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The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications
YGYNO-975470; No. of pages: 4; 4C: Gynecologic Oncology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno
The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications Stephen J. Lee, Bianca Calderon, Ginger J. Gardner, Allison Mays, Stephanie Nolan, Yukio Sonoda, Richard R. Barakat, Mario M. Leitao Jr. ⁎ Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
H I G H L I G H T S • Same-day discharge was planned in 200 cases and 157 (78%) had successful same-day discharge. • Forty-three (22%) patients required postoperative admission, 23 for medical reasons and 20 for non-medical reasons. • Operative time, case ending before 6 pm, and use of intraoperative ketorolac were associated with successful same-day discharge.
a r t i c l e
i n f o
Article history: Received 31 December 2013 Accepted 4 April 2014 Available online xxxx Keywords: Robotic-assisted hysterectomy Same-day discharge TLH BSO
a b s t r a c t Objective. This study aimed to report the feasibility and safety of same-day discharge after robotic-assisted hysterectomy. Methods. Same-day discharge after robotic-assisted hysterectomy was initiated 07/2010. All cases from then through 12/2012 were captured for quality assessment monitoring. The distance from the hospital to patients' homes was determined using http://maps.google.com. Procedures were categorized as simple (TLH +/− BSO) or complex (TLH +/− BSO with sentinel node mapping, pelvic and/or aortic nodal dissection, appendectomy, or omentectomy). Urgent care center (UCC) visits and readmissions within 30 days of surgery were captured, and time to the visit was determined from the initial surgical date. Results. Same-day discharge was planned in 200 cases. Median age was 52 years (range, 30–78), BMI was 26.8 kg/m2 (range, 17.4–56.8), and ASA was class 2 (range, 1–3). Median distance traveled was 31.5 miles (range, 0.2–149). Procedures were simple in 109 (55%) and complex in 91 (45%) cases. The indication for surgery was: endometrial cancer (n = 82; 41%), ovarian cancer (n = 5; 2.5%), cervical cancer (n = 8; 4%), and nongynecologic cancer/benign (n = 105; 53%). One hundred fifty-seven (78%) had successful same-day discharge. Median time for discharge for these cases was 4.8 h (range, 2.4–10.3). Operative time, case ending before 6 pm, and use of intraoperative ketorolac were associated with successful same-day discharge. UCC visits occurred in 8/157 (5.1%) same-day discharge cases compared to 5/43 (11.6%) requiring admission (P = .08). Readmission was necessary in 4/157 (2.5%) same-day discharge cases compared to 3/43 (7.0%) requiring admission (P = .02). Conclusions. Same-day discharge after robotic-assisted hysterectomy for benign and malignant conditions is feasible and safe. © 2014 Elsevier Inc. All rights reserved.
Introduction More than 600,000 hysterectomies are performed in the United States annually, and ever-increasing numbers are being completed using minimally invasive techniques [1–3]. In 2005, the US Food and ⁎ Corresponding author at: Memorial Sloan-Kettering Cancer Center, Gynecology Service, Department of Surgery, 1275 York Avenue, New York, NY 10065, USA. Fax: + 1 212 717 3214. E-mail address: [email protected] (M.M. Leitao).
Drug Administration approved the robotic surgical platform for gynecologic surgery. The benefits of minimally invasive surgery for both benign and malignant gynecologic conditions, including smaller incisions, decreased blood loss, decreased pain, shorter hospital stay and earlier return to activities, have been well documented [4–7]. The robotic platform offers the additional benefits of increased range of instrument motion, 3-dimensional stereoscopic visualization, and improved surgeon ergonomics [8,9]. For patients undergoing simple minimally invasive oophorectomies or ovarian cystectomies, same-day discharge has become routine.
http://dx.doi.org/10.1016/j.ygyno.2014.04.006 0090-8258/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Lee SJ, et al, The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.006
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S.J. Lee et al. / Gynecologic Oncology xxx (2014) xxx–xxx
However, most gynecologists still admit patients overnight for observation after a laparoscopic or robotic-assisted hysterectomy. Concerns regarding patient safety, such as bleeding or identifying inadvertent injury to adjacent structures, are often cited as reasons for overnight admission after minimally invasive gynecologic surgery. Nevertheless, major bleeding should be detected prior to discharge from the postoperative unit, and injury to nearby organs is either identified at the time of surgery or not until several days later. Adequate pain control and nausea/vomiting are additional concerns. Several single-institution reports describe successful discharge within 12–24 h after laparoscopic hysterectomy for both benign and malignant conditions [10–14]; however, we are unaware of any studies reporting same-day discharge after robotic-assisted hysterectomy. The purpose of this study was to evaluate the feasibility and safety of same-day discharge for patients undergoing robotic-assisted hysterectomy alone or with other procedures for benign and malignant conditions.
vital signs, adequate oxygenation, no nausea, pain control with oral medications, and voided postoperatively. Nursing staff contacted all patients on postoperative day 1 to ensure a smooth transition home. All patients had their first postoperative visit within 4 weeks of surgery. Electronic medical records were reviewed to ascertain if any postoperative UCC visit or hospital readmission occurred within 30 days of surgery, and the time to the visit was determined from the surgical date. Outpatient clinic notes were also reviewed to discern if patients had been evaluated at a local emergency room or admitted to their community hospital within 30 days of surgery. Categorical variables were compared using the Chi-square test, and continuous variables were compared using the Mann–Whitney U or the Kruskal–Wallis test as appropriate. All statistical analyses were performed using SPSS Statistics 20.0 (IBM, Chicago, IL).
