Institutional Outcomes Should Be a Determinant in Decision to Perform Laparoscopic Proctectomies for Rectal Cancer.

Purpose Minimally invasive rectal cancer (RC) resection has become common, despite recent high-profile trials failing to show non-inferiority to open proctectomy. We hypothesized that at a high-volume center, laparoscopic resection may have superior outcomes compared to those seen in ALaCaRT and ACOSOG Z6051. Methods Retrospective review of patients undergoing laparoscopic proctectomy from 2007 to 2015 for RC was performed at a high-volume center. Primary outcome was successful resection defined by negative circumferential resection margin (CRM) and distal margin (DM), and complete total mesorectal excision (TME). Results A total of 89 patients were included. Of 33 patients with TME grading, 31 (93.9%) had complete/near complete TME, and 29 (87.9%) had a "successful resection" compared with 81.7% in ACOSOG and 82% in ALaCART trials using same criteria. CRM was ≥1 mm in 87 (97.8%) of patients. Mean DM was 3.8 cm; 97.8% of patients had negative DM. Conclusion High-volume centers can achieve similar high quality RC outcomes to those demonstrated in recent trials. Institutional outcomes should determine optimal surgical technique.

Does umbilical contamination correlate with colorectal surgery patient outcomes?

PURPOSE: Most preoperative assessment tools to evaluate risk for postoperative complications require multiple data points to be collected and can be logistically burdensome. This study evaluated if umbilical contamination, a simple bedside assessment, correlated with surgical outcomes. METHODS: A 6-point score to measure umbilical contamination was developed and applied prospectively to patients undergoing colorectal surgery at an academic medical center. RESULTS: There were 200 patients enrolled (mean age 58.1 ± 14.8; 56% female). The mean BMI was 28.6 ± 7.4. Indications for surgery included colon cancer (24%), rectal cancer (18%), diverticulitis (13.5%), and Crohn's disease (12.5%). Umbilical contamination scores were 0 (23%, cleanest), 1 (26%), 2 (21%), 3 (24%), 4 (6%), and 5 (0%, dirtiest). Umbilical contamination did not correlate with preoperative functional status (p > 0.2). Umbilical contamination correlated with increased length of stay (rho = 0.19, p = 0.007) and postoperative complications (OR 1.3, 1.02-1.7, p = 0.04), but not readmission (p = 0.3) or discharge disposition (p > 0.2). CONCLUSION: Sterile preparation of the abdomen is an important component of proper surgical technique and umbilical contamination correlates with increased postoperative complications.

Phylogeography, genetic diversity, and connectivity of brown bear populations in Central Asia.

Knowledge of genetic diversity and population structure is critical for conservation and management planning at the population level within a species' range. Many brown bear populations in Central Asia are small and geographically isolated, yet their phylogeographic relationships, genetic diversity, and contemporary connectivity are poorly understood. To address this knowledge gap, we collected brown bear samples from the Gobi Desert (n = 2360), Altai, Sayan, Khentii, and Ikh Khyangan mountains of Mongolia (n = 79), and Deosai National Park in the Himalayan Mountain Range of Pakistan (n = 5) and generated 927 base pairs of mitochondrial DNA (mtDNA) sequence data and genotypes at 13 nuclear DNA microsatellite loci. We documented high levels of mtDNA and nDNA diversity in the brown bear populations of northern Mongolia (Altai, Sayan, Buteeliin nuruu and Khentii), but substantially lower diversity in brown bear populations in the Gobi Desert and Himalayas of Pakistan. We detected 3 brown bear mtDNA phylogeographic groups among bears of the region, with clade 3a1 in Sayan, Khentii, and Buteeliin nuruu mountains, clade 3b in Altai, Sayan, Buteeliin nuruu, Khentii, and Ikh Khyangan, and clade 6 in Gobi and Pakistan. Our results also clarified the phylogenetic relationships and divergence times with other brown bear mtDNA clades around the world. The nDNA genetic structure analyses revealed distinctiveness of Gobi bears and different population subdivisions compared to mtDNA results. For example, genetic distance for nDNA microsatellite loci between the bears in Gobi and Altai (FST = 0.147) was less than that of the Gobi and Pakistan (FST = 0.308) suggesting more recent male-mediated nuclear gene flow between Gobi and Altai than between Gobi and the Pakistan bears. Our results provide valuable information for conservation and management of bears in this understudied region of Central Asia and highlight the need for special protection and additional research on Gobi brown bears.

