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A Novel Program to Reduce the Total Abdominal Hysterectomy Rate in a Community Hospital System to Less Than 10%
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S1–S49
S11
This program can easily be replicated at other institutions interested in providing more minimally invasive options to their patients. 31
Open Communications 3dHysterectomy (11:24 AM d 11:29 AM)
Mechanical Bowel Preparation before Laparoscopic Hysterectomy: A Randomized Controlled Trial Siedhoff MT, Clark LH, Findley AD, Hobbs KA, Carey ET. Advanced Laparoscopy & Pelvic Pain, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
The three classes did not differ significantly in age, race, type of hysterectomy (route, removal of cervix) and complication rate. In particular, readmission rate, length of stay, BMI, uterine weight and baseline pain all differed among the three classes. Conclusion: ‘‘Person-centered’’ analyses are more appropriate when response patterns aren’t homogeneous with respect to the outcome of interest. The identification of variables (BMI, uterine weight and baseline pain) that may impact well-being after hysterectomy would be crucial in counseling the patient prior to surgery. Additionally, interventions addressing these variables prior to undergoing hysterectomy may minimize risks associated with surgery and improve well-being for women. Furthermore, focusing on reducing readmission rate and length of stay would not only improve patient well-being but impact quality of care and patient safety. 30
Open Communications 3dHysterectomy (11:18 AM d 11:23 AM)
A Novel Program to Reduce the Total Abdominal Hysterectomy Rate in a Community Hospital System to Less Than 10% Lenihan JP Jr, Brower M. Robotics and MIS, MultiCare Health Systems, Tacoma, Washington Study Objective: The purpose of this study was to determine if a novel program emphasizing minimally invasive hysterectomies could influence surgeons to lower the incidence of Total Abdominal Hysterectomies (TAH) to \10%. Design: Prospective cohort analysis of all patients undergoing hysterectomy as to method (Canadian Task Force Classification III). Primary outcome is the reduction in the rate of abdominal hysterectomy to \ 10%. Setting: Three hospital Community Healthcare System in the Pacific Northwest. Patients: All women (2969) undergoing a hysterectomy in 2004 and 2007 through 2012. Intervention: A formal program was initiated in 2007 to lower the TAH rate system wide to less than 10% at all hospitals. We encouraged vaginal, laparoscopic and robotic assisted approaches to accomplish this goal. We retrospectively analyzed our rates of hysterectomies by type prior to this. The program had three components: quarterly feedback to the surgeons about their rates of hysterectomy by type compared to their peers, education and training regarding how to avoid open surgery, and encouragement to refer if a surgeon wasn’t comfortable performing a minimally invasive hysterectomy. Measurements and Main Results: The TAH rate was reduced at our main hospitals, TGH/AH, from 45% in 2004 to 9% by the end of 2010; and at a third newly acquired hospital, GSH, from 56% in 2008 to 14% by the end of 2012. This was accomplished by increasing the rate of vaginal (VH) and robotic hysterectomies (RALH). The rate of laparoscopic hysterectomies (LH) decreased at all hospitals after the implementation of robotics. Conclusion: This novel program involving education and training, timely feedback, comparison to peers and encouragement to refer clearly had a significant impact on lowering the TAH rate at all MultiCare hospitals.
