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Impact of Physician Training on Choice of Route of Hysterectomy
Abstracts / Journal of Minimally Invasive Gynecology 18 (2011) S24–S46 Patients: 2133 patients that underwent a hysterectomy at Brigham and Women’s Hospital in the years 2006 and 2009. Measurements and Main Results: The total number of hysterectomies performed remained stable (1054 procedures in 2006 versus 1079 in 2009) but the relative proportions of abdominal and laparoscopic cases changed markedly during the three-year period (64.7% to 35.8% for abdominal, p\0.0001 and 17.7% to 46% for laparoscopic cases, p = 0.0001). The overall rate of intra-operative complications and minor postoperative complications decreased significantly (7.2% to 4%, p = 0.0012 and 18% to 5.7%, p\0.0001, respectively). Operative costs increased significantly for all procedures aside from robotic hysterectomy, though no significant change was noted in total mean costs. Conclusion: A change from majority abdominal hysterectomy to minimally invasive hysterectomy was accompanied by a significant decrease in procedure-related complications without an increase in total mean costs. Our data suggest that with dedication to the implementation of minimally invasive techniques, goals such as decreased complications, decreased operative time, decreased conversion rate and decreased estimated blood loss can be realized without sacrificing cost-effectiveness.
99
Open Communications 3dHysterectomy (4:02 PM d 4:07 PM)
Impact of Physician Training on Choice of Route of Hysterectomy Eisenstein DI, Abdi I, Wegienka G. Women’s Health, Henry Ford Health System, West Bloomfield, Michigan Study Objective: This study seeks to document the impact of physician training on choice of route for hysterectomy in a large clinical department. Design: Retrospective cohort study. Setting: The Department of Women’s Health is an urban medical center comprising oth clinical and academic faculty of 35 physicians. Patients: 557 patients who underwent hysterectomy for benign indications over the course of one calendar year (2010) were selected via the health system database and identified by procedure code. Intervention: Patient charts were selected by procedural code and record reviews performed by accessing the electronic medical record. Data were collected, digitized, and analyzed by statistical software package.(SAS, Cary, NC). Measurements and Main Results: Open Hysterectomy Rates by Years out of Training Years since Residency
Total # Hysterectomies
% non laparotomy
\10 11-20 21-30 31+
55 142 251 109
78.2 85.9 84.1 64.2
Odds of Open Hysterectomy Associated with Years since Training Years since residency
Odds Ratio
95% confidence Interval
P-value
\10 11-20 21-30 Ref
0.50 0.29 0.34 Ref
0.24, 1/1 0.16, 0.54 0.20, 0.57 Ref
0.07 \0.0001 \0.0001 Ref
Logistic regression supports the conclusion that the group with the most years out of residency is the most likely to complete an open procedure while the other groups did not differ from each other. Uterine size was not associated with years since residency (Spearman r = 0.03, p = 0.52). Further, it did not alter the odds ratios in the logistic regression model. These analyses do not account for surgeon volume or practice habits. Conclusion: The AAGL position paper on hysterectomy states ‘‘..most hysterectomies for benign disease should be performed either vaginally of laparoscopically and that continued efforts should be taken to facilitate these approaches.’’ These data are part of ongoing project to maximize utilization rates of minimally invasive approaches in the Department of Women’s
S31
Health at Henry Ford Health Systems. They suggest that program support for surgeons > 30 years out of training will help lower laparotomy rates in our institution. Ongoing data analysis will focus efforts on training and education and seek to document efficacy of these efforts.
