Most abdominal surgical procedures can be performed through minimally invasive techniques with clear benefits to patients. This has been paired with a significant reduction in morbidity and mortality for many simple and complex abdominal surgical procedures. In contrast, laparoscopy has not been widely adopted in low-and middle-income countries (LMICs) [1, 2].

Many barriers exist for safe and efficient laparoscopic surgery in LMICs, resulting in open surgery remaining the preferred surgical approach [3, 4]. Hospital systems in LMICs such as Senegal, with a gross domestic product (GDP) per capita of $1636, face many financial and infrastructural challenges compared to those in the United States, a high-income country (HIC) with a GDP per capita of $70,248 [2]. For example, the regular maintenance of laparoscopic equipment, including repair and/or replacement of fiber optic cables, cameras, lenses, and other broken or lost parts, can incur exorbitant costs which are often prohibitive for hospitals in LMICs [5]. To properly function throughout the duration of a procedure, laparoscopic instruments also require a continuous power source which may not be readily available in many LMICs [6]. These obstacles can lead to instances where unplanned conversion, or the intraoperative transition from laparoscopy to open surgery, a commonly reported problem in hospitals throughout LMICs [3, 4].

In HICs like the United States, minimally invasive approaches have been widely implemented with favorable short- and long-term outcomes for patients [7,8,9]. In this setting, unplanned conversion to laparotomy is largely considered a quality metric that may indicate a lack of advanced training or surgical case volume [10,11,12]. Failure of laparoscopic instrumentation, which is commonly encountered in LMICs and can contribute to conversion, is generally underreported in the United States [1, 2, 5, 13].

Multiple retrospective series from HICs have shown unplanned conversion to laparotomy is associated with higher morbidity and mortality rates, longer lengths of hospitalization, and increased risk of additional procedures [14, 15]. The decision to convert to open surgery can be complex and involve factors related to the surgeon, patient, and procedure [4]. A study of these factors in LMICs would allow better preparation and preoperative planning to reduce the risk of complications for these underserved patient populations. As such, the objective of this work is to analyze the factors associated with unplanned conversion to laparotomy in a low-resource setting.

Materials and methods

The present study was conducted at the Department of Surgery at Saint-Louis Regional Hospital, a tertiary care center in West Africa, between May 1, 2018 and October 31, 2021. All patients undergoing laparoscopic surgery were prospectively studied.

The primary outcome was the frequency of unplanned conversion to laparotomy. The factors analyzed were age, sex, body mass index (BMI), length of hospitalization, existence of an intraoperative complication (e.g., accidental enterotomy, hemorrhage), equipment malfunction (e.g., failure of the equipment, break in CO2 lines), and operative time.

Data were prospectively retrieved from operating notes and patient records. The study was approved by our institution’s ethics committee.

Statistical analysis

All baseline characteristics were summarized with descriptive statistics. Categorical characteristics were reported as a frequency and percentage. Continuous characteristics were reported as mean ± standard deviation if normally distributed or median with interquartile range if not normally distributed. Skewness and kurtosis tests were used to assess normality of variables. Continuous variables were compared using Student’s t-test, and categorical variables were compared using Fischer exact tests or chi-squared tests where appropriate.

Bivariate analysis was performed to select variables associated with conversion from the study population. All variables that met threshold criteria (p < 0.20) were included for analysis in the final multivariable model. Independent factors associated with conversion were identified using logistic regression with calculation of Odds Ratios (OR) and confidence intervals (CI) according to the top-step method with Wald’s test. All hypothesis tests were two-sided with a significance threshold of p < 0.05. Statistical analyses were performed using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA).

Results

Over the study period, 123 laparoscopic surgeries were performed, representing 1.1% (23/11034) of total procedures at our institution in the same period. The average age of patients was 31.2 years (range 11–75) and there were 66 (53.6%) women. 22.7% (n = 28) had a BMI > 25 kg/m2. The average BMI was 22.5 kg/m2 ± 2.7. The procedure was urgent in 68 cases (55.2%). Diagnostic laparoscopy was performed in 19% of cases, therapeutic in 76.5% of patients and both diagnostic and therapeutic in 4.8%. The average operative time was 80.5 min (range 20–210 min). The average length of hospitalization was 3 days (range 1–16 days). The procedures performed included appendix procedures (48%), followed by gynecological (18.7%), gallbladder (14.6%), digestive (10.56%), and abdominal wall (4%). The baseline characteristics and distribution of surgical procedures according to procedure type are detailed in Tables 1  and 2. Equipment malfunction was encountered in 9.8% (n = 12) cases and surgical complications were noted in 11 cases (8.9%). The mean operative time was 86 min (range 20–210 min).

