78: Perioperative outcomes of hysterectomy at a large academic center and elaboration of a clinical decision tree algorithm

Abstract

To evaluate differences in perioperative outcomes between minimally invasive surgery and abdominal surgery within a large metropolitan academic center and develop an effective algorithm for safe prevention of abdominal hysterectomy based upon our findings. We completed a retrospective chart review of patients who had undergone abdominal, laparoscopic, or vaginal hysterectomies at two different hospitals at our academic medical center between 1/1/2015 and 12/31/2016. Statistical analysis was performed using SPSS 22. Categorical data was analyzed with Chi-square and Fisher’s exact, logistic regression was used to calculate adjusted p-values. T-test and ANOVA were used to obtain p-values for continuous data, and general linear model was used for the adjusted p-values. Six hundred seven charts were reviewed. Surgeries performed for pelvic organ prolapse and robotic hysterectomies were excluded. Four hundred thirteen patients were included in our analysis. Sixty-six percent (n = 273) of the hysterectomies were performed abdominally, 31% (n = 129) were performed laparoscopically and 3% (n = 11) vaginally. The proportion of abdominal hysterectomies (AH) performed at our system’s county hospital and at the university’s private hospital were 70% and 48%, respectively. There was a higher proportion of African Americans who had abdominal hysterectomies (p < 0.05). There was no significant difference (p = 0.316) in the BMI of patients who had AH compared to laparoscopic hysterectomy (LH), but the BMI of patients undergoing vaginal hysterectomy (VH) was significantly lower (p = 0.03) than the other 2 groups. Interestingly, there was no significant difference in the number of comorbidities (p = 0.063) or previous abdominal surgeries (p = 0.846) between the groups. As expected, LH had the least blood loss (mean of 144 ml, p < 0.001). Blood transfusion rates were also significantly lower(p = 0.035) in the laparoscopic than in the AH group. There were no differences in rates of intraoperative consultation, intraoperative complications, post-operative ileus, wound infection, reoperation or readmission rates. Length of stay was significantly less (p < 0.001) with laparoscopic cases with a mean stay of 1.36 days compared to 2.88 days in the AH group. The rate of conversion to laparotomy was 12% (n = 15). The mean uterine size in the conversion to laparotomy group was 13 weeks (SD = 6.3), the mean BMI 30 kg/m2 (SD = 7.4) and most of the patients had at least 1 previous abdominal surgery. The majority of hysterectomies performed at our academic center were AH. Patients who were African-American were more likely to undergo an AH. The vast majority of patients had an open hysterectomy if uterine weight was >500 g. As expected, laparoscopic cases had less blood loss, lower transfusion rates, and shorter length of stay when compared to open and vaginal cases. It is our belief that a good amount of AH could have been avoided. Using criteria gleaned from the patients converted to laparotomy, we created an algorithm (Figure 1) to select the most appropriate type of hysterectomy. This is intended for cases of benign disease with the intent of minimizing the amount of abdominal hysterectomies performed.