ORIGINAL RESEARCH & CONTRIBUTIONS

Transcription

1 credits vilble for this rticle see pge 96. ORIGINAL RESEARCH & CONTRIBUTIONS Sfely Increse the Minimlly Invsive Hysterectomy Rte: A Novel Three-Tiered Preopertive Ctegoriztion System Cn Predict the Difficulty for Benign Disese Estebn Andryjowicz, BScPhm, MD, FACOG; Teres B Wry, MD, FACOG; V Reinldo Ruiz, MD, FACOG; Jmes Rudolf, MD, FACOG; Sr Noroozkhni, MD, FACOG; Sndr Crowder, MD, FACOG; Jeff M Slezk Perm J 2015 Fll;19(4): ABSTRACT Context: A nonlprotomic route is recommended for hysterectomy for benign indictions. Objective: 1) Predict the difficulty of hysterectomy to tret benign disese s mesured by opertive time nd risk of lprotomy, 2) confirm the sfety nd qulity of incresing our minimlly invsive hysterectomy (MIH) rte, nd 3) determine whether the ssistnt s experience ffected the likelihood of n MIH being performed in eqully difficult hysterectomies. Design: All hysterectomies for benign disese performed t the Kiser Permnente Fontn Medicl Center in Fontn, CA, in 2012 were reviewed for length of surgery, length of sty, complictions, nd redmissions. A three-tiered ctegory system ws developed from four preopertive prmeters (body mss index, number of vginl deliveries, clinicl uterine size, nd history of mjor bdominl surgery) to nticipte length nd difficulty of surgery. Min Outcome Mesures: Rtes of MIH, complictions, nd redmissions s well s length of surgery nd length of sty for similrly difficult hysterectomies. These outcomes were compred with surgeons nd ssistnts experience. Results: Of 576 hysterectomies performed for benign disese, 89% were MIH with 3% compliction rte nd 4% redmission rte. An increse in the hysterectomy ctegory ws sttisticlly significntly ssocited with longer surgery times nd higher percentge of lprotomy. With the most experienced ssistnts, the MIH rte ws 98%. Conclusions: Using 4 preopertive prmeters, the verge operting time for hysterectomy for benign disese cn be predicted. A higher hysterectomy ctegory predicts more difficult surgery. Our center hs incresed its MIH rte to 89% while mintining sfety. INTRODUCTION Approximtely 600,000 hysterectomies re performed nnully in the US. 1 In 1998, pproximtely 65% of hysterectomies were performed vi lprotomy, nd in 2010, this rte went down to 54.2%. 2 Both the Americn College of Obstetricins nd Gynecologists 3 nd Advncing Minimlly Invsive Gynecology Worldwide 4 hve recommended minimlly invsive route (nonlprotomic) for hysterectomy for benign disese. Andryjowicz nd Wry 5 demonstrted how the Southern Cliforni Permnente Medicl Group reched 78% rte of minimlly invsive hysterectomy (MIH), cross 13 Medicl Centers involving more thn 350 generl gynecologists performing 4000 hysterectomies yerly for benign indictions. This ws chieved with eduction nd expert mentoring. With continued increse in MIH t our Medicl Center, we wnted to ensure tht sfety nd qulity were mintined. It is more importnt thn ever to be excellent stewrds of our helth cre resources in this time of emphsis on vlue in helth cre. The bility to determine how difficult hysterectomy will be nd to estimte the time required to perform it would enble gynecologic prctice to enhnce surgeon nd ssistnt piring nd operting room (OR) utiliztion s well s recognize the incresed skills needed for the more difficult surgeries. Time in the OR is n expensive commodity, estimted to be more thn $30 minute t our Medicl Center. Underbooking or overbooking cses is costly to the system in both dollrs nd stress on stffing. It lso inconveniences ptients witing longer for elective surgeries if ORs re underutilized. From review of surgicl cse times t our Medicl Center, cross multiple specilties, we believed we could reduce the time between the closing incision t the end of one cse to the strt of the next cse incision to 65 minutes for hysterectomies for benign disese. We chose this metric over the well-known out of room to into room becuse it better describes wht the surgeon sees s the totl nonoperting time in n OR. In our ll-dy surgicl block, the first cse ws to be on the OR tble by 7:15 m with time for the surgeon s incision by 7:55 m, nd the lst cse ws expected to be closed by 5 pm. This llowed 