Does conversion from a minimally invasive to open procedure hurt the patient, the surgeon’s ego, or the healthcare system?

Dr. Fourdrain and colleagues have presented an interesting article that attempts to answer if intraoperative conversion to thoracotomy from a video-assisted thoracoscopic approach is harmful to patients. It is an important question, and few if any articles have attempted to answer it. This question has clinical value as well—if intraoperative conversion is harmful and leads to poorer patient outcomes, if it adds operative time and expense, or if the surgeon skill set or patient anatomy indicates that intraoperative conversion is more than likely—should the surgeon just start off open?