study involved 1285 hepatectomy patients,with a total conversion rate of 13.1%.Descriptive analysis and univariate analysis of risk factors in the conversion of laparoscopic to laparotomy indicates that Cholangiocarcinoma(P<0.001),and Gallbladder carcinoma(P<0.001),the right half liver resection(P<0.001),posterior lobe resection(P=0.014),larger tumor diameter(>10 cm)(P=0.004).GGTP(gamma glutamyl transpeptidase)(P<0.001),alkaline phosphatase(P<0.001),total bilirubin(P=0.027)and direct bilirubin(P=0.021)is the risk factors for conversion surgery.Benign lesions(P<0.001),left lateral lobectomy(P<0.001),left non-anatomic liver resection(P=0.004),grade 1 ASA(P=0.027)and good liver function(level A Child)(P=0.033)were protective factors in the conversion.Using Logistic regression for multivariate analysis,and it is found that right hepatectomy,right posterior lobectomy,gallbladder cancer and elevated alkaline phosphatase are risk factors for patients underwent conversion to laparotomy during laparoscopic hepatectomy.Besides,left lateral lobectomy is a protective factor in the conversion of laparoscopic to laparotomy.In this study,the main reasons accounted for conversion included:difficulty in exposure(42.9%),abdominal adhesion(28.6%),uncontrollable intraoperative bleeding(12.5%),negative margin assurance(14.9%)and influence of pneumoperitoneum on hemodynamics(1.2%).Postoperative complication of conversion included pleural effusion(12.5%),ascites(1 1.3%),incision infection(6.5%),subphrenic abscess(4.8%),bile leakage(2.4%),intraperitoneal hemorrhage(2.4%),liver failure(1.2%),hepatic infarction(1.8%),and portal vein thrombosis(1.2%).Conclusion:For patients underwent the conversion from laparoscopic hepatectomy to laparotomy hepatetomy,there are significant differences in the types of disease,surgery resection range,maximum tumor diameter,ASA classification and Child classification,compared with the non-conversion group.For patients with gallbladder cancer or in need of laparoscopic resection of a difficult liver segment,it is suggested to evaluate the general information and serum index of patients,combining with the experience of the surgeon to consider the possibility of laparotomy surgery in advance,in order to reduce the incidence of conversion to laparotomy.Part ? A Case-control study of laparoscopic liver resection for conversion to open surgeryObjective:Laparoscopic hepatectomy plays an important role in laparoscopic surgery.As a result of bleeding,peritoneal adhesion,unclear lesion exposure,it may lead to the occurrence of conversion,the rate of which is about 10%.Compared with laparoscopic hepatectomy and laparotomy hepatectomy,the possible effect of conversion to laparotomy surgery on the prognosis of patients remains to be further explored and studied,and the impact of the conversion to laparotomy for patient in different conditions and different surgical methods is not yet clear.This study focuses on conversion in laparoscopic hepatectomy,conducting researches in the aspect of operative prognosis to give reference for clinical practice.Method:A total number of 1990 eligible hepatectomy patients,including laparoscopic liver resection(without conversion),conversion,and laparotomy liver resection,in our center from January 2013 to December 2018 were collected in this study.Based on six basic indicators,patients in the conversion group were paired 1:1 with patients in laparoscopic group and laparotomy group respectively,and a case control study was conducted in order to explore the overall prognosis of patients in conversion group and in different subcategories.SPSS20.0 was used for data analysis,and P<0.05 was considered statistically significant.Results:70 patients in conversion group were paired successfully with another 70 patients in laparoscopic group.Compared with laparoscopic patients,patients in conversion group had significantly longer operation time(P=0.001),more intraoperative bleeding(P<0.001),higher intraoperative blood transfusion rate(P=0.001),larger volume of intraoperative blood transfusion(P=0.001).and longer postoperative hospital stay(P=0.049).However,there was no significant difference in the postoperative complications(P=0.103)and long-term survival(P=0.586)between the two groups.110 patients were paired successfully in conversion group and laparotomy group,Compared with laparotomy group,patients in conversion group had longer operative time(P=0.003),and there was no significant difference in intraoperative bleeding,blood transfusion,complications and long-term survival(P=0.586).In term of benign diseases,the operative time and intraoperative bleeding in the conversion group were significantly higher than in laparoscopic group(P<0.05).for patients with biliary tract carcinoma,the rate of intraoperative bleeding and complications in the conversion group were higher than those in laparoscopic group.Besides,conversion group had a longer operative time(P=0.032)compared with laparotomy group.There was no significant difference in long-term survival of various diseases in the three groups.For patients with non-anatomic hepatectomy,conversion group had a longer operative time(P=0.01)and increasing rate of postoperative complication(P=0.034);for patients with left lateral lobectomy,intraoperative bleeding was increased in conversion group(P<0.05);for patients with left hepatic resection,a longer operative time was required in conversion group(P=0.047).Compared with laparotomy group,the conversion group had longer operative time(P=0.039)and larger amount of intraoperative bleeding(P=0.041)in right liver resection.The long-term prognosis had no significant difference in the three groups.For patients without cirrhosis,the conversion group had a longer operative time(P=0.001),more intraoperative bleeding(P=0.001),and higher intraoperative transfusion(P=0.001)than laparoscopic group.Compared with laparotomy group,the conversion group had a longer operative time(P=0.039),either.For patients with tumor diameter less than 5 cm,conversion group will extend operative time(P=0.005),increase the risk of intraoperative bleeding(P=0.038),increase intraoperative transfusion(P=0.041)and extend hospital stay time(P=0.041)when compared to laparoscopic group.Besides,the conversion group had a longer operative time(P=0.015)than laparotomy group as well.Patients with large tumor diameter or multiple tumors in conversion group had.a higher risk of intraoperative bleeding or transfusion(P<0.05).Conclusion:Conversion from laparoscopic hepatectomy to laparotomy results in poorer perioperative short-term prognosis,including longer operative time,more intraoperative bleeding,higher rate of intraoperative blood transfusion,more volume of intraoperative blood transfusion,and significantly longer postoperative hospital stay than laparoscopic surgery.Compared with laparotomy hepatectomy,conversion hepatectomy has a longer operative time,and there is no significant difference in other indicators and long-term prognosis.Whether it is a difficult operation or a relatively simple operation,it is important for surgeons to grasp the timing of the conversion to laparotomy during the operation.