Original Research
Risk Factors and Outcomes for Conversion to
Laparotomy of Laparoscopic Hysterectomy
in Benign Gynecology
Courtney S. Lim, MD, Erika L. Mowers, MD, Nichole Mahnert, MD, Bethany D. Skinner,
Neil Kamdar, MA, Daniel M. Morgan, MD, and Sawsan As-Sanie, MD, MPH
OBJECTIVE: To estimate the incidence and factors for
conversion to laparotomy in women scheduled for
laparoscopic hysterectomy for benign gynecologic indi-
cations and to examine the effect of conversion on
patient outcomes.
METHODS: A retrospective cohort study of a Michigan
multicenter prospective database was abstracted from
January 1, 2013, through July 2, 2014. Participants were
collected from an all-payer quality and safety database
maintained by the Michigan Surgical Quality Collabora-
tive. Women with a preoperative indication of cancer or
obstetric indications were excluded. A logistic regression
model was used to calculate odds of conversion using
patient preoperative and intraoperative attributes.
RESULTS: During the study period, 6,992 women
underwent an attempted laparoscopic hysterectomy
with 3.93% (n5275) converted to laparotomy. After ad-
justing for socioeconomic differences, hysterectomy
indication, and intraoperative factors, there were
decreased odds of conversion to laparotomy with use
of robotic-assisted laparoscopy compared with tradi-
tional laparoscopy (adjusted odds ratio [OR] 0.14, 95%
confidence interval [CI] 0.07–0.25) with a predicted risk
of conversion of 0.8% compared with 5.4% (P,.001).
High-volume surgeons were less likely to convert to lap-
arotomy compared with low- and medium-volume
From the Department of Obstetrics and Gynecology, University of Michigan, Ann
Arbor, Michigan.
Presented at the 44th American Association of Gynecologic Laparoscopists Global
Congress on Minimally Invasive Gynecology, November 15–19, 2015, Las
Vegas, Nevada.
Corresponding author: Courtney S. Lim, MD, L4000 Women’s Hospital, 1500 E
Medical Center Drive, SPC 5276, Ann Arbor, MI 48109-5276; e-mail:
courtlim@med.umich.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2016 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/16
VOL. 128, NO. 6, DECEMBER 2016
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
MD,
surgeons (adjusted OR 0.66, 95% CI 0.47–0.92) with
a predicted risk of conversion of 1.4% compared with
2.25% (P5.015). Conversion was associated with moder-
ate or severe adhesive disease and increasing specimen
weight. Conversion was associated with increased rates
of surgical site infection, blood transfusion, severe sep-
sis, and reoperation.
CONCLUSION: This analysis demonstrates that conver-
sion to laparotomy is associated with increased odds of
postoperative morbidity, and robotic assistance and
surgeon volume are strongly associated with decreased
odds of conversion.
(Obstet Gynecol 2016;128:1295–305)
DOI: 10.1097/AOG.0000000000001743
T he benefits of laparoscopic surgery are well known
and include shorter hospital stay, less postopera-
tive pain, quicker return to normal activities, fewer
wound infections, and decreased blood loss in com-
parison with an abdominal approach.1 Given these
clear benefits, the use of laparoscopy has increased
substantially and is the preferred approach when vag-
inal hysterectomy is not feasible.2
Despite the increased utilization of laparoscopy
for hysterectomy, conversion to laparotomy (or “con-
version”) remains a risk and has been reported in 0–
19% of patients.3 Reported risk factors for conversion
include patient factors such as increasing age,3
increasing body mass index (BMI, calculated as
weight (kg)/[height (m)]2),3–5 history of abdominopel-
vic surgery,4 presence of adhesions,4–6 endometriosis
or leiomyomata,4 uterine weight3,5,6 as well as a less
experienced surgeon.3 However, these risk factors are
not consistently reported across all major studies,3–6
and prior studies have not examined the effect of the
robotic surgical system. Furthermore, many of the
prior studies are limited by small sample size and out-
comes from a single institution.
OBSTETRICS & GYNECOLOGY 1295
 The objective of this study was to evaluate the
incidence and risk factors for conversion to laparot-
omy for both traditional laparoscopic and robotic
hysterectomy performed for benign indications using
a statewide multicenter prospective database. Our
secondary objective was to determine differences in
30-day outcomes of women who had conversion to
laparotomy. This information will enhance risk strat-
ification and improve preoperative planning and
patient selection for hysterectomy.
MATERIALS AND METHODS
All laparoscopic hysterectomies performed from
January 1, 2013, through July 2, 2014, in the Michigan
Surgical Quality Collaborative database were
included in this analysis. The selected timeframe
reflected the most complete data set at the time of
the analysis. The Michigan Surgical Quality Collab-
orative consists of 52 academic and community
hospitals voluntarily participating in this collabora-
tive. Sixty percentage are community-based. Funded
by Blue Cross and Blue Shield of Michigan/Blue Care
Network, this represents approximately 30% of Mich-
igan hospitals, and it includes patients from all
insurance payers. At each participating hospital,
a trained, dedicated nurse researcher reviews the
entire medical record and uses a standardized data
collection instrument to abstract patient character-
istics, operative findings, complications, pathology
results, and 30-day postoperative outcomes. Data
were abstracted from clinic and hospital notes, oper-
ative reports, and pathology reports.
Cases collected in the Michigan Surgical Quality
Collaborative database include general surgery pro-
cedures (such as appendectomy, cholecystectomy,
colectomy) as well as hysterectomies. A standardized
data collection methodology is used to reduce sam-
pling bias. The year is divided into consecutive 8-day
cycles so that each cycle starts on a different day. The
intended effect is to promote surgeon sampling
because it is common practice for surgeons to cluster
procedures on 1 or 2 days of the week. At each
hospital, the first 25 cases of a previously identified list
of Current Procedural Terminology codes of an 8-day
cycle are collected. The process of data abstraction
and methodology is routinely validated through
scheduled site visits, conference calls, and internal
audits. The University of Michigan institutional
review board provided “nonregulated” status to this
study (HUM00073978).
All benign hysterectomies that were initiated with
laparoscopy during the study period within the
sample were included in this analysis. Laparoscopic
1296 Lim et al Laparoscopic Hysterectomy and Conversion
Copyright ª by The American College of Obstetricians
