Increasing the Rate of Laparoscopic Hysterectomy Safely for Benign Gynecologic Disease

Abstract

Objective:

Complication rates during laparoscopic hysterectomy performed at high-volume surgical centers have not been reviewed recently; rather, reliance is placed on older data when counseling patients. This study reviewed patient demographics and surgical complications occurring during laparoscopic hysterectomy for benign gynecologic disease at a major academic teaching institution. The relationship between surgeon experience and perioperative outcomes were also assessed.

Materials and Methods:

This was a retrospective chart review of consecutive women who underwent hysterectomy for benign gynecologic disease from September 2014 to August 2016. Clinical, demographic, and surgical characteristics were ascertained. Complications and readmission rates were assessed. Primary outcomes were surgical complications, estimated blood loss (EBL), operative times, and blood transfusions. The patients were treated at a single, high-volume tertiary-care teaching hospital. They were divided into 5 groups. In groups 1–4, surgeries were performed by 4 individual experts. Group 5 had surgeries performed by minimally invasive gynecologic-surgery fellows. Numeric data were expressed as medians and ranges, unless stated otherwise. Statistical analyses were performed with SPSS version 21.0 for Windows.

Results:

A total of 1095 hysterectomies were included: 1040 (94.98%) were performed laparoscopically; 33 (3.01%) were performed via laparotomy; and 22 (2.01%) via vaginal procedures. Median operative time was 117 minutes (range: 23–499 minutes). Median EBL was 100 mL (range: 10–1000 mL). Only 1 surgery was converted to laparotomy (0.10%). Intraoperative injuries occurred 6 times—3 ureteral (0.29%), 2 bladder (0.19%), and 1 bowel (0.10%). All injuries were noted during the procedures with intraoperative repair performed in each case and subsequent postoperative complications avoided. Blood transfusions were required in 4 patients (0.38%). No ureteral and vesical fistulae occurred. Laparoscopic hysterectomy rates of 100% without conversions were achieved by Surgeons #1 and #3. Compared to other groups, Surgeons #1 and #2 had lower EBLs and shorter mean surgical times. Surgeon #1 had more frequent pelvic adhesions than other groups. Surgeon #4 had the largest uterine weights, while fellows operated on uteri weighing >500 g or >1000 g less frequently. Rates of bowel occlusions were higher for Surgeon #4 and the fellows. Fellows had more-frequent skin infections. Other postoperative complications and readmission rates were similar among the groups.

Conclusions:

Laparoscopic hysterectomy is a safe, feasible option for benign gynecologic surgery. This procedure is safe even during the initial learning-curves of fellows with low and reasonable complication rates, but with longer associated operative times. An increase in experience is associated with a higher rate of laparoscopic hysterectomies, shorter operating times, less blood loss, and a low incidence of complications.

Introduction

Hysterectomy is one of the most commonly performed surgical procedures in women with ∼600,000 hysterectomies performed annually in the United States.¹ Since the first laparoscopic hysterectomy was reported in 1989,² the proportion of hysterectomies performed laparoscopically has continued to rise.³ Benefits include shorter hospital stays, fewer wound infections, and more-rapid resumption of normal activities.^4,5 Gynecologists might prefer a laparoscopic approach, compared to abdominal hysterectomy.⁶

As recently as 2010, laparoscopy was the surgical approach in only 20.6%–30.5% of hysterectomies performed in the United States.^7,8 Despite recommendations by the American Association of Gynecologic Laparoscopists (AAGL) and the American College of Obstetricians and Gynecologists (ACOG) that minimally invasive hysterectomy should be the standard of care, more than 50% of hysterectomies for benign indications were still performed as open procedures in 2010.^9–11

This study was conducted to estimate the rate of laparoscopic hysterectomies for benign gynecologic disease and complication rates of this treatment at the Division of Minimally Invasive Gynecologic Surgery of Magee–Women's Hospital, of the of University of Pittsburgh Medical Center, Pittsburgh, PA, and three affiliated hospitals. The authors' experience is shared to help increase the rate of laparoscopic hysterectomy safely for benign gynecologic disease.

Materials and Methods

A retrospective study was performed after institutional review board approval was obtained. A medical-record review was conducted for 1095 consecutive women who underwent hysterectomies for benign indications between September 2014 and August 2016 at the Division of Minimally Invasive Gynecologic Surgery, Magee–Women's Hospital and its three affiliated hospitals. Data regarding patient characteristics, intraoperative details, short- and long-term postoperative recoveries were collected to create a database using REDCap [Research Electronic Data Capture] through a retrospective review of the hospital and outpatient records. Patients were divided into 5 groups: in groups 1–4, surgeries were performed by 4 individual experts at the Division. In group 5, the surgeries were performed by minimally invasive gynecologic surgery fellows in their second year of fellowship.

Numeric data were expressed as medians and ranges unless stated otherwise. Analysis of variance was used to compare the median of each value among the groups. Significance was assessed for categorical variables, using a χ² test or, when there were small cell sizes, Fisher's exact test. A p-value <0.05 was considered statistically significant. All statistical analyses were performed with the IBM Statistical Package for the Social Sciences (SPSS) version 21.0 program

Results

A total of 1095 patients underwent hysterectomy during the study period. A total of 33 (3.01%) patients had characteristics that made them unsuitable for laparoscopic surgery based on individual surgeons' experience. Surgeon #2 completed 8 abdominal hysterectomies; surgeon #4 performed 22; and the fellows performed 3. The indications for laparotomy are shown in Table 1. Size of the uterus was the most common indication for laparotomy, with 21 patients undergoing open surgery for this reason. The median weight in this group was 1484 g (range: 810–5102 g). Additionally, 1 patient's operation was converted from laparoscopic to open surgery due to intraoperative hemorrhage. This patient had a broad-ligament fibroid.

Table 1.

Indications for Abdominal Hysterectomy via Laparotomy

Indications for laparotomy	Laparotomy (N = 33)
Volume of uterus	21
Large vaginal mass	1
Large pelvic mass suspected of malignancy	2
Extensive peritoneal adhesions	1
History of ureteral implantation	1
Multiple prior surgeries including mesh placement for hernias	4
Patient preferred to proceed with open procedure	3

Patients' characteristics

Of the 1095 patients who had hysterectomies during the study period, 1040 patients had laparoscopic procedures, a rate of 94.98%; and 22 patients had vaginal procedures, a rate of 2.01%. The minimally invasive surgery rate was 96.99%. For these laparoscopic procedures, 376 cases were completed by Surgeon #1, with a laparoscopic hysterectomy rate of 100%; 375 by Surgeon #2, with a rate of 97.91%; 167 by Surgeon #3, with a rate of 100%; 58 by Surgeon #4, with a rate of 56.86%; and 64 by fellows, with a rate of 95.31%. For the vaginal procedures, 22 were completed by Surgeon #4, with a vaginal hysterectomy rate of 21.57% and a minimally invasive surgery rate of 78.43% by Surgeon #4. There was a significant difference in hysterectomy routes among the 5 groups (p < 0.01), with a laparoscopic hysterectomy rate of 100% noted in Surgeon #1 and Surgeon #3.

Of these laparoscopic procedures there were 805 total laparoscopic hysterectomies (TLHs), 9 robotic-assisted TLHs, 6 laparoscopic supracervical hysterectomies, and 220 modified radical laparoscopic hysterectomies. The patients underwent hysterectomy for 1 or several of the following indications: 584 menometrorrhagia; 341 pelvic pain; 303 fibroids; 165 endometriosis; 14 prolapse; 30 postmenopausal bleeding; 21 cervical dysplasia; 14 prophylactic/cancer reducing; and 16 atypical endometrial hyperplasia.

The median patient age was 42 years (range: 22–87 years) and the median body mass index (BMI) was 29.08 kg/m² (range: 13.15–74.79 kg/m²). In all, 323 (31.06%) patients were obese (BMI range: 30–39.9 kg/m²), and 157 (15.10%) were morbidly obese (BMI ≥40 kg/m²). There were no statistically significant differences in the BMIs of patients operated on among the groups (p > 0.05).

The majority of patients had at least one previous surgery, with 803 (77.21%) undergoing abdominal and/or pelvic surgical procedures. The average prior surgical procedures were 1.79. Previous cesarean sections were noted in 323 patients (31.06%); this included 62 patients with more than 2 cesarean sections. Associated procedures included 23 (2.21%) ovarian cystectomy, 347 (33.37%) excision of endometriosis (of these, 75.79% were deep-infiltrating endometriosis), 17 (1.63%) oophoropexy, 242 (23.27%) ureterolysis, 51 (4.90%) enterolysis, 153 (14.71%) lysis of adhesions, 415 (39.90%) cystoscopy, 247 (23.75%) ureteral stenting, 28 (2.69%) proctoscopy, 5 (0.48%) sacrocolpopexy, 6 (0.58%) Burch urethropexy, 7 (0.67%) appendectomy, 13 (1.25%) oversewn bladder, 44 (4.23%) oversewn bowel, and 149 (14.33%) other procedures. The mean rates of concurrent procedures were 2.36 procedures per laparoscopic hysterectomy. Patients' characteristics, including clinical data, are presented in Table 2.

Table 2.

Patients' Characteristics

Clinical characteristics of patients	# of patients (%) N = 1040
Age (yrs; range)
BMI (kg/m²; range)	42 (22–87)
29.08 (13.15–74.79)
Nulliparous	247 (23.75%)
Menopause	54 (5.19%)
Comorbid condition
Hypertension	186 (17.88%)
Diabetes	59 (5.67%)
Asthma	133 (12.79%)
# of previous abdominal-pelvic surgical procedures, median(range)	2 (0–8)
# of previous cesarean sections, median (range)	0 (0–6)
# of concurrent procedures, median (range)	2 (0–9)

yrs, years; BMI, body mass index.

Intraoperative outcomes

The median operative time for laparoscopic hysterectomies (including time spent on associated procedures) was 117 minutes (range: 23–499 minutes). The median blood loss was 100 mL (range: 10–1000 mL). Uterine weight in 180 (17.31%) patients was 250–500 g, while 88 (8.46%) were from 500 g to 1000 g, and 21(2.02%) were >1000 g. Compared to other groups, Surgeon #1 and Surgeon #2 had lower estimated blood losses (EBLs) and shorter mean surgical times. For pelvic adhesions, Surgeon #1 had more frequent pelvic adhesion than the other groups. Surgeon #4 had the highest average uterine weights.

One surgery was converted to a laparotomy due to a large broad-ligament fibroid with associated intraoperative hemorrhage, an overall conversion rate of 0.10%. There were 2 bladder injuries, both in patients with prior cesarean sections and extensive adhesions between the lower uterine segment and bladder. Both were repaired laparoscopically at the time of the procedures and healed without complications.

There were 3 complications involving injuries to the ureter. In 1 patient with morbid obesity, a ureteral false passage was created during placement of the ureteral stent. A urologist was consulted who placed a double-J stent in this patient to remain in place for 4 weeks; this patient's postoperative course uncomplicated. The other 2 injuries were thermal traumata in patients with extensive adhesions; laparoscopic ureteral reanastomosis and repair were performed and the patients' postoperative courses were uneventful. The 1 bowel injury occurred in a patient with extensive adhesions between the anterior abdominal wall and the omentum. She had an anterior abdominal wall diastasis with loops of small bowel herniating into it. Repair of this injury to the small bowel was performed laparoscopically. Blood transfusions were required in 2 patients due to intraoperative bleeding. All of the injuries were recognized during the hysterectomies, and subsequent postoperative complications and repeat surgical procedures were avoided. When comparing intraoperative outcomes by individual surgeons, there were no significant differences among the groups (Table 3).

Table 3.

Intraoperative Outcomes

Parameters	Total (%)	Surgeon #1	Surgeon #2	Surgeon #3	Surgeon #4	Fellows	p-Value
Parameters	(n = 1040)	(n = 376)	(n = 375)	(n = 167)	(n = 58)	(n = 64)	p-Value
Operation time (min; range)	117 (23–499)	108 (28–481)	95 (42–479)	166 (23–338)	239 (173–499)	200 (50-424)	< 0.01
EBL (mL; range)	100 (10–1000)	50 (10–850)	50 (10–500)	150 (50–500)	100 (25–1000)	100 (25–350)	< 0.01
Uterine weight (g; range)	154 (25-2086)	159 (33–2550)	137 (29–1116)	170 (34–2086)	328 (56–1600)	150 (25–912)	< 0.01
Uterine weight >1000	21 (2.02%)	8 (2.13%)	3 (0.8%)	7 (4.19%)	3 (5.17%)	0	< 0.01
Uterine weight >500	109 (10.48%)	34 (9.04%)	25 (6.67%)	33 (19.76%)	14 (24.14%)	3 (4.69%)	< 0.01
Pelvic adhesions	222 (21.35%)	109 (28.99%)	72 (19.2%)	14 (8.38%)	12 (20.69%)	15 (23.44%)	< 0.05
Intraoperative transfusion	4 (0.38%)	2 (0.53%)	1 (0.27%)	1 (0.6%)	0	0	NS
Conversion to laparotomy	1 (0.10%)	0	0	0	1 (1.72%)	0	NS
Intraoperative hemorrhage	2 (0.19%)	1 (0.27%)	0	0	1 (1.72%)	0	NS
Intraoperative complications							NS
Ureter injury	3 (0.29%)	1 (0.27%)	1 (0.27%)	1 (0.6%)	0	0	NS
Bladder injury	2 (0.19%)	1 (0.27%)	0	0	0	1 (1.56%)	NS
Bowel injury	1 (0.10%)	1 (0.27%)	0	0	0	0	NS

Min, minutes; EBL, estimated blood loss; NS, not significant.

Postoperative outcomes

There were 2 cases of postoperative hemorrhage, 1 from a lower trocar incision and 1 from a uterine artery. Both patients were treated laparoscopically without further complications. There were 3 cases of vaginal lacerations that were repaired vaginally.

There were 2 cases of postoperative small-bowel obstruction, both due to incarcerated incisional hernias. Both cases were treated surgically, 1 via laparoscopy and 1 with laparoscopy that was converted to laparotomy. Following 1 surgery, there was a small hematoma of the anterior abdominal wall, which was absorbed spontaneously and did not require surgery. No ureteral and vesical fistulae occurred. Overall, postoperative complications resulted in 7 additional surgeries, a reoperation rate of 0.67%.

Same-day discharge occurred in 645 patients (62.02%), while 338 patients (32.50%) were discharged on postoperative day 1, and 57 patients (5.48%) on postoperative day 2 or beyond. There were 21 patients who were readmitted within 30 days of the time of their surgeries, a rate of 2.02%. The rate of 30-day hospital readmissions and postoperative complications by individual surgeons are presented in Table 4. There was more frequent skin infections in patients operated on by fellows. Other postoperative complications and readmission rate were similar among groups.

Table 4.

Postoperative Outcomes

Parameters	Total (%)	Surgeon #1	Surgeon #2	Surgeon #3	Surgeon #4	Fellows	p-Value
Parameters	(n = 1040)	(n = 376)	(n = 375)	(n = 167)	(n = 58)	(n = 64)	p-Value
Postoperative hemorrhage	2 (0.19%)	0	1 (0.27%)	0	1 (1.72%)	0	NS
Vesical fistulae	0	0	0	0	0	0	NS
Pulmonary embolism	1	0	1 (0.27%)	0	0	0	NS
Skin infection	15 (1.44%)	3 (0.8%)	3 (0.8%)	4 (2.4%)	2 (3.45%)	3 (4.69%)	< 0.05
Incision hematoma	1 (0.10%)	1 (0.27%)	0	0	0	0	NS
Cuff cellulitis/abscess	3 (0.29%)	1 (0.27%)	2 (0.53%)	0	0	0	NS
Vaginal laceration	3 (0.29%)	2 (0.53%)	1 (0.27%)	0	0	0	NS
Reoperation	7 (0.67%)	2 (0.53%)	2 (0.53%)	0	2 (3.45%)	1 (1.56%)	NS
30-day hospital readmission rate	21 (2.02%)	7 (1.86%)	7 (1.87%)	3 (1.8%)	0	4 (6.25%)	NS

NS, not significant.

Discussion

Hysterectomy is one of the most commonly performed gynecologic surgeries. Experts recommend that many of these surgeries should be performed through minimally invasive methods when possible.

Technical difficulty and potential for complications have been reported most often as the main barriers to offering laparoscopic hysterectomies.¹² Situations that distort pelvic anatomy—such as large fibroids, deep-infiltrating endometriosis, extensive pelvic adhesions, and morbid obesity—can affect the success of a laparoscopic approach.

From 2000 to 2010, the overall rate of a laparoscopic approach for hysterectomy increased from 3.3% to 43% at Magee–Women's Hospital.¹³ This current study reports on the surgical outcome of the minimally invasive gynecologic surgery this hospital. The hospital has 4 high-volume gynecologic surgeons, 3 of whom have had fellowship training through the AAGL. Together these surgeons accounted for 1031 (94.16%) of the hysterectomies performed in this study. A small number—64 (5.84%)—were performed by the minimally invasive gynecologic surgery fellows in this program in the role of teaching/attending surgeons.

The objective of this study was to evaluate the rates of completion for laparoscopic hysterectomy, complications, operative times, and blood losses. In this study, nearly all hysterectomies were completed laparoscopically with acceptably low conversion and complication rates. Commonly cited reasons for choosing to perform laparotomies rather than laparoscopic procedures were evaluated.

Nearly half of patients—480 (46.16%)—were obese or morbidly obese with BMIs >30. Many patients had large uteri, with 88 (8.46%) weighing 500–1000 g, while 21 (2.02%) weighed >1000 g, with a maximum of 2550 g.

Previous surgery was common, with 803 (77.21%) patients reporting prior abdominal and/or pelvic surgical procedures. The average number of surgical procedures was 1.79, with a maximum of 8.

Endometriosis was present in a large number of patients, with 347patients (33.37%) undergoing concurrent excision of endometriosis, including 263 cases of deep-infiltrating endometriosis (75.79% cases of endometriosis were deep-infiltrating endometriosis).

The median EBL was 100 mL, and the intraoperative complication rate was low. These findings suggest that the complexity of laparoscopic hysterectomy in this study did not affect surgical outcomes. Thus, the current authors believe that the laparoscopic approach allows effective management of complex cases or complex pathologies and that there are no absolute contraindications to TLH for benign gynecologic conditions.

Previous studies have shown a conversion rate to laparotomy of 2%–8%.^14,15 Risk factors for conversion to laparotomy include elevated BMIs, lateral- or lower-uterine segment fibroids, and previous abdominal or pelvic surgeries.¹⁶ Severe pelvic adhesions as a result of underlying pathology were reported to increase the rate of conversion during laparoscopic hysterectomy to as high as 6.3% in one 1 study.¹⁷ Prior cesarean section or concomitant adhesiolysis were more likely to result in conversion to laparotomy.¹⁸ In the current study, of the patients who underwent laparoscopic management, 323 patients (31.06%) had prior cesarean sections, including 62 with more than 2 cesarean sections, with a maximum of 6 cesarean sections.

At the time of hysterectomy 242 patients (23.27%) had concurrent ureterolysis, 51 (4.90%) had enterolysis, and 153 (14.71%) had lysis of adhesions. However, only 1 patient needed conversion to laparotomy because of intraoperative hemorrhage, which occurred due to a large broad-ligament fibroid. The overall rate of conversion to laparotomy was 0.10%.

The most-common complications of hysterectomy can be categorized as infectious, as well was venous thromboembolic, genitourinary, and gastrointestinal-tract injuries.¹⁹ Studies have noted that laparoscopic hysterectomy is associated with higher rates of urinary-tract injury compared with abdominal or vaginal approaches.^20,21 The incidence of ureteral injuries (including transection, obstruction, fistula formation, and necrosis from thermal injury) during gynecologic laparoscopy has ranged from 1% to 2%.²² Ureteral injury was reported in 1.7% of cases during laparoscopic hysterectomy.²³

In this current study, 3 patients(0.29%) had ureteral injuries. In 1 case, a ureteral false passage formed during ureteral catheterization. The other 2 patients had extensive adhesions with severe distortions of their anatomies. In case 2, when the surgeon wanted to ligate the uterine artery from its origin, the ureter was sealed instead. In case 3 a fibrotic band on the side wall was mistaken for a ureteral stent on palpation. As a result, a nick was made in the ureter during surgery.

Pelvic anatomy may be distorted in patients with a histories of pelvic surgeries, pelvic infections, or advanced endometriosis. Visualization and dissection of the ureter is recommended to minimize the risk of ureter injuries in patients with severely distorted anatomies.²⁴ Not knowing the location of the ureters halts surgical progress for the careful surgeon and invites disaster for the careless surgeon. Ureteral catheterization during hysterectomy lets a surgeon know the course of the ureter so he or she can progress rapidly when working away from the ureter and refine the dissection when closer to the ureter. Prophylactic placement of ureteral stents can improve the ability to identify ureters and decrease ureteral injury rates in appropriately selected cases.^25–26

In the current study, 247 (23.75%) patients had prophylactic ureteral stenting, but 2 ureteral injuries occurred despite this ureteral catheterization, 1 of which was the result of placement of the stent. Palpation of ureteral stents is not reliable during laparoscopic procedures; maintaining visual identification of the ureters is paramount. Ureteral catheterization should not be a substitute for using a meticulous surgical technique and paying attention to pelvic anatomy.

Same-day discharge after laparoscopic hysterectomy is safe and associated with decreased healthcare expenditures.²⁷ In 1 study the rate of presentation to an emergency department within 60 days was 4.0% for patients who were discharged on the same day, 3.6% after a 1-day stay, and 5.1% for those whose stays were 2 days.²⁸ Data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) showed a readmission rate of 3.8% after abdominal hysterectomy, 3.0% after vaginal hysterectomy, and 2.9% after laparoscopic hysterectomy.²⁹ Another study showed that the rate of 30-day readmission was 3.4% after hysterectomy for benign gynecologic disease in 36,471 patients.³⁰ In this study, 62.02% of patients were discharged on the day of surgery and 32.50% of patients were discharged on postoperative day 1, with an overall 30-day readmission rate of 2.02% following laparoscopic hysterectomy.

Robotic-assisted laparoscopic hysterectomy is an alternative approach to performing minimally invasive hysterectomy. The use of robotically assisted hysterectomy for benign gynecologic disease has increased substantially. Several reports have shown that robotic-assisted laparoscopic hysterectomy could offer some operative advantages, including fewer conversions to laparotomy, shorter surgical times, lower blood losses, and earlier discharges.^31–34 Robotic assistance was developed to overcome the difficulties encountered with a conventional laparoscopic approach. The robotic approach provides technology that can extend the ability to perform laparoscopic hysterectomy in more-complex cases. Patients with obesity, large uteri, or severe adhesions could potentially benefit from robotic assistance, compared with conventional laparoscopy.^35–38

However, Swenson et al. used a statewide database to analyze utilization and outcomes of minimally invasive hysterectomy performed for benign indications.³⁹ When hysterectomy was performed via a robotic-assisted route, the average blood loss was 94.2 mL and surgical time was 2.3 hours. Only 0.8% patients received blood transfusions. The rates of bowel and bladder injuries were 0.6% and 0.8%, respectively, and 2.0% of patients underwent reoperations. In that study, 21.9% patients were discharged on postoperative day 2 or beyond, with a readmission rate of 3.0 %.³⁹ Compared with this series of robotic-assisted hysterectomies involving 4725 patients, the current study showed improved outcomes with laparoscopic hysterectomy, compared with robotic-assisted hysterectomy.

Moreover, the current study showed that even more-complex hysterectomies (such as in patients with morbid obesity, large uteri, severe pelvic adhesions, and endometriosis) can be managed effectively and efficiently via the laparoscopic approach. As robotic-assisted hysterectomy is associated with no more benefits than a laparoscopic procedure but costs significantly more,⁴⁰ the advantage of robotic assistance does not exist in hospitals with high-volume surgeons. Thus, the current authors prefer laparoscopic hysterectomy rather than robotic-assisted hysterectomy when feasible.

Performing more-complex procedures and treating more-challenging patients can potentially result in less-optimal surgical outcomes. However, surgical experience is associated with successful outcomes for laparoscopic hysterectomy.⁴¹ This shows that an increase in experience positively predicted successful outcomes in laparoscopic hysterectomies with short operating times, lower blood losses, and a low incidence of complications.

There is a learning curve for TLH. Mäkinen et al. concluded that surgeons who had performed more than 30 laparoscopic hysterectomies had significantly lower rates of intraoperative complications.⁴² In the current study, none of the fellows had performed more than 30 laparoscopic hysterectomies in a 1-year period. Compared to other groups, fellows had less-frequent uteri weighing >500 g, and no uterus weighed >1000 g. The median operative time was 200 minutes (range: 50–424 minutes), which was slightly longer than that of more experienced surgeons. The median blood loss was 100 mL (range: 25–350 mL). Bladder injury occurred in 1 patient. Although more-frequent skin infections occurred in this group, the overall rate of laparoscopic hysterectomy was 95.31% without conversion to laparotomy. The current study showed that laparoscopic hysterectomy was performed safely—even during the initial learning curve of the fellows—with low and reasonable complication rates, but with longer operation times. This might be attributed to having a high surgical volume in the first year of the fellowships paired with a focus on attention to surgical techniques and attention to anatomy.

Conclusions

The data from the current study suggest that the rate of laparoscopic hysterectomy can be increased without compromising patient safety. Laparoscopic hysterectomy was associated with good outcomes and low complication rates, irrespective of the severity of pathology or patient habitus.

Footnotes

Author Disclosure Statement

No financial conflicts of interest exist. Dr. Lee is a consultant for Ethicon Endosurgery.

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