Table 1 Baseline characteristics (n = 123)
Full size table
Table 2 Distribution of surgical procedures by type of surgery (n = 123)
Full size table

In 11 cases (8.9%), conversion to open surgery was needed. The reasons for conversion are shown in Table 3. Logistic regression found the following factors related to conversion: BMI > 25 kg/m2 (OR 4.6; p = 0.034), the existence of an intraoperative complication (OR 12.6; p = 0.028), and equipment malfunction (OR 9.4; p = 0.002). The results of the bivariate and multivariate analyses are detailed in Tables 4 and 5.

Table 3 Reasons for conversion (n = 11)
Full size table
Table 4 Factors associated with conversion after bivariate analysis
Full size table
Table 5 Factors associated with conversion after multivariate analysis
Full size table

Postoperative complications were noted in 7.3% (n = 9), including: trocar site infection (n = 2), biliary leak (n = 3), missed enterotomy (n = 1), postoperative peritonitis (n = 1), and wound dehiscence (n = 2). Two deaths (1 bile leak, 1 pulmonary embolism) were recorded, leading to a mortality rate of 1.6% for this study.

Discussion

Our study represents a single-center experience describing factors that lead to laparoscopic to open conversion in a sub-Saharan LMIC. In this series of 123 laparoscopic procedures in a low-resource setting, we showed that BMI > 25, intraoperative complications, and equipment failure are associated with conversion. Existing literature on risk factors for unplanned conversion to laparotomy in LMICs is limited to case reports, short case series, or retrospective studies [2]. A better understanding of the factors associated with unplanned conversion is needed to improve procedural planning and gain insight into training and equipment needs in LMICs [16]. Notably, although Saint-Louis Regional Hospital is among the largest tertiary care centers in Senegal, the 123 laparoscopic procedures recorded in the study period comprised a small minority of total surgical procedures at this institution. This is consistent with practice patterns from other LMICs, such as the Philippines, whose largest tertiary government medical center reported 55% of cholecystectomies performed using an open approach in 2013 [17]. These findings from low-resource settings further suggest that slow adoption of laparoscopy likely prevails due to a combination of financial, infrastructural, and educational barriers [1,2,3,4].

Similar to this study, others have reported similar risk factors although the reported rates of conversion vary significantly. Pizzol et al. reported a conversion rate of 1.9% due to intraoperative complications in a retrospective series of 363 patients in Mozambique who underwent laparoscopic appendectomy and gynecological procedures [2]. In contrast to the present study, the relatively low conversion rate reported by Pizzol et al. is explained by the fact that diagnostic laparoscopy was the primary indication, although the reasons for conversion were similar [2]. In South Africa, Matsevych et al. studied 318 patients who received laparoscopy for abdominal trauma and detailed a conversion rate of 12.9% [18]. Uncontrolled intrabdominal bleeding was the primary reason for conversion. This study from the same continent demonstrated a higher conversion rate than the present study (8.9%), which may give insight into potential variability in laparoscopic practice patterns and outcomes across LMICs from similar regions. Similar to our findings, a recent retrospective study of 52 patients in Colombia who underwent laparoscopy for abdominal trauma showed a conversion rate of 7.7% also due to uncontrolled intraabdominal bleeding [19]. The relatively high rate of conversion due to intraoperative complications described in our study, in conjunction with the here reported studies, may be attributed to deficiencies in training or equipment availability in LMICs across multiple continents. Improved reporting on outcomes of laparoscopy, including operative time and potential intraoperative complications, is the first step for surgical teams to better anticipate complications and improve patient outcomes.

The present study also highlights instrument failure as a critical factor of conversion to laparotomy. This has been previously described in studies detailing resource-limited environments with frequent instrument reuse or lack of maintenance of laparoscopic instruments. For example, an 8-year prospective study from a single institution in Pakistan found 14.8% of conversions to have been converted to laparotomy due to instrument failure [20]. Similarly, a 2-year retrospective study in India found an alarming 71.4% of converted cases to have been caused by failure of laparoscopic instrumentation [21]. In our study, instrument failure was reported in 36.4% of converted cases. Despite the wide variability, all three studies illustrate technological shortcomings as contributing to unplanned conversion in low-resource settings. Despite the benefits associated with laparoscopic surgery, instrument failure represents an additional obstacle to the implementation of minimally invasive surgery in LMICs [22].