Evaluating the Accuracy of Hemorrhoids: Comparison Among Specialties and Symptoms.

BACKGROUND: A large proportion of patients with anorectal complaints are referred to colorectal surgeons with the label of hemorrhoids. OBJECTIVE: The purpose of this study was to review presenting symptoms and frequency of accurate diagnosis, as well as to analyze determinants of misdiagnosis to guide educational endeavors. DESIGN: This was a retrospective study. SETTINGS: The study was conducted at a tertiary care academic center. PATIENTS: The charts of patients referred to a colorectal clinic with the diagnosis of hemorrhoids from January 1, 2012, to January 1, 2017, were reviewed. MAIN OUTCOME MEASURES: The accuracy of the referring provider's diagnosis of hemorrhoids was measured. RESULTS: Review of charts identified 476 patients with the referral diagnosis of hemorrhoids. The most common presenting symptoms were bleeding (63%; n = 302), pain (48%; n = 228), and protrusion (39%; n = 185). Anal examination (ie, external inspection and/or digital internal examination) was documented in only 48%. The hemorrhoid diagnostic accuracy was 65% (n = 311). Among patients with incorrect hemorrhoid diagnoses (35%; n = 169), actual diagnosis was anal fissure (34%), skin tag (27%), and hypertrophied papilla (6%). One rectal and 2 anal carcinomas were found (0.63%). Compared with general practitioners, gastroenterologists had 86% higher odds of correct diagnosis (OR = 1.86 (95% CI, 1.10-3.10); p = 0.02), whereas the gynecologists had 68% lower odds of correct diagnosis at the time of referral (OR = 0.32 (95% CI, 0.10-0.80); p = 0.02). On multivariable analysis, referring specialty was not predictive of accurate diagnosis. Patients presenting with protrusion had 73% higher odds of accurate diagnosis (OR = 1.7 (95% CI, 1.1-2.7); p = 0.02), whereas patients presenting with pain (OR = 1.6 (95% CI, 1.1-2.5); p = 0.03) or pruritus (OR = 2.5 (95% CI, 1.2-5.0); p = 0.008) were more likely to be misdiagnosed. LIMITATIONS: This is a retrospective study. Not all of the charts contained all data points. The number of patients may limit the power of the study to detect some differences. CONCLUSIONS: A variety of anorectal complaints are diagnosed as hemorrhoids by providers who have initial contact with the patients. Educational programs directed toward improving physician knowledge can potentially improve diagnostic accuracy and earlier initiation of appropriate care. Presenting symptoms other than protrusion lead to higher rate of misdiagnosis by a referring physician. See Video Abstract at http://links.lww.com/DCR/A847.

Do psoas muscle area and volume correlate with postoperative complications in patients undergoing rectal cancer resection?

BACKGROUND: Increasingly, patients with multiple co-morbidities undergo surgery for rectal cancer. We aimed to evaluate if decreased psoas muscle area and volume, as measures for sarcopenia, were associated with postoperative morbidity. METHODS: Retrospective review of patients undergoing rectal cancer resection at a tertiary medical center (2007-2015). Variables included demographics, co-morbidities, preoperative psoas muscle area and volume, and postoperative complications. RESULTS: Among 180 patients (58% male, mean age 62.7 years), 44% experienced complications (n = 79), of which 38% (n = 30) were major complications. Malnourished patients had smaller height-adjusted total psoas area than non-malnourished patients (6.4 vs. 9.5 cm2/m2, p = 0.004). Among patients with imaging obtained within 90 days of surgery, major morbidity was associated with smaller total psoas area (6.7 vs. 10.5 cm2/m2, p = 0.04) and total psoas volume (26.7 vs. 42.2 cm3/m2, p = 0.04) compared to those with minor complications. CONCLUSION: Preoperative cross-sectional imaging may help surgeons anticipate postoperative complications following rectal cancer surgery.