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hysterectomy included traditional laparoscopy,
robotic-assisted (or “robotic”), and laparoscopic-
assisted vaginal approaches. Patients with a known
malignancy or obstetric indication were excluded
from this analysis. Route of hysterectomy and conver-
sion to laparotomy were obtained from operative re-
ports and intraoperative records. The objective of this
study was to evaluate the incidence and risk factors for
conversion to laparotomy for both traditional laparo-
scopic and robotic-assisted laparoscopic hysterectomy
performed for benign gynecologic indications.
We evaluated patient preoperative and perioper-
ative characteristics. Patient demographics included
age, parity, self-reported race (white or nonwhite), and
type of insurance at the time of surgery. The patient’s
insurance was classified as private, Medicaid, Medi-
care, uninsured, or self-pay. Private insurance included
Blue Cross Blue Shield of Michigan, Blue Care Net-
work, health maintenance organization plans, and
other private insurance plans. Medicare included
Medicare only, Medicare with a supplemental plan
such as Medigap insurance, or Medicare Advantage
(Blue Cross Blue Shield or Blue Care Network of
Michigan). Patients were considered to have Medicaid
if they had Medicaid or a health maintenance organi-
zation Medicaid plan. Uninsured and self-pay were
reported but not considered for additional multivariate
analysis as a result of small numbers.
Additional patient characteristics included med-
ical comorbidities (BMI, history of hypertension,
deep vein thrombosis, preoperative blood transfu-
sion), American Society of Anesthesiologists physical
status classifications, surgical indications for hyster-
ectomy, and history of prior abdominal or pelvic
surgery. Surgical indications were determined based
on the outpatient clinic notes, preoperative history,
and physical or operative notes. These indications
included abnormal uterine bleeding, leiomyomas,
endometriosis, pelvic inflammatory disease, pelvic
mass, chronic pelvic pain, and pelvic organ prolapse.
Surgical indications were not mutually exclusive and
patients could have more than one indication. Intra-
operative information was based on operative notes
and pathology notes. This included presence of
abdominal or pelvic adhesions; presence of endome-
triosis anywhere in the pelvis; presence of endome-
triosis on the uterus, ovaries, or fallopian tubes; type
of hysterectomy performed (total compared with
supracervical); intraoperative complications; speci-
men weight; estimated blood loss in milliliters; and
procedure duration (incision to closure) in minutes.
The finding of unexpected malignancy, defined as
hysterectomy performed for a benign indication and
OBSTETRICS & GYNECOLOGY
final pathology identified a malignancy, was also
included. Adhesions were classified as none or mild,
moderate, or severe. None or mild adhesions were
those that were not mentioned in the operative report
or described as “few” or “limited.” Moderate adhe-
sions were described as “some,” “multiple,” or
“many,” which may require lysis but do not impair
the ability to do the operation. Severe adhesions were
defined as “severe,” “dense,” “extensive,” “signifi-
cant,” or “hostile”; taking an hour or more to lyse;
or both. Severe adhesions were also defined as adhe-
sions prohibiting the planned procedure.
Intraoperative complications included bowel,
bladder, ureter, or vascular injury identified before
completion of the hysterectomy. Specimen weight for
the uterus was measured in grams and classified as less
than 250, 250–499, 500–999 g, and greater than or
equal to 1,000 g. Estimated blood loss was classified
as less than or equal to 100, 101–300, 301–500, 501–
1,000 mL, and greater than 1,000 mL. The duration of
surgery was split into 2-hour increments ranging from
less than 2 hours to greater than 6 hours.
Hospital characteristics included teaching status,
as defined by the 2012 American Hospital Association
survey. Hospital bed size was defined as small (less
than 300 beds), medium (300–499 beds), and large
(500 beds or greater).
Surgeon volume was determined by the number
of all hysterectomies contributed to the Michigan
Surgical Quality Collaborative sample in the prior
24 months by each surgeon. This included abdom-
inal, laparoscopic, and vaginal hysterectomies. This
was used as a proxy for total surgeon volume
because the Michigan Surgical Quality Collabora-
tive does not capture every surgery performed at
each hospital, only the first 25 cases of each 8-day
data-capture cycle. Thus, a surgeon’s total annual
caseload was not available and we considered this
measure the best available proxy. We then exam-
ined the distribution of surgeon volume and divided
the surgeons into equal volume-based tertiles of low,
medium, and high volume, as has previously been
reported.7–9 The distribution of cases in each tertile
can be seen in Table 1. The lowest volume tertile
contributed one to four hysterectomies in the 24-
month period, the intermediate-volume tertile
contributed 5–17, and the high-volume tertile con-
tributed 18 or more hysterectomies to the sample in
the prior 24 months. Given that the top tertile still
included a low number of hysterectomies contrib-
uted to the sample, we also examined ultrahigh-
volume surgeons by dividing the surgeons into those
below the 75th percentile, 75th–89th percentile,
90th–94th percentile, 95th–98th percentile, and
99th percentile or greater.
Our secondary objective was to determine differ-
ences in 30-day outcomes of women who had
conversion to laparotomy, including the incidence of
surgical site infection, postoperative transfusion,
venous thromboembolism, readmission, and reopera-
tion. This information was abstracted from hospital
notes, office notes, laboratory results, radiology re-
sults, nursing notes, and emergency department
documentation. Surgical site infection definitions were
based on definitions from the Centers for Disease
Control and Prevention surveillance definition of
health care-associated infections.10 Sepsis was defined
as a recent history of new infection within 30 days
postoperatively with any two of the following signs
and symptoms: temperature greater than 38.3°C or
less than 36°C, heart rate greater than 90 beats
per minute, respiratory rate greater than 20 breaths
per minute, white blood cell count greater than 12,000
cells per cubic millimeter or less than 4,000 cells per
cubic millimeter, hyperglycemia (plasma glucose
greater than 120 mg/dL) in the absence of diabetes,
or acutely altered mental status.11
Distributions for continuous variables were
checked for normality looking at skew and kurtosis.
Continuous variables were examined and extreme

