Is total laparoscopic hysterectomy with longer operative time associated with a decreased benefit compared with total abdominal hysterectomy?

Published:October 03, 2022DOI:


      It is well known that, in general, total laparoscopic hysterectomy is associated with less perioperative morbidity compared with total abdominal hysterectomy. However, total laparoscopic hysterectomy is also associated with longer operating times, which itself is an independent predictor of morbidity. Currently, it is unknown whether there is an operative time threshold beyond which total laparoscopic hysterectomy provides a diminishing return and higher risk of morbidity than a shorter abdominal hysterectomy.


      This study aimed to determine whether there is an operative time limit beyond which the benefits of total laparoscopic hysterectomy diminished compared with shorter total abdominal hysterectomy.

      Study Design

      Targeted hysterectomy-specific data from the National Surgical Quality Improvement Project was used to identify patients undergoing total laparoscopic hysterectomy and total abdominal hysterectomy for benign indications between the years 2014 and 2018. The primary outcomes of interest were any major morbidity, and the length of stay after surgery was analyzed using generalized linear models. The models controlled for demographic data, comorbidities, and hysterectomy-specific information, such as uterine weight, presence of endometriosis, and pelvic inflammatory disease at the time of surgery. Missing data were addressed using multiple imputation analysis. Sensitivity analyses using propensity score matching and generalized additive models were performed to assess the effect of selection bias and nonlinear interactions between covariates and the outcomes, respectively. Common Procedural Terminology codes were used to identify women who underwent total abdominal hysterectomy (n=58,152) or total laparoscopic hysterectomy (n=58,570–58,573). Conventional laparoscopy could not be differentiated from robotic surgery as there is no mechanism for doing so within the National Surgical Quality Improvement Project. Therefore, total laparoscopic hysterectomy also includes robotic-assisted surgery. Additional exclusion criteria included any surgery lasting >360 minutes, as these represent significant outliers in the data and clinical practice; pelvic reconstructive procedure; anti-incontinence surgery; lymphadenectomy; radical hysterectomy; cytoreductive surgery; a pre- or postoperative diagnostic code for gynecologic malignancy; preoperative sepsis or renal failure; emergency surgery; or any concurrent nongynecologic surgery. Patients who underwent ureteral stenting during the procedure with no additional urologic procedures were included, as this may be performed at the time of hysterectomy or to address ureteral injury.


      The mean operating time was similar for both routes, 129±60 minutes for total laparoscopic hysterectomy and 129±64 minutes for total abdominal hysterectomy (P=.45). The complication rate was higher for total abdominal hysterectomy than total laparoscopic hysterectomy (16.6% vs 7.7%; P<.001); and the median length of stay was longer for total abdominal hysterectomy (2 [interquartile range, 2–3] days vs 1 [interquartile range, 0–1] days; P<.001). After adjusting for confounders, an increase of 1 hour in operative time for hysterectomy was associated with a 45% (95% confidence interval, 41%–49%) increase in the risk of major morbidity; furthermore, total abdominal hysterectomy was associated with an additional time detriment, such that there was an additional 61% (95% confidence interval, 53%–68%) increase in the risk of a major morbidity for each additional hour of a total abdominal hysterectomy. There was no time point at which total abdominal hysterectomy was associated with less morbidity or a shorter length of stay than total laparoscopic hysterectomy, even if total laparoscopic hysterectomy was significantly longer than total abdominal hysterectomy. The same conclusions remained true with the propensity-matched analysis and generalized additive model analyses.


