Tackling Uterine Artery at the Origin Is Safe and Effective for TLH

Value-based assessment of hysterectomy approaches

AIM

By evaluating operative outcomes relative to cost, we compared the value of minimally invasive hysterectomy approaches, including a technique discussed less often in the literature, laparoscopic retroperitoneal hysterectomy (LRH), which incorporates retroperitoneal dissection and ligation of the uterine arteries at their vascular origin.

METHODS

Retrospective chart review of all women (N = 2689) aged greater than or equal to 18 years who underwent hysterectomy for benign conditions from 2011 to 2013 at a high-volume hospital in Maryland, USA. Procedures included: laparoscopic supracervical hysterectomy, robotic-assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total vaginal hysterectomy (TVH), and LRH.

RESULTS

Total vaginal hysterectomy had the highest intraoperative complication rate (9.6%; P < 0.0001) but the lowest postoperative complication rate (1.8%; P < 0.0001). Robotics had the highest postoperative complication rate (11.4%; P < 0.0001). LRH had the shortest operative time (71.2 min; P < 0.0001) and the lowest intraoperative complication rates (2.1%; P < 0.0001). LRH and TVH were the least costly (averaging $4061 and $6416, respectively), while RALH was the most costly ($9354). Taking both operative outcomes and cost into account, LRH, TVH and laparoscopic-assisted vaginal hysterectomy yielded the highest value scores; total laparoscopic hysterectomy, RALH, and laparoscopic supracervical hysterectomy yielded the lowest.

CONCLUSION

Understanding the value of surgical interventions requires an evaluation of both operative outcomes and direct hospital costs. Using a quality-cost framework, the LRH approach as performed by high-volume laparoscopic specialists emerged as having the highest calculated value.

Laparoscopic Hysterectomy Outcomes: Hospital vs Ambulatory Surgery Center

BACKGROUND AND OBJECTIVE

Compare operative outcomes of laparoscopic hysterectomy in an outpatient hospital setting versus freestanding ambulatory surgery center.

METHODS

Retrospective cohort study of two groups in an outpatient hospital surgery department and freestanding ambulatory surgical center, both serving the Washington, DC area. Women, 18 years or older, who underwent laparoscopic hysterectomy for benign conditions in an outpatient hospital setting between 2011 and 2014 (n = 821), and at an ambulatory surgery center between 2013 and 2017 (n = 1210). Laparoscopic hysterectomy with retroperitoneal dissection and early ligation of the uterine arteries at the origin, performed by gynecologic surgical specialists from a single practice. Patient characteristics, medical history, uterine weight, pathology, operating times, estimated blood loss, and complications were analyzed.

RESULTS

The mean uterine size between settings was not significantly different (Ambulatory Surgery Center, 349.4 g; Hospital, 329.7 g). The largest uteri removed at the surgery center was 3500 g; at the hospital it was 2489 g. The surgery center had a shorter average operating time than the hospital (53.7 and 61.3 minutes, respectively; P < .001). Intraoperative and postoperative complication rates were not significantly different between settings (2.7% and 3.7%, surgery center; 2.1% and 4.8%, hospital). There were two hospital transfers from the surgery center: 1 for blood transfusion, and 1 for low oxygen saturation. Same-day discharge occurred in 99.8% of surgery center patients versus 88% hospital patients.

CONCLUSIONS

Laparoscopic hysterectomy can be performed safely and effectively by skilled surgeons at a freestanding ambulatory surgery center, even in complex cases with large uteri.