• Diane Mege and Fabrizio Michelassi.
• Department of Surgery, Weill Cornell Medicine, New York, NY.
• Ann. Surg. 2020 Feb 1; 271 (2): 317-324.

ObjectiveTo identify preoperative characteristics to help in selecting laparoscopy or laparotomy in Crohn disease (CD).Summary BackgroundLaparoscopy in CD is associated with high rates of conversion.MethodsAll patients undergoing abdominal surgery for CD in 2004 to 2016 by the senior author. Patients operated by laparoscopy, laparotomy, and converted to open were compared.ResultsFour hundred fifty-eight procedures were performed in 427 patients [F:M 1:1; median age = 41 (12-95) yrs], through laparotomy (n = 157, 34%) or laparoscopy (n = 301, 66%). Laparotomy rates decreased over time. Concomitant surgical procedures requiring laparotomy continued to dictate an open approach throughout the study. Sixty-five cases (21.6%) required conversion to laparotomy which occurred within 15' from start of case in 77%. Most common reasons for conversion included dense adhesions (34%), pelvic sepsis with fistulizing disease (26%), large inflammatory mass (18%), and thickened mesentery (9%). After multivariate analysis, predictive factors for conversion included recurrent disease after previous small bowel resection, thickened mesentery, large inflammatory mass, and extensive disease.ConclusionDespite the increasing experience with laparoscopy in CD, one-fifth of selected cases still need conversion. Recurrent disease with dense adhesions, pelvic sepsis with fistulizing disease, large inflammatory mass, and thickened mesentery are all conditions predisposing to a conversion. When the severity of these conditions is known preoperatively or a simultaneous procedure requires a laparotomy, an open approach should be considered; if laparoscopy is selected, conversion to laparotomy can be decided early in the performance of the case.

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