      Our findings showed that there is no reasonable operative time at which total laparoscopic hysterectomy is associated with a higher rate of complications or longer length of stay than total abdominal hysterectomy.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Wright J.D.
        • Herzog T.J.
        • Tsui J.
        • et al.
        Nationwide trends in the performance of inpatient hysterectomy in the United States.
        Obstet Gynecol. 2013; 122: 233-241
        • Luchristt D.
        • Brown O.
        • Kenton K.
        • Bretschneider C.E.
        Trends in operative time and outcomes in minimally invasive hysterectomy from 2008 to 2018.
        Am J Obstet Gynecol. 2021; 224 (e1–12): 202
        • Walsh C.A.
        • Walsh S.R.
        • Tang T.Y.
        • Slack M.
        Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis.
        Eur J Obstet Gynecol Reprod Biol. 2009; 144: 3-7
        • Johnson N.
        • Barlow D.
        • Lethaby A.
        • Tavender E.
        • Curr L.
        • Garry R.
        Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials.
        BMJ. 2005; 330: 1478
        • Hoffman C.P.
        • Kennedy J.
        • Borschel L.
        • Burchette R.
        • Kidd A.
        Laparoscopic hysterectomy: the Kaiser Permanente San Diego experience.
        J Minim Invasive Gynecol. 2005; 12: 16-24
        • Janda M.
        • Gebski V.
        • Brand A.
        • et al.
        Quality of life after total laparoscopic hysterectomy versus total abdominal hysterectomy for stage I endometrial cancer (LACE): a randomised trial.
        Lancet Oncol. 2010; 11: 772-780
        • Aarts J.W.
        • Nieboer T.E.
        • Johnson N.
        • et al.
        Surgical approach to hysterectomy for benign gynaecological disease.
        Cochrane Database Syst Rev. 2015; 2015: CD003677
        • Shah D.K.
        • Vitonis A.F.
        • Missmer S.A.
        Association of body mass index and morbidity after abdominal, vaginal, and laparoscopic hysterectomy.
        Obstet Gynecol. 2015; 125: 589-598
        • Vree F.E.
        • Cohen S.L.
        • Chavan N.
        • Einarsson J.I.
        The impact of surgeon volume on perioperative outcomes in hysterectomy.
        JSLS. 2014; 18: 174-181
        • Uccella S.
        • Cromi A.
        • Bogani G.
        • Casarin J.
        • Formenti G.
        • Ghezzi F.
        Systematic implementation of laparoscopic hysterectomy independent of uterus size: clinical effect.
        J Minim Invasive Gynecol. 2013; 20: 505-516
        • Catanzarite T.
        • Saha S.
        • Pilecki M.A.
        • Kim J.Y.
        • Milad M.P.
        Longer operative time during benign laparoscopic and robotic hysterectomy is associated with increased 30-day perioperative complications.
        J Minim Invasive Gynecol. 2015; 22: 1049-1058
        • Vargas M.V.
        • Larson K.D.
        • Sparks A.
        • et al.
        Association of operative time with outcomes in minimally invasive and abdominal myomectomy.
        Fertil Steril. 2019; 111: 1252-1258.e1
        • Margulies S.L.
        • Vargas M.V.
        • Denny K.
        • et al.
        Comparing benign laparoscopic and abdominal hysterectomy outcomes by time.
        Surg Endosc. 2020; 34: 758-769
        • Ingraham A.M.
        • Richards K.E.
        • Hall B.L.
        • Ko C.Y.
        Quality improvement in surgery: the American College of Surgeons national surgical quality improvement program approach.
        Adv Surg. 2010; 44: 251-267
        • Cohen M.E.
        • Liu Y.
        • Ko C.Y.
        • Hall B.L.
        Improved surgical outcomes for ACS NSQIP hospitals over time: evaluation of hospital cohorts with up to 8 years of participation.
        Ann Surg. 2016; 263: 267-273
        • Lawson E.H.
        • Wang X.
        • Cohen M.E.
        • Hall B.L.
        • Tanzman H.
        • Ko C.Y.
        Morbidity and mortality after colorectal procedures: comparison of data from the American College of Surgeons case log system and the.
        ACS NSQIP. J Am Coll Surg. 2011; 212: 1077-1085
        • Subramaniam S.
        • Aalberg J.J.
        • Soriano R.P.
        • Divino C.M.
        New 5-factor modified frailty index using American College of Surgeons NSQIP data.
        J Am Coll Surg. 2018; 226: 173-181.e8
        • Von Elm E.
        • Altman D.G.
        • Egger M.
        • et al.
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Prev Med. 2007; 45: 247-251
        • Clavien P.A.
        • Barkun J.
        • De Oliveira M.L.
        • et al.
        The Clavien-Dindo classification of surgical complications: five-year experience.
        Ann Surg. 2009; 250: 187-196
        • Van Buuren S.
        • Groothuis-Oudshoorn K.