While most studies from LMICs report high conversion rates for low complexity laparoscopy, HICs largely report low conversion rates for high complexity laparoscopy. In Japan, a retrospective study of 208 patients who underwent laparoscopic liver resection showed a conversion rate of 3.8% and only determined uncontrollable intraoperative bleeding as a factor associated with conversion [23]. This experience from a HIC showed a lower conversion rate and fewer risk factors than our analysis. Notably, absent from the identified risk factors was instrument failure and obesity, which contrasts with our findings but is in line with others from HICs. A systematic review and meta-analysis of conversion during laparoscopic cholecystectomy by Rothman et al. identified 32 prospective and observational studies from HICs (including 460,995 total patients) and determined older age and male gender to be significant risk factors [24]. A total of 13 studies evaluated BMI as a preoperative risk factor, of which only six studies determined obesity to be associated with conversion to open surgery [24]. However, the quality of evidence among these 6 studies was highly heterogenous and subsequently demonstrated to be very low using the GRADE approach, leading researchers to recommend further inquiry to verify the role of BMI [24]. A recent retrospective series of 356 patients undergoing laparoscopic hysterectomy in the Netherlands showed a conversion rate of 2.8%, lower than that of the present study, due to poor intraoperative visibility [25]. With 79.8% of patients in this cohort reporting a BMI > 25 kg/m2, this nine-year experience suggested that conversion rates do not significantly change with increasing BMI, which is consistent with previous literature from HICs [25,26,27]. Overall, in contrast to our experience in Senegal, laparoscopy in HICs encounters a lower incidence of conversion for more complex surgical procedures, and weight or instrument failure are generally not demonstrated to be factors related to conversion.

Structured laparoscopic training is limited in low-resource settings such as Senegal. If present, formal training can lead to decreased conversion rates [10, 11]. Yi et al. detail a 9-year prospective experience and surgical training intervention in the Philippines, wherein 521 patients undergoing laparoscopic cholecystectomy experienced an overall conversion rate of 3.3% resulting from intraoperative complications [28]. The overall conversion rate decreased following completion of a 1-week surgical training course for laparoscopic naïve surgeons in this low-resource setting [28]. These findings help corroborate previous literature which suggests an association between the learning curve and rates of unplanned conversion to laparotomy [10, 11, 29].

Although technical skills are crucial to consider for the conversion rate, there is also a substantial body of literature emphasizing the significance of non-technical skills. Specifically, studies conducted in LMICs have suggested that relying solely on technical skills may not be sufficient for enhancing the quality of laparoscopic surgery. Therefore, it would be important to incorporate training on non-technical surgical skills, such as clinical decision-making and team communication, into the laparoscopy training program [30].

Professional surgical organizations are critical in ensuring safe and effective practice of laparoscopy by raising surgical standards across LMICs through modular training programs and hospital accreditation. The College of Surgeons of East, Central, and Southern Africa (COSECA) recently distributed a laparoscopic surgery needs assessment across its 44 accredited teaching hospitals in 16 different countries and found a lack of consumables, limited quantity of equipment, scarcity of skilled minimally invasive surgeons, and prohibitory costs associated with laparoscopic procedures as the main barriers of further developing laparoscopy [31, 32]. Despite the efforts of COSECA over the past two decades, these factors limit the practice of laparoscopy across COSECA hospitals and keep minimally invasive surgery inaccessible to millions of patients. To help fill this gap, the aid organizations Surgeons for Africa and Operation Hernia have implemented a structured laparoscopic surgical training program for postgraduate surgical trainees in east Africa, successfully educating 36 trainees in both mesh and non-mesh hernia repair over a 3-year period [33]. Such programs have tremendous potential to reduce unplanned conversion to laparotomy, postoperative morbidity, and mortality in low-resource settings by improving access to structured laparoscopic training. Further targeted development by national and international organizations can encourage improvements in surgical care throughout resource-limited settings.

In our institution, while some surgeons have received training in laparoscopy, we have observed that other members of the surgical team, such as OR nurses and other support staff, do not possess the necessary training in laparoscopic techniques. This lack of comprehensive training across the entire team can hinder the seamless integration of laparoscopic surgery into routine practice. Furthermore, it is worth noting that the administration’s perception of laparoscopy as an urgent and essential need may not always align with other surgical priorities such as obstetrics or open surgeries. This discrepancy in prioritization could result in limited investment in laparoscopic resources and infrastructure. The acquisition of materials and equipment supplies for laparoscopy can be costly and challenging to establish due to intricate procurement processes, even if reusable materials are utilized. These factors collectively contribute to the underutilization of laparoscopic surgery in our setting.

Limitations

The present study has a number of limitations. The single-center design and small number of patients limit the generalizability of the results, although these limitations are characteristic of the low-resource setting in Senegal. In addition, the analysis of conversion factors was not evaluated for the same types of surgical techniques. In addition, as conversion is related to a mix of patient, procedural, surgeon, and environmental factors, we did not analyze surgeon factors (e.g., age, years in practice, laparoscopic experience, subspecialty training). Despite these limitations, our study had the strength of prospective data collection over a 3-year study period.

Conclusion

Conversion is necessary when the proposed laparoscopic approach can no longer be pursued without significant risk. Understanding the factors associated with conversion, including BMI > 25 kg/m2, intraoperative complications, and equipment malfunction as per our analysis, may facilitate better procedural planning to reduce postoperative morbidity in low-resource settings such as LMICs.