545 minutes of totl OR time for the dy, which would include the nonoperting close to incision time of 65 minutes between cses. Estebn Andryjowicz, BScPhm, MD, FACOG, is n Obstetricin/Gynecologist t the Fontn Medicl Center in CA. E-mil: estebn..ndryjowicz@kp.org. Teres B Wry, MD, FACOG, is the former Regionl Chief of Obstetrics nd Gynecology for the Southern Cliforni Permnente Medicl Group t the Fontn Medicl Center in CA nd the present Chief of Obstetrics nd Gynecology t the Fontn Medicl Center in CA. E-mil: teres.b.wry@kp.org. V Reinldo Ruiz, MD, FACOG, is n Obstetricin/ Gynecologist t the Fontn Medicl Center in CA. E-mil: reinldo.v.ruiz@kp.org. Jmes Rudolf, MD, FACOG, is n Obstetricin/ Gynecologist t the Fontn Medicl Center in CA. E-mil: jmes.d.rudolf@kp.org. Sr Noroozkhni, MD, FACOG, is n Obstetricin/ Gynecologist t the Fontn Medicl Center in CA. E-mil: sr.x.noroozkhni@kp.org. Sndr Crowder, MD, FACOG, is n Obstetricin/Gynecologist t the Fontn Medicl Center in CA. E-mil: sndr.c.crowder@kp.org. Jeff M Slezk is the Reserch Mnger of Biosttistics for the Southern Cliforni Permnente Medicl Group in Psden. E-mil: jeff.m.slezk@kp.org. The Permnente Journl/ Fll 2015/ Volume 19 No. 4 39

2 Severl fctors hve been shown individully to ffect the difficulty of performing hysterectomy for benign disese. We combined four of these fctors to preopertively predict the length nd difficulty of surgery. A lck of history of vginl delivery hs been shown to increse the length of the surgicl procedure, lthough it my or my not increse the compliction rte, nd it does not chnge the length of sty (LOS) or the redmission rtes. 6-9 An incresing uterine size lso hs been shown to increse the opertive time, compliction rtes, nd surgicl conversions from MIH to lprotomy With incresing body mss index (BMI), there is n increse in length of surgery, but no mjor incresed risk of conversion from n MIH to lprotomy or of LOS, complictions, or redmissions A history of lprotomies increses the risk of conversion from vginl hysterectomy to lprotomy, which cn increse the length of surgery 25 nd the number of complictions. 15,26,27 Surgeon experience nd volume of surgery cn ffect operting time, compliction rtes, risk of conversion from MIH to lprotomy, LOS, costs, nd surgicl pproch tken for hysterectomy for benign disese. 26,28-34 The more experienced gynecologists t our Medicl Center re ble to predict the difficulty, nd therefore the length of time required to perform hysterectomy for benign disese, lthough this skill is not universl. They frequently rrnge for n experienced ssistnt when difficult surgery is nticipted, gin not universlly. We sought to develop method to help ll our gynecologists identify the more chllenging cses so tht they could both book longer OR time nd rrnge more experienced ssistnt to improve their MIH rtes while mintining sfety. Additionlly, if ll the cses for the dy were nticipted to be of shorter durtion, n extr cse could be booked to improve efficiency. The ims of this study were 1. to predict the difficulty of hysterectomy for benign disese, mesured by opertive time nd risk of lprotomy 2. to confirm the sfety nd qulity of incresing the MIH rte by compring compliction nd redmission rtes with the literture 3. to determine if the ssistnt s experience ffected the likelihood of n MIH. METHODS This study ws pproved by the Kiser Permnente Southern Cliforni (KPSC) institutionl review bord nd ws crried out t Kiser Permnente Fontn Medicl Center in Fontn, CA, 1 of 14 KPSC Medicl Centers. In 2012, Fontn Medicl Center provided services to pproximtely 430,000 ptients. There were 39 generl obstetricin-gynecologists performing hysterectomies for benign disese. We rbitrrily lbeled the 19 clinicins hving less thn 3 yers of consultnt experience s junior. The 2 clinicins with extensive MIH experience were lbeled senior, nd the 18 clinicins with experience between these 2 levels were lbeled midlevel. In 55 cses resident physicin from Lom Lind University ws the primry ssistnt. For type of hysterectomy performed, stndrd definition ws used for totl bdominl hysterectomy. Hysterectomy included the following: Lproscopic-ssisted vginl hysterectomy: most cses included uterine rtery cogultion