Materials and methods
Two hundred patients were scheduled for same-day discharge, robotic-assisted hysterectomy alone or with other procedures during the study period. Clinicopathologic characteristics of the overall cohort are presented in Table 1. The median age was 52 years (range, 30– 78), BMI was 26.8 kg/m2 (range, 17.4–56.8), and ASA class was 2 (range, 1–3). Fifty-eight (29%) patients met the definition of obesity (BMI ≥ 30), with 26 (13%) patients with a BMI ≥ 35. Medical comorbidities included hypertension (n = 33), coronary artery disease (n = 10), dyslipidemia (n = 35), heart murmur (n = 13), arrhythmia (n = 3), chronic obstructive pulmonary disease (n = 14), obstructive sleep apnea (n = 6), and diabetes mellitus (n = 10). More than half of the patients had a prior laparoscopy and/or laparotomy. Gynecologic cancer was the surgical indication in 47% of the cases, with 45% of the cases being categorized as complex. The median EBL was 50 mL (range, 5– 800), and the median operative time was 136 min (range, 79–291). Three quarters of the patients received intraoperative ketorolac and
A same-day discharge approach after robotic-assisted hysterectomy was initiated at our institution in July 2010. After the Institutional Review Board approval, we identified all patients who were scheduled to undergo robotic-assisted hysterectomy with planned same-day discharge from that time until December 2012. Procedures were scheduled as same-day discharge at the discretion of the surgeon, and all cases discharged home from the post-anesthesia care unit (PACU) without requiring admission to the inpatient unit were classified as same-day discharge. All electronic medical records, including operative and pathology reports, postoperative unit records, urgent care center (UCC) encounters, as well as outpatient clinic notes, were reviewed. Information collected from the records included age, body mass index (BMI), American Society of Anesthesiology (ASA) class, past medical history, previous pelvic and/or abdominal surgery, preoperative diagnosis, and surgical procedure. Simple procedures were defined as robotic-assisted hysterectomies +/− bilateral salpingo-oophorectomy (BSO), and complex procedures were defined as robotic-assisted hysterectomies +/− BSO with any of the following: sentinel node mapping, pelvic and/or aortic nodal dissection, appendectomy, or omentectomy. Perioperative data collected included estimated blood loss (EBL), amount of crystalloid infused, uterine weight, conversion to laparotomy, room time (time from patient entering the operating room to leaving the operating room), operative time (time from skin incision to completion of skin closure), time to discharge (time from patient leaving the operating room to time of discharge), and intraoperative or immediate postoperative complications. The distance (in miles) from the hospital to the patient's home was determined using an online service (http://maps.google.com). All surgeons are fellowship-trained gynecologic oncologists who performed robotic-assisted hysterectomy alone or in conjunction with other procedures using the da Vinci® Si dual console platform. The setup required the use of 5 ports: a 12 mm camera port, 2 ports (8 mm) in bilateral lower quadrants, an 8 mm port inferior to the R subcostal margin, and a 10/12 mm assistant port inferior to the L subcostal margin. Standard robotic monopolar shears and bipolar forceps were used. Suture for vaginal cuff closure was either vicryl or V-Loc (Covidien, Mansfield, MA) based on surgeon preference. Intraoperative ketorolac and trocar site bupivacaine administration was at the discretion of the surgeon. Prior to fascial closure, positive pressure ventilations were administered to decrease residual pneumoperitoneum and reduce postoperative pain. All patients received a similar oral pain and bowel medication regimen, consisting of diclofenac 75 mg every 12 h, hydrocodone/acetaminophen 5 mg/325 mg 1–2 tablets every 4 h as needed, docusate 100 mg every 8 h as needed, and sennosides 8.6 mg every 12 h as needed. Prescriptions for these postoperative medications were given at the preoperative visit. There was no standard anti-emetic regimen. Patients were discharged home if they had normal
Results
Table 1 Clinicopathologic characteristics of overall cohort (N = 200). Median (range) or N (%) Age, y BMI, kg/m2 ASA class Prior laparoscopy and/or laparotomy Preoperative diagnosis Endometrial cancer Cervical cancer Ovarian cancer Benign/preinvasive disease Procedure type Simplea Complexb EBL, mL Intraoperative crystalloid, mL Intraoperative ketorolac Trocar site bupivacaine Uterine weight, g Room timec, min Operative timed, min Time case endede, h:min Distance from hospital, miles Time to discharge, h
52 (30–78) 26.8 (17.4–56.8) 2 (1–3) 109 (55) 82 (41) 8 (4) 5 (2.5) 105 (53) 109 (55) 91 (45) 50 (5–800) 1700 (600–3000) 151 (76) 105 (53) 116 (31.5–979) 196 (134–360) 136 (79–291) 13:22 (9:53–22:03) 31.5 (0.2–149) 5.23 (2.4–95.1)
BMI, body mass index; ASA, American Society of Anesthesiologists; EBL, estimated blood loss. a Simple procedure — robotic-assisted hysterectomy +/− bilateral salpingo-oophorectomy. b Complex procedure — simple procedure in conjunction with any of the additional: sentinel lymph node mapping, pelvic and/or aortic lymph node dissection, appendectomy, omentectomy. c Room time is the time from patient entering the operating room to leaving the operating room. d Operative time is the time from skin incision to skin closure. e Time to discharge is the time from patient getting out of the operating room to being discharged.
