Abstract
Background:
A laparoscopic approach to hysterectomy can significantly reduce patient morbidity and improve the quality of recovery. Subsequent perioperative advances have led to an increasingly shorter hospitalization period following laparoscopic surgery, with the same-day discharge being common. However, due to infrastructural challenges, these shorter times to discharge have mostly been limited to developed countries.
Objectives:
To provide a descriptive analysis and evaluate the safety and feasibility of day-case laparoscopic hysterectomy in Trinidad and Tobago.
Design:
A retrospective analysis of all total laparoscopic hysterectomies over a 3-year period at a secondary medical center in Trinidad and Tobago.
Methods:
The medical records of 154 women who underwent total laparoscopic hysterectomy (TLH) from January 2020 to January 2023 were reviewed. Patient demographics, indications for surgery, perioperative variables, requirements for any additional operative procedures, and perioperative complications were recorded and analyzed. The perioperative management protocol was also outlined.
Results:
The most common indication for TLH was uterine leiomyoma (45%), followed by endometrial cancer (17.5%). In this study, 96% of patients were discharged satisfactorily within 24 h of surgery, and the mean ± standard deviation (SD) duration of hospitalization was 21 ± 2 h. The mean ± SD surgical time was 91 ± 36 min, and the average estimated blood loss was 93 ± 31 ml. No patients required postoperative blood transfusion. No postoperative opioids were required in 41% of patients, and no perioperative mortality was recorded in this study, with no patients requiring re-operation. Four postoperative complications were noted (2.6%), and this included two patients who developed deep vein thrombosis (DVT) (1.3%), one port-site infection (0.6%), and one case of pulmonary embolism (0.6%). The 30-day readmission rate was 1.9%, and this comprised the patients with DVT and pulmonary embolism. On subgroup analysis, there was no difference in surgical time between patients with body mass index >30 kg/m2, uterine size >12 weeks, and previous abdominal surgery (p > 0.05).
Conclusion:
Day-case laparoscopic hysterectomy is feasible in a low-resource setting like Trinidad and Tobago. The procedure is safe and associated with a low postoperative complication rate.
Introduction
Advancements in minimally invasive surgical techniques have allowed hysterectomies to be performed laparoscopically with several well-established advantages. 1 Laparoscopy is the gold-standard approach to hysterectomy for many benign and malignant gynecological conditions. 1 Laparoscopic hysterectomy results in fewer medical and surgical complications, less intraoperative blood loss, fewer postoperative analgesic requirements, fewer infections, faster rates of recovery, lower patient and institutional costs, and better cosmetic outcomes. 2 The laparoscopic approach to hysterectomy has also been linked to a shorter duration of hospitalization, such that a hysterectomy may now be performed as a day-case procedure.
Day-case hysterectomies may result in considerable institutional and patient-related cost reductions and high patient satisfaction. 3 Laparoscopy and advances in surgical technology and training have enabled shorter lengths of stay after gynecological surgery, with up to 97% success rates of “outpatient” laparoscopic hysterectomies performed in the United States. 4 Proper candidate selection ensures a safe and practical approach to same-day discharge following a laparoscopic hysterectomy. In addition, the implementation of the Enhanced Recovery After Surgery (ERAS) protocols, modifying the intraoperative surgical steps, utilizing energy instruments and a low insufflation pressure, along with appropriate postoperative care and follow-up, facilitates the successful implementation of a day-case laparoscopic hysterectomy service. 5 These measures help reduce hospital costs by reducing the length of hospital stay and improving theatre efficiency and patient flow while maintaining high patient safety and satisfaction. 6
Several international retrospective and prospective analyses have determined that same-day discharge is a feasible and safe option for selected patients undergoing uncomplicated total laparoscopic hysterectomy (TLH). 7 However, in the Caribbean, a higher percentage of women have a larger uterine size due to uterine leiomyoma, which may constitute a relative contraindication to TLH. 8
This study aimed to determine the feasibility, practicality, and safety of TLH as a day-case procedure for benign and selected malignant gynecologic conditions in a low-resource setting. We retrospectively investigated the number of TLHs performed as day-case procedures, the frequency of perioperative complications, unexpected postoperative readmissions, and the determinants of positive procedural outcomes.