Study Objective: To examine the influence of mechanical bowel preparation (MBP) on visualization during laparoscopic hysterectomy. Design: Randomized controlled trial. Setting: Tertiary-care university-based teaching hospital. Patients: Patients undergoing laparoscopic hysterectomy for benign indications. Intervention: MBP. Measurements and Main Results: 114 subjects were randomized, 57 to MPB group and 57 to no-MBP. The primary outcome was the surgeon’s evaluation of field visualization at surgery outset. Additional measures included other assessments of visualization and questions regarding patient perioperative comfort. Mean participant age was 41, BMI 33. Fibroids, abnormal bleeding, and pelvic pain were the most common indications for surgery. All underwent total, rather than supracervical, hysterectomy and the majority (96%) were done with conventional, as opposed to robotic, laparoscopy. On average, subjects had a history of 1 prior laparoscopy (range 0-4) and 1 prior laparotomy (range 0-6). Mean surgery time was 134 min (range 50-299 min), EBL 59ml (range 10-400ml), and uterine weight 392g (range 34-3300g). Complications included a delayed ureteral injury, unavoidable enterotomy primarily repaired, perineal laceration during specimen removal, umbilical incision separation, and ureteral kinking which resolved with re-suturing the vaginal cuff. There were no differences in the surgeon’s perception of visualization at the outset of the case (p=0.3), visualization at the end of the case (p=0.4), bowel handling (p=0.8), degree of small bowel preparation (p=0.9), degree of large bowel preparation (p=0.3), visualization of the uterus (p=0.6), adnexae (p=.07), or posterior culdesac (p=0.8). Cramps (p=0.5), hunger (p=0.9), bloating (p=0.6), embarrassment (p=0.5), weakness (p=0.4), dizziness (p=0.8), nausea (p=0.4), and incontinence (p=0.6) were rated similarly between groups. Insomnia (p=0.01) and thirst (p=0.06) were reported more frequently in the no-MBP group. Surgeons guessed subject assignment correctly 55% of the time in the MBP group and 53% of the time in the no-MBP group. Conclusion: MBP does not influence surgical field visualization for laparoscopic hysterectomy and should be abandoned as routine practice. 32
Open Communications 3dHysterectomy (11:30 AM d 11:35 AM)
National Trends and Disparities in Minimally Invasive Approaches to Hysterectomy for Benign Indications Price JT,1 Lee S.2 1Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; 2Department of Gynecology, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania Study Objective: Minimally invasive approaches to hysterectomy have several advantages to abdominal hysterectomy. Nonetheless, there have been disparities reported in the application of new minimally invasive technologies. The intent of this study was to assess whether racial and socioeconomic factors correlate with hysterectomy approach. Design: Retrospective cohort study. Setting: The Nationwide Inpatient Sample database from the Healthcare Cost and Utilization Project, 2010. Patients: Abdominal, laparoscopic and vaginal hysterectomies performed for menorrhagia or uterine leiomyomata during the year 2010 were identified using the Nationwide Inpatient Sample database. Intervention: Socioeconomic variables including race, median household income quartile and insurance status were analyzed using chi-square and
S11
This program can easily be replicated at other institutions interested in providing more minimally invasive options to their patients. 31
Open Communications 3dHysterectomy (11:24 AM d 11:29 AM)
Mechanical Bowel Preparation before Laparoscopic Hysterectomy: A Randomized Controlled Trial Siedhoff MT, Clark LH, Findley AD, Hobbs KA, Carey ET. Advanced Laparoscopy & Pelvic Pain, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
The three classes did not differ significantly in age, race, type of hysterectomy (route, removal of cervix) and complication rate. In particular, readmission rate, length of stay, BMI, uterine weight and baseline pain all differed among the three classes. Conclusion: ‘‘Person-centered’’ analyses are more appropriate when response patterns aren’t homogeneous with respect to the outcome of interest. The identification of variables (BMI, uterine weight and baseline pain) that may impact well-being after hysterectomy would be crucial in counseling the patient prior to surgery. Additionally, interventions addressing these variables prior to undergoing hysterectomy may minimize risks associated with surgery and improve well-being for women. Furthermore, focusing on reducing readmission rate and length of stay would not only improve patient well-being but impact quality of care and patient safety. 30
Open Communications 3dHysterectomy (11:18 AM d 11:23 AM)
A Novel Program to Reduce the Total Abdominal Hysterectomy Rate in a Community Hospital System to Less Than 10% Lenihan JP Jr, Brower M. Robotics and MIS, MultiCare Health Systems, Tacoma, Washington Study Objective: The purpose of this study was to determine if a novel program emphasizing minimally invasive hysterectomies could influence surgeons to lower the incidence of Total Abdominal Hysterectomies (TAH) to \10%. Design: Prospective cohort analysis of all patients undergoing hysterectomy as to method (Canadian Task Force Classification III). Primary outcome is the reduction in the rate of abdominal hysterectomy to \ 10%. Setting: Three hospital Community Healthcare System in the Pacific Northwest. Patients: All women (2969) undergoing a hysterectomy in 2004 and 2007 through 2012. Intervention: A formal program was initiated in 2007 to lower the TAH rate system wide to less than 10% at all hospitals. We encouraged vaginal, laparoscopic and robotic assisted approaches to accomplish this goal. We retrospectively analyzed our rates of hysterectomies by type prior to this. The program had three components: quarterly feedback to the surgeons about their rates of hysterectomy by type compared to their peers, education and training regarding how to avoid open surgery, and encouragement to refer if a surgeon wasn’t comfortable performing a minimally invasive hysterectomy. Measurements and Main Results: The TAH rate was reduced at our main hospitals, TGH/AH, from 45% in 2004 to 9% by the end of 2010; and at a third newly acquired hospital, GSH, from 56% in 2008 to 14% by the end of 2012. This was accomplished by increasing the rate of vaginal (VH) and robotic hysterectomies (RALH). The rate of laparoscopic hysterectomies (LH) decreased at all hospitals after the implementation of robotics. Conclusion: This novel program involving education and training, timely feedback, comparison to peers and encouragement to refer clearly had a significant impact on lowering the TAH rate at all MultiCare hospitals.
