Impact of a High-Volume Gynecologic Surgeon Preceptor on Benign Laparoscopic Hysterectomy

Abstract

Objective:

To compare operative times and surgical outcomes of women undergoing benign laparoscopic hysterectomy by general obstetrician–gynecologists (OB-GYNs) alone with those performed by general OB-GYNs in conjunction with a high-volume minimally invasive gynecologic surgeon preceptor.

Design:

This is a retrospective cohort study. (Canadian Task Force Classification II-2).

Materials and Methods:

A surgical preceptoring program for low-volume OB-GYNs was implemented in 2011 at an academic-affiliated community hospital. All women undergoing laparoscopic hysterectomy for benign disease between 2011 and 2013 are included.

Results:

A total of 391 laparoscopic hysterectomies were performed: 179 by low-volume OB-GYNs alone and 212 with the assistance of a preceptor. Laparoscopic hysterectomies performed with a preceptor had shorter operative times (128.4 vs. 105.4 minutes, p < 0.01). After adjusting for differences between groups, those performed in conjunction with a preceptor were 42 minutes faster. The group receiving surgery in conjunction with a preceptor had decreased rates of composite organ injury (6% vs. 1%, p < 0.01), ureteral injury (3% vs. 0%, p = 0.02), and conversion to open approach (5% vs. 0%, p < 0.01). The estimated blood loss was also significantly lower (163 vs. 134 mL, p = 0.03) and there were fewer intraoperative consultations (6% vs. 0.5%, p < 0.01) in the preceptor group. There was no difference in postoperative rates of blood transfusion, readmission, or reoperation.

Conclusion:

Women undergoing laparoscopic hysterectomy in conjunction with a high-volume minimally invasive gynecologic surgeon preceptor have improved outcomes, including shorter operative time, lower rate of organ injury and conversion to laparotomy fewer intraoperative consultations, and lower estimated blood loss than women undergoing laparoscopic hysterectomy by general OB-GYNs alone. (J GYNECOL SURG 36:115)

Introduction

The benefits of minimally invasive hysterectomy have been well established.^1–3 For hysterectomies that cannot be performed vaginally, the American College of Obstetricians and Gynecologists (ACOG) recommends a laparoscopic approach be chosen.² Rates of abdominal hysterectomy have been decreasing since 2002 (Ref.⁴); however, they remain high accounting for 40% to 50% of benign inpatient hysterectomies.^5,6 Abdominal hysterectomies result in longer hospitalizations, higher blood loss, less cosmetic surgical incisions, and increased postoperative pain. Barriers to pursuing a minimally invasive route include lack of training in residency, technical difficulty of the procedure, and low surgical volume while in practice.^7,8

To increase laparoscopic hysterectomy rates and improve surgical outcomes, Missouri Baptist Medical Center, an academic-affiliated community hospital in the Midwestern United States, developed a minimally invasive gynecologic surgeon preceptoring program. ACOG describes a surgical preceptor as an instructor of cognitive and technical skills who is responsible for the actions of the preceptee.⁹ The program started in 2011 when a high-volume gynecologic surgeon was hired by the hospital to serve as a preceptor for general obstetrician–gynecologists (OB-GYNs) during laparoscopic hysterectomies. To our knowledge, no prior studies have examined the effects of implementing a formal preceptoring program.

Objectives

The purpose of this study is to describe outcomes of women undergoing benign laparoscopic hysterectomy performed by general OB-GYNs alone, compared with similar cases performed with the assistance of a high-volume minimally invasive gynecologic surgeon. The primary outcome of this study is operative time. Secondary outcomes are organ injury, conversion to laparotomy, estimated blood loss, intraoperative consultations, and postoperative readmissions.

Design

We conducted a retrospective cohort study of patients who underwent laparoscopic hysterectomy for benign disease at Missouri Baptist Medical Center from March 2011 to December 2013. Missouri Baptist is an academic-affiliated community hospital where resident physicians and fellows participate in gynecologic surgery cases.

Materials and Methods

Hospital billing data, International Classification of Diseases, Ninth Revision (ICD-9) codes, and surgeon name were used to identify hysterectomies performed. Hysterectomies were classified by type: abdominal (ICD-9 68.39, 68.49, and 68.69), vaginal (ICD-9 68.59 or 68.79), laparoscopic (ICD-9 68.31, 68.41, 68.51, 68.61, and 68.71), or robotic (identified by robot-assisted code [ICD-9 17.42 or 17.44] or a charge for robotic instrumentation in combination with a laparoscopic hysterectomy). In this study, laparoscopic hysterectomy refers to conventional straight-stick laparoscopy. Preceptored cases were identified when the surgical preceptor was listed as the surgical assistant in the operative report.

