Case-Mix Variables and Predictors for Outcomes of Laparoscopic Hysterectomy: A Systematic Review

Driessen, Sara R. C.; Sandberg, Evelien M.; Chapelle, Claire F. la; Twijnstra, Andries R. H.; Rhemrev, Johann; Jansen, Frank Willem

doi:10.1016/j.jmig.2015.11.008

Cited by 31 publications

(31 citation statements)

References 92 publications

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“…In considering studies on laparoscopic hysterectomy for large uteri reporting that increased uterine size is associated with an increase of procedure time [4, 7, 8], our case had an acceptable operative time. Noteworthy, in the present case the timing spent for the hysterectomy was limited, whilst the greatest time was dedicated to the extraction of the huge uterus that required also a lot of attention in performing morcellation, avoiding spillage; then, it was the extraction that influenced significantly the time of the entire operation.…”

Section: Discussionmentioning

confidence: 89%

Laparoscopic removal of a very large uterus weighting 5320 g is feasible and safe: a case report

et al. 2017

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BackgroundTotal laparoscopic hysterectomy (TLH) has demonstrated to be feasible and safe in the presence of very large uteri. However, it is currently difficult to establish the upper uterine weight limit for successful performance of a laparoscopic hysterectomy.Case presentationHere we report the case of a TLH performed for a very large fibromatous uteri weighing 5320 g in a 40-year-old Caucasian woman. The surgery had no complications with an operating time of approximately 220 min. The patient was discharged from the hospital on postoperative day 3 in very good condition. To our knowledge, the present paper is the only to describe a uterus of this size removed by laparoscopic hysterectomy.ConclusionsOur case demonstrates that uterine size is not a determinant for a final surgical decision to use laparoscopic hysterectomy. Therefore, if not contraindicated by the patient’s comorbidities or peculiar anatomical conditions, we believe that laparoscopic hysterectomy could be performed in the presence of large uteri without hypothetical weight limits.

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Section: Discussionmentioning

confidence: 89%

Laparoscopic removal of a very large uterus weighting 5320 g is feasible and safe: a case report

et al. 2017

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“…One possible explanation for the longer learning curve found in this study is that a more experienced surgeon may take on more complex procedures, which can consequently cause more complications and less optimal outcomes [4]. The outcomes in this study were corrected for case-mix characteristics such as uterine weight, BMI and previous abdominal surgery, although there may be unknown variables for which no correction was applied such as severe endometriosis, age and other comorbidities [3]. Hence, our data suggest that experience alone is not sufficient to assure the quality of surgical care; individual skills may provide more information about the actual quality of individual surgical performance.…”

Section: Discussionmentioning

confidence: 99%

“…One of the main problems of this widely released data is the lack of an accurate case-mix correction (patient characteristics that could influence outcomes). As referral hospitals perform more complex procedures and treat more challenging patients, this can potentially result in less optimal surgical outcomes [3]. This case-mix correction may be appropriate when analyzing data on a surgeon level as well, and has been recommended for parameters including uterine weight and BMI regarding laparoscopic hysterectomy (LH) [3].…”

Section: Introductionmentioning

confidence: 99%

“…As referral hospitals perform more complex procedures and treat more challenging patients, this can potentially result in less optimal surgical outcomes [3]. This case-mix correction may be appropriate when analyzing data on a surgeon level as well, and has been recommended for parameters including uterine weight and BMI regarding laparoscopic hysterectomy (LH) [3]. In addition, many of the quality assessment registries focus only solely on hospital outcome measures, merging all individual surgeon outcomes.…”

Section: Introductionmentioning

confidence: 99%

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Hospital versus individual surgeon’s performance in laparoscopic hysterectomy