Table 1. Surgeon Volume by Equal Volume Tertiles Within the Michigan Surgical Quality Collaborative
Database

Tertile
Characteristic Low-Volume Middle-Volume High-Volume

No. of surgeons 284 301 303

No. of hysterectomies performed 615 2,184 9,323
Median no. of patients/surgeon 2 10 32
Lowest no. of cases/surgeon 1 5 18
Highest no. of cases/surgeon 4 17 258

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outliers were identified and removed. Approximately
normally distributed data were reported as mean-
6standard deviation and nonparametric data were
reported as median (interquartile range). Wilson-
binomial 95% confidence intervals were calculated
for proportions where appropriate. Descriptive anal-
ysis of categorical variables was conducted using x2
or Fisher exact test in the case of small cell sizes and
Student t test or analysis of variance for continuous
variables as appropriate.
Clinically relevant covariates were considered for
multivariable logistic regression to examine likeli-
hood of conversion from laparoscopy to laparotomy.
Candidate covariates were assessed for missing data
and those with sufficient data for model development
were considered for analysis. Although parity and
history of prior abdominal surgeries were clinically
relevant covariates, they were excluded as a result of
a significantly larger proportion of cases missing
compared with other covariates considered for bivar-
iate and multivariate analyses. To account for clus-
tering of patients within hospitals, Huber-White
robust standard errors were calculated for each of
the parameter estimates. For categorical variables
with more than two categories, dummy variables
were derived to measure direct effect sizes. Because
collinearity resulting from a significant correlation
can dramatically affect parameter estimates and effect
sizes for the model, Spearman or Pearson correlation
matrices for all variables considered in a model were
obtained. Iterative variable selection taking into
account collinearity and clinical relevance of selected
variables led to a reduced model with a strong C-
statistic (concordance). Final model diagnostics
included decile and quintile analysis comparing
observed and adjusted rates for conversion. Logistic
regression models were used to calculate the pre-
dicted incidence of conversion among robotic and
traditional laparoscopic cases adjusted for the varia-
bles included in the final model. A secondary analysis
was performed that fit the previously defined model
in addition to an interaction term. This interaction
term accounted for the relationship between surgical
approach (robotic-assisted laparoscopy compared
with traditional laparoscopy) and surgeon volume.
This was used to calculate the predicted risk of
conversion based on surgical approach across sur-
geon volume groups. Data analyses were performed
using Stata 14.0.
RESULTS
A total of 12,122 hysterectomies were available in the
data set from January 1, 2013, to July 2, 2014. After
1298 Lim et al Laparoscopic Hysterectomy and Conversion
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
exclusion of cases for surgical approach (2,832
abdominal, 1,343 vaginal, and one not discernible as
a result of a lack of data), an absence of pathology data
(232), gynecologic cancer (719), and obstetric indica-
tions (3), there were 6,992 hysterectomies eligible for
inclusion (Fig. 1). Of these, 6,717 were completed
laparoscopically, and 275 were converted to an open
procedure, for an overall rate of conversion of 3.93%.
Seven of these cases were initiated emergently, and
none of those were converted to laparotomy.
Univariate analyses are shown in Tables 2 and 3.
Multiple preoperative characteristics (Table 2) were
associated with a significantly increased risk of conver-
sion, including BMI greater than 30 and preoperative
indication of leiomyomas, pelvic inflammatory dis-
ease, or a pelvic mass. Factors that were associated
with decreased odds of conversion included previous
failure of an alternative treatment and preoperative
indication of pelvic organ prolapse. Compared with
moderate-volume surgeons, high-volume surgeons
had lower odds of conversion in the univariate analy-
sis. In addition, the rate of conversion was significantly
higher in traditional laparoscopy than robotic-assisted
laparoscopy (8.28% compared with 1.57%, P,.001).
Those who were self-pay or uninsured had an
increased odds of conversion compared with those
with private insurance (odds ratio [OR] 2.98, 95% con-
fidence interval [CI] 1.47–6.04). This was not included
in the multivariate analysis as a result of small num-
bers. Compared with those who underwent traditional
laparoscopy, the group of patients undergoing robotic-
assisted laparoscopic hysterectomy had characteristics
associated with higher surgical complexity, with statis-
tically significantly higher BMIs and more frequent
Fig. 1. Flow diagram of hysterectomies included in the
analysis.
Lim. Laparoscopic Hysterectomy and Conversion. Obstet Gynecol
2016.
OBSTETRICS & GYNECOLOGY
Table 2. Demographics and Preoperative Risk Factors and Risk of Conversion of Laparoscopic
Hysterectomy to Laparotomy

