Laparoscopic Hysterectomy Route, Resource Use, and Outcomes

Abstract

OBJECTIVE: To examine changes in utilization of different types of laparoscopic hysterectomy, as well as their associated resource use and surgical outcomes, after the U.S. Food and Drug Administration (FDA) safety statement in April 2014 regarding power morcellation. METHODS: We retrospectively analyzed data from the 2012–2016 American College of Surgeons National Surgical Quality Improvement Program and identified 145,746 women undergoing hysterectomy for benign indications. We measured use of laparoscopic supracervical hysterectomy compared to total laparoscopic hysterectomy (including laparoscopic-assisted vaginal hysterectomy) in these patients, as well as operative time, surgical setting (inpatient vs outpatient), length of stay, and 30-day surgical outcomes (wound complication, medical complication, reoperation, and readmission). We used an interrupted time series analysis to examine the association between FDA warning and changes in utilization and outcomes of laparoscopic hysterectomy. RESULTS: After adjusting for patient characteristics and background trends in practice, use of laparoscopic supracervical hysterectomy was significantly lower in the postwarning than prewarning period (odds ratio [OR]=0.49, 95% CI 0.45–0.53), whereas use of total laparoscopic hysterectomy was not affected (OR 1.01, 95% CI 0.96–1.06). Overall, after an initial reduction, use of laparoscopic hysterectomy (laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy combined) increased over time in the postwarning period (adjusted OR of utilization for each calendar quarter elapsed=1.03, 95% CI 1.02–1.03). After the FDA warning, operative time for laparoscopic supracervical hysterectomy increased by 11.45 minutes (95% CI 6.22–16.69), whereas the decreasing trend in the likelihood of inpatient stay for total laparoscopic hysterectomy was attenuated (OR for each calendar quarter elapsed=0.92 in prewarning period, 95% CI 0.91–0.93; and 0.97 in postwarning period, 95% CI 0.97–0.98). There was no significant change in 30-day surgical outcomes after the FDA warning. CONCLUSION: Rates of laparoscopic supracervical hysterectomy fell in association with power morcellation safety warnings, whereas rates of other laparoscopic hysterectomies continued to rise. There was no change in patient outcomes among laparoscopic hysterectomies.

Choosing a Surgical Access Point for Hysterectomy: A Paradigm Shift Over a 10-Year Span

“…The topic was also debated at Ulm University Hospital. The present analysis shows that this openended discussion did not lastingly influence the trend toward minimally invasive procedures (19,20). This result is remarkable since efforts to achieve a reliable preoperative sarcoma diagnosis have not yet yielded a feasible test (13,21) and Desai et al (20), for example, report a clear decline in supracervical hysterectomies in the wake of the FDA warning.…”

Hospital variation in responses to safety warnings about power morcellation in hysterectomy

“…For instance, uterine tissues can often be removed without morcellation via total laparoscopic hysterectomy or laparoscopically assisted vaginal ajog.org GYNECOLOGY Original Research hysterectomy, allowing patients to still benefit from the lower complication risk of minimally invasive surgery. 36 Despite reduced use of LSH, hospitals in the "decreased high use" group still performed 24.2% of its hysterectomies via LSH in the postwarning period. Because our data lacked clinical detail regarding preoperative evaluations (eg, assessment for potential occult uterine cancer) and method of tissue extraction (eg, contained power morcellation or other methods), we were unable to investigate the appropriateness of these LSH procedures.…”

Laparoscopic specimen retrieval bags in gyn surgery: Expert guidance on selection

“…MIGS, which includes vaginal hysterectomy and laparoscopic hysterectomy, is safe and has fewer complications and a more rapid recovery period than open abdominal surgery. 1,2 In 2005, the role of MIGS was expanded further when the US Food and Drug Administration (FDA) approved robot-assisted surgery for the performance of gynecologic procedures. 3 As knowledge and experience in the safe performance of MIGS progresses, the rates for MIGS procedures have skyrocketed and continue to grow.…”

“…4 Due to the benefits of minimally invasive surgery over open abdominal surgery, patient and physician preference for minimally invasive procedures has grown significantly in popularity. 1,5 Because incisions are small in minimally invasive surgery, surgeons have been challenged with removing large specimens through incisions that are much smaller than the presenting pathology. One approach is to use a specimen retrieval bag for specimen extraction.…”