Inclusion criteria were total laparoscopic hysterectomy or laparoscopic supracervical hysterectomy with or without adnexectomy performed by general OB-GYNs with or without the surgical preceptor. All general OB-GYNs in this study were in private practice or hospital-owned physician groups. Exclusion criteria were surgical route other than conventional laparoscopy, concomitant procedures (other than adnexectomy), hysterectomy performed by the preceptor alone or another surgical subspecialist, and surgery performed for malignancy (ICD-9 180–184.9).

Operative time, intraoperative organ injury, conversion to laparotomy, blood loss, intraoperative consultation, blood transfusion, length of stay, readmission, and reoperation were evaluated. Intraoperative organ injury was defined as a full-thickness injury to an organ that required repair. Conversion to laparotomy was defined as a procedure that started laparoscopically and then converted to laparotomy for either completion of the hysterectomy or for repair of an organ injury. Conversions to laparotomy were captured by reviewing operative notes of all hysterectomies coded as laparoscopic and those coded as both a laparoscopic and abdominal hysterectomy in the same case. Intraoperative consultation was defined as an unplanned intraoperative request for assistance from another surgeon that was documented either in the primary operative report or in an additional operative report for the same case. Operative time was defined as in-room time to room-departure time as documented in the nursing operative notes. Readmissions were defined as an inpatient stay within 6 weeks of the initial surgery.

A sample size calculation was performed based on the previously described 25-minute decrease in operative time between high-volume and low-volume surgeons.¹⁰ It was determined that 134 patients per group would provide 80% power to detect a 25-minute difference between groups with a significance level of 0.05.

Analysis

Demographics including age, race, insurance type, body mass index (BMI), medical comorbidities, and number of prior open abdominal surgeries were abstracted from the medical record. Descriptive statistics were used for continuous variables. Pearson's chi-square and Fisher's exact test were used to compare categorical data. Student's t-test and Mann–Whitney U-test were used to compare continuous variables. Multivariable linear regression modeling was used to identify and control for confounders between groups. For total operative time, a stepwise selection algorithm (entry level, p = 0.15; model selection criteria: Akaike Information Criterion (AIC) minimization) was implemented to select among the following possible confounders: preceptor, presence of trainees in the room, age, sex, race, BMI, insurance, failed ablation, procedures performed, morcellation, and cystoscopy performance. A p-value of <0.05 was considered statistically significant. Analyses were performed in SAS 9.3 (SAS, Cary, NC). This study was reviewed and approved by the Washington University School of Medicine Human Research Protection Office, approval no. 201309060, approved September 26, 2013, and the Missouri Baptist Medical Center Institutional Review Board, approval no. 1003, approved November 6, 2013.

Results

During the 2-year study period, there were 391 laparoscopic hysterectomies performed at Missouri Baptist Medical Center for benign indications by general OB-GYNs (nonpreceptored n = 179, preceptored n = 212) (Table 1). Demographic characteristics, medical comorbidities, and number of prior open surgeries (including cesarean sections) were compared between groups. The groups were similar with the exception of higher BMI in the preceptored group (nonpreceptored 28, preceptored 30, p = 0.04). Baseline surgical characteristics were also compared (Table 2). Preceptored cases had a lower rate of failed endometrial ablation as the indication for surgery (nonpreceptored 25%, preceptored 17%, p = 0.05), and were more likely to have trainees present in the operating room (OR) (median trainee number: nonpreceptored 0, preceptored 2, p < 0.01). Concomitant procedures varied between the groups with the preceptored group less likely to have an adnexectomy performed (nonpreceptored 47%, preceptored 30%, p < 0.01), but more likely to have a routine intraoperative cystoscopy performed (nonpreceptored 54%, preceptored 89%, p < 0.01) as it is the practice of the preceptor to perform routine cystoscopy after all total laparoscopic hysterectomies. Uterine weight was greater in the preceptored group (nonpreceptored 148 g, preceptored 194 g, p < 0.01), but less likely to require morcellation (nonpreceptored 45%, preceptored 30%, p < 0.01).

Table 1.