Total Completed Laparoscopically Conversion to Open Unadjusted OR

Characteristic (N56,992) (n56,717 [96.07]) (n5275 [3.93]) (95% CI) P

Age (y)
40 or younger 2,065 (29.53) 2,011 (97.38) 54 (2.62) Referent
Older than 40 and 4,271 (61.08) 4,074 (95.39) 197 (4.61) 1.80 (1.32–2.44) ,.001
60 or younger
Older than 60 656 (9.38) 632 (96.34) 24 (3.66) 1.41 (0.86–2.31) .165
Race
White 5,503 (78.70) 5,318 (96.64) 185 (3.36) Referent
Nonwhite 1,489 (21.30) 1,399 (93.96) 90 (6.04) 1.85 (1.43–2.40) ,.001
Insurance
Private 5,222 (79.37) 5,020 (96.13) 202 (3.87) Referent
Medicaid 676 (10.28) 650 (96.15) 26 (3.85) 0.99 (0.66–1.51) .978
Medicare 597 (9.07) 579 (96.98) 18 (3.02) 0.77 (0.47–1.26) .302
Uninsured or self- 84 (1.28) 75 (89.29) 9 (10.71) 2.98 (1.47–6.04) .002
pay
Missing 413 (5.91)
Use of robot
Traditional 2,464 (35.24) 2,260 (91.72) 204 (8.28) Referent
laparoscopic
Robotic 4,528 (64.76) 4,457 (98.43) 71 (1.57) 0.18 (0.13–0.23) ,.001
Prior pelvic surgery
No 2,701 (38.63) 2,601 (96.30) 100 (3.70) Referent
Yes 4,291 (61.37) 4,116 (95.92) 175 (4.08) 1.11 (0.86–1.42) .431
ASA class
1 761 (10.88) 739 (97.11) 22 (2.89) Referent
2 4,947 (70.75) 4,764 (96.30) 183 (3.70) 1.29 (0.82–2.02) .266
3 or greater 1,284 (18.36) 1,214 (94.55) 70 (5.45) 1.94 (1.19–3.15) .008
BMI (kg/m2)
Less than 25 1,711 (24.56) 1,666 (97.37) 45 (2.63) Referent
25 to less than 30 1,976 (28.36) 1,916 (96.96) 60 (3.04) 1.15 (0.78–1.71) .460
30 to less than 40 2,409 (34.57) 2,284 (94.81) 125 (5.19) 2.02 (1.43–2.87) ,.001
40 or greater 872 (12.51) 827 (94.84) 45 (5.16) 2.01 (1.32–3.07) .001
Missing 24 (0.34)
Prior alternative
treatment
No 2,893 (41.38) 2,757 (95.30) 136 (4.70) Referent
Yes 4,099 (58.62) 3,960 (96.61) 139 (3.39) 0.71 (0.56–0.91) .006
Indications for
hysterectomy
Abnormal uterine
bleeding
No 2,244 (32.09) 2,153 (95.94) 91 (4.06) Referent
Yes 4,748 (67.91) 4,564 (96.12) 184 (3.88) 0.95 (0.74–1.23) .718
Leiomyomas
No 4,297 (61.46) 4,168 (97.00) 129 (3.00) Referent
Yes 2,695 (38.54) 2,549 (94.58) 146 (5.42) 1.85 (1.45–2.36) ,.001
Endometriosis
No 6,012 (85.98) 5,775 (96.06) 237 (3.94) Referent
Yes 980 (14.02) 942 (96.12) 38 (3.88) 0.98 (0.69–1.39) .923
Pelvic inflammatory
disease
No 6,975 (99.76) 6,703 (96.10) 272 (3.90) Referent
Yes 17 (0.24) 14 (82.35) 3 (17.65) 5.28 (1.51–18.48) .009
Pelvic mass
No 6,514 (93.16) 6,267 (96.32) 247 (3.79) Referent
Yes 478 (6.84) 450 (94.14) 28 (5.86) 1.58 (1.06–2.36) .026
(continued )