Methods
Study design
We performed a retrospective case series of TLHs conducted in a secondary hospital center from January 1, 2020 to January 1, 2023. All patients scheduled for TLH were considered for day surgery and had planned discharge within 24 h of the procedure. The analysis included 154 patients, representing the entire cohort available during the study period. Given the descriptive nature of this study, no formal sample size calculations or power analysis was conducted prior to data collection. This study was reported based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement guidelines. 9
Data collection
The medical records of all consecutive women scheduled for TLH between January 2020 and January 2023 were reviewed. We examined the patients’ demographics, including age, body mass index (BMI), comorbidities, and American Society of Anesthesiologists (ASA) score. The patient’s indication for surgery and the need for additional procedures apart from a total hysterectomy, such as bilateral salpingo-oophorectomy, pelvic lymph node dissection, or omentectomy, were recorded. In addition, the uterine size, duration of operation, intraoperative pressure utilized, estimated blood loss, and duration of hospital stay were recorded. The duration of the operation was defined as the period from skin incision to complete closure, disregarding the room, and anesthesia time. Blood loss was estimated by the contents within the suction container with irrigation fluid subtracted. Unplanned admissions, clinic and emergency department visits, and complications within the first 3 months of surgery were also recorded. Two authors of this study collected the data from the medical records. The data from medical records were collected and anonymized, with each patient given a unique identifying registration number and stored in a password-protected Microsoft Excel file.
Statistical analysis
The statistical analyses were conducted with Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA). A value of p < 0.05 was considered significant. Categorical data were displayed as percentages and continuous data as mean ± standard deviation (SD). Subgroup analysis was performed using an independent two-sample t-test to compare mean surgical times between groups.
Surgical management
All total laparoscopic hysterectomies were performed under general anesthesia utilizing a standard three-port laparoscopic technique by the same surgeon with more than 7 years of experience in this field.
Patients were positioned on the operating table in the dorsal lithotomy with the lower limbs secured in booted stirrups. Patients were then cleaned and draped by aseptic techniques, catheterized, and a uterine manipulator (VCare® Manipulator) was inserted vaginally to aid with uterine exposition and mobilization. Abdominal entry was achieved using a 5-mm optical trocar placed at the umbilicus with the patient in a horizontal position. Once entry was confirmed, pneumoperitoneum was established utilizing carbon dioxide gas with an initial insufflation pressure of 15 mmHg, and the position changed to a Trendelenburg at a 20-degree tilt. Two accessory laparoscopic ports were placed to the left of the midline, lateral to the inferior epigastric vessels.
A zero-degree laparoscope was used in all cases along with the LigaSure™ (Medtronic, Dublin, Ireland). No single-port or robotic-assisted surgical equipment was utilized. Following port placement, the insufflation pressure was reduced to 8 mmHg, and a standard procedure for TLH was followed. The colpotomy was performed utilizing the J-shaped monopolar hook. All surgical specimens, including the uterus, cervix, Fallopian tubes, and in some cases, the ovaries and pelvic lymph nodes, were extracted vaginally without the conversion to laparotomy or mini-laparotomy incision. Larger uterine specimens were reduced in size (in an endoscopic bag where indicated) with sharp dissection in the vagina to facilitate extraction. The vaginal vault was closed with a delayed-absorbable barbed suture (V-loc™), and hemostasis was ensured. The pneumoperitoneum was evacuated, and the skin incisions were closed with either 2-0 polyglactin 910 suture or topical skin adhesive. Lastly, each surgical incision sites were infiltrated with 1–2 ml of 2% lidocaine.
