02: A county hospital experience with determining route of hysterectomy: can we safely increase the minimally invasive hysterectomy rate?

Abstract

The aim of this study is to review a county hospital’s practice pattern and compare the perioperative outcomes in patients who did or did not receive the recommended surgical route for hysterectomy (vaginal, laparoscopic or abdominal) using a recent evidence-based clinical decision tree algorithm to evaluate the surgical approach. (Figure 1). A retrospective case series was performed on women aged 18 or older who underwent a hysterectomy at a county hospital from January to December 2017. Exclusion criteria included malignancy, planned concomitant bowel or hernia surgery, or cesarean hysterectomy. Information collected included demographic information, risk factors for adhesive disease, estimated uterine size, adequate uterine descensus, operative route performed, and surgical complications such as blood loss, length of stay and readmission. An evidence-based algorithm was applied to the preoperative characteristics of our patients to assess whether we could have offered different route of hysterectomy. Patients were assigned to the appropriate match group when the recommended and the actual surgery did or did not match. STATA software was used for the statistical analysis. Chi-square, T test and ANOVA were used to calculate p values when appropriate. A total of 246 patients were included in the analysis, 89 (36%) had a total vaginal hysterectomy (TVH), 84 (34%) had a total laparoscopic hysterectomy (TLH) or laparoscopic assisted vaginal hysterectomy (LAVH), and 73 (30%) had a total abdominal hysterectomy (TAH). Conversion rate from laparoscopic to abdominal was 5%, mean uterine weight was 362 (SD=217) grams with most patients having severe adhesive disease. After applying the algorithm, 15% of patients recommended to have a TVH had a more invasive surgical route (p<0.0001) and 40% of patients recommended to have a TLH/LAVH had a different surgical route, half had a TVH and the other half underwent a TAH (p< 0.0001). Patients with pelvic pain, history of endometriosis, and larger estimated uterine size were more likely to match into the recommended surgery type (p<0.04). 100% of the patients underwent the recommended surgical type when the algorithm suggested the TAH approach. (Figure 2). After adjusting for actual surgery performed, we found no difference in length of stay, blood loss, transfusion, UTI, readmission to the hospital within 60 days, and presence of adhesive disease between the matching and the non-matching surgery group (Figure 3). Our hospital’s minimally invasive hysterectomy rate is 70%. Applying the algorithm may significantly increase this number to 83%. After adjusting for the surgery performed, perioperative morbidity was not different if the surgery did or did not match with the algorithm recommendation in our cohort.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)