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Table 2. Demographics and Preoperative Risk Factors and Risk of Conversion of Laparoscopic
Hysterectomy to Laparotomy (continued )
Total Completed Laparoscopically Conversion to Open Unadjusted OR
Characteristic (N56,992) (n56,717 [96.07]) (n5275 [3.93]) (95% CI) P

Chronic pelvic pain

No 4,158 (59.47) 3,993 (96.03) 165 (3.97) Referent
Yes 2,834 (40.53) 2,724 (96.12) 110 (3.88) 0.98 (0.76–1.25) .855
Pelvic organ
prolapse
No 6,140 (87.81) 5,878 (95.73) 262 (4.27) Referent
Yes 852 (12.19) 839 (98.47) 13 (1.53) 0.35 (0.20–0.61) ,.001
Bed size
Less than 300 2,617 (38.0) 2,534 (96.83) 83 (3.17) Referent
300–499 3,103 (45.06) 2,979 (96.0) 124 (4.0) 1.27 (0.96–1.69) .097
500 or greater 1,167 (16.94) 1,102 (94.43) 65 (5.57) 1.80 (1.29–2.51) .001
Missing 105 (1.50)
Teaching hospital
No 2,534 (36.79) 2,430 (95.90) 104 (4.10) Referent
Yes 4,353 (63.21) 4,185 (96.14) 168 (3.86) 0.94 (0.73–1.20) .615
Missing 105 (1.50)
Surgeon volume by
tertile
Low volume 278 (3.98) 265 (95.32) 13 (4.68) 0.63 (0.31–1.14) .127
Middle volume 1,143 (16.35) 1,060 (92.74) 83 (7.26) Referent
High volume 5,571 (79.68) 5,392 (96.79) 179 (3.21) 0.42 (0.32–0.55) ,.001
OR, odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists; BMI, body mass index.
Data are n (%) unless otherwise specified.

removal of the cervix and presence of endometriosis.
There was no difference on other covariates including
specimen weight and adhesion severity.
As shown in Table 3, intraoperative factors that
were associated with an increased odds of conversion
included presence of either moderate or severe adhe-
sions or unexpected malignancy. Presence of endome-
triosis on the uterus, ovaries, or fallopian tubes also
increased the risk of conversion. The risk of conver-
sion was significantly higher with any complication
including bowel, bladder, ureteral, or vascular injury.
Increasing specimen weight, blood loss, and operative
time all were associated with significantly increased
odds of conversion.
Patients who underwent concurrent procedures
such as oophorectomy or hernia repair were not at
increased odds of conversion (Table 3). Having con-
current bowel surgery (n55) was associated with con-
version in the bivariate analysis. However, on further
investigation of these cases, all of these bowel surger-
ies appeared to be initiated as a result of an intraoper-
ative bowel complication. This was reflected in the
documentation of bowel injury by Current Procedural
Terminology codes. Therefore, this was not included
in the model.
As shown in Table 4, the significant risk factors
for conversion with multivariate logistic regression
modeling were age older than 40 years and 60 years
or younger, BMI greater than or equal to 30, preop-
erative indications of pelvic mass, presence of moder-
ate or severe adhesions, and specimen weight greater
than 250 g. The factors most strongly associated with
decreased odds of conversion in the multivariate
model were having a robotic procedure and having
a high-volume surgeon. Other factors that decreased
the risk of conversion included having an alternative
treatment before hysterectomy or a preoperative indi-
cation of pelvic organ prolapse. This model was then
used to estimate predicted means of conversion based
on route of surgery and surgeon volume. After arriv-
ing at a parsimonious model, the C-statistic was 0.85
and the Hosmer-Lemeshow test statistic was 8.60 with
a P value of .38 for 10 groups. Using this model, the
predicted risk of conversion to laparotomy with tradi-
tional laparoscopy compared with robotic-assisted
laparoscopy was 5.4% compared with 0.8% (P,.001)
after adjusting for all other variables in the model.
High-volume surgeons were less likely to convert to
laparotomy compared with low- and medium-volume
surgeons with a predicted risk of conversion of 1.4%
compared with 2.25% (P5.015).
The high-volume tertile surgeons performed 18–
258 hysterectomies captured within the 24-month
sample. We identified a significant correlation between

1300 Lim et al Laparoscopic Hysterectomy and Conversion OBSTETRICS & GYNECOLOGY

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Table 3. Intraoperative Factors and Risk of Conversion of Laparoscopic Hysterectomy to Laparotomy

Completed Conversion to
Total Laparoscopically Laparotomy Unadjusted OR
Characteristic (N56,992) (n56,717 [96.07]) (n5275 [3.93]) (95% CI) P