Anesthetic management
All patients were managed by the same anesthesiologist. Patients were screened beforehand via a telephone conversation and optimized as necessary. Clear fluids were encouraged up to 2 h before surgery, wherever possible. Intraoperatively, all patients received intravenous propofol, remifentanil target-controlled infusion (TCI) 1–2 ng/ml, and cisatracurium to facilitate induction and intubation. Maintenance anesthesia was provided by sevoflurane in oxygen and air, along with remifentanil TCI. Deep paralysis was provided intraoperatively using cisatracurium boluses facilitated by continuous train-of-four (TOF) monitoring of the patient’s thumb, Stimpod NMS 450X™.
Patients were ventilated to a target ETCO2 of 35 mmHg, with a peak airway pressure of ⩽35 cmH2O, using pressure or volume-controlled ventilation via a Mindray A5 anesthesia machine ventilator. Intravenous paracetamol, parecoxib, 5-HT3 antagonist, and dexamethasone were administered to patients once not contraindicated.
After surgery, patients were returned to the supine position and transitioned to pressure support ventilation (5–15 cmH2O) to avoid lung de-recruitment. After surgery, TOF monitoring was continued, and patients were left on the ventilator and remifentanil infusion until the TOF ratio recovered to 0.9, after which they were extubated. Intravenous long-acting opioids, 5–10 mg morphine or meperidine 20 mg, were administered either immediately prior to or following extubation. Intravenous opioid titration was continued in the immediate postoperative period until adequate analgesia was achieved (Numeric Rating Scale 4/10).
Postoperative management
Postoperatively, patients were managed on the standard postoperative surgical ward and were kept nil per oral until they fully recovered from anesthesia. Patients underwent a trial of oral liquids until they felt comfortable enough to graduate to a soft diet. Intravenous fluids were continued for approximately 6–8 h, and the Foley catheter was discontinued once patients could ambulate comfortably and urine output was >0.5 ml/kg/h. Postoperative analgesics included acetaminophen administered intravenously or orally every 6 h, a non-steroidal anti-inflammatory drug such as Parecoxib 40 mg IV every 12 h or diclofenac 75 mg IM every 8 h. Opioid analgesics were prescribed on an as-needed basis for additional analgesia if required. Early ambulation and oral hydration were encouraged after surgery. Patients had to meet the following criteria to be eligible for discharge: a minimum postoperative observation of 6–8 h, stable vital signs, well-controlled underlying medical conditions, adequate pain control, tolerating oral liquids without vomiting, no significant nausea, ambulating without support, voiding urine spontaneously after removal of the urinary catheter, and a soft abdomen with a clean and dry wound. Low-molecular-weight heparin was administered 6–8 h after surgery in cases with no contraindications.
Discharge medications included a 7-day supply of a non-steroidal anti-inflammatory drug such as diclofenac, ibuprofen, or etoricoxib, a tramadol hydrochloride/acetaminophen combination, dimenhydrinate or metoclopramide, and antibiotics such as cefuroxime, as per local hospital guidelines. A discharge summary was provided with an information leaflet, emergency contact numbers, and a 10-day follow-up appointment. On the second to fifth postoperative day, each patient was contacted by telephone, and a postoperative interview was conducted.
Ethics approval
This was a retrospective study using a patient dataset that was anonymized using unique patient identifier numbers. The University of the West Indies research ethics committee, St. Augustine approved the study protocol (CREC-SA.1129/08/2021). Due to the study’s retrospective nature, the Ethics Committee waived written informed consent.
Results
A total of 154 patients presenting for laparoscopic hysterectomy were sequentially analyzed. This represented the complete dataset, as no patients were excluded. TLH and BSO were the most common procedure performed in this patient cohort (80%, 124 patients). TLH/BSO/PLND was performed in 17% and TLH alone in 2.6%. The most common indication was uterine leiomyoma (45%), followed by endometrial cancer (17.5%).
Surgery was performed in a wide variety of age groups, with patients more than 60 years old comprising 36% of the cohort. The oldest patient operated on was 81 years old. Obesity was common, with more than 25% of patients having a BMI of more than 30 kg/m2. Four patients with a BMI greater than 40 kg/m2 successfully underwent laparoscopic surgery, with the highest BMI of 51 kg/m2.
