title: Impact of surgeon laparoscopic training and case volume of laparoscopic surgery on conversion during elective laparoscopic colorectal surgery.
abstract: OBJECTIVE
  The study aimed to determine whether laparoscopic volume and type of training influence conversion during elective laparoscopic colorectal surgery.
  
  
  METHODS
  An Institutional Review Board-approved prospective database was reviewed for patients who underwent colorectal resection, performed by six colorectal surgeons, for all diagnoses from 2009 to 2014. Surgeons were designated as laparoscopic- or open-trained based on formal laparoscopic colorectal surgery training, and were classified as low laparoscopic volume (LLV) (i.e. had performed < 100 laparoscopic procedures) or high laparoscopic volume (HLV) (i.e. had performed ≥ 100 laparoscopic procedures). Technique was laparoscopic, open or converted (pre-emptive or reactive). Conversion was compared among three groups: LLV, laparoscopic trained (group A); LLV, open trained (group B); and HLV, open trained (group C).
  
  
  RESULTS
  In total, 159/567 procedures were open and 408 laparoscopic procedures were attempted. Of the 408 laparoscopic procedures, 73 were converted. Among the 567 patients [mean age: 56 ± 17 years (44% male)], the overall conversion rate was 13% (73/567), including 75% pre-emptive and 25% reactive. Conversion rates for groups A, B and C were 17.9%, 42.6% and 14.3%, respectively. Significantly higher conversion was seen in group B compared with group C (P = 0.01), but not between group A and group C (P = 0.85) or between group B and group A (P = 0.11). Converted patients were older (P < 0.001), with lower rates of proctectomy (P = 0.007), higher rates of anastomosis (P < 0.001) and higher body mass index (BMI) (P < 0.001). After adjusting for patient and surgeon factors, training type was not associated with conversion (P = 0.15). Compared with successful laparoscopy, converted patients had a significantly higher incidence of ileus (P < 0.001), length of stay (P = 0.002), time to flatus (OR = 3.21, P < 0.001) and time to solids (P < 0.001). Converted patients experienced increased morbidity.
  
  
  CONCLUSIONS
  Training is not associated with conversion. Rather, HLV surgeons, regardless of training, convert less frequently than do LLV surgeons.
authors.affiliation: Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA.
authors.forename: H
authors.initials: H
authors.lastname: Massarotti
authors.affiliation: Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA.
authors.forename: F
authors.initials: F
authors.lastname: Rodrigues
authors.affiliation: Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA.
authors.forename: C
authors.initials: C
authors.lastname: O'Rourke
authors.affiliation: Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA.
authors.forename: S A
authors.initials: SA
authors.lastname: Chadi
authors.affiliation: Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA.
authors.forename: S
authors.initials: S
authors.lastname: Wexner
mesh_terms: D000368:Aged; D061887:Conversion to Open Surgery / Q000706:statistics & numerical data*; D004522:Educational Status; D016145:Endoscopy, Digestive System / Q000193:education / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000193:education / Q000379:methods / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D066231:Surgeons / Q000193:education / Q000706:statistics & numerical data*; D016526:Workload
keywords: Laparoscopy; colorectal surgery; conversion; laparotomy; proctectomy; training