Presence of adhesions
None or mild 5,251 (75.10) 5,138 (97.85) 113 (2.15) Referent
Moderate 931 (13.32) 884 (94.95) 47 (5.05) 2.42 (1.71–3.42) ,.001
Severe 810 (11.58) 695 (85.80) 115 (14.20) 7.52 (5.74–9.87) ,.001
Any endometriosis
No 5,877 (84.05) 5,652 (96.17) 225 (3.83) Referent
Yes 1,115 (15.95) 1,065 (95.52) 50 (4.48) 1.18 (0.86–1.61) .302
Endometriosis of uterus, fallopian
tubes, and ovaries
No 6,362 (90.99) 6,124 (91.17) 238 (3.74) Referent
Yes 630 (9.01) 593 (94.13) 37 (5.87) 1.61 (1.12–2.29) .009
Cervical preservation
Supracervical 1,095 (15.66) 1,032 (94.25) 63 (5.75) Referent
Total 5,897 (84.34) 5,685 (96.40) 212 (3.60) 0.61 (0.46–0.82) .001
Concurrent procedures
Oophorectomy
No 4,206 (62.69) 4,054 (96.39) 152 (3.61) Referent
Yes 2,503 (37.31) 2,392 (95.57) 111 (4.43) 1.24 (0.96–1.59) .094
Missing 283 (4.05)
Hernia repair
No 6,955 (99.47) 6,683 (96.09) 272 (3.91) Referent
Yes 37 (0.53) 34 (91.89) 3 (8.11) 2.16 (0.66–7.10) .201
Bowel surgery
No 6,987 (99.93) 6,715 (96.11) 272 (3.89) Referent
Yes 5 (0.07) 2 (40.00) 3 (60.00) 37.03 (6.16–222.53) ,.001
Intraoperative complications
No 6,808 (97.37) 6,572 (96.53) 236 (3.47) Referent
Yes 184 (2.63) 145 (78.80) 39 (21.20) 7.49 (5.14–10.92) ,.001
Bowel complications
No 6,950 (99.40) 6,686 (96.20) 264 (3.80) Referent
Yes 42 (0.60) 31 (73.81) 11 (26.19) 8.99 (4.47–18.07) ,.001
Bladder injury
No 6,941 (99.27) 6,678 (96.21) 263 (3.79) Referent
Yes 51 (0.73) 39 (76.47) 12 (23.53) 7.81 (4.04–15.10) ,.001
Ureteral injury
No 6,978 (99.80) 6,708 (96.13) 270 (3.87) Referent
Yes 14 (0.20) 9 (64.29) 5 (35.71) 13.80 (4.59–41.46) ,.001
Vascular injury
No 6,977 (99.79) 6,707 (96.13) 270 (3.87) Referent
Yes 15 (0.21) 10 (66.67) 5 (33.33) 12.42 (4.22–36.59) ,.001
Pathology
Benign 6,794 (97.20) 6,534 (96.17) 260 (3.83) Referent
Unexpected malignancy 196 (2.80) 181 (92.35) 15 (7.65) 2.08 (1.21–3.58) .008
Missing 2 (0.03)
Specimen weight (g)
Less than 250 5,697 (82.78) 5,535 (97.16) 162 (2.84) Referent
250–499 857 (12.45) 790 (92.18) 67 (7.82) 2.90 (2.16–3.89) ,.001
500–999 268 (3.89) 240 (89.55) 28 (10.45) 3.99 (2.62–6.08) ,.001
1,000 or greater 60 (0.87) 50 (83.33) 10 (16.67) 6.83 (3.40–13.72) ,.001
Missing 110 (1.57)
EBL (mL)
100 or less 4,842 (70.95) 4,800 (99.13) 42 (0.87) Referent
More than 100 to 300 1,479 (21.67) 1,376 (93.04) 103 (6.96) 8.55 (5.95–12.31) ,.001
More than 300 to 500 317 (4.64) 250 (78.86) 67 (21.14) 30.63 (20.40–45.97) ,.001
(continued )

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Table 3. Intraoperative Factors and Risk of Conversion of Laparoscopic Hysterectomy to Laparotomy
(continued )
Completed Conversion to
Total Laparoscopically Laparotomy Unadjusted OR
Characteristic (N56,992) (n56,717 [96.07]) (n5275 [3.93]) (95% CI) P

More than 500 to 1,000 147 (2.15) 99 (67.35) 48 (32.65) 55.41 (35.0–87.73) ,.001
Greater than 1,000 40 (0.59) 26 (65.00) 14 (35.00) 61.54 (30.04–126.08) ,.001
Missing 167 (2.39)
Operating room time (min)
120 or less 3,319 (47.48) 3,260 (98.22) 59 (1.78) Referent
More than 120 to 240 3,258 (46.61) 3,085 (94.69) 173 (5.31) 3.10 (2.30–4.18) ,.001
More than 240 to 360 359 (5.14) 325 (90.53) 34 (9.47) 5.78 (3.73–8.95) ,.001
More than 360 54 (0.77) 45 (83.33) 9 (16.67) 11.05 (5.17–23.64) ,.001
Missing 2 (0.03)
OR, odds ratio; CI, confidence interval; EBL, estimated blood loss.
Data are n (%) unless otherwise specified.