Most patients had an ASA score of 2, with 13 patients classified as ASA 3. Previous abdominal surgery was common and found in more than 20% of the cohort, with 69% of patients having an enlarged uterus of >10 weeks in size. Patient characteristics are shown in Table 1.
Patient characteristics and outcomes.
DVT: deep vein thrombosis; TLH: total laparoscopic hysterectomy; ASA: American Society of Anesthesiologists; BMI: body mass index.
The mean surgical time was 91 ± 36 min, with an average estimated blood loss of 93 ± 31 ml. No patients required a postoperative blood transfusion or had an estimated blood loss of >500 ml. Surgical characteristics are shown in Table 2.
Surgical characteristics and outcomes.
SD: standard deviation.
No perioperative mortality was recorded in this patient cohort, and no patient required re-operation. Four postoperative complications were noted (2.6%). These are shown in Table 1 and include two deep vein thrombosis (DVT), one port site infection, and one case of pulmonary embolism. The 30-day readmission rate was 1.9% and comprised the patients with DVT and pulmonary embolism.
The mean hospital stay was 21 h, with 59% of patients requiring only one dose of postoperative opioids (Tables 1 and 2). Discharge within 24 h was achieved in 96% of patients. On subgroup analysis, neither BMI, uterine size, nor previous abdominal surgery was associated with a statistically significant increase in surgical time (p > 0.05) (Table 3).
Showing subgroup analysis of patient factors and its effect on surgical time.
SD: standard deviation; BMI: body mass index.
Discussion
Minimal access surgery (MAS) has gained increasing traction in the field of gynecology. Compared to abdominal hysterectomy, minimally invasive hysterectomy is associated with less bleeding, fewer perioperative complications, shorter duration of hospitalization, and faster recovery. 1 Several studies report comparable early surgical outcomes between laparoscopic and robotic hysterectomy, although the costs and learning curve associated with the latter are significantly higher. 2 MAS is the gold-standard approach to hysterectomy for most benign and malignant gynecological conditions. 10 Currently, most patients undergoing TLH are discharged approximately 1–2 days after surgery. 11 However, day-case TLH has also been described with good patient outcomes in North American countries. 11 Introducing a day-case TLH service reduces patient and institutional costs, improves patient flow and satisfaction, and improves theatre efficiency while maintaining patient safety.
Most patients (96%) were discharged within 24 h of surgery. Six patients were unable to be discharged due to protracted postoperative nausea and vomiting despite routine antiemetic use. This is similar to the results of Byford et al. in a retrospective audit of implementing a day-case TLH service, where they achieved a 94.8% same-day discharge rate. 7 Byford et al. reported a mean postoperative stay of 7.72 (SD ±3.36) hours with no differences in readmission or complication rates. 7
Uterine size is considered a relative contraindication to TLH. 12 In the Caribbean, there is a higher incidence of uterine leiomyomas and, therefore, larger uterine sizes. 8 Likewise, in our cohort, approximately 70% of patients had a uterine size greater than 10 weeks, with an 18-week uterus being the largest recorded. Although many patients with uterine leiomyomas were included in this study, we did not record the time taken for specimen removal in the vagina. Future studies can consider looking at this variable in TLHs. Obesity, another challenge during laparoscopic surgery, was common in our cohort, with a maximum BMI of 51 kg/m2 being successfully operated on. Previous abdominal surgery, while traditionally seen as a relative contraindication to laparoscopic surgery, was present in 25% of patients. A subgroup analysis was conducted on patient data to determine the impact of uterine size, BMI and previous abdominal surgery on operative time. In this cohort, none of these factors significantly affected operative time (p > 0.05). These findings are similar to a retrospective study by O’Hanlan et al., who reported no significant difference in uterine weight in the median surgical duration or hospital stay. 13
A prospective observational study by Choi et al., investigating postoperative pain characteristics in the first 72 h following TLH, showed that incisional and visceral pain was most intense 30 min after surgery and gradually decreased thereafter. 14 This type of pain can usually be effectively managed with multi-modal non-opioid analgesics such as paracetamol, non-steroidal anti-inflammatory drugs, and selective cyclooxygenase-2 inhibitors like parecoxib. 14 Based on the work of Choi et al., our study protocol used a multi-modal approach to pain relief, including pharmacological interventions and modifications to intra-operative techniques, which reduced the need for postoperative opioids. As shown in our cohort, TLH using multimodal analgesia leads to a low postoperative opioid requirement.