vi lproscopy Vginl hysterectomy Totl lproscopic hysterectomy: most removed vginlly Minilprotomy: 4- to 5-cm or smller incision for removl of the specimen No robotic-ssisted hysterectomies were crried out during the study period. Minilprotomy ws clssified s n MIH-type procedure. It hs been shown tht minilprotomy for hysterectomy is better thn lprotomy but not s good s the lproscopic pproch s relted to morbidity nd LOS In our 21 cses with minilprotomy for removl of the specimen, 19 ptients went home by morning, nd the highest pin score during their sty ws less thn 5 of 10 on visul nlog scle, with morbidity similr to ny other MIH procedure. All hysterectomies for benign disese performed in 2012 were identified from dischrge codes (Interntionl Clssifiction of Diseses, Ninth Revision): 68.41, 68.49, 68.51, nd These electronic medicl records were then individully reviewed by the uthors (ech uthor reviewed bout 120 chrts) to remove ll oncology cses, s well s ny cses with dd-on procedures plnned other thn cystoscopy. Outcome mesures reviewed included length of surgery in minutes (incision to close), LOS in hours (out of room to out of hospitl), complictions, nd redmissions before the 4-week postopertive visit. Other prmeters reviewed included surgeonssistnt piring s well s the ptient s BMI, medicl history, surgicl history, obstetric history, estimted uterine size, nd ctul uterine weight. Opertive notes, dischrge summries, nd notes from the first postopertive office visit were reviewed s well s the notes section in the electronic medicl record to look for ny other dmission nd dischrge summries fter the initil surgicl dte. Follow-up ws from 3 to 14 months postopertively t the time of dt collection. We ctegorized hysterectomy for benign disese into Ctegory 1, 2, or 3 depending on 4 preopertive prmeters: 1) clinicl uterine size (equivlence by weeks of gesttion, common gynecologic descriptive to indicte the size of nonpregnnt uterus), 2) BMI, 3) number nd type of previous mjor bdominl surgeries (defined s cesren delivery; herni repir; ppendectomy; myomectomy; britric; bowel; or endometriosis surgery), nd 4) number of vginl deliveries. Tble 1 demonstrtes how the ctegories were defined nd how mny hysterectomies were in ech ctegory. Ctegory 1 included uterine size equivlent to or less thn 12 weeks gesttion, BMI less thn 30 kg/m 2, up to 1 previous lprotomy, nd t lest 1 vginl delivery. Ctegory 2 included 1 or 2 of the following fctors: clinicl uterine size of greter thn 12 weeks but less thn 18 weeks, BMI of 30 to 40 kg/m 2, 2 or 3 prior mjor bdominl surgeries, nd no prior vginl deliveries. If there were 3 Ctegory 2 items, the ptient moved up to Ctegory 3. Ctegory 3 lso included those with ny one of the 40 The Permnente Journl/ Fll 2015/ Volume 19 No. 4

3 Tble 1. Ptient chrcteristics of the ctegories of hysterectomy (N = 576) Ctegory Mesure Ctegory 1: All of below items (n = 140) BMI, kg/m 2 < 30 Mjor bdominl surgery, no. 1 Clinicl uterine size, weeks 12 Vginl delivery, no. 1 Ctegory 2: 1 or 2 of below items (n = 279) BMI, kg/m Mjor bdominl surgery, no. 2-3 Clinicl uterine size, weeks >12 - <18 Vginl delivery, no. 0 Ctegory 3: Any of below items (n = 157) BMI, kg/m 2 > 40 Mjor bdominl surgery, no. > 3 Clinicl uterine size, weeks 18 Totl Ctegory 2 items 3 or 4 BMI = body mss index; n = number of hysterectomies performed in ech ctegory. following: clinicl uterine size 18 weeks or greter, BMI greter thn 40 kg/m 2, or 4 or more prior mjor bdominl surgeries. All surgeons were encourged to ctegorize their hysterectomies preopertively nd to be proctive in obtining n ssistnt with the pproprite level of experience. The OR schedulers were lso encourged to use ctegoriztion nd their knowledge of the surgeons nd ssistnts to notify the Chief of the Deprtment (TBW) when there seemed to be mismtch between difficulty of surgery nd surgeon-ssistnt piring. When mismtch ws identified, gynecologist more experienced in MIH ws moved in to ssist. However, this did not occur in ll cses becuse of scheduling conflicts or simple oversight. The entire group ws wre of the vilbility of the senior clinicins for the most difficult cses. In our center, the surgeon nd ssistnt ech tend to