use of robotic surgery and surgical volume with a sig-
nificantly greater proportion of high-volume surgeons
using the robotic platform (72.02%) compared with the
low-volume surgeons (49.09%, P,.001). Given some
collinearity between the use of the robotic surgical
platform and high-volume surgeons, we then per-
formed a subanalysis of high-volume surgeons to
examine the effect of robotic use in high-volume sur-
geons. Even among high-volume surgeons, the odds of
conversion was lower with the robotic procedure
(7.54% compared with 1.46%, P,.001; adjusted OR
0.13, 95% CI 0.06–0.27), even when controlling for
other factors including uterine weight and adhesive
disease.
To further examine the relationship among high-
surgeon volume, use of robotic surgery, and the effect
on conversion, a secondary analysis was conducted
among ultrahigh-volume surgeons. We divided sur-
geon volume into those below the 75th percentile,
75th–89th percentile, 90th–94th percentile, 95th–98th
percentile, and 99th percentile or greater. The num-
ber of hysterectomies contributed to the sample in 24
months in each group was 1–23, 24–41, 42–60, 61–
127, and 128–258, respectively. After adjusting for
patient risk factors, surgical approach (robotic-assisted
laparoscopy compared with traditional laparoscopy),
surgeon volume categories, and significant interaction
between approach and volume, we calculated the
adjusted predicted risk of conversion with the robotic
surgical system compared with traditional laparos-
copy (Fig. 2). This demonstrated that there remained
a benefit of use of robotics even among ultrahigh-
volume surgeons.
Complications after conversion were examined
(Table 5), and those who had a conversion had
increased risk of incisional infections, postoperative
transfusion, postoperative severe sepsis (sepsis with
organ dysfunction), and need for reoperation within
30 days. There was no difference in rates of postop-
erative organ space surgical site infection, pulmo-
nary embolism or deep vein thrombosis, sepsis, or
readmission within 30 days. We found that intrao-
perative complications, which may have influenced
the decision to convert to laparotomy, occurred in
less than 20% of those who had a postoperative com-
plication. Therefore, the association between conver-
sion and postoperative complications was not
entirely related to the prior occurrence of an intra-
operative complication.
DISCUSSION
In this regional collaborative of 52 hospitals, there was
a sevenfold reduction in the odds of conversion to
laparotomy with use of robotic-assisted laparoscopy
compared with traditional laparoscopy. The avoid-
ance of conversion in our cohort of patients had
important clinical repercussions. Patients who had
conversion were more likely to experience surgical
site infection, blood transfusion, severe sepsis, and
reoperation even when no prior intraoperative com-
plication occurred. Similar results were seen in the
colorectal surgery literature with poorer outcomes in
morbidity, mortality, blood transfusion, and postop-
erative hospital stay.12,13
A wide range of conversion rates for hysterectomy
has been reported, ranging from 0% to 19%.3 The
2014 Cochrane Review, which pooled the outcomes
from four randomized controlled studies, did not find
a difference in conversion rates of robotic and tradi-
tional laparoscopies (3.55% compared with 2.98%).
That analysis involved 337 patients with 11 conver-
sions.15 This small sample size may have insufficient

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Table 4. Multivariable Logistic Regression of Risk Factors for Conversion of Laparoscopic Hysterectomy to
Laparotomy*

Characteristic Unadjusted OR (95% CI) P Adjusted OR (95% CI) P

Age (y)
40 or younger Referent Referent
Older than 40 and 60 or younger 1.80 (1.33–2.44) ,.001 1.55 (1.03–2.31) .034
Older than 60 1.41 (0.87–2.31) .165 1.83 (1.00–3.35) .050
Nonwhite vs white 1.85 (1.43–2.40) ,.001 1.07 (0.76–1.52) .694
Surgeon volume
Lower two tertiles Referent Referent
Top tertile 0.46 (0.36–.59) ,.001 0.66 (0.47–0.92) .015
Robotics vs traditional laparoscopy 0.18 (0.13–0.23) ,.001 0.14 (0.07–0.25) ,.001
BMI (kg/m2)
Less than 30 Referent Referent
30 or greater 1.86 (1.45–2.39) ,.001 1.62 (1.24–2.13) ,.001
Alternative treatment before hysterectomy vs none 0.71 (0.56–0.91) .006 0.63 (0.42–0.96) .031
Indications for hysterectomy
Pelvic inflammatory disease
No Referent Referent
Yes 5.28 (1.51–18.48) .009 3.53 (0.75–16.65) .110
Pelvic mass
No Referent Referent
Yes 1.58 (1.06–2.36) .026 1.64 (1.00–2.69) .050
Pelvic organ prolapse
No Referent Referent
Yes 0.35 (0.20–0.61) ,.001 0.40 (0.19–0.83) .015
Adhesions
None or mild Referent Referent
Moderate 2.42 (1.71–3.42) ,.001 2.49 (1.58–3.92) ,.001
Severe 7.52 (5.74–9.87) ,.001 8.07 (5.60–11.62) ,.001
Endometriosis of uterus, fallopian tubes, and ovaries vs none 1.61 (1.12–2.29) .009 1.32 (0.88–1.97) .174
Total vs supracervical hysterectomy 0.61 (0.46–0.82) .001 1.47 (0.92–2.31) .100
Cancer on final pathology vs none 2.08 (1.21–3.58) .008 1.47 (0.76–2.82) .255
Specimen weight (g)
Less than 250 Referent Referent
250–499 2.90 (2.16–3.89) ,.001 2.97 (2.12–4.16) ,.001
500–999 3.99 (2.62–6.08) ,.001 4.88 (2.78–8.58) ,.001
1,000 or greater 6.83 (3.40–13.72) ,.001 5.15 (2.15–12.36) ,.001
OR, odds ratio; CI, confidence interval; BMI, body mass index.
* All covariates listed were included in the multivariable model with accounting for clustering by site using robust standard errors.