In the United Kingdom, the average reported emergency readmission rate within 30 days following laparoscopic hysterectomy is 4.9%. 15 This figure is comparable to our cohort, which showed a 30-day readmission rate of 1.9%, mainly for lower limb DVT and one case of pulmonary embolism. In a large retrospective analysis of 3351 patients, Kaya reported a low incidence of postoperative complications (6.5%) with a 0.1% risk of port-site infection and a 0.4% risk of venous thromboembolism following TLH. 16 Similarly, our study showed a relatively low complication rate of 2.6%, and no patient required conversion to laparotomy. As per our hospital protocol, low-molecular-weight heparin was given as a stat dose on the night of surgery, provided there were no contraindications. No follow-up doses were used. Given that the primary cause of morbidity in our patient cohort is DVT/pulmonary embolism, consideration can be given to the routine use of LMWH in all cases of TLH. This may, however, be challenging in low-resource settings. Moreover, on further review of the study protocol, given the low incidence of postoperative infections, oral antibiotics on discharge can be withheld and only prescribed in select cases.
Patient selection is crucial to identify individuals suitable for day-case TLH. 17 Factors such as medical comorbidities, social support, and surgical complexity must be considered and optimized preoperatively. 3 Implementing the ERAS program represented a paradigm shift in the perioperative management of patients undergoing gynecological surgery. The program is based on perioperative medical optimization, including preoperative counselling, pain relief, carbohydrate loading, thromboembolic prophylaxis, a standard anesthetic protocol, intraoperative fluid management, early recovery of gastrointestinal function, and early mobilization. 18 The ERAS program’s main aim is to accelerate functional recovery to improve postoperative outcomes, reduce overall healthcare costs, reduce the duration of hospital stay, and improve patient satisfaction. 18 ERAS provides a structural framework for the safe implementation of day-case TLH, ensuring that patients meet specific criteria and receive appropriate preoperative education and postoperative monitoring. 18 In our study, we implemented several ERAS principles in our perioperative care, beginning with proper patient education during the initial visit.
Several perioperative modifications can also be implemented to expedite postoperative recovery and facilitate early discharge following TLH. These modifications include, but are not limited to, refined surgical techniques, the utilization of a uterine manipulator, advanced hemostatic devices, and optimal pain management strategies.18,19 The utilization of advanced energy devices promotes enhanced vessel sealing capabilities and enhances safe dissection with minimal risk to surrounding structures. Furthermore, optimizing intraoperative pressure to maintain the pneumoperitoneum between 8 and 10 mmHg reduces the adverse effects on cardiovascular and respiratory function, facilitating the liberal use of Trendelenburg positioning to enhance surgical exposure and shorten surgical time. 20 Individual patient factors, surgical complexity, and procedure duration must be carefully considered when implementing these strategies to ensure optimal outcomes.