perform bout hlf of the surgery (ie, their side of the hysterectomy). Eductionl rounds nd expert mentoring were the primry methods used to improve our MIH rtes sfely. Ptient chrcteristics were described using percentges or the men nd stndrd devition (SD). Sttisticl nlysis to ssess differences mong ptient chrcteristics nd surgicl mesures between procedure types or ctegories ws performed using the Kruskl-Wllis test for continuous mesures nd the χ 2 test for ctegoricl fctors. The number nd percentge of MIH surgeries by combintion of surgeon nd ssistnt were tbulted. Multivrite liner regression ws used to ssess the ssocition of preopertive fctors with length of surgery. Logistic regression ws used to ssess the likelihood of MIH by surgeon nd ssistnt. As senior surgeons performed only MIH in 2012, they were excluded from the model. Logistic regression ws lso used to ssess the likelihood of MIH by surgeon nd ssistnt when djusting for surgicl ctegory nd in the subset of Ctegory 3 surgeries. Sttisticl nlysis ws performed using SAS 9.2 (SAS, Cry, NC). All tests were 2-sided, nd p vlues of less thn 0.05 were tken to indicte sttisticl significnce. RESULTS There were 576 hysterectomies for benign disese crried out t the Fontn Medicl Center in 2012, with n overll 89% MIH rte. Tble 2 shows the number of ech type of MIH. Figure 1 shows the ssocition of ctegory with type of hysterectomy performed. As the ctegory incresed, the percentge of MIH decresed from 98% in Ctegory 1 to 91% in Ctegory 2 to 77% in Ctegory 3. The odds rtio to perform MIH for Ctegory 2 vs 1 ws 0.21 (confidence intervl = ) nd for Ctegory 3 vs 1 ws 0.06 (confidence intervl = ), both significntly reduced. Tble 3 reviews the type, number, nd percentges of complictions nd redmissions, with totl rte of 4% complictions nd 3% redmissions. One ureteric injury ws identified 1 week postopertively nd ws repired 2 months lter, with no long-term sequele. Tble 2 compres the vrious types of hysterectomy performed. It demonstrtes tht there were significnt differences between the type of hysterectomy performed nd uterine weight, previous mjor bdominl surgery nd vginl delivery, with no significnt difference relted to BMI. There Tble 2. Comprison fctor by type of hysterectomy (N = 576) Fctor LAVH (n = 409) VH (n = 68) TLH (n = 14) Minilprotomy (n = 21) TAH (n = 44) TAH from conversion (n = 20) p vlue Men BMI, kg/m 2 (SD) 31 (7) 30 (7) 32 (9) 32 (8) 32 (7) 33 (6) 0.51 Men uterine weight, g (SD) 241 (203) 157 (89) 220 (158) 1112 (620) 755 (916) 843 (1421) < Previous mjor bdominl 202 (49) 13 (19) 10 (71) 9 (43) 23 (52) 13 (61) < surgery, no. (%) Vginl delivery, no. (%) 294 (72) 67 (98) 5 (36) 6 (29) 19 (43) 9 (39) < Men incision-close, minutes (SD) 121 (48) 70 (25) 156 (62) 229 (63) 121 (40) 192 (75) < Men length of sty, hours (SD) 19 (12) 24 (10) 27 (20) 24 (10) 67 (27) 64 (38) < Compliction, no. (%) 11 (2) 3 (4) 1 (7) 0 (0) 2 (4) 7 (35) < Redmission, no. (%) 11 (2) 3 (4) 0 (0) 1 (5) 2 (4) 0 (0) Sttisticlly significnt t p < BMI = body mss index; LAVH = lproscopic-ssisted vginl hysterectomy; SD = stndrd devition; TAH = totl bdominl hysterectomy; TLH = totl lproscopic hysterectomy; VH = vginl hysterectomy. The Permnente Journl/ Fll 2015/ Volume 19 No. 4 41

4 Figure 1. Number nd percentges of minimlly invsive hysterectomies (MIH) nd open hysterectomies versus ctegory of hysterectomy (N = 576). were lso sttisticlly significnt differences in length of surgery, LOS, nd compliction rte but not in redmission rte. The lrgest uterus for MIH weighed 2482 g nd for lprotomy 6071 g. The lrgest BMI for ptient undergoing MIH ws 57 kg/m 2 nd for lprotomy ws 52 kg/m 2. The highest number of previous lprotomies for ptient undergoing MIH ws 6, nd for lprotomy it ws 4. Of the 20 conversions to lprotomy, 18 originted s lproscopic-ssisted vginl hysterectomy (4.4% of ll lproscopic-ssisted vginl hysterectomies performed) nd 2 originted s vginl hysterectomy (2.9% of ll vginl hysterectomies). Tble 4 compres the ctegories of hysterectomy. As expected from the criteri used to ctegorize, Ctegory 1 hd the smllest uteri, lightest ptients, lowest percentge of previous mjor bdominl surgeries, nd the highest percentge of previous vginl