Background
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.
Objective
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.
Results
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.
Conclusion
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
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Article info
Publication history
Published online: October 03, 2022
Accepted:
September 28,
2022
Received in revised form:
September 18,
2022
Received:
July 11,
2022
Footnotes
D.S. is a member of the editorial board of the Obstetrics & Gynecology. All other authors report no conflict of interest.
D.S. receives research funding from Renalis, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the Agency for Healthcare Research and Quality provided to University Hospitals and a consulting fee from Caldera Medical Inc. All other authors report no relevant financial disclosure.
Cite this article as: Chakraborty N, Rhodes S, Luchristt D, et al. Is total laparoscopic hysterectomy with longer operative time associated with a decreased benefit compared with total abdominal hysterectomy? Am J Obstet Gynecol 2023;228:205.e1-12.
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