Please cite this article as: Lee SJ, et al, The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.006
S.J. Lee et al. / Gynecologic Oncology xxx (2014) xxx–xxx
just over half received bupivacaine at the trocar sites. The median distance patients had to travel from the hospital was 31.5 miles (range, 0.2–149). The median time to discharge was 5.2 h (range, 2.4–95.1). One hundred fifty-seven (78%) patients were successfully discharged the same day, while 43 (22%) were admitted. Of those admitted, 30 (70%) stayed less than 24 h in the hospital, 12 (28%) between 24 and 48 h, and 1 (2%) more than 48 h. Reasons for admission are summarized in Table 2. Non-medical reasons included patient desire (n = 12), late case — all ending after 6 pm (n = 5), long commute home — one patient 85 miles and another 115 miles (n = 2), and inclement weather (n = 1). Of the patients admitted for medical reasons, just over half were admitted for reasons such as nausea (n = 5), pain (n = 3), and urinary retention (n = 4). Six patients were admitted secondary to large uterine specimens necessitating mini-laparotomy (n = 2) or resulting in vaginal lacerations during removal (n = 4). In addition, 2 patients were admitted for vasovagal episodes and one each for fever, abnormal electrocardiogram, and hypoxemia. None of the postoperative admissions resulted in the detection of a major complication. All UCC visits and readmissions occurred at the hospital where the original surgery took place (Table 3). Within 30 days postoperatively, there were 13 (6.5%) UCC visits resulting in 7 (3.5%) hospital readmissions, with the majority occurring more than 48 h after the surgery. In the same-day discharge group, there were 8 (5.1%) UCC visits: bleeding (n = 3), infection (n = 2), fever (n = 1), medication misuse (n = 1), and to rule out deep vein thrombosis (n = 1). There were no UCC visits for pain management in those who were discharged the same day. The 4 readmissions were in 3 patients — pelvic hematoma with subsequent readmission for superinfected hematoma, abdominal wall hematoma, and fever. In the group requiring postoperative admission, there were 5 (12%) UCC visits: bleeding (n = 2), fever (n = 1), foreign body (n = 1), and nausea/vomiting (n = 1). The 3 readmissions were for trocar site wound infection after hematoma evacuation, incarcerated hernia (not at trocar site) and retained foreign body. Comparing patients who successfully completed same-day discharge to those who were admitted postoperatively (Table 4), the following differences were noted to be statistically significant: EBL (P = .005), room time (P b .001), operative time (P b .001), time case ended (P = .001), and intraoperative ketorolac use (P = .03). Age, BMI, ASA class, medical comorbidities, prior pelvic and/or abdominal surgery, preoperative diagnosis, procedure type, uterine weight, trocar site bupivacaine use, and distance from hospital to home did not show a statistically significant difference. Discussion This study was designed to evaluate the feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with
Table 2 Reasons for postoperative admission (N = 43). N (%) Non-medical reasons Patient desire Late case Long commute Inclement weather Medical reasons Nausea Urinary retention Intraoperative vaginal laceration Pain Postoperative vasovagal episode Mini-laparotomy to remove specimen Fever Abnormal EKG Hypoxemia
20 (47) 12 5 2 1 23 (53) 5 4 4 3 2 2 1 1 1
3
Table 3 Urgent care center (UCC) visit and hospital readmission rates within 30 days postoperatively.
UCC visit ≤48 h 48 h to 7 days 7 to 30 days Hospital readmission ≤48 h 48 h to 7 days 7 to 30 days
All cases (N = 200)
Same-day dischargea (N = 157)
Admitted (N = 43)
P
13 (6.5) 2 3 8 7 (3.5) 1 2 4
8 (5.1) 2 1 5 4 (2.5) 1 1 2
5 (12) 0 2 3 3 (7.0) 0 1 2
.08
.02
a In the same-day discharge group, one patient had two UCC visits resulting in two readmissions.
other procedures for benign and malignant conditions. Operative time, case ending before 6 pm, and use of intraoperative ketorolac were associated with successful same-day discharge. Of note, 75% (68/91) of complex cases and 50% of cases ending after 6 pm resulted in same-day discharge. In 1994, Taylor first described a series of 7 patients discharged 4 to 6 h after laparoscopic hysterectomy followed by same-day home nurse visits in which no complications or readmissions were noted [10]. Hoffman et al. [11] reported a 30-day readmission rate after laparoscopic hysterectomy of 4.9% for same-day discharge (n = 81) compared with 2.2% for later-day discharge (n = 278). Perron-Burdick et al. [12] documented readmission rates of 0.6%, 3.6% and 4% at 48 h, 3 months and Table 4 Comparison of same-day discharge vs admitted cases.
Age, y BMI, kg/m2 ASA class Prior laparoscopy and/ or laparotomy Preoperative diagnosis Endometrial cancer Cervical cancer Ovarian cancer Non-gynecologic cancer or benign Procedure type Simplea Complexb EBL, mL Intraoperative crystalloid, mL Intraoperative ketorolac Trocar site bupivacaine Uterine weight, g Room timec, min Operative timed, min Time case endede, h:min Before 6 pm After 6 pm Distance from hospital, miles Time to discharge, h
Same-day discharge (N = 157)
Admitted (N = 43)
52 (30–77) 26.7 (17.4–56.8) 2 (1–3) 90 (57)
53 (38–78) 26.9 (19.5–55.7) 2 (1–3) 19 (44)
63 (40) 7 (4.5) 3 (2) 84 (54)
19 (44) 1 (2) 2 (5) 21 (49)
89 (57) 68 (43) 50 (5–300) 1700 (700–3000) 124 (79) 87 (55) 120 (31.5–874) 193 (134–351) 130 (79–289) 13:08 (9:53–21:00) 147 (82)f 10 (50)f 35.6 (0.9–149) 4.8 (2.4–10.3)
20 (47) 23 (54) 50 (10–800) 2000 (600–3000) 27 (63) 18 (42) 112 (49.3–979) 226 (142–360) 163 (98–291) 15:33 (10:20–22:03) 33 (11)f 10 (50)f 23.1 (0.2–117) 22.2 (14–95.1)
P
.3 .6 .8 .1 .6
.2
.005 .09 .03 .12 .9 b.001 b.001 b.001 .001 .4 b.001
Data are median (range) or N (%). a Simple procedure — robotic-assisted hysterectomy +/− bilateral salpingo-oophorectomy. b Complex procedure — simple procedure in conjunction with any of the additional: sentinel lymph node mapping, pelvic and/or aortic lymph node dissection, appendectomy, omentectomy. c Room time is the time from patient entering the operating room to leaving the operating room. d Operative time is the time from skin incision to skin closure. e Time to discharge is the time from patient getting out of the operating room to being discharged. f For time case ended, before 6 pm and after 6 pm, percentages are calculated with the denominator being the row total.