deliveries. Ctegory 3 ws t the other end of the spectrum, nd Ctegory 2 ws in-between. All these were sttisticlly significnt differences (Tble 4). There were lso sttisticlly significnt differences found in length of surgery nd LOS, but not in compliction or redmission rtes. Ctegory 1 hysterectomies lsted pproximtely 1.5 hours; Ctegory 2, pproximtely 2 hours; nd Ctegory 3, pproximtely 2.5 hours. The men LOS incresed from 20 (SD = 19) hours for Ctegory 1 to 23 (SD = 18) hours for Ctegory 2 nd to 32 (SD = 25) hours for Ctegory 3 (p < ). However, if one looks t the MIH procedures only, the increse in LOS ws much smller, from 18 (SD = 10) hours for Ctegory 1 to 19 (SD = 12) hours for Ctegory 2 nd 23 (SD = 14) hours for Ctegory 3, nd did not rech sttisticl significnce (p = 0.088). Ctegory 3 simply hd lrger percentge of open cses (23%) with their expected longer LOS. Senior surgeons performed only MIH during the yer (mening no plnned lprotomies or surgicl conversions in 2012), wheres for midlevel nd junior surgeons, 88% of the hysterectomies they performed were MIH. Tble 5 reviews the rtes of MIH depending on surgeon nd ssistnt experience. For both junior nd midlevel surgeons, their rtes of MIH were below 85% when pired with junior ssistnt nd bove 95% when pired with senior ssistnt, with rtes in-between for midlevel ssistnts. The likelihood of MIH bsed on the combintion of surgeon nd ssistnt is shown in Tble 6. The effect of the surgeon s experience between junior nd midlevel ws not significnt. Also, there ws no difference when junior or resident ws ssisting. However, both junior nd midlevel surgeons were somewht more likely to perform MIH if pired with midlevel ssistnt nd gretly more likely to perform MIH if pired with senior ssistnt, compred with junior ssistnt. Tble 7 shows the impct of surgeon-ssistnt piring on likelihood of MIH ccounting for the ctegory (difficulty) of the surgery. Although higher ctegories were ssocited with significntly lower odds of MIH, more experienced ssistnts were still ssocited with significntly greter likelihood of MIH. In the Ctegory 3 hysterectomies (most complex nd lest likely to be performed in minimlly invsive fshion), only the surgeries with senior ssistnts were significntly more likely to be performed s n MIH compred with those procedures with junior ssistnts. DISCUSSION Using ctegoriztion, we find tht we cn ccurtely predict difficulty of hysterectomy for benign disese, nd thus ccurtely determine lloction of OR time nd the need for ssistnce from n experienced surgeon with excellent MIH rtes. In ddition, we confirm the sfety, qulity, nd efficiency of our 89% MIH rte with compliction nd redmission rte of 4% nd 3% respectively, consistent with rtes from recent review. 38 Importntly, ctegoriztion of hysterectomy llows for more ccurte reserch comprisons. We cn now look to Tble 3. Complictions nd redmissions of hysterectomy for benign disese (N = 576) Compliction type No. (%) Bldder injury 9 (1.6) Trnsfusion 8 (1.4) Repet surgery sme dmission 4 (0.7) Ureter injury (1 week postopertive) 1 (0.2) Ileus needing hospitliztion 1 (0.2) Bowel injury 0 (0) Totl 23 (4.0) Redmission reson Vginl vult bleeding 1 (0.2) Abscess 3 (0.5) Hemtom 1 (0.2) Fever 1 (0.2) Wound infection 2 (0.3) Bowel obstruction 2 (0.3) Ureter repir 1 (0.2) Pin 1 (0.2) Pulmonry embolism 1 (0.2) Crdic disese 1 (0.2) Urine retention with renl filure 1 (0.2) Abscess, fever, nd hemtom 1 (0.2) Abscess, fever, IR drin, vesicovginl fistul, nd 1 (0.2) vginl repir 2 months lter Totl 17 (3.0) IR = plced by Interventionl Rdiology. 42 The Permnente Journl/ Fll 2015/ Volume 19 No. 4

