Sara L Zettervall, MD, Richard Amdur, PhD, Khashayar Vaziri, MD, FACS. Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC.
INTRODUCTION: Prolonged operative time is often considered a drawback to laparoscopic surgery due to concerns for increased morbidity. There is limited data on the specific operative time (ORT) when the benefits of laparoscopic procedures are outweighed by faster open procedures. The objective of this study is to identify the time when an open operation becomes superior to its laparoscopic counterpart.
METHODS AND PROCEDURES – Patients who underwent laparoscopic and open procedures in the National Surgical Quality Improvement Program (NSQIP) database between 2005 and 2010 (colectomy, splenectomy, and nephrectomy, bariatric) were identified. Open and laparoscopic procedures were stratified into 4 ORT groups: 0-90 minutes, 91 minutes-3 hours, 3-6 hours, and ≥6 hours. 30-day morbidity outcomes were analyzed comparing each laparoscopic ORT to equal or shorter ORT for open procedures. Univariate analysis was performed using chi-square and Fishers Exact tests. Outcomes with significant univariate results were then tested using stepwise logistic regression, controlling for patient demographics, comorbidities, and preoperative treatments.
RESULTS – 149,775 patients were identified (90,416 colectomies, 4,593 nephrectomies, 48,274 bariatric procedures, and 6,482 splenectomies). Laparoscopic procedures had significantly improved outcomes compared to open procedures of similar ORT (p<0.05). In bariatric operations, laparoscopic procedures with ORT <6 hours were equivocal or better than open bariatric procedures except for a higher incidence of return to OR when compared to open procedures with ORT <90 minutes (p<0.05). Laparoscopic bariatric procedures with ORT >6 hours have worse outcomes when compared to open operations <90 minutes in 7 of 12 outcomes (sepsis, DVT, length of stay, surgical site infections, renal complications, return to OR, and reintubation, p<0.05), and 4 of 12 outcomes (sepsis, length of stay, reintubation, return to OR, p<0.05) when compared to open operations 91 minutes – 3 hours.
In colectomies, laparoscopic procedures performed with ORT <6 hours were equivocal or better than open surgery except for a higher incidence of peripheral neuropathy when compared to open procedures <90 min (p<0.05). Laparoscopic colectomies with ORT >6 hours have a higher incidence of peripheral neuropathy and surgical site infection when compared to open procedures <6 hours and <90 minutes respectively (p<0.05).
In nephrectomies, laparoscopic procedures with ORT <6 hours were equivocal or better than open surgery. Laparoscopic nephrectomies with ORT >6 hours have higher rates of reintubation compared to shorter open operations (p<0.05). Sepsis is more common in patients undergoing a laparoscopic nephrectomy with ORT >6 hours when compared with open operations <90 minutes. Open splenectomies never provide any outcome benefits (p<0.05).
CONCLUSION(S) – Laparoscopic operations of similar ORT have better outcomes than open operations. The advantages of the laparoscopic approach diminish when ORT exceeds 6 hours in bariatric, colon, and nephrectomies when compared to open procedures lasting less than 6 hours. All other outcomes are equivocal or improved with a laparoscopic approach. There is no advantage in outcomes of open splenectomy when compared to the laparoscopic technique.
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