Please cite this article as: Lee SJ, et al, The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.006
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12 months, respectively, in a series of 527 patients undergoing sameday laparoscopic hysterectomy. In addition, 1.5% had urgent clinic appointments within 72 h of surgery and 4% visited the emergency department within 48 h of surgery. In patients undergoing same-day laparoscopic gynecologic oncology procedures, Gien et al. [15] noted that 12.9% were evaluated in the emergency department and 2.7% were readmitted within 3 weeks postoperatively. Our 30-day UCC visit rate (5.1%) and readmission rate (2.5%) for those discharged the same day after robotic-assisted hysterectomy alone or in with other procedures compare favorably with these prior studies. Four of the 8 same-day discharge patients evaluated in the UCC required admission, which should alert the clinician to take seriously any complaints after robotic-assisted hysterectomy as patients undergoing minimally invasive procedures generally improve each and every day. The two visits in the UCC within 48 h of discharge were for one patient with diclofenac misuse and another with a pelvic hematoma who restarted anticoagulation for atrial fibrillation on the evening of surgery. It is unlikely that postoperative admission overnight would have prevented these visits as both of these patients presented on postoperative day 2. In the group of 43 patients admitted postoperatively, we noted a 12% UCC visit and 7.0% readmission rate. One UCC visit and readmission on postoperative day 6 was for an incarcerated hernia at a non-trocar site, thus unrelated to the initial surgery. Another UCC visit and readmission on postoperative day 12 was for a very rare complication—a retained foreign body; the metal plate on one blade of the robotic needle driver became dislodged during the course of the operation. Given these uncommon events, in a larger series, we would expect that these rates would be more in line with those of prior studies. Forty-three (22%) patients required postoperative admission. At first glance this may seem incongruous with the feasibility of same-day discharge in our cohort of patients undergoing robotic-assisted hysterectomies. However, nearly half of these postoperative admissions were for non-medical reasons (20/43) — patient desire, late case, long commute and inclement weather. The postoperative admission rate for medical reasons was only 12% (23/200). Furthermore, in comparing our data for the first 100 planned same-day cases to the next 100 cases, the rate of postoperative admission for medical reasons remained consistent (12 to 11%) while decreasing from 14 to 6% for non-medical reasons, suggesting that over time improved preoperative counseling and scheduling of cases had a clear impact on admission rates. Our cohort of patients is from a single institution specializing in cancer care, and the surgeons are all fellowship-trained gynecologic oncologists, thus potentially limiting the generalizability of our findings. However, as 53% of the cases were either for benign or preinvasive disease, we believe that our findings are applicable to both the gynecologist and gynecologic oncologist performing robotic-assisted hysterectomies.
There are no established criteria for the ideal patient for same-day discharge. A successful same-day discharge program requires sound patient selection, preoperative counseling with clear patient expectations, anesthesia protocols for pain and nausea prevention, ready access to pain medications and help at home, well-defined discharge criteria, detailed postoperative instructions, and scheduling of same-day procedures to start as the first case or earlier in the day. With these principles in mind, our study demonstrates that same-day discharge for robotic-assisted hysterectomies alone or with other procedures for benign and malignant indications is both feasible and safe. Conflict of interest statement Dr. Leitao is a consultant for Intuitive Surgical, Inc. All other authors have no conflicts of interest to declare.
References [1] Kesharvarz H, Hillis SD, Kieke BA, Marchbank PA. Hysterectomy surveillance: United States 1994–1999. MMWR Morb Mortal Wkly Rep 2002;51:1–8. [2] Farquhar CM, Steiner CA. Hysterectomy rates in the US, 1990–1997. Obstet Gynecol 2002;2:229–34. [3] Wu JM, Wecther ME, Geller EJ, Nguyen V, Visco AG. Hysterectomy rates in the US, 2003. Obstet Gynecol 2007;110(5):1091–5. [4] Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009;3:CD003677. [5] Gaia G, Holloway RW, Santoro L, Ahmad S, Di Silverio E, Spinillo A. Robotic-assisted hysterectomy for endometrial cancer compared with traditional laparoscopic and laparotomy approaches: a systematic review. Obstet Gynecol 2010;116:1422–31. [6] Lowe MP, Chamberlain DH, Kamelle SA, Johnson PR, Tillmanns TD. A multiinstitutional experience with robotic assisted radical hysterectomy for early stage cervical cancer. Gynecol Oncol 2009;113:191–4. [7] Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol 2009;27 (32):5331–6. [8] Liu H, Lu D, Wang L, Shi G, Song H, Clarke J. Robotic surgery for benign gynaecological disease. Cochrane Database Syst Rev 2012;2:CD008978. [9] Maeso S, Reza M, Mayol JA, Blasco JA, Guerra M, Andradas E, et al. Efficacy of the da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis. Ann Surg 2010;252(2):254–62. [10] Taylor RH. Outpatient laparoscopic hysterectomy with discharge in four to six hours. J Am Assoc Gynecol Laparosc 1994;1(4 pt 2):S35. [11] Hoffman CP, Kennedy J, Borschel L, Burchette R, Kidd A. Laparoscopic hysterectomy: the Kaiser Permanente San Diego experience. J Minim Invasive Gynecol 2005; 12:16–24. [12] Perron-Burdick M, Yamamoto M, Zaritsky E. Same-day discharge after laparoscopic hysterectomy. Obstet Gynecol 2011;117(5):1136–41. [13] Chou DC, Rosen DM, Cario GM, Carlton MA, Lam AM, Chapman M, et al. Home within 24 hours of laparoscopic hysterectomy. Aust N Z J Obstet Gynaecol 1999;39:234–8. [14] Thiel J, Gamelin A. Outpatient total laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc 2003;10:481–3. [15] Gien LT, Kupets R, Covens A. Feasibility of same-day discharge after laparoscopic surgery in gynecologic oncology. Gynecol Oncol 2011;121:339–43.