Driessen

Wallwiener

Taran

et al. 2016

Arch Gynecol Obstet

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PurposeTo compare hospital versus individual surgeon’s perioperative outcomes for laparoscopic hysterectomy (LH), and to assess the relationship between surgeon experience and perioperative outcomes.MethodsA retrospective analysis of all prospective collected LHs performed from 2003 to 2010 at one medical center was performed. Perioperative outcomes (operative time, blood loss, complication rate) were assessed on both a hospital level and surgeon level using Cumulative Observed minus Expected performance graphs.ResultsA total of 1618 LHs were performed, 16 % total laparoscopic hysterectomies and 84 % laparoscopic supracervical hysterectomies. Overall outcomes included mean (SD±) blood loss 108.9 ± 69.2 mL, mean operative time 95.4 ± 39.7 min and a complication occurred in 76 (4.7 %) of cases. Suboptimal perioperative outcomes of an individual surgeon were not always detected on a hospital level. However, collective suboptimal outcomes were faster detected on a hospital level compared to individual surgeon’s level. Evidence of a learning curve is seen; for the first 100 procedures, a decrease in operative time is observed as individual surgeon experience increases. Similarly, the risk of conversion decreases up to the first 50 procedures.ConclusionAn individual outlier (i.e., surgeon with consistently suboptimal performance) will not always be detected when monitoring outcome measures only on a hospital level. However, monitoring outcome measures on a hospital level will detect suboptimal performance earlier compared to monitoring only on an individual surgeon’s level. To detect performance outliers timely, insight into an individual surgeon’s outcome and skills is recommended. Furthermore, an experienced surgeon is no guarantee for acceptable surgical outcomes.

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“…We consider patient-related risk factors of a different nature compared to the other registered risk factors, for example as doctors cannot influence comorbidity of a patient (e.g., extent of adhesions and obesity) [13]; however, we do have a responsibility for technological issues or surgical team-related problems, and these are therefore important targets for future improvements regarding patient safety.…”

Section: Discussionmentioning

confidence: 99%

Identification of risk factors in minimally invasive surgery: a prospective multicenter study

et al. 2016

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BackgroundSince the introduction of minimally invasive surgery (MIS), concerns for patient safety are more often brought to the attention. Knowledge about and awareness of patient safety risk factors are crucial in order to improve and enhance the surgical team, the environment, and finally surgical performance. The aim of this study was to identify and quantify patient safety risk factors in laparoscopic hysterectomy and to determine their influence on surgical outcomes.MethodsA prospective multicenter study was conducted from April 2014 to January 2016, participating gynecologists registered their performed laparoscopic hysterectomies (LHs). If deemed necessary, gynecologists could fill out a checklist with validated patient safety risk factors. Association between procedures with and without an occurred risk factor(s) and the surgical outcomes (blood loss, operative time, and complications) were assessed, using multivariate logistic regression and generalized estimation equations.ResultsEighty-five gynecologists participated in the study, registering a total of 2237 LHs. For 627(28 %) procedures, the checklist was entered (in total 920 items). The most reported risk factors were related to the surgeon (19.6 %), the surgical team (14.4 %), technology (16.6 %), and the patient (26.8 %). The procedures where a risk factor was registered had significantly less favorable outcomes, higher complication rate (10.5 vs. 4.8 % (p = 0.002), longer operative time [114 vs. 95 min (p < 0.001)], and more blood loss [110 vs. 168 mL (p = 0.047)], which was mainly due to the technological and patient-related risk factors.ConclusionTechnological incidents are the most important and clinically relevant risk factors affecting surgical outcomes of LH. Future improvements of MIS need to focus on this. As awareness of safety risk factors in MIS is important, embedding of a safety risk factor checklist in registration systems will help surgeons to evaluate and improve their individual performance. This will inherently improve the surgical outcomes and thus patient safety.

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Case-Mix Variables and Predictors for Outcomes of Laparoscopic Hysterectomy: A Systematic Review

Cited by 31 publications

References 92 publications

Laparoscopic removal of a very large uterus weighting 5320 g is feasible and safe: a case report

Laparoscopic removal of a very large uterus weighting 5320 g is feasible and safe: a case report

Hospital versus individual surgeon’s performance in laparoscopic hysterectomy

Identification of risk factors in minimally invasive surgery: a prospective multicenter study

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