100
Open Communications 3dHysterectomy (4:08 PM d 4:13 PM)
Long Term Outcomes Following Laparoscopic Supracervical Hysterectomy Performed with and without Excision of the Endocervix Berner E, Qvigstad E, Langebrekke A, Lieng M. Departement of Gynecology, Oslo University Hospital Ullev al, Oslo, Norway Study Objective: To compare the occurrence of continued vaginal bleeding as well as patient satisfaction after laparoscopic supracervical hysterectomy performed with and without excision of the endocervix in a reverse cone pattern. Design: Prospective randomised trial. Study patients were followed up 3 and 12 months after the operation at the outpatient clinic. Setting: Norwegian university teaching hospital. Patients: Premenopausal women who were referred to the department due to a benign condition requiring hysterectomy. 140 women planned for laparoscopic supracervical hysterectomy were enrolled in the study. They were operated in the period from November 2008 to October 2010. Intervention: The study participants were randomized to laparoscopic supracervical hysterectomy performed with peroperative electrocoagulation of the upper cervical canal (n = 70) or performed by excision of the endocervix in a reverse cone pattern followed by electrocoagulation of the reminant cervical canal (n = 70). The intervention was blinded both for the patient and the doctor that examined the patients at the outpatient clinic. Measurements and Main Results: The main outcomes of the study were occurrence of vaginal bleeding and patient satisfaction 12 months after laparoscopic supracervical hysterectomy. The results of the study are ready in time for the AAGL Congress November 2011. 101
Open Communications 3dHysterectomy (4:14 PM d 4:19 PM)
Single-Incision Laparoscopy as the Primary Approach to Benign Hysterectomy: One Year Experience Fridman D,1 Saraf S,1 Wagner JR.2 1Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York; 2Obstetrics and Gynecology, Huntington Hospital, Huntington, New York Study Objective: To analyze our experience with single-incision laparoscopy as a primary approach to all benign hysterectomies. Design: Retrospective cohort. Setting: North-eastern hospital-based practice. Patients: Patients undergoing hysterectomy by a single surgeon over 1 year for benign indications, before and after initiation of a single-incision program. Intervention: Single-incision laparoscopic access for hysterectomy. Measurements and Main Results: Primary outcomes were operative time, estimated blood loss, intraoperative complications and conversion to laparotomy. Overall 35 patients underwent hysterectomy via singleincision approach, while 42 had conventional multiport laparoscopy. There were no statistically significant differences in body mass index, age or number of previous surgeries between these two groups. Mean time of procedure, weight of the specimen, estimated blood loss did not differ significantly between the two groups. There was one conversion to laparotomy in the multiport laparoscopy group due to extensive adhesions and technical difficulties, and one major intraoperative complication in the single-incision group (bowel injury) requiring laparotomy. Twelve (34%) cases in the single-incision laparoscopy group required placement of at least one additional trocar. Conclusion: Transition to single-incision laparoscopy as a primary access to hysterectomy for benign indications is possible without significant alterations in operative time or morbidity.
99
Open Communications 3dHysterectomy (4:02 PM d 4:07 PM)
Impact of Physician Training on Choice of Route of Hysterectomy Eisenstein DI, Abdi I, Wegienka G. Women’s Health, Henry Ford Health System, West Bloomfield, Michigan Study Objective: This study seeks to document the impact of physician training on choice of route for hysterectomy in a large clinical department. Design: Retrospective cohort study. Setting: The Department of Women’s Health is an urban medical center comprising oth clinical and academic faculty of 35 physicians. Patients: 557 patients who underwent hysterectomy for benign indications over the course of one calendar year (2010) were selected via the health system database and identified by procedure code. Intervention: Patient charts were selected by procedural code and record reviews performed by accessing the electronic medical record. Data were collected, digitized, and analyzed by statistical software package.(SAS, Cary, NC). Measurements and Main Results: Open Hysterectomy Rates by Years out of Training Years since Residency
Total # Hysterectomies
% non laparotomy
\10 11-20 21-30 31+
55 142 251 109
78.2 85.9 84.1 64.2
Odds of Open Hysterectomy Associated with Years since Training Years since residency
Odds Ratio
95% confidence Interval
P-value
\10 11-20 21-30 Ref
0.50 0.29 0.34 Ref
0.24, 1/1 0.16, 0.54 0.20, 0.57 Ref
0.07 \0.0001 \0.0001 Ref
Logistic regression supports the conclusion that the group with the most years out of residency is the most likely to complete an open procedure while the other groups did not differ from each other. Uterine size was not associated with years since residency (Spearman r = 0.03, p = 0.52). Further, it did not alter the odds ratios in the logistic regression model. These analyses do not account for surgeon volume or practice habits. Conclusion: The AAGL position paper on hysterectomy states ‘‘..most hysterectomies for benign disease should be performed either vaginally of laparoscopically and that continued efforts should be taken to facilitate these approaches.’’ These data are part of ongoing project to maximize utilization rates of minimally invasive approaches in the Department of Women’s
S31
Health at Henry Ford Health Systems. They suggest that program support for surgeons > 30 years out of training will help lower laparotomy rates in our institution. Ongoing data analysis will focus efforts on training and education and seek to document efficacy of these efforts.