5 find the best MIH procedure for length of surgery, short-term nd long-term morbidity, LOS, redmissions, totl costs, return-to-work timing, nd ptient stisfction. We cn lso investigte the surgeon s nd ssistnt s contribution to these outcomes. At some point, this method could lso be used for determining reltive vlue unit decisions relted to hysterectomies for benign disese, recognizing the incresed effort required to perform more complex surgeries. We s surgeons re the stewrds of mjor component of helth cre costs, nd it is impertive tht we mximize our vlue t the sme time s we improve our surgicl outcomes. By using 4 preopertive prmeters, the pproximte surgicl time for hysterectomy for benign disese cn be predicted. Identifiction of more difficult cses (Ctegory 3) hs llowed proctive scheduling of cses with more experienced MIH ssistnts in most, but not ll, cses. In our center of 39 generl gynecologists, with 49% hving less thn 3 yers of consultnt experience, 576 hysterectomies were performed for benign indictions, with n 89% MIH rte. With incresing ctegory, there ws significnt decrese in MIH overll. These prmeters were chosen becuse they were obtinble preopertively nd hd individully been shown in the literture to ffect surgicl time nd possibly LOS, complictions, or redmissions. A review of these prmeters follows with dt relted to ny effects on hysterectomy. Vginl Delivery History The medicl literture ws reviewed for studies tht evluted the effect of nulliprity or lck of vginl delivery on hysterectomy nd outcomes. Although most hysterectomy studies use prity s one of severl cse-control fctors, very few directly compred nulliprous with prous outcomes. Most of the nulliprous ptient studies were designed to refute the long-held belief tht vginl hysterectomy is contrindicted when there is no history of vginl delivery. This hs been done with gret success nd is well documented in the literture. 9 Two studies hve identified n incresed length of surgery in the nulliprous ptient compred with the prous ptient. 6,7 There ws no difference in LOS postopertively between nulliprous nd prous ptients hving similr procedures. 7 Regrding complictions in nulliprous vs prous ptients t hysterectomy, there re mixed reports in the literture. Two studies reported higher compliction rtes in the nullipr, 6,7 nd one study reported no difference in compliction rtes between nulliprous nd prous ptients. 8 One study showed no difference in hospitl redmission rtes between nulliprous nd prous ptients fter lproscopic-ssisted vginl hysterectomy. 6 Uterine Size Lproscopic hysterectomy cn be performed sfely even in the presence of lrge uterus, 10 yet studies hve reported complictions such s bldder injury nd ureteric injury directly relted to uterine size. 11 Some surgeons set n upper limit to uterine size when considering lproscopic pproch to hysterectomy, of usully 15 to 16 weeks gesttion or weight of 500 g becuse of higher risk of bowel nd urinry trct injury s well s hemorrhge. 12 Tble 4. Comprison fctor by ctegory of hysterectomy (N = 576) Fctor Ctegory 1 (n = 140) Ctegory 2 (n = 279) An increse in opertive time nd greter estimted blood loss hve been observed to prllel incresing uterine size. 13 With greter estimted blood loss, there is lso greter risk of blood trnsfusion ssocited with incresing uterine weight. This is true for both bdominl nd lproscopic hysterectomy. 14 Also, n increse in the conversion rte from lproscopic pproch to n open surgicl procedure hs been reported with lrger uteri. 15 Body Mss Index Studies show n incresed opertive time with lrger BMI. 16,20,22-24 Another study showed no sttisticl difference in the length of surgery in obese ptients compred with nonobese ptients, 17 but difficult cses were performed by senior ttending physicin s opposed to junior ttending or resident. Another study showed no difference in operting time with higher BMI during robotic hysterectomies. 18 There ws no chnge in LOS 17,20,23 in obese ptients, including during robotic hysterectomies. 18 However, there ws n incresed LOS in obese women undergoing bdominl hysterectomies. 22 There ws no chnge in the compliction rte depending on BMI 16,17,19,22 except for one study indicting n incresed Ctegory 3 (n = 157) p vlue Men BMI, kg/m 2 (SD) 26 (3) 31 (5) 36 (8) < Men uterine weight, g (SD) 162 (94) 250 (208) 586 (790) < Previous mjor bdominl surgery, 32 (23) 139 (50) 99 (63) < no. (% of ctegory) Vginl delivery, no. (% of ctegory) 140 (100) 199 (71) 62 (39) < Men incision to close, minutes (SD) 96 (43) 122 (54) 146 (61) < Men length of sty, hours (SD) 20 (19) 23 (18) 32 (25) < Compliction, no. (% of ctegory) 5 (4) 8 (3) 7 (4) Redmission, no. (% of ctegory) 4 (3) 7 (3) 6 (4) Sttisticlly significnt t p < BMI = body mss index; SD = stndrd devition. Tble 5. Surgeon-ssistnt piring nd likelihood of MIH Surgeon (N = 576) Assistnt No MIH, no. (%) MIH, no. (%) Junior (n = 250) Resident 1 (7) 13 (93) Junior 10 (18) 45 (82) Midlevel 18 (13) 123 (87) Senior 1 (3) 39 (97) Midlevel (n = 284) Resident 5 (14) 30 (86) Junior 19 (17) 90 (83) Midlevel 9 (9) 9 (91) Senior 1 (3) 35 (97) Senior (n = 42) Resident 0 (0) 6 (100) Junior 0 (0) 15 (100) Midlevel 0 (0) 13 (100) Senior 0 (0) 8 (100) See Methods section in the text for n explntion of levels of provider experience. MIH = minimlly invsive hysterectomy. The Permnente Journl/ Fll 2015/ Volume 19 No. 4 43