Treatment for anal fissure: Is there a safe option?

BACKGROUND: Surgeons often approach anal fissure with chemical denervation (Botulinum toxin, BT) instead of initial lateral internal sphincterotomy (LIS) due to concerns for long-term incontinence. We evaluated the characteristics and outcomes of patients who received BT or LIS. METHODS: We performed a retrospective chart review of patients undergoing LIS and BT for anal fissure between 2009 and 2015. In 2015, a telephone survey was performed to evaluate durability, long-term incontinence and patient satisfaction. RESULTS: Ninety-four patients met criteria: 73 LIS and 21 BT. Age (BT 49 vs. LIS 52) was similar between groups (p = 1.0). Cleveland Clinic Fecal Incontinence (CCFI) score pre-intervention was higher in BT than LIS patients (2.1 vs. 0.4, p = 0.007) with fewer BT patients with perfect continence (50% vs. 88%). Telephone survey response was 61%. Fissure recurrence was significantly higher for BT than LIS patients (36% vs. 9%, p = 0.03). CONCLUSION: Patients undergoing LIS were less likely to recur. Both LIS and BT patients had some durable changes in continence raising the question of whether there is a safe technique.

Do patients requiring a multivisceral resection for rectal cancer have worse oncologic outcomes than patients undergoing only abdominoperineal resection?

INTRODUCTION: Abdominoperineal Resection (APR) remains an important option for patients with advanced rectal cancer though some may require multivisceral resection (MVR) in addition to APR. We hypothesized that oncological outcomes would be worse with MVR. METHODS: A retrospective review from 2006 to 2015 of 161 patients undergoing APR or MVR for rectal cancer, of whom 118 underwent curative APR or APR with MVR. Perioperative, oncologic and survival metrics were evaluated. RESULTS: There were 82 patients who underwent APR and 36 who underwent MVR. Surgical approach and incidence of complications were similar (All P > 0.05). There was 1 local recurrence in each of the APR and MVR groups at a mean follow-up of 34 and 32 months, respectively. Distant recurrences occurred in 3 APR patients and 4 MVR patients. CONCLUSIONS: APR and APR with MVR can be performed with comparable morbidity and oncologic outcomes.

Influence of intraoperative radiation therapy on locally advanced and recurrent colorectal tumors: A 16-year experience.

BACKGROUND: Intraoperative radiation therapy (IORT) has been proposed as a tool to improve local control in patients with locally advanced primary or recurrent colorectal cancer. METHODS: A retrospective review (1999-2015) of all patients undergoing IORT for locally advanced or recurrent colorectal cancer at a single academic center was performed. Patient demographics, oncologic staging, short-term and long-term outcomes were reviewed. RESULTS: There were 77 patients (mean age 63 ± 11 years) identified, of whom 19 had colon cancer, 57 had rectal cancer, and 2 had appendiceal cancers. R0 resection was performed in 53 patients (69%), R1 in 19 (25%) and R2 in 5 (6%). Ten (13%) patients had a local recurrence at 18 ± 14 months and 34 (44%) had a distant recurrence at 18 ± 18 months. Mean survival was 47 ± 41 months. CONCLUSION: IORT resulted in low local failure rates and should be considered for patients with locally advanced or recurrent colorectal cancers.

Pharmacogenetics-guided analgesics in major abdominal surgery: Further benefits within an enhanced recovery protocol.