Please cite this article as: Lee SJ, et al, The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.006
Contents lists available at ScienceDirect
Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno
The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications Stephen J. Lee, Bianca Calderon, Ginger J. Gardner, Allison Mays, Stephanie Nolan, Yukio Sonoda, Richard R. Barakat, Mario M. Leitao Jr. ⁎ Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
H I G H L I G H T S • Same-day discharge was planned in 200 cases and 157 (78%) had successful same-day discharge. • Forty-three (22%) patients required postoperative admission, 23 for medical reasons and 20 for non-medical reasons. • Operative time, case ending before 6 pm, and use of intraoperative ketorolac were associated with successful same-day discharge.
a r t i c l e
i n f o
Article history: Received 31 December 2013 Accepted 4 April 2014 Available online xxxx Keywords: Robotic-assisted hysterectomy Same-day discharge TLH BSO
a b s t r a c t Objective. This study aimed to report the feasibility and safety of same-day discharge after robotic-assisted hysterectomy. Methods. Same-day discharge after robotic-assisted hysterectomy was initiated 07/2010. All cases from then through 12/2012 were captured for quality assessment monitoring. The distance from the hospital to patients' homes was determined using http://maps.google.com. Procedures were categorized as simple (TLH +/− BSO) or complex (TLH +/− BSO with sentinel node mapping, pelvic and/or aortic nodal dissection, appendectomy, or omentectomy). Urgent care center (UCC) visits and readmissions within 30 days of surgery were captured, and time to the visit was determined from the initial surgical date. Results. Same-day discharge was planned in 200 cases. Median age was 52 years (range, 30–78), BMI was 26.8 kg/m2 (range, 17.4–56.8), and ASA was class 2 (range, 1–3). Median distance traveled was 31.5 miles (range, 0.2–149). Procedures were simple in 109 (55%) and complex in 91 (45%) cases. The indication for surgery was: endometrial cancer (n = 82; 41%), ovarian cancer (n = 5; 2.5%), cervical cancer (n = 8; 4%), and nongynecologic cancer/benign (n = 105; 53%). One hundred fifty-seven (78%) had successful same-day discharge. Median time for discharge for these cases was 4.8 h (range, 2.4–10.3). Operative time, case ending before 6 pm, and use of intraoperative ketorolac were associated with successful same-day discharge. UCC visits occurred in 8/157 (5.1%) same-day discharge cases compared to 5/43 (11.6%) requiring admission (P = .08). Readmission was necessary in 4/157 (2.5%) same-day discharge cases compared to 3/43 (7.0%) requiring admission (P = .02). Conclusions. Same-day discharge after robotic-assisted hysterectomy for benign and malignant conditions is feasible and safe. © 2014 Elsevier Inc. All rights reserved.
Introduction More than 600,000 hysterectomies are performed in the United States annually, and ever-increasing numbers are being completed using minimally invasive techniques [1–3]. In 2005, the US Food and ⁎ Corresponding author at: Memorial Sloan-Kettering Cancer Center, Gynecology Service, Department of Surgery, 1275 York Avenue, New York, NY 10065, USA. Fax: + 1 212 717 3214. E-mail address: [email protected] (M.M. Leitao).
Drug Administration approved the robotic surgical platform for gynecologic surgery. The benefits of minimally invasive surgery for both benign and malignant gynecologic conditions, including smaller incisions, decreased blood loss, decreased pain, shorter hospital stay and earlier return to activities, have been well documented [4–7]. The robotic platform offers the additional benefits of increased range of instrument motion, 3-dimensional stereoscopic visualization, and improved surgeon ergonomics [8,9]. For patients undergoing simple minimally invasive oophorectomies or ovarian cystectomies, same-day discharge has become routine.
http://dx.doi.org/10.1016/j.ygyno.2014.04.006 0090-8258/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Lee SJ, et al, The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.006
2
S.J. Lee et al. / Gynecologic Oncology xxx (2014) xxx–xxx
However, most gynecologists still admit patients overnight for observation after a laparoscopic or robotic-assisted hysterectomy. Concerns regarding patient safety, such as bleeding or identifying inadvertent injury to adjacent structures, are often cited as reasons for overnight admission after minimally invasive gynecologic surgery. Nevertheless, major bleeding should be detected prior to discharge from the postoperative unit, and injury to nearby organs is either identified at the time of surgery or not until several days later. Adequate pain control and nausea/vomiting are additional concerns. Several single-institution reports describe successful discharge within 12–24 h after laparoscopic hysterectomy for both benign and malignant conditions [10–14]; however, we are unaware of any studies reporting same-day discharge after robotic-assisted hysterectomy. The purpose of this study was to evaluate the feasibility and safety of same-day discharge for patients undergoing robotic-assisted hysterectomy alone or with other procedures for benign and malignant conditions.