6 The primry strength of this rticle is tht the uthors reviewed ll 576 hysterectomies for benign disese performed by 39 generl gynecologists during n entire yer. Tble 6. Likelihood of minimlly invsive hysterectomy depending on surgeon nd ssistnt Surgeon-ssistnt piring Odds rtio (95% CI) p vlue Surgeon midlevel vs junior 1.17 ( ) Assistnt resident vs junior 1.53 ( ) Assistnt midlevel vs junior 1.80 ( ) Assistnt senior vs junior 8.19 ( ) Sttisticlly significnt t p < CI = confidence intervl. severity of complictions with greter BMI. 20,23 There ws no incresed obesity-relted risk of conversion to open surgery from lproscopic 17 or robotic hysterectomies. 18 There ws n incresed risk of conversion to lprotomy in study performed by Shen et l, 19 but there were low numbers of obese women in this study. There lso were no chnges in redmission rtes in obese ptients. 16 Previous Abdominl Surgery One study reveled longer opertive time in surgeries converted from vginl hysterectomy to lprotomy; the most frequent reson for conversion ws dense dhesions, so previous bdominl surgery incresed the risk of conversion. 25 Three studies indicted tht the number of previous bdominl surgeries incresed the risk of complictions, 15,26,27 two of which specificlly mentioned previous cesren deliveries nd bldder injury. Surgeon Experience nd Surgicl Volume A surgeon s experience nd/or volume of surgicl cses hs been very difficult re to quntitte, yet cn ffect the outcomes of hysterectomy. One of mny confounding vribles is tht high-volume surgeons tend to perform more complicted cses nd be involved in teching, which my be fctor in some studies tht do not show correltion with surgicl times. On review, three studies showed decrese in OR times for high-volume surgeons, 28,31,32 wheres one study showed no significnt difference. 26 For complictions, three studies hve shown reduction in high-volume surgeons, Tble 7. Likelihood of minimlly invsive hysterectomy depending on ctegory Surgeon-ssistnt piring Odds rtio (95% CI) p vlue Surgeon midlevel vs junior, ll ctegories 1.35 ( ) Assistnt resident vs junior, ll ctegories 1.48 ( ) Assistnt midlevel vs junior, ll ctegories 2.26 ( ) Assistnt senior vs junior, ll ctegories 13.2 ( ) Surgeon midlevel vs junior, Ctegory ( ) Assistnt resident vs junior, Ctegory ( ) Assistnt midlevel vs junior, Ctegory ( ) Assistnt senior vs junior, Ctegory ( ) Bold highlights surgeon comprison vs other comprisons, which relte to ssistnts. Sttisticlly significnt t p < CI = confidence intervl. wheres three other studies showed no difference 28,32,39 nd one showed significnt decrese over time reflective of volume nd experience. 33 There ws no difference in conversions between high- nd low-volume surgeons, but mong highvolume surgeons decresed conversions occurred over time. 32 A minimlly invsive surgicl pproch ws offered more often by high-volume surgeons. 30,34 Also, the cost for delivery of surgery ws lower for high-volume surgeons, 29,31 nd the hospitl LOS ws reduced for high-volume surgeons Even though there were efforts to ensure tht ll Ctegory 3 cses would hve t lest 1 member of the surgeon-ssistnt tem be more experienced, we found tht in 13% of these cses junior surgeon ws working with either nother junior surgeon or resident. In this subgroup, there ws 38% lprotomy rte. It ws interesting to see tht plcing senior ssistnt with ny level surgeon significntly improved the likelihood of n MIH in Ctegory 3 cses. Since the beginning of this study, we hve found stedy increse in clinicin experience in MIH procedures. A scoring system is being developed to quntitte the miniml mount of surgeon-ssistnt experience