OBJECTIVE: Effective, narcotic sparing analgesia is a major component of Enhanced Recovery Protocols (ERP), however the risk of poor analgesia and opioid related side effects (ORADE) remains an issue related to poor outcomes and satisfaction, and is strongly related to the risk of narcotic dependence after surgery. A variety of genes can impact narcotic and non-steroidal (NSAID) drug efficacy including: the CYP family (drug metabolism-narcotics and NSAID), or COMT/ABCB1/OPRM1 (functional receptor and transport activity for analgesia vs side effects). The purpose of this study was to perform the first assessment of the impact of a pharmacogenetics (PGx) guided selection of analgesics following major abdominal surgery within an ERP. METHODS: A consecutive series of open and laparoscopic colorectal resections or major ventral hernia repair (PGx group) had a guided analgesic protocol based upon assessment of CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, COMT, OPRM1, and ABCB1 genes. Study patients were compared to a recent historical series of patients (H group) managed using our well validated ERP. The primary outcome measure was the Overall Benefit of Analgesia Score (OBAS). Pain scores were also assessed. RESULTS: The data demonstrated a similar mix of procedures and gender between groups and more than half of the PGx group had revised analgesia from the standard ERP. The PGx group demonstrated significantly lower OBAS scores (p = 0.0.1) from POD1 (3.8 vs 5.4) through POD 5 (3.0 vs 4.5) Analgesia was also superior for the PGx group from POD1 through POD 5 (p = 0.04). CONCLUSION: Pharmacogenetics guidance resulted in frequent modifications of the analgesic program, resulting in excellent analgesia with a 50% reduction in narcotic consumption, and a reduced incidence of analgesic related side effects compared to our standard ERP. These data suggest further improvement in ERP resulting from a patient centric analgesic, reduced narcotic regimen which provides early and durable pain control with fewer narcotic related side effects.

Rectourethral fistulas: A comparison of the National Inpatient Sample and the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) and the National Inpatient Sample (NIS) may be used to evaluate outcomes for uncommon conditions such as rectourethral fistulas (RUFs). We sought to review cases of RUFs and compare variables from both registries to evaluate disparities among reported data. METHODS: Review of NSQIP (2005-2013) and NIS (2006-2011) of all patients with a RUF or RUF repair based on ICD-9-CM or CPT coding. RESULTS: The NSQIP and NIS data sets were compared based on International Classification of Diseases, 9th Revision, Clinical Modification diagnosis coding for a RUF (599.1; American College of Surgeons National Surgical Quality Improvement Program: n = 286, NIS: n = 2,357). Comorbidities varied between data sets, and in-hospital morbidity in RUF cases was greater in the NIS vs NSQIP data sets (48% vs 11%; P < .01). Further analysis identified similar outcomes when cases of a RUF that underwent an operation were compared in the NSQIP (n = 284) and NIS (n = 274) database. CONCLUSIONS: This study represents the largest cohort of RUF cases and characterizes how using variables from both databases better elucidates details of this rare condition. These results exhibit how evaluating comparable metrics demonstrates inconsistencies between databases.

Multivisceral resection for advanced rectal cancer: outcomes and experience at a single institution.

BACKGROUND: Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated. METHODS: A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation. RESULTS: Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma. CONCLUSIONS: Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients.

High-resolution anoscopy or expectant management for anal intraepithelial neoplasia for the prevention of anal cancer: is there really a difference?