Laparoscopic hysterectomy also requires deep neuromuscular blockade to facilitate surgical exposure. 21 This may lead to residual neuromuscular blockade at the end of the procedure, which can be significant and lead to patient morbidity and delayed recovery. Strategies to manage this include quantitative neuromuscular monitoring, appropriate timing and reversal of neuromuscular blocking agents, and a rocuronium/sugammadex combination. 22
Despite its many advantages, laparoscopic gynecological surgery is also associated with significant physiological challenges. These challenges must be navigated to facilitate successful day-case surgery. Key physiologic challenges imposed are primarily due to the use of steep Trendelenburg position and the effect of the pneumoperitoneum. 23 Modern ventilatory strategies can often mitigate the respiratory impact of these combined insults. These include pressure-controlled ventilation, inverse ratio ventilation, recruitment maneuvers and optimal positive end-expiratory pressure. 24 Optimized intraoperative ventilation strategies that target lower-end tidal carbon dioxide have also been shown to reduce postoperative nausea, vomiting, and headaches secondary to raised intracranial pressure, which also aids in facilitating rapid discharge. 25
In the context of day-case TLH, several factors must align to facilitate safe and successful early discharge from the hospital. Early removal of the urinary catheter within 4–6 h of surgery, offering patients regular non-opioid analgesia, encouraging early ambulation, the prescription of anti-emetic medications and early advancement of diet is crucial to achieving safe and early discharge. 26 A recent randomized controlled trial showed that voiding within 6 h of surgery was associated with successful same-day discharge. 26 Several studies have shown the most common reasons for prolonged hospitalization were pain, nausea and vomiting, and urinary retention. 30 Teleconsultations in the early postoperative care following day-case TLH enhance patient care by facilitating remote monitoring, reducing hospital visits, providing timely follow-up and improving overall communication and patient education. 27 This approach aligns with the evolving landscape of healthcare delivery, which emphasizes integrating technology and close outpatient follow-up to optimize patient outcomes and decrease readmission rates. 28
According to the British Association of Day Surgery, day surgery should be considered wherever possible, particularly in the post-pandemic period, to meet demands for elective gynecological surgery. 26 As demonstrated in multiple studies and our cohort, TLH can be successfully offered with discharge within 24 h, even in a low-resource setting such as ours. This promotes patient-centered care by allowing women to recover in the comfort of their homes, potentially reducing the psychological impact of hospitalization and enhancing overall satisfaction. 4 Furthermore, it releases valuable bed stock and reduces the burden of highly skilled staff during out-of-hours. 29 This can prove especially beneficial in low-resource settings, with multimodal effects in healthcare, including decreased hospital costs by reducing the length of stay and overnight admissions, improved theatre efficiency and patient flow, and increased patient satisfaction while maintaining patient safety. 30 Given the feasibility of day-case TLH, consideration can be extended to same-day discharge in selected patient groups.
Limitations of study
This study was conducted by a single surgeon, thereby minimizing variability in surgical proficiency that could influence outcomes. However, this approach inherently limits the generalizability of the findings, as surgical skills and techniques may differ across practitioners. Similarly, the exclusive use of resources and equipment from a single site reduces variability in procedural execution but constrains broader applicability due to potential disparities in resource availability across other settings.
Moreover, the retrospective nature of this study introduces inherent limitations, including selection bias; patients deemed unfit for the procedure were excluded, potentially skewing the results. Additionally, this study design is restricted to identifying associations and makes it difficult of casual relationships between variables.
Conclusion
In conclusion, day-case TLH is a safe, practical, and feasible option for carefully selected patients requiring hysterectomy for a broad range of benign and malignant gynecological conditions. This review demonstrated the feasibility of having a laparoscopic hysterectomy with less than a 24-h hospital stay in a low-resource setting. In our population, with a high incidence of uterine leiomyomas, TLH was performed in a variety of patients with uterine sizes up to 18 weeks, increased BMI and previous abdominal surgery with minimal morbidity.
Footnotes
Ethics approval
The Ethics Review Committee of the University of the West Indies, St. Augustine Campus approved the study protocol (CREC-SA.1129/08/2021). Due to the study’s retrospective nature, the Ethics Committee waived written informed consent.
Consent to participate
The Ethics Review Committee waived the need for written informed consent.
Author contributions
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The datasets generated during and/or analyzed during the current study are not publicly available due to institutional restrictions but are available from the corresponding author upon reasonable request.