needed to tke on ech ctegory of hysterectomy. Surgicl times, s n element of efficiency nd vlue, ffect overll utiliztion of the operting rooms, nd ctegoriztion cn ccurtely determine how mny cses cn be performed in n ll-dy operting room block. The surgicl times of 1.5 hours, 2 hours, nd 2.5 hours for Ctegories 1, 2, nd 3, respectively, were significntly different. This cretes the opportunity to dd dditionl cses to ll-dy OR blocks with lower-ctegory hysterectomies, leding to more efficient strtegy for operting room scheduling. Study Strengths nd Limittions The primry strength of this rticle is tht the uthors reviewed ll 576 hysterectomies for benign disese performed by 39 generl gynecologists during n entire yer. The primry wekness is tht this is n observtionl nd retrospective study. We ssigned surgeons to junior, midlevel, nd senior on the bsis of yers of surgicl experience nd volumes of MIH cses performed. The technique for doing our surgeries did not chnge over the study period nd did not require the use of power morcelltion. When morcelltion ws required, it ws primrily performed vginlly or vi 4-cm minilprotomy. We hve ttempted to improve other periopertive prmeters tht could ffect surgicl times but hve not found obvious improvement, especilly during our study period. We believe tht by using our ptient chrcteristics ctegoriztion system, our comprisons were looking t eqully difficult hysterectomies, thereby removing most bis. CONCLUSIONS We demonstrted tht ctegoriztion of hysterectomies into three ctegories of complexity enbles the surgeon to better predict the difficulty of hysterectomy nd to determine the verge operting time nd the need for experienced surgicl ssistnts while incresing our MIH rtes sfely nd efficiently. 44 The Permnente Journl/ Fll 2015/ Volume 19 No. 4

7 Ctegorizing hysterectomies for benign disese lso llows much more reserch to be done on eqully difficult surgeries. v Disclosure Sttement The uthor(s) hve no conflicts of interest to disclose. Acknowledgment Kthleen Louden, ELS, of Louden Helth Communictions provided editoril ssistnce. References 1. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG. Hysterectomy rtes in the United Sttes, Obstet Gynecol 2007 Nov;110(5): DOI: org/ /01.aog b. 2. Wright JD, Herzog TJ, Tsui J, et l. Ntionwide trends in the performnce of inptient hysterectomy in the United Sttes. Obstet Gynecol 2013 Aug;122 (2 Pt 1): DOI: 3. ACOG Committee Opinion No. 444: choosing the route of hysterectomy for benign disese. Obstet Gynecol 2009 Nov;114(5): DOI: org/ /aog.0b013e3181c33c AAGL Advncing Minimlly Invsive Gynecology Worldwide. AAGL position sttement: route of hysterectomy to tret benign uterine disese. J Minim Invsive Gynecol 2011 Jn-Feb;18(1):1-3. DOI: jmig Andryjowicz E, Wry T. 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Does surgicl volume influence short-term outcomes of lproscopic hysterectomy? Am J Obstet Gynecol 2010 Jul;203(1):24.e1-6. DOI: Brummer TH, Seppälä TT, Härkki PS. Ntionl lerning curve for lproscopic hysterectomy nd trends in hysterectomy in Finlnd Hum Reprod 2008 Apr;23(4): DOI: Hung CC, Wu MP, Hung YT. Gynecologist s chrcteristics ssocited with the likelihood of performing lproscopic-ssisted hysterectomy: ntionwide popultion-bsed study. Eur J Obstet Gynecol Reprod Biol 2012 Apr;161(2): DOI: Royo P, Alcázr JL, Grcí-Mnero M, Olrtecoeche B, López-Grcí G. The vlue of minilprotomy for totl hysterectomy for benign uterine disese: comprtive study with conventionl Pfnnenstiel nd lproscopic pproches. Int Arch Med 2009 Apr 22;2(1):11. DOI: Perron-Burdick M, Clhoun A, Idowu D, Pressmn A, Zritsky E. Minilprotomy vs lproscopic hysterectomy: comprison of length of hospitl sty. J Minim Invsive Gynecol 2014 Jul-Aug;21(4): DOI: jmig Pelosi MA 2nd, Pelosi MA 3rd. Pelosi minilprotomy hysterectomy: effective lterntive to lproscopy nd lprotomy. OBG Mngement 2003 Apr;15(4): Clrke-Person DL, Geller LJ. Complictions of hysterectomy. Obstet Gynecol 2013 Mr;121(3): DOI: AOG.0b013e Wright JD, Hershmn DL, Burke WM, et l. Influence of surgicl volume on outcome for lproscopic hysterectomy for endometril cncer. Ann Surg Oncol 2012 Mr;19(3): DOI: The Permnente Journl/ Fll 2015/ Volume 19 No. 4 45