100
Open Communications 3dHysterectomy (4:08 PM d 4:13 PM)
Long Term Outcomes Following Laparoscopic Supracervical Hysterectomy Performed with and without Excision of the Endocervix Berner E, Qvigstad E, Langebrekke A, Lieng M. Departement of Gynecology, Oslo University Hospital Ullev al, Oslo, Norway Study Objective: To compare the occurrence of continued vaginal bleeding as well as patient satisfaction after laparoscopic supracervical hysterectomy performed with and without excision of the endocervix in a reverse cone pattern. Design: Prospective randomised trial. Study patients were followed up 3 and 12 months after the operation at the outpatient clinic. Setting: Norwegian university teaching hospital. Patients: Premenopausal women who were referred to the department due to a benign condition requiring hysterectomy. 140 women planned for laparoscopic supracervical hysterectomy were enrolled in the study. They were operated in the period from November 2008 to October 2010. Intervention: The study participants were randomized to laparoscopic supracervical hysterectomy performed with peroperative electrocoagulation of the upper cervical canal (n = 70) or performed by excision of the endocervix in a reverse cone pattern followed by electrocoagulation of the reminant cervical canal (n = 70). The intervention was blinded both for the patient and the doctor that examined the patients at the outpatient clinic. Measurements and Main Results: The main outcomes of the study were occurrence of vaginal bleeding and patient satisfaction 12 months after laparoscopic supracervical hysterectomy. The results of the study are ready in time for the AAGL Congress November 2011. 101
Open Communications 3dHysterectomy (4:14 PM d 4:19 PM)
Single-Incision Laparoscopy as the Primary Approach to Benign Hysterectomy: One Year Experience Fridman D,1 Saraf S,1 Wagner JR.2 1Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York; 2Obstetrics and Gynecology, Huntington Hospital, Huntington, New York Study Objective: To analyze our experience with single-incision laparoscopy as a primary approach to all benign hysterectomies. Design: Retrospective cohort. Setting: North-eastern hospital-based practice. Patients: Patients undergoing hysterectomy by a single surgeon over 1 year for benign indications, before and after initiation of a single-incision program. Intervention: Single-incision laparoscopic access for hysterectomy. Measurements and Main Results: Primary outcomes were operative time, estimated blood loss, intraoperative complications and conversion to laparotomy. Overall 35 patients underwent hysterectomy via singleincision approach, while 42 had conventional multiport laparoscopy. There were no statistically significant differences in body mass index, age or number of previous surgeries between these two groups. Mean time of procedure, weight of the specimen, estimated blood loss did not differ significantly between the two groups. There was one conversion to laparotomy in the multiport laparoscopy group due to extensive adhesions and technical difficulties, and one major intraoperative complication in the single-incision group (bowel injury) requiring laparotomy. Twelve (34%) cases in the single-incision laparoscopy group required placement of at least one additional trocar. Conclusion: Transition to single-incision laparoscopy as a primary access to hysterectomy for benign indications is possible without significant alterations in operative time or morbidity.