vital signs, adequate oxygenation, no nausea, pain control with oral medications, and voided postoperatively. Nursing staff contacted all patients on postoperative day 1 to ensure a smooth transition home. All patients had their first postoperative visit within 4 weeks of surgery. Electronic medical records were reviewed to ascertain if any postoperative UCC visit or hospital readmission occurred within 30 days of surgery, and the time to the visit was determined from the surgical date. Outpatient clinic notes were also reviewed to discern if patients had been evaluated at a local emergency room or admitted to their community hospital within 30 days of surgery. Categorical variables were compared using the Chi-square test, and continuous variables were compared using the Mann–Whitney U or the Kruskal–Wallis test as appropriate. All statistical analyses were performed using SPSS Statistics 20.0 (IBM, Chicago, IL).
Materials and methods
Two hundred patients were scheduled for same-day discharge, robotic-assisted hysterectomy alone or with other procedures during the study period. Clinicopathologic characteristics of the overall cohort are presented in Table 1. The median age was 52 years (range, 30– 78), BMI was 26.8 kg/m2 (range, 17.4–56.8), and ASA class was 2 (range, 1–3). Fifty-eight (29%) patients met the definition of obesity (BMI ≥ 30), with 26 (13%) patients with a BMI ≥ 35. Medical comorbidities included hypertension (n = 33), coronary artery disease (n = 10), dyslipidemia (n = 35), heart murmur (n = 13), arrhythmia (n = 3), chronic obstructive pulmonary disease (n = 14), obstructive sleep apnea (n = 6), and diabetes mellitus (n = 10). More than half of the patients had a prior laparoscopy and/or laparotomy. Gynecologic cancer was the surgical indication in 47% of the cases, with 45% of the cases being categorized as complex. The median EBL was 50 mL (range, 5– 800), and the median operative time was 136 min (range, 79–291). Three quarters of the patients received intraoperative ketorolac and
A same-day discharge approach after robotic-assisted hysterectomy was initiated at our institution in July 2010. After the Institutional Review Board approval, we identified all patients who were scheduled to undergo robotic-assisted hysterectomy with planned same-day discharge from that time until December 2012. Procedures were scheduled as same-day discharge at the discretion of the surgeon, and all cases discharged home from the post-anesthesia care unit (PACU) without requiring admission to the inpatient unit were classified as same-day discharge. All electronic medical records, including operative and pathology reports, postoperative unit records, urgent care center (UCC) encounters, as well as outpatient clinic notes, were reviewed. Information collected from the records included age, body mass index (BMI), American Society of Anesthesiology (ASA) class, past medical history, previous pelvic and/or abdominal surgery, preoperative diagnosis, and surgical procedure. Simple procedures were defined as robotic-assisted hysterectomies +/− bilateral salpingo-oophorectomy (BSO), and complex procedures were defined as robotic-assisted hysterectomies +/− BSO with any of the following: sentinel node mapping, pelvic and/or aortic nodal dissection, appendectomy, or omentectomy. Perioperative data collected included estimated blood loss (EBL), amount of crystalloid infused, uterine weight, conversion to laparotomy, room time (time from patient entering the operating room to leaving the operating room), operative time (time from skin incision to completion of skin closure), time to discharge (time from patient leaving the operating room to time of discharge), and intraoperative or immediate postoperative complications. The distance (in miles) from the hospital to the patient's home was determined using an online service (http://maps.google.com). All surgeons are fellowship-trained gynecologic oncologists who performed robotic-assisted hysterectomy alone or in conjunction with other procedures using the da Vinci® Si dual console platform. The setup required the use of 5 ports: a 12 mm camera port, 2 ports (8 mm) in bilateral lower quadrants, an 8 mm port inferior to the R subcostal margin, and a 10/12 mm assistant port inferior to the L subcostal margin. Standard robotic monopolar shears and bipolar forceps were used. Suture for vaginal cuff closure was either vicryl or V-Loc (Covidien, Mansfield, MA) based on surgeon preference. Intraoperative ketorolac and trocar site bupivacaine administration was at the discretion of the surgeon. Prior to fascial closure, positive pressure ventilations were administered to decrease residual pneumoperitoneum and reduce postoperative pain. All patients received a similar oral pain and bowel medication regimen, consisting of diclofenac 75 mg every 12 h, hydrocodone/acetaminophen 5 mg/325 mg 1–2 tablets every 4 h as needed, docusate 100 mg every 8 h as needed, and sennosides 8.6 mg every 12 h as needed. Prescriptions for these postoperative medications were given at the preoperative visit. There was no standard anti-emetic regimen. Patients were discharged home if they had normal
Results
Table 1 Clinicopathologic characteristics of overall cohort (N = 200). Median (range) or N (%) Age, y BMI, kg/m2 ASA class Prior laparoscopy and/or laparotomy Preoperative diagnosis Endometrial cancer Cervical cancer Ovarian cancer Benign/preinvasive disease Procedure type Simplea Complexb EBL, mL Intraoperative crystalloid, mL Intraoperative ketorolac Trocar site bupivacaine Uterine weight, g Room timec, min Operative timed, min Time case endede, h:min Distance from hospital, miles Time to discharge, h
52 (30–78) 26.8 (17.4–56.8) 2 (1–3) 109 (55) 82 (41) 8 (4) 5 (2.5) 105 (53) 109 (55) 91 (45) 50 (5–800) 1700 (600–3000) 151 (76) 105 (53) 116 (31.5–979) 196 (134–360) 136 (79–291) 13:22 (9:53–22:03) 31.5 (0.2–149) 5.23 (2.4–95.1)
BMI, body mass index; ASA, American Society of Anesthesiologists; EBL, estimated blood loss. a Simple procedure — robotic-assisted hysterectomy +/− bilateral salpingo-oophorectomy. b Complex procedure — simple procedure in conjunction with any of the additional: sentinel lymph node mapping, pelvic and/or aortic lymph node dissection, appendectomy, omentectomy. c Room time is the time from patient entering the operating room to leaving the operating room. d Operative time is the time from skin incision to skin closure. e Time to discharge is the time from patient getting out of the operating room to being discharged.