        mice: multivariate imputation by chained equations in R.
        J Stat Softw. 2011; 45: 1-67
        • Rubin D.B.
        Multiple imputation for nonresponse in surveys.
        John Wiley & Sons, Chichester, England2004
        • Granger E.
        • Sergeant J.C.
        • Lunt M.
        Avoiding pitfalls when combining multiple imputation and propensity scores.
        Stat Med. 2019; 38: 5120-5132
        • Wiser A.
        • Holcroft C.A.
        • Tulandi T.
        • Abenhaim H.A.
        Abdominal versus laparoscopic hysterectomies for benign diseases: evaluation of morbidity and mortality among 465,798 cases.
        Gynecol Surg. 2013; 10: 117-122
        • Hanwright P.J.
        • Mioton L.M.
        • Thomassee M.S.
        • et al.
        Risk profiles and outcomes of total laparoscopic hysterectomy compared with laparoscopically assisted vaginal hysterectomy.
        Obstet Gynecol. 2013; 121: 781-787
        • Procter L.D.
        • Davenport D.L.
        • Bernard A.C.
        • Zwischenberger J.B.
        General surgical operative duration is associated with increased risk-adjusted infectious complication rates and length of hospital stay.
        J Am Coll Surg. 2010; 210 (60–5.e2)
        • Jackson T.D.
        • Wannares J.J.
        • Lancaster R.T.
        • Rattner D.W.
        • Hutter M.M.
        Does speed matter? The impact of operative time on outcome in laparoscopic surgery.
        Surg Endosc. 2011; 25: 2288-2295
        • Cui N.
        • Liu J.
        • Tan H.
        Comparison of laparoscopic surgery versus traditional laparotomy for the treatment of emergency patients.
        J Int Med Res. 2020; 48300060519889191
        • Scheer A.
        • Martel G.
        • Moloo H.
        • et al.
        Laparoscopic colon surgery: does operative time matter?.
        Dis Colon Rectum. 2009; 52: 1746-1752
        • ACOG Committee Opinion No
        444: choosing the route of hysterectomy for benign disease.
        Obstet Gynecol. 2009; 114: 1156-1158
        • Patel P.R.
        • Lee J.
        • Rodriguez A.M.
        • et al.
        Disparities in use of laparoscopic hysterectomies: a nationwide analysis.
        J Minim Invasive Gynecol. 2014; 21: 223-227
        • Chen I.
        • Wise M.R.
        • Dunn S.
        • et al.
        Social and geographic determinants of hysterectomy in Ontario: a population-based retrospective cross-sectional analysis.
        J Obstet Gynaecol Can. 2017; 39: 861-869
        • Chen I.
        • Wise M.R.
        • Dunn S.
        • et al.
        Social and geographic determinants of hysterectomy in Ontario: a population-based retrospective cross-sectional analysis.
        J Obstet Gynaecol Can. 2017; 39: 861-869
        • Katon J.G.
        • Bossick A.S.
        • Doll K.M.
        • et al.
        Contributors to racial disparities in minimally invasive hysterectomy in the US Department of Veterans Affairs.
        Med Care. 2019; 57: 930-936
        • Ranjit A.
        • Sharma M.
        • Romano A.
        • et al.
        Does universal insurance mitigate racial differences in minimally invasive hysterectomy?.
        J Minim Invasive Gynecol. 2017; 24: 790-796
        • Fowler A.J.
        • Ahmad T.
        • Phull M.K.
        • Allard S.
        • Gillies M.A.
        • Pearse R.M.
        Meta-analysis of the association between preoperative anaemia and mortality after surgery.
        Br J Surg. 2015; 102: 1314-1324
        • Wallenstein M.R.
        • Ananth C.V.
        • Kim J.H.
        • et al.
        Effect of surgical volume on outcomes for laparoscopic hysterectomy for benign indications.
        Obstet Gynecol. 2012; 119: 709-716
        • Boyd L.R.
        • Novetsky A.P.
        • Curtin J.P.
        Effect of surgical volume on route of hysterectomy and short-term morbidity.
        Obstet Gynecol. 2010; 116: 909-915
        • Wright J.D.
        • Devine P.
        • Shah M.
        • et al.
        Morbidity and mortality of peripartum hysterectomy.
        Obstet Gynecol. 2010; 115: 1187-1193
        • Silvestri M.T.
        • Pettker C.M.
        • Brousseau E.C.
        • Dick M.A.
        • Ciarleglio M.M.
        • Erekson E.A.
        Morbidity of appendectomy and cholecystectomy in pregnant and nonpregnant women.
        Obstet Gynecol. 2011; 118: 1261-1270
        • Moore H.B.
        • Juarez-Colunga E.
        • Bronsert M.
        • et al.
        Effect of pregnancy on adverse outcomes after general surgery.
        JAMA Surg. 2015; 150: 637-643
        • Abdelwahab M.
        • Lynch C.D.
        • Schneider P.
        • et al.
        Postoperative complications after non-obstetric surgery among pregnant patients in the National Surgical Quality Improvement Program, 2005-2012.
        Am J Surg. 2022; 223: 364-369