Study Objective: To examine the influence of mechanical bowel preparation (MBP) on visualization during laparoscopic hysterectomy. Design: Randomized controlled trial. Setting: Tertiary-care university-based teaching hospital. Patients: Patients undergoing laparoscopic hysterectomy for benign indications. Intervention: MBP. Measurements and Main Results: 114 subjects were randomized, 57 to MPB group and 57 to no-MBP. The primary outcome was the surgeon’s evaluation of field visualization at surgery outset. Additional measures included other assessments of visualization and questions regarding patient perioperative comfort. Mean participant age was 41, BMI 33. Fibroids, abnormal bleeding, and pelvic pain were the most common indications for surgery. All underwent total, rather than supracervical, hysterectomy and the majority (96%) were done with conventional, as opposed to robotic, laparoscopy. On average, subjects had a history of 1 prior laparoscopy (range 0-4) and 1 prior laparotomy (range 0-6). Mean surgery time was 134 min (range 50-299 min), EBL 59ml (range 10-400ml), and uterine weight 392g (range 34-3300g). Complications included a delayed ureteral injury, unavoidable enterotomy primarily repaired, perineal laceration during specimen removal, umbilical incision separation, and ureteral kinking which resolved with re-suturing the vaginal cuff. There were no differences in the surgeon’s perception of visualization at the outset of the case (p=0.3), visualization at the end of the case (p=0.4), bowel handling (p=0.8), degree of small bowel preparation (p=0.9), degree of large bowel preparation (p=0.3), visualization of the uterus (p=0.6), adnexae (p=.07), or posterior culdesac (p=0.8). Cramps (p=0.5), hunger (p=0.9), bloating (p=0.6), embarrassment (p=0.5), weakness (p=0.4), dizziness (p=0.8), nausea (p=0.4), and incontinence (p=0.6) were rated similarly between groups. Insomnia (p=0.01) and thirst (p=0.06) were reported more frequently in the no-MBP group. Surgeons guessed subject assignment correctly 55% of the time in the MBP group and 53% of the time in the no-MBP group. Conclusion: MBP does not influence surgical field visualization for laparoscopic hysterectomy and should be abandoned as routine practice. 32
Open Communications 3dHysterectomy (11:30 AM d 11:35 AM)
National Trends and Disparities in Minimally Invasive Approaches to Hysterectomy for Benign Indications Price JT,1 Lee S.2 1Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; 2Department of Gynecology, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania Study Objective: Minimally invasive approaches to hysterectomy have several advantages to abdominal hysterectomy. Nonetheless, there have been disparities reported in the application of new minimally invasive technologies. The intent of this study was to assess whether racial and socioeconomic factors correlate with hysterectomy approach. Design: Retrospective cohort study. Setting: The Nationwide Inpatient Sample database from the Healthcare Cost and Utilization Project, 2010. Patients: Abdominal, laparoscopic and vaginal hysterectomies performed for menorrhagia or uterine leiomyomata during the year 2010 were identified using the Nationwide Inpatient Sample database. Intervention: Socioeconomic variables including race, median household income quartile and insurance status were analyzed using chi-square and