Surgical Endoscopy

, Volume 34, Issue 2, pp 598–609 | Cite as

Incidence, associated risk factors, and impact of conversion to laparotomy in elective minimally invasive sigmoidectomy for diverticular disease

  • Amir L. BastawrousEmail author
  • Ron G. Landmann
  • Yuki Liu
  • Emelline Liu
  • Robert K. Cleary



Benefits of minimally invasive surgical approaches to diverticular disease are limited by conversion to open surgery. A comprehensive analysis that includes risk factors for conversion may improve patient outcomes.


The US Premier Healthcare Database was used to identify patients undergoing primary elective sigmoidectomy for diverticular disease between 2013 and September 2015. Propensity-score matching was used to compare conversion rates for laparoscopic and robotic-assisted sigmoidectomy. Patient, clinical, hospital, and surgeon characteristics associated with conversion were analyzed using multivariable logistic regression, providing odds ratios for comparative risks. Clinical and economic impacts were assessed comparing surgical outcomes in minimally invasive converted, completed, and open cases.


The study population included 13,240 sigmoidectomy patients (8076 laparoscopic, 1301 robotic-assisted, 3863 open). Analysis of propensity-score-matched patients showed higher conversion rates in laparoscopic (13.6%) versus robotic-assisted (8.3%) surgeries (p < 0.001). Greater risk of conversion was associated with patients who were Black compared with Caucasian, were Medicaid-insured versus Commercially insured, had a Charlson Comorbidity Index ≥ 2 versus 0, were obese, had concomitant colon resection, had peritoneal abscess or fistula, or had lysis of adhesions. Significantly lower risk of conversion was associated with robotic-assisted sigmoidectomy (versus laparoscopic, OR 0.58), hand-assisted surgery, higher surgeon volume, and surgeons who were colorectal specialties. Converted cases had longer operating room time, length of stay, and more postoperative complications compared with minimally invasive completed and open cases. Readmission and blood transfusion rates were higher in converted compared with minimally invasive completed cases, and similar to open surgeries. Differences in inflation-adjusted total ($4971), direct ($2760), and overhead ($2212) costs were significantly higher for converted compared with minimally invasive completed cases.


Conversion from minimally invasive to open sigmoidectomy for diverticular disease results in additional morbidity and healthcare costs. Consideration of modifiable risk factors for conversion may attenuate adverse associated outcomes.


Diverticulitis Sigmoidectomy Robotic-assisted surgery Laparoscopic surgery Colon resection Conversion 



The authors wish to express their gratitude to Helen B. Hubert, PhD, consulting epidemiologist, for her assistance with manuscript preparation.

Compliance with ethical standards


Dr. Amir Bastawrous has received honoraria for courses, lectures, and proctoring from Intuitive Surgical, Inc. Dr. Robert Cleary has received honoraria for courses and lectures from Intuitive Surgical, Inc. Dr. Ron Landmann has received honoraria for teaching from Intuitive Surgical, Inc. Yuki Liu is a Health Economist and Data Scientist at Intuitive Surgical, Inc. Emelline Liu is the Director of Global Health Economics and Outcomes Research at Intuitive Surgical, Inc.

Supplementary material

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Supplementary material 1 (DOCX 14 kb)
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Supplementary material 2 (DOCX 13 kb)
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Supplementary material 3 (DOCX 14 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Swedish Medical CenterSwedish Cancer InstituteSeattleUSA
  2. 2.MD Anderson Cancer CenterBaptist HealthJacksonvilleUSA
  3. 3.Intuitive Surgical, Inc., Global Health Economics and Outcomes ResearchSunnyvaleUSA
  4. 4.St. Joseph Mercy HospitalAnn ArborUSA

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