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Background: Unplanned return to the operating room has recently gained favor as a reliable indicator of surgery-specific complications. Despite this, reoperation rate has not been well studied as a primary outcome when comparing laparoscopic with open approaches for colorectal resection. The goal of this study was to determine the impact of a laparoscopic approach on rate of reoperation after elective segmental colectomy.
Methods: The NSQIP Participant Use Data File for 2005-2011 was used to retrospectively identify all patients who underwent either open or laparoscopic segmental colon resection for neoplasms, diverticular disease, and polyp disease. To capture only elective cases, the following were excluded: emergency cases, ASA class 5 (moribund patient who is not expected to survive without the operation), and preoperative sepsis. The primary outcome measure was rate of early return to the operating room, defined in NSQIP as returns to the operating room within the 30-day postoperative period. A multiple logistic regression model was constructed to determine the independent effect of surgical approach on rates of unplanned reoperation.
Results: Between 2005 and 2011, a total of 39,897 patients were identified who met the study inclusion criteria. Preoperative characteristics between open and laparoscopic groups were similar, despite being statistically significant due to very large sample sizes (Table 1). A total of 1,726 reoperations (4.3%) were identified. In the open approach group, 852 of 16,644 patients (5.1%) required reoperation, compared to 874 of 23,253 patients (3.8%) in the laparoscopic group. After adjusting for potential confounders, laparoscopic colorectal resection was found to have an adjusted odds ratio of 0.82 (95% CI 0.74 to 0.92, p = 0.001) as compared to the traditional open approach for risk of return to the operating room.
Discussion: Numerous studies have included reoperation rate as a univariate secondary endpoint when comparing laparoscopic versus open approach to colorectal procedures, with inconclusive results. Using a large administrative dataset, we found that for segmental colectomy, laparoscopic approach was associated with a small but statistically significant decrease in odds of return to the operating room. Reoperation is a relatively rare but costly complication after elective segmental colectomy, and remains a potential area for significant quality improvement.
Preoperative and intra-operative characteristics

Characteristic	Surgical Approach
	Open (n = 16,644)	Laparoscopic (n = 23,253)	p-value
Age (median) in years	67 (56,77)	65 (55,74)	<0.001
Female gender	8752 (52.7%)	12045 (52.0%)	0.181
Smoking status	2967 (17.8%)	3367 (14.5%)	<0.001
Preoperative dyspnea	2134 (12.8%)	2209 (9.5%)	<0.001
Do-not-resuscitate order	169 (1.1%)	79 (0.4%)	<0.001
Diabetes mellitus	2885 (17.3%)	3403 (14.6%)	<0.001
Chronic steroid use	509 (3.1%)	481 (2.1%)	<0.001
Non-independent functional status	996 (6.0%)	553 (2.4%)	<0.001
Alcohol > 2 drinks/day	569 (3.8%)	704 (3.5%)	0.17
History of COPD	1106 (6.6%)	1015 (4.4%)	<0.001
History of CAD	1865 (12.5%)	1953 (9.8%)	<0.001
History of CHF	199 (1.2%)	138 (0.6%)	<0.001
Dialysis-dependent preoperatively	122 (0.7%)	82 (0.4%)	<0.001
Disseminated malignancy	965 (5.8%)	450 (1.9%)	<0.001
>10% weight loss in last 6 months	1008 (6.1%)	545 (2.3%)	<0.001
Bleeding disorder	767 (4.6%)	622 (2.7%)	<0.001
Preoperative transfusion	240 (1.4%)	152 (0.7%)	<0.001
Chemotherapy in 30 days preop	155 (1.0%)	75 (0.4%)	<0.001
Radiation therapy in 90 days preop	51 (0.3%)	25 (0.1%)	<0.001
Preoperative ventilator dependence	11 (0.1%)	2 (<0.1%)	0.002
Resident participation in OR	8774 (60.3%)	11680 (60.1%)	0.71
Contaminated or dirty case	2715 (16.3%)	1884 (8.1%)	<0.001
ASA class 3 or greater	9117 (54.8%)	9395 (40.4%)	<0.001
Operative time (median)	131 (95,181)	141 (107,184)	<0.001

Multivariable logistic regression for postoperative outcomes following laparoscopic approach

Complication	Odds ratio	95% Confidence Interval		p-value
		Lower	Upper
Return to the operating room within 30 days	0.82	0.74	0.92	0.001
Superficial surgical site infection	0.64	0.59	0.70	<0.001
Deep incisional surgical site infection	0.50	0.40	0.63	<0.001
Organ space surgical site infection	0.76	0.66	0.88	<0.001
Post-operative sepsis	0.61	0.53	0.69	<0.001
All-cause 30-day mortality	0.58	0.47	0.73	<0.001

Adjusted for the following pre-operative variables: age, gender, smoking status, body mass index, alcohol use, functional independence level, do-not-resuscitate status, medical comorbidities (bleeding disorders, COPD, CAD, CHF, dyspnea, renal failure), case contamination, operative time, disseminated malignancy, pre-operative weight loss, chemotherapy, radiation therapy, ASA class 3 or greater, resident assistance in OR.