Laparoscopic Hysterectomy Outcomes: Hospital vs Ambulatory Surgery Center

Abstract

Background and Objective
Compare operative outcomes of laparoscopic hysterectomy in an outpatient hospital setting versus freestanding ambulatory surgery center.

Methods
Retrospective cohort study of two groups in an outpatient hospital surgery department and freestanding ambulatory surgical center, both serving the Washington, DC area. Women, 18 years or older, who underwent laparoscopic hysterectomy for benign conditions in an outpatient hospital setting between 2011 and 2014 (n = 821), and at an ambulatory surgery center between 2013 and 2017 (n = 1210). Laparoscopic hysterectomy with retroperitoneal dissection and early ligation of the uterine arteries at the origin, performed by gynecologic surgical specialists from a single practice. Patient characteristics, medical history, uterine weight, pathology, operating times, estimated blood loss, and complications were analyzed.

Results
The mean uterine size between settings was not significantly different (Ambulatory Surgery Center, 349.4 g; Hospital, 329.7 g). The largest uteri removed at the surgery center was 3500 g; at the hospital it was 2489 g. The surgery center had a shorter average operating time than the hospital (53.7 and 61.3 minutes, respectively; P < .001). Intraoperative and postoperative complication rates were not significantly different between settings (2.7% and 3.7%, surgery center; 2.1% and 4.8%, hospital). There were two hospital transfers from the surgery center: 1 for blood transfusion, and 1 for low oxygen saturation. Same-day discharge occurred in 99.8% of surgery center patients versus 88% hospital patients.

Conclusions
Laparoscopic hysterectomy can be performed safely and effectively by skilled surgeons at a freestanding ambulatory surgery center, even in complex cases with large uteri.

Full text

Laparoscopic Hysterectomy Outcomes: Hospital vs
Ambulatory Surgery Center
Paul MacKoul, MD, FACOG, Natalya Danilyants, MD, FACOG, Rupen Baxi, MD, FACOG,
Louise van der Does, PhD, Leah Haworth, BSN, RN
ABSTRACT
Background and Objective: Compare operative out-
comes of laparoscopic hysterectomy in an outpatient hos-
pital setting versus freestanding ambulatory surgery cen-
ter.
Methods: Retrospective cohort study of two groups in an
outpatient hospital surgery department and freestanding
ambulatory surgical center, both serving the Washington,
DC area. Women, 18 years or older, who underwent
laparoscopic hysterectomy for benign conditions in an
outpatient hospital setting between 2011 and 2014 (n ⫽
821), and at an ambulatory surgery center between 2013 and
2017 (n ⫽1210). Laparoscopic hysterectomy with retroper-
itoneal dissection and early ligation of the uterine arteries at
the origin, performed by gynecologic surgical specialists
from a single practice. Patient characteristics, medical history,
uterine weight, pathology, operating times, estimated blood
loss, and complications were analyzed.
Results: The mean uterine size between settings was not
significantly different (Ambulatory Surgery Center, 349.4
g; Hospital, 329.7 g). The largest uteri removed at the
surgery center was 3500 g; at the hospital it was 2489 g.
The surgery center had a shorter average operating time
than the hospital (53.7 and 61.3 minutes, respectively; P⬍
.001). Intraoperative and postoperative complication rates
were not significantly different between settings (2.7%
and 3.7%, surgery center; 2.1% and 4.8%, hospital). There
were two hospital transfers from the surgery center: 1 for
blood transfusion, and 1 for low oxygen saturation. Same-
day discharge occurred in 99.8% of surgery center patients
versus 88% hospital patients.
Conclusions: Laparoscopic hysterectomy can be per-
formed safely and effectively by skilled surgeons at a
freestanding ambulatory surgery center, even in complex
cases with large uteri.
Key Words: Arteries, Ligation, Regression, Retroperito-
neal, Uterine.
INTRODUCTION
The first Ambulatory Surgery Center (ASC) opened in
1970. Today, there are more than 5400 ASCs in the United
States, accounting for nearly 35% of all surgeries per-
formed in the United States and approximately 10% of
surgical revenue.
1,2
ASCs have demonstrated advantages
over hospital-based outpatient surgery, such as improved
patient accessibility, on-time scheduling, customized sur-
gical environments, highly efficient surgical teams, shorter
operative and facility times, lower costs, less potential
exposure to nosocomial infections, and intensified quality
control processes.
3–8
The advantages of an ASC have re-
sulted in a migration of surgical procedures from the
hospital to the ambulatory setting. The specialty catego-
ries of gastrointestinal, ophthalmology, pain management,
orthopedic, and genitourinary currently constitute over
70% of all procedures performed at ASCs.
9
Advances in technology and more emphasis on laparo-
scopic techniques in residency have enabled the shift in
gynecological surgery from the inpatient to the outpatient
setting, with 13.3% of hysterectomies performed as an
outpatient procedure in 2008 vs 57.5% in 2014.
10
This shift
The Center for Innovative GYN Care, Rockville, MD 20852, USA (Drs MacKoul,
Danilyants, Baxi, van der Does; Ms. Haworth).
Disclosures: Drs MacKoul and Danilyants are both co-owners of The Center for
Innovative GYN Care (CIGC). The CIGC owners did not play a role in the
collection, analysis, or interpretation of the data. Drs Baxi and van der Does are
employed by CIGC. Ms. Haworth is an independent contractor retained by CIGC.
The authors declare they have no competing interests.
Source of