Please cite this article as: Lee SJ, et al, The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.006
S.J. Lee et al. / Gynecologic Oncology xxx (2014) xxx–xxx
just over half received bupivacaine at the trocar sites. The median distance patients had to travel from the hospital was 31.5 miles (range, 0.2–149). The median time to discharge was 5.2 h (range, 2.4–95.1). One hundred fifty-seven (78%) patients were successfully discharged the same day, while 43 (22%) were admitted. Of those admitted, 30 (70%) stayed less than 24 h in the hospital, 12 (28%) between 24 and 48 h, and 1 (2%) more than 48 h. Reasons for admission are summarized in Table 2. Non-medical reasons included patient desire (n = 12), late case — all ending after 6 pm (n = 5), long commute home — one patient 85 miles and another 115 miles (n = 2), and inclement weather (n = 1). Of the patients admitted for medical reasons, just over half were admitted for reasons such as nausea (n = 5), pain (n = 3), and urinary retention (n = 4). Six patients were admitted secondary to large uterine specimens necessitating mini-laparotomy (n = 2) or resulting in vaginal lacerations during removal (n = 4). In addition, 2 patients were admitted for vasovagal episodes and one each for fever, abnormal electrocardiogram, and hypoxemia. None of the postoperative admissions resulted in the detection of a major complication. All UCC visits and readmissions occurred at the hospital where the original surgery took place (Table 3). Within 30 days postoperatively, there were 13 (6.5%) UCC visits resulting in 7 (3.5%) hospital readmissions, with the majority occurring more than 48 h after the surgery. In the same-day discharge group, there were 8 (5.1%) UCC visits: bleeding (n = 3), infection (n = 2), fever (n = 1), medication misuse (n = 1), and to rule out deep vein thrombosis (n = 1). There were no UCC visits for pain management in those who were discharged the same day. The 4 readmissions were in 3 patients — pelvic hematoma with subsequent readmission for superinfected hematoma, abdominal wall hematoma, and fever. In the group requiring postoperative admission, there were 5 (12%) UCC visits: bleeding (n = 2), fever (n = 1), foreign body (n = 1), and nausea/vomiting (n = 1). The 3 readmissions were for trocar site wound infection after hematoma evacuation, incarcerated hernia (not at trocar site) and retained foreign body. Comparing patients who successfully completed same-day discharge to those who were admitted postoperatively (Table 4), the following differences were noted to be statistically significant: EBL (P = .005), room time (P b .001), operative time (P b .001), time case ended (P = .001), and intraoperative ketorolac use (P = .03). Age, BMI, ASA class, medical comorbidities, prior pelvic and/or abdominal surgery, preoperative diagnosis, procedure type, uterine weight, trocar site bupivacaine use, and distance from hospital to home did not show a statistically significant difference. Discussion This study was designed to evaluate the feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with
Table 2 Reasons for postoperative admission (N = 43). N (%) Non-medical reasons Patient desire Late case Long commute Inclement weather Medical reasons Nausea Urinary retention Intraoperative vaginal laceration Pain Postoperative vasovagal episode Mini-laparotomy to remove specimen Fever Abnormal EKG Hypoxemia
20 (47) 12 5 2 1 23 (53) 5 4 4 3 2 2 1 1 1
3
Table 3 Urgent care center (UCC) visit and hospital readmission rates within 30 days postoperatively.
UCC visit ≤48 h 48 h to 7 days 7 to 30 days Hospital readmission ≤48 h 48 h to 7 days 7 to 30 days
All cases (N = 200)
Same-day dischargea (N = 157)
Admitted (N = 43)
P
13 (6.5) 2 3 8 7 (3.5) 1 2 4
8 (5.1) 2 1 5 4 (2.5) 1 1 2
5 (12) 0 2 3 3 (7.0) 0 1 2
.08
.02
a In the same-day discharge group, one patient had two UCC visits resulting in two readmissions.
other procedures for benign and malignant conditions. Operative time, case ending before 6 pm, and use of intraoperative ketorolac were associated with successful same-day discharge. Of note, 75% (68/91) of complex cases and 50% of cases ending after 6 pm resulted in same-day discharge. In 1994, Taylor first described a series of 7 patients discharged 4 to 6 h after laparoscopic hysterectomy followed by same-day home nurse visits in which no complications or readmissions were noted [10]. Hoffman et al. [11] reported a 30-day readmission rate after laparoscopic hysterectomy of 4.9% for same-day discharge (n = 81) compared with 2.2% for later-day discharge (n = 278). Perron-Burdick et al. [12] documented readmission rates of 0.6%, 3.6% and 4% at 48 h, 3 months and Table 4 Comparison of same-day discharge vs admitted cases.