Baseline Demographic Characteristics of Women Undergoing Laparoscopic Hysterectomy for Benign Indications by General Obstetrician–Gynecologists

Characteristics	Nonpreceptored, n = 179 (%)	Preceptored, n = 212 (%)	p
Age, mean years (SD)	45 (8)	46 (8)	0.06
Race			0.38
Caucasian	145 (81)	164 (77)	—
Non-Caucasian	34 (19)	48 (23)	—
Private insurance	175 (98)	209 (99)	0.71
BMI (kg/m²), mean (SD)	28 (7)	30 (8)	0.04
Medical comorbidities
Cardiovascular disease	51 (29)	72 (34)	0.26
Diabetes mellitus	8 (5)	14 (7)	0.37
Pulmonary disease	19 (11)	36 (17)	0.08
Smoker	22 (12)	26 (12)	0.98
Number of cesarean sections			0.26
0	124 (70)	157 (74)	—
1–2	16 (9)	30 (14)	—
>2	37 (21)	25 (12)	—
Total prior abdominal surgeries			0.05
0	112 (63)	137 (65)	—
1–2	28 (16)	47 (22)	—
>2	38 (21)	28 (13)	—

Bold figures are statistically significant.

SD, standard deviation.

Table 2.

Baseline Surgical Characteristics of Women Undergoing Laparoscopic Hysterectomy for Benign Indications by General Obstetrician–Gynecologists

Characteristics	Nonpreceptored, n = 179 (%)	Preceptored, n = 212 (%)	p
Indication
Bleeding	103 (57)	117 (55)	0.64
Fibroids	78 (44)	103 (49)	0.32
Pain	69 (38)	83 (39)	0.90
Failed ablation	45 (25)	36 (17)	0.05
Other	54 (30)	71 (33)	0.48
Primary procedure (hysterectomy)			<0.01
Total laparoscopic	115 (64)	205 (97)	—
Laparoscopic supracervical	59 (33)	7 (3)	—
Total abdominal	5 (3)	0 (0)	—
Secondary procedure
Adnexal procedure	84 (47)	63 (30)	<0.01
Cystoscopy	54 (30)	188 (89)	<0.01
Morcellation	80 (45)	63 (30)	0.02
No. of trainees, median (IQR)	0 (1)	2 (1)	<0.01
Uterine weight (g), median (IQR)	130 (148)	171 (194)	<0.01

Bold figures are statistically significant.

IQR, interquartile range.

Unadjusted case length was 23 minutes faster in the preceptored group (128.4 vs. 105.4 minutes) (Table 3). After adjusting BMI, failed ablation, procedures performed, morcellation, cystoscopy performance, and presence of trainees, preceptored cases were 42 minutes faster than nonpreceptored cases (confidence interval 33–55, p < 0.01). When comparing the nonpreceptored with the preceptored group, the preceptored group had lower rates of organ injury (6% vs. 1%, p < 0.01), ureteral injury (3% vs. 0%, p = 0.02), conversion to laparotomy (5% vs. 0%, p < 0.01), and intraoperative consultations (7% vs. 0.05%, p < 0.01) (Table 3). In the preceptored group, the length of stay was significantly shorter (1.16 vs. 1.01 days, p < 0.01) and estimated blood loss was lower (163 vs. 134, p = 0.034). Change in hemoglobin and rates of intraoperative and postoperative blood transfusion were the same between groups (p = 0.17). Readmission and reoperation rates were low and similar between groups (p = 1.0). The analysis was repeated including laparoscope-assisted vaginal hysterectomies, but this inclusion did not significantly change the results, so the decision was made to report the data exclusively for total laparoscopic hysterectomy.

Table 3.

Intraoperative and Postoperative Outcomes of Women Undergoing Laparoscopic Hysterectomy for Benign Indications by General Obstetrician–Gynecologists

Characteristics	Nonpreceptored, n = 179 (%)	Preceptored, n = 212 (%)	p
Procedure time (minutes)	127.7	105.4	<0.01
Intraoperative injury
Composite	11 (6)	2 (1)	<0.01
Small bowel	1 (1)	0 (0)	0.46
Large bowel	1 (1)	0 (0)	0.46
Bladder	4 (2)	2 (1)	0.42
Ureter	5 (3)	0 (0)	0.02
Conversion to open	9 (5)	0 (0)	<0.01
Intraoperative consult	12 (7)	1 (0.50)	<0.01
Length of stay, mean days (SD)	1.16 (0.60)	1.01 (0.21)	<0.01
Blood transfusion
Intraoperative	0 (0)	0 (0)	—
Postoperative	6 (3)	2 (1)	0.17
Estimated blood loss (IQR)	162.8 (153.0)	133.6 (150.8)
Readmission	5 (2)	6 (3)	1.0
Reoperation	2 (1)	3 (1)	1.0

Bold figures are statistically significant.