power to detect a difference between the approaches.
Furthermore, this analysis only included surgeries per-
formed by 13 high-volume surgeons from four tertiary
care centers. In contrast, our analysis involved 6,992
hysterectomies from a sample of 638 surgeons at com-
munity and tertiary academic hospitals with bed size
ranging from less than 100 to greater than 1,000. The
larger, diverse sample size in our study may explain
why we found a difference where authors of the Co-
chrane Review did not. This lower conversion rate
using the robotic surgical system has also been seen
in other surgical specialties with decreased rates of
conversion using robotics for prostatectomy and sur-
gery for colorectal cancer.13,15–17 Consistent with prior
studies, surgeon volume was found to be associated
with lower odds of conversion,3,18,19 and increasing
BMI, adhesive disease, and increasing uterine weight
were all found to be associated with increased odds of
conversion.3,4,6,20
Strengths of this analysis are a large sample of
hysterectomies from a statewide database that in-
cludes all payer groups, academic, and community
hospitals. However, we do not know the indication
for conversion and cannot differentiate between
conversions as a result of an adverse, emergent event
and those without complication and related to
surgeon judgment.21 The indication for conversion
has been associated with different risks of complica-
tions and length of hospital stay.3 There is also an
inherent limitation of the sampling methodology,
which captures a random sample of patients at each
institution and not every patient for each surgeon.

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Fig. 2. Predicted risk of conversion to laparotomy of
robotic-assisted laparoscopy compared with traditional
laparoscopy across surgeon volume.
Lim. Laparoscopic Hysterectomy and Conversion. Obstet Gynecol
2016.
Although our surgeon volume variable likely reflects
the relative range of surgical experience, surgeon
skill and decision-making cannot be ascertained from
a surgical database, and this analysis is limited to the
available variables and cases included in the Michi-
gan Surgical Quality Collaborative database. We
were also unable to determine the patient distribu-
tion of surgical approach by any given surgeon. Also,
many complications are rare events after hysterec-
tomy and even larger samples may be necessary to
detect a difference in rare outcomes such as venous
thromboembolism. Lastly, the population and prac-
tice patterns in Michigan may not be applicable to
other geographic regions.
In summary, our study showed that more than
96% of all hysterectomies for benign indications
initiated laparoscopically are completed laparoscopi-
cally. Use of the robotic platform and higher surgeon
volume were both significantly and independently
associated with decreased odds of conversion. Fur-
thermore, conversion to laparotomy is associated with
increased risk of morbidity. Although previous stud-
ies22 including the Cochrane Review have demon-
strated no benefit and higher cost to robotic surgery
compared with traditional laparoscopy, many studies
were limited by smaller samples and single high-
volume institutions and prior cost data do not account
for the potential increased morbidity and cost associ-
ated with conversion.23 Indeed, this study demon-
strates a potential advantage of robotic surgery in
a generalizable population. Although the relationship
between the use of the robotic surgical platform and
surgeon volume is complex and interrelated, there
appears to be a sustained lower predicted risk of con-
version in robotic hysterectomy across surgeon vol-
umes, including high-volume surgeons. Future
research should further examine the association
among surgical volume, surgical approach, morbidity,
and cost associated with conversion to laparotomy.
Although the findings of this study suggest
a significant relationship among the robotic platform,
high-volume surgeons, and lower odds of conversion
to laparotomy, these results are not intended to define
medical policies or surgical privileging. Indeed, the
balance between high-quality surgical care and access
to quality care is complex. Our specialty needs to

Table 5. Thirty-Day Postoperative Outcomes After Conversion of Laparoscopic Hysterectomy to

Laparotomy

Total Completed Laparoscopically Conversion to Open

Outcome (N56,992) (n56,717 [96.07]) (n5275 [3.93]) P

Incisional surgical site infection 48 (0.69) 40 (0.60) 8 (2.91) ,.001

Deep or organ space surgical site 55 (0.79) 53 (0.79) 2 (0.73) 1.000*
infections
Postoperative transfusion 71 (1.02) 47 (0.70) 24 (8.73) ,.001
Postoperative pulmonary 8 (0.11) 8 (0.12) 0 (0) 1.000*
embolism
Postoperative deep vein 5 (0.07) 5 (0.07) 0 (0) 1.000*
thrombosis
Postoperative severe sepsis 5 (0.07) 3 (0.04) 2 (0.73) .014*
Postoperative readmission 209 (3.10) 193 (3.03) 13 (4.81) .098
Need for reoperation 117 (1.74) 107 (1.65) 10 (3.70) .012
Any complication 308 (4.41) 270 (4.02) 38 (13.82) ,.001
Data are n (%) unless otherwise specified.
* Calculated with Fisher exact test owing to low cell size.

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further address the effect of decreased surgical train-
ing, increased skill required to offer minimally inva-
sive options to patients with complex pelvic
pathology, and clinical practices with low surgical
volume on quality of care.
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