Vaginal, Abdominal & Robotic Laparoscopic Hysterectomy: Comparative study including the clinical outcomes and the cost. Magdi Hanafi, M.D., FACOG, FACS Medical Director Gyn & Fertility Specialists Emory Saint Joseph s Hospital Atlanta, Georgia
Study Objective To compare the effect of different methods of hysterectomy on length of hospital stay, operating time, post-operative outcome (patient pain level, days until self-care, days of pain, analgesics use, days first bowel movement, days returning to work, weeks until first intercourse), estimated blood loss and total hospital charges.
Methods Retrospective study for all consecutive hysterectomy cases performed by the author from 1/01/2008 to 7/31/2013. Data collected from the EMR of the office and the hospital 203 cases were reviewed and 145 patients questionnaires were completed. Patients were divided into three surgical groups: Total vaginal hysterectomy (TVH), Total abdominal hysterectomy (TAH), and Da Vinci Robotic laparoscopic total hysterectomy (RLH). Patient s records were used to determine patient demographics, length of hospital stay, operative time, estimated blood loss and total hospital charges. Patient s surveys were used to determine patient s postoperative outcome.
Total Vaginal Hysterectomy Total Abdominal Hysterectomy Da Vinci Robotic Laparoscopic Hysterectomy Three surgical groups
Introduction Hysterectomy is the most common surgical gynecological performed every year all over the world. Approximately 600,000 hysterectomies are performed annually in the United States alone. The most common approach for this procedure is still abdominal hysterectomy. With advancement in minimally invasive endoscopic surgery in gynecology, laparoscopic hysterectomy is becoming more appealing to the patients and their gynecologists especially after the Da Vinci Robotic system utilization, became available.
Introduction Vaginal hysterectomy is the most preferred approach by gynecologist, if the patients clinical findings are suitable for the procedure. Our study is comparing Vaginal, Abdominal and Da Vinci Robotic Laparoscopic Hysterectomy with the clinical outcome and the hospital cost involved in each procedure.
Results TAH had a significant higher hospital stay at 2.71 days (95% Cl: 2.70-2.73) versus TVH with 1.62 days (95% Cl: 1.57-1.67) and RLH with 1.38 days ( 95% Cl: 1.36-1.40). RLH had a significantly higher operative time ( 200 minutes, 95% Cl: 190-210) versus TAH (175 minutes, 95% Cl: 165-184) and TVH (139 minutes, 95% Cl: 118-160). Length of Hospital Stay Operative Time Mean Hospital Stay (days) 3.00 2.50 2.00 1.50 1.00 0.50 0.00 2.71 1.62 1.38 TVH TAH RLH Surgery Method Mean Operatve Time (minutes) 250 200 150 100 50 0 200 175 139 TVH TAH RLH Surgery Method
Results TAH had a significantly higher estimated blood loss (197 ml, 95% Cl: 142-251) versus RLH (98 ml, 95% Cl: 89-107) and TVH (116 ml, 95% Cl: 91-142). Mean Estimated Blood Loss (ml) 300 250 200 150 100 50 0 Estimated Blood Loss 116 197 98 TVH TAH RLH Surgery Method TAH ( $19,135, 95% Cl: 18,273 19,991) had significantly higher total charges than TVH ( $15, 354, 95% Cl: 13,788-16,918). Total charges for RLH ($18,255, 95% Cl: 17,644-18,866) were significantly higher than TVH and not significantly different from TAH. Mean Total Charges ($) 20000 15000 10000 5000 0 15354 Total Charges 19132 18255 TVH TAH RLH Surgery Method
Patient Records Results Total Patients 27 92 84 TVH TAH RLH Comparisons Significant Differences Operative Time (min) [mean] 139 175 200 RLH>TAH> TVH Length of Hospital Stay (days) [mean] 1.62 2.71 1.38 TAH>TVH, RLH no significant difference between Total Charges ($) [mean] 15,354 19,132 18,252 TAH, RLH > TVH; no significant difference between TAH & TVH or between TVH & RLH Estimated Blood loss (ml) [mean] 116 197 98 TAH> RLH; no significant difference between TAH & TVH or between TVH & RLH
Patient Questionnaire Results Total Patient Responses Post-operative Pain level [mean] Days of Analgesic use [mean] Days until Self-care [mean] Days until Work [mean] Days until first BM [mean] Weeks until first intercourse [mean] TVH TAH RLH Comparisons 62 63 21 P* Significant differences 4 7 5 <0.0001 TAH>RLH, TVH No significant difference between TVH & RLH 6 12 7 0.0072 TAH> RLH, TVH no significant difference between TVH & RLH 3 6 6 0.4659 None 27 39 28 0.0164 TAH > RLH no significant difference between TVH 2 2 2 0.0882 None 9 11 9 0.1128 None *p vale of total comparison between all groups using analysis of variance
Discussion Our retrospective study of the groups of hysterectomy, demonstrated that each group posses each strengths and weakness. TAH, which is sometimes the only method which can be performed in certain clinical cases e.g., very lager uterus (>20 weeks in size), previous multiple abdominal and pelvic surgery with high expectation of severe dense abdominal and pelvic adhesions. RLH operative time, recently, has been reduced due to the experienced surgical approach and the new advanced instrumentations used by this study surgeon and OR staff.
Conclusion Study findings reveal a significant difference in hospital stay in TAH versus all other methods of hysterectomy. TAH & RLH have a significantly higher hospital charges versus TVH No significant difference between TAH and RLH in hospital charges. TAH had a higher level of post operative pain than RLH, and TVH. TAH had a significantly higher estimated blood loss than RLH.