Age, y BMI, kg/m2 ASA class Prior laparoscopy and/ or laparotomy Preoperative diagnosis Endometrial cancer Cervical cancer Ovarian cancer Non-gynecologic cancer or benign Procedure type Simplea Complexb EBL, mL Intraoperative crystalloid, mL Intraoperative ketorolac Trocar site bupivacaine Uterine weight, g Room timec, min Operative timed, min Time case endede, h:min Before 6 pm After 6 pm Distance from hospital, miles Time to discharge, h
Same-day discharge (N = 157)
Admitted (N = 43)
52 (30–77) 26.7 (17.4–56.8) 2 (1–3) 90 (57)
53 (38–78) 26.9 (19.5–55.7) 2 (1–3) 19 (44)
63 (40) 7 (4.5) 3 (2) 84 (54)
19 (44) 1 (2) 2 (5) 21 (49)
89 (57) 68 (43) 50 (5–300) 1700 (700–3000) 124 (79) 87 (55) 120 (31.5–874) 193 (134–351) 130 (79–289) 13:08 (9:53–21:00) 147 (82)f 10 (50)f 35.6 (0.9–149) 4.8 (2.4–10.3)
20 (47) 23 (54) 50 (10–800) 2000 (600–3000) 27 (63) 18 (42) 112 (49.3–979) 226 (142–360) 163 (98–291) 15:33 (10:20–22:03) 33 (11)f 10 (50)f 23.1 (0.2–117) 22.2 (14–95.1)
P
.3 .6 .8 .1 .6
.2
.005 .09 .03 .12 .9 b.001 b.001 b.001 .001 .4 b.001
Data are median (range) or N (%). a Simple procedure — robotic-assisted hysterectomy +/− bilateral salpingo-oophorectomy. b Complex procedure — simple procedure in conjunction with any of the additional: sentinel lymph node mapping, pelvic and/or aortic lymph node dissection, appendectomy, omentectomy. c Room time is the time from patient entering the operating room to leaving the operating room. d Operative time is the time from skin incision to skin closure. e Time to discharge is the time from patient getting out of the operating room to being discharged. f For time case ended, before 6 pm and after 6 pm, percentages are calculated with the denominator being the row total.
Please cite this article as: Lee SJ, et al, The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.006
4
S.J. Lee et al. / Gynecologic Oncology xxx (2014) xxx–xxx
12 months, respectively, in a series of 527 patients undergoing sameday laparoscopic hysterectomy. In addition, 1.5% had urgent clinic appointments within 72 h of surgery and 4% visited the emergency department within 48 h of surgery. In patients undergoing same-day laparoscopic gynecologic oncology procedures, Gien et al. [15] noted that 12.9% were evaluated in the emergency department and 2.7% were readmitted within 3 weeks postoperatively. Our 30-day UCC visit rate (5.1%) and readmission rate (2.5%) for those discharged the same day after robotic-assisted hysterectomy alone or in with other procedures compare favorably with these prior studies. Four of the 8 same-day discharge patients evaluated in the UCC required admission, which should alert the clinician to take seriously any complaints after robotic-assisted hysterectomy as patients undergoing minimally invasive procedures generally improve each and every day. The two visits in the UCC within 48 h of discharge were for one patient with diclofenac misuse and another with a pelvic hematoma who restarted anticoagulation for atrial fibrillation on the evening of surgery. It is unlikely that postoperative admission overnight would have prevented these visits as both of these patients presented on postoperative day 2. In the group of 43 patients admitted postoperatively, we noted a 12% UCC visit and 7.0% readmission rate. One UCC visit and readmission on postoperative day 6 was for an incarcerated hernia at a non-trocar site, thus unrelated to the initial surgery. Another UCC visit and readmission on postoperative day 12 was for a very rare complication—a retained foreign body; the metal plate on one blade of the robotic needle driver became dislodged during the course of the operation. Given these uncommon events, in a larger series, we would expect that these rates would be more in line with those of prior studies. Forty-three (22%) patients required postoperative admission. At first glance this may seem incongruous with the feasibility of same-day discharge in our cohort of patients undergoing robotic-assisted hysterectomies. However, nearly half of these postoperative admissions were for non-medical reasons (20/43) — patient desire, late case, long commute and inclement weather. The postoperative admission rate for medical reasons was only 12% (23/200). Furthermore, in comparing our data for the first 100 planned same-day cases to the next 100 cases, the rate of postoperative admission for medical reasons remained consistent (12 to 11%) while decreasing from 14 to 6% for non-medical reasons, suggesting that over time improved preoperative counseling and scheduling of cases had a clear impact on admission rates. Our cohort of patients is from a single institution specializing in cancer care, and the surgeons are all fellowship-trained gynecologic oncologists, thus potentially limiting the generalizability of our findings. However, as 53% of the cases were either for benign or preinvasive disease, we believe that our findings are applicable to both the gynecologist and gynecologic oncologist performing robotic-assisted hysterectomies.
There are no established criteria for the ideal patient for same-day discharge. A successful same-day discharge program requires sound patient selection, preoperative counseling with clear patient expectations, anesthesia protocols for pain and nausea prevention, ready access to pain medications and help at home, well-defined discharge criteria, detailed postoperative instructions, and scheduling of same-day procedures to start as the first case or earlier in the day. With these principles in mind, our study demonstrates that same-day discharge for robotic-assisted hysterectomies alone or with other procedures for benign and malignant indications is both feasible and safe. Conflict of interest statement Dr. Leitao is a consultant for Intuitive Surgical, Inc. All other authors have no conflicts of interest to declare.
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Please cite this article as: Lee SJ, et al, The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.006