BACKGROUND: High-resolution anoscopy has been shown to improve identification of anal intraepithelial neoplasia but a reduction in progression to anal squamous-cell cancer has not been substantiated when serial high-resolution anoscopy is compared with traditional expectant management. OBJECTIVE: The aim of this study was to compare high-resolution anoscopy versus expectant management for the surveillance of anal intraepithelial neoplasia and the prevention of anal cancer. DESIGN: This is a retrospective review of all patients who presented with anal squamous dysplasia, positive anal Pap smears, or anal squamous-cell cancer from 2007 to 2013. SETTING: This study was performed in the colorectal department of a university-affiliated, tertiary care hospital. PATIENTS: Included patients had biopsy-proven anal intraepithelial neoplasia from 2007 to 2013. INTERVENTIONS: Patients were treated with high-resolution anoscopy with ablation or standard anoscopy with ablation. Both groups were treated with imiquimod and followed every 6 months indefinitely. MAIN OUTCOME MEASURES: The incidence of anal squamous-cell cancer in each group was the primary end point. RESULTS: From 2007 to 2013, 424 patients with anal squamous dysplasia were seen in the clinic (high-resolution anoscopy, 220; expectant management, 204). Three patients (high-resolution anoscopy, 1; expectant management, 2) progressed to anal squamous-cell cancer; 2 were noncompliant with follow-up and with HIV treatment, and the third was allergic to imiquimod and refused to take topical 5-fluorouracil. The 5-year progression rate was 6.0% (95% CI, 1.5-24.6) for expectant management and 4.5% (95% CI, 0.7-30.8) for high-resolution anoscopy (p = 0.37). LIMITATIONS: This was a retrospective review. There is potential for selection and referral bias. Because of the rarity of the outcome, the study may be underpowered. CONCLUSIONS: Patients with squamous-cell dysplasia followed with expectant management or high-resolution anoscopy rarely develop squamous-cell cancer if they are compliant with the protocol. The cost, morbidity, and value of high-resolution anoscopy should be further evaluated in lieu of these findings.

The effect of transversus abdominis plane blocks on postoperative pain in laparoscopic colorectal surgery: a prospective, randomized, double-blind trial.

BACKGROUND: Superior early pain control has been suggested with transversus abdominis plane blocks, but evidence-based recommendations for transversus abdominis plane blocks and their effects on patient outcomes are lacking. OBJECTIVE: The aim of this study was to determine whether transversus abdominis plane blocks improve early postoperative outcomes in patients undergoing laparoscopic colorectal resection already on an optimized enhanced recovery pathway. DESIGN: This study is based on a prospective, randomized, double-blind controlled trial. SETTINGS: The trial was conducted at a tertiary referral center. PATIENTS: Patients undergoing elective laparoscopic colorectal resection were selected. INTERVENTIONS(S): Patients were randomly assigned to receive either a transversus abdominis plane block or a placebo placed intraoperatively under laparoscopic guidance. All followed a standardized enhanced recovery pathway. Patient demographics, perioperative procedures, and postoperative outcomes were collected. MAIN OUTCOME MEASURES: Postoperative pain and nausea/vomiting scores in the postanesthesia care unit and department, opioid use, length of stay, and 30-day readmission rates were measured. RESULTS: The trial randomly assigned 41 patients to the transversus abdominis plane block group and 38 patients to the control group. Demographic, clinical, and procedural data were not significantly different. In the postanesthesia care unit, the transversus abdominis plane block group had significantly lower pain scores (p < 0.01) and used fewer opioids (p < 0.01) than the control group; postoperative nausea/vomiting scores were comparable (p = 0.99). The transversus abdominis plane group had significantly lower pain scores on postoperative day 1 (p = 0.04) and throughout the study period (p < 0.01). There was no significant difference between groups in postoperative opioid use (p = 0.65) or nausea/vomiting (p = 0.79). The length of stay (median, 2 days experimental, 3 days control; p = 0.50) and readmission rate (7% experimental, 5% control, p = 0.99) was similar across cohorts. LIMITATIONS: This study was conducted a single center. CONCLUSIONS: Transversus abdominis plane blocks improved immediate short-term opioid use and pain outcomes. Pain improvement was durable throughout the hospital stay. However, the blocks did not translate into less overall narcotic use, shorter length of stay, or lower readmission rates.

Factors influencing disease recurrence after ileocolic resection in adult and pediatric onset Crohn's disease.

BACKGROUND: Factors influencing recurrence of ileocecal Crohn's disease (CD) after surgical resection may differ between adolescents and adults. METHODS: CD patients who underwent ileocecectomy were retrospectively divided into pediatric onset (age at diagnosis ≤ 16 years, n = 34) and adult onset (>16, n = 108) patients to evaluate differences in risks of endoscopic and clinical recurrence. RESULTS: In 142 patients, rates of any recurrence, endoscopic recurrence, and clinical recurrence at 5 years were 78%, 88%, and 65%, respectively. Risks of recurrence were similar between groups. Younger patients were more likely to be on immunologics preoperatively and more likely to be started on immunoprophylaxis postoperatively. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in the older group. CONCLUSIONS: Despite increased preoperative and postoperative immunoprophylaxis in younger patients, recurrence rates of CD after ileocecectomy do not differ between these groups. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in patients with adult onset CD.

Cost-effectiveness of laparoscopy in rectal cancer.

BACKGROUND: There is an increasing trend to use laparoscopy for rectal cancer surgery. Although laparoscopic and open rectal resections appear oncologically equivalent, there is little information on the cost of different surgical approaches. With the current health care crisis and the importance of optimizing health care resources and patient outcomes, the cost of care is an important factor. OBJECTIVE: The aim of this study was to evaluate the cost-effectiveness of laparoscopy in rectal cancer. DESIGN: This was a case-matched study. SETTINGS: This study was conducted at a tertiary referral center. PATIENTS: Patients undergoing elective rectal cancer resection between 2007 and 2012 were selected. METHODS: A review of a prospective database for elective laparoscopic rectal cancer resections was performed. Laparoscopic cases were matched to open cases based on age, BMI, operative procedure, and diagnostic-related group. MAIN OUTCOME MEASURES: The primary outcomes measured were the cost of care, hospital length of stay, discharge disposition, readmission, postoperative complications, and mortality rates. RESULTS: Two hundred fifty-four matched cases were included in the analysis: 125 laparoscopic (49%) and 129 open (51%). The cTNM stage (p = 0.39), tumor distance from the anal verge (p = 0.07), and rate of neoadjuvant therapy received between the laparoscopic and open groups were similar (p = 0.12). Operating time (p< 0.01) and cost per operating room minute (p = 0.04) were significantly higher in the open group. The groups were oncologically equivalent, based on circumferential resection margin (p = 0.15). The laparoscopic group had a significantly shorter length of stay (p < 0.01) and lower total hospital cost (p < 0.01). Postoperative complications, 30-day readmission, reoperation, and mortality rates were similar. However, significantly more patients undergoing open resection required intensive care unit care (p = 0.03), skilled nursing (p = 0.03), or home care services (p < 0.01) at discharge. LIMITATIONS: This investigation was conducted at a single institution and it is a retrospective study with potential bias. CONCLUSIONS: Laparoscopy is cost-effective for rectal cancer surgery, improving both health care expenditures and patient outcomes. For selected patients, laparoscopic rectal cancer resection can reduce length of stay, operating time, and resource utilization.

Laparoscopic and converted approaches to rectal cancer resection have superior long-term outcomes: a comparative study by operative approach.

BACKGROUND AND OBJECTIVES: The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes. METHODS: Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach. RESULTS: Overall, 294 patients were analyzed-116 LAP (39.5%), 153 OPEN (52.0%), and 25 (8.5%) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1-20) LAP, 6 days (range 3-13) CONVERTED, and 8 days (range 1-35) OPEN (p < 0.01). More OPEN had postoperative complications (p < 0.01)-complication rates were 43.8% OPEN, 32.0% CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6% OPEN, 16.0% CONVERTED, 12.1% LAP). Overall 3-year disease-free survival (DFS) was 98.3%, and local recurrence rate was 2.0%. By approach, DFS was 100% CONVERTED, 93.1% LAP, and 87.6% OPEN (p = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1% LAP, and 97.4%. OPEN. Local recurrence was 0% CONVERTED, 2% OPEN, and 2.6% LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (p = 0.05), with comparable local recurrence (p = 0.07) and OS rates (0.43). CONCLUSIONS: LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.