Discussion

Multiple studies have found that performance of surgery by a high-volume gynecologic surgeon improves patient outcomes.^10–17 However, the applicability of many of these studies is limited due to the heterogeneity of the surgeons and patient populations included. Our study describes a novel approach to expand patient access to high-volume minimally invasive gynecologic surgery care, and affords comparison of low- and high-volume surgeon outcomes in a homogeneous low-risk population.

It is well established that longer anesthesia and operative times are associated with increased rates of complications.^18–20 Our findings show that preceptoring by a high-volume surgeon leads to significantly shorter operative times with a 42-minute decrease in hysterectomy duration. An additional time saving aspect of preceptor involvement in surgery is the significantly lower rate of intraoperative consultations in the preceptored group, 0.5% as compared with 7% in the nonpreceptored group. As cost per minute of OR time is one of the most expensive components of surgery, it is of paramount importance to improve OR efficiency, thereby making our system safer and more affordable for patients.²¹

In this study, the patient groups are similar with a few key exceptions. The preceptored group comprised patients with a significantly higher BMI and greater uterine weight. In addition, the preceptored group contained a higher proportion of total laparoscopic hysterectomies, whereas the nonpreceptored group contained a higher proportion of supracervical hysterectomies. Supracervical hysterectomies are a faster and technically less challenging procedure, as they do not require laparoscopic suturing. These differences in patient and operative characteristics would favor finding no difference between the preceptored and nonpreceptored groups. Despite these biases, a significant decrease in both operative time and complications was identified in the preceptored group.

The multiple benefits of minimally invasive surgery have been well described, with faster recovery and low complication rates among the most important.^1–3 Our study demonstrates that involvement of a high-volume surgical preceptor leads to a sixfold decrease in composite surgical complications from 6% in the non-preceptored group to 1% in the preceptored group. The most striking differences between groups are the significantly lower rate of ureteral injury and conversion to laparotomy in the preceptored group. The degree of decreased complication rates seen between groups is both statistically significant and clinically substantial. Owing to the elective nature of most benign hysterectomies and the serious morbidity associated with organ injury and conversion to laparotomy, continued strides must be made to decrease these complications.^3,22–29 Our findings demonstrate that a preceptoring program is one reasonable method.

A limitation of prior large database studies is the inability to control for the complexity of patients referred to subspecialist surgeons.^10,11,30 Our study is unique because the patients in both groups are low-risk surgical candidates and homogeneous between groups (with the exception of higher BMI and greater uterine weight in the preceptored group). We found greater magnitudes of difference in operative time, conversion to laparotomy, and rate of organ injury than have previously been described.^10,11,30 These findings can be explained by several factors. First, there are inherent differences in the patients presenting for surgery to a general OB-GYN practice versus a gynecologic subspecialty referral practice. In our study, the similarity between surgical groups allows a more accurate assessment of surgeon volume on operative outcomes. Second, data in this study were collected directly from the medical record, whereas prior studies have largely relied on national databases that may under-report complications.¹¹ Third, the definition of “high-volume” gynecologic surgeon in prior studies ranged from 14 to 30 cases per year,^10,11,30 which is arguably too low a number to detect a difference in surgical outcomes. The preceptor in this study was a true high-volume surgeon performing >200 laparoscopic hysterectomies per year. The generalist OB-GYNs in this study were true low-volume surgeons performing on average 4.3 hysterectomies per year (range of 0.4–12).

This study has many strengths, including a complete data set on a large group of patients powered to detect a difference in operative time. Data were extracted directly from patients' charts instead of relying on administrative or national databases, which likely improves the ability to capture complications. Whereas many studies take place at high-volume tertiary referral centers, this study took place at an academic-affiliated community hospital, making the results more widely generalizable. Limitations to this study include those inherent to a retrospective observational study, making it difficult to control for unknown confounders and to determine causality. This is a single institution experience, and the effectiveness of a preceptoring program likely depends on the skill and volume of the preceptor and the generalist OB-GYNs at the institution. Patients in the study group were predominantly Caucasian and privately insured, which potentially limits generalizability to other populations. Finally, only outcomes of laparoscopic hysterectomies were compared, so decreases in complications more often associated with abdominal hysterectomy were not addressed in this analysis.^1–3,6,29

Conclusion

Preceptoring by a high-volume minimally invasive gynecologic surgeon at time of benign laparoscopic hysterectomy performance decreases operative time, rate of organ injury, and conversion to a laparotomy, and improves patient outcomes. Because of the improved OR efficiency and lower complication rates, this preceptoring model has been found to be both desirable and affordable to the hospital system, general OB-GYNs, and patients involved in the program.

Footnotes

Author Disclosure Statement

No competing financial interests exit.

Funding Information

No funding was required for the completion of this study.

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