Increasing the Rate of Laparoscopic Hysterectomy Safely for Benign Gynecologic Disease

Abstract

Objective:

Complication rates during laparoscopic hysterectomy performed at high-volume surgical centers have not been reviewed recently; rather, reliance is placed on older data when counseling patients. This study reviewed patient demographics and surgical complications occurring during laparoscopic hysterectomy for benign gynecologic disease at a major academic teaching institution. The relationship between surgeon experience and perioperative outcomes were also assessed.

Materials and Methods:

This was a retrospective chart review of consecutive women who underwent hysterectomy for benign gynecologic disease from September 2014 to August 2016. Clinical, demographic, and surgical characteristics were ascertained. Complications and readmission rates were assessed. Primary outcomes were surgical complications, estimated blood loss (EBL), operative times, and blood transfusions. The patients were treated at a single, high-volume tertiary-care teaching hospital. They were divided into 5 groups. In groups 1–4, surgeries were performed by 4 individual experts. Group 5 had surgeries performed by minimally invasive gynecologic-surgery fellows. Numeric data were expressed as medians and ranges, unless stated otherwise. Statistical analyses were performed with SPSS version 21.0 for Windows.

Results:

A total of 1095 hysterectomies were included: 1040 (94.98%) were performed laparoscopically; 33 (3.01%) were performed via laparotomy; and 22 (2.01%) via vaginal procedures. Median operative time was 117 minutes (range: 23–499 minutes). Median EBL was 100 mL (range: 10–1000 mL). Only 1 surgery was converted to laparotomy (0.10%). Intraoperative injuries occurred 6 times—3 ureteral (0.29%), 2 bladder (0.19%), and 1 bowel (0.10%). All injuries were noted during the procedures with intraoperative repair performed in each case and subsequent postoperative complications avoided. Blood transfusions were required in 4 patients (0.38%). No ureteral and vesical fistulae occurred. Laparoscopic hysterectomy rates of 100% without conversions were achieved by Surgeons #1 and #3. Compared to other groups, Surgeons #1 and #2 had lower EBLs and shorter mean surgical times. Surgeon #1 had more frequent pelvic adhesions than other groups. Surgeon #4 had the largest uterine weights, while fellows operated on uteri weighing >500 g or >1000 g less frequently. Rates of bowel occlusions were higher for Surgeon #4 and the fellows. Fellows had more-frequent skin infections. Other postoperative complications and readmission rates were similar among the groups.

Conclusions:

Laparoscopic hysterectomy is a safe, feasible option for benign gynecologic surgery. This procedure is safe even during the initial learning-curves of fellows with low and reasonable complication rates, but with longer associated operative times. An increase in experience is associated with a higher rate of laparoscopic hysterectomies, shorter operating times, less blood loss, and a low incidence of complications.