Characteristics of Open and Conversion to Open Operations in a Minimally Invasive Era: Implications for the Physician Fee Schedule

BACKGROUND: Current procedural terminology (CPT) valuation historically treated open and minimally invasive (MIS) abdominopelvic operations as interchangeable services performed on similar patients. As MIS has become the dominant approach, open surgery may now represent a distinct and more complex clinical scenario. This study characterized contemporary open operation for common abdominopelvic procedures.

STUDY DESIGN: The 2023 American College of Surgeons National Surgical Quality Improvement Program database was analyzed for appendectomy, cholecystectomy, right colectomy, low anterior resection, and Hartmann's procedure. Cases were categorized as MIS, straight-to-open, or conversion-to-open. Patient characteristics, operative time, length of stay, and 30-day complications were compared across approaches using binomial regression models.

RESULTS: Among 105,085 operations, MIS predominated for appendectomy (98%), cholecystectomy (98%), low anterior resection (84%), and right colectomy (72%), whereas Hartmann's procedures were primarily open (77%). Conversions represented approximately half of open appendectomies and cholecystectomies and had the longest operative times, exceeding MIS operations by 147% for appendectomy and 116% for cholecystectomy. Compared with MIS, straight-to-open appendectomy was associated with increased length of stay (IRR 2.92) and higher complication odds (OR 4.02), with conversion-to-open appendectomy showing further stepwise increases (IRR 4.85; OR 7.07). Similar stepwise patterns from MIS to straight-to-open to conversion-to-open were observed across procedures.

CONCLUSIONS: In contemporary practice, open abdominopelvic operations are uncommon and frequently represent conversion from MIS, identifying a subgroup with longer operations, longer hospitalization, and higher complication rates. Current CPT coding and work relative value units may not reflect the greater clinical complexity and effort associated with these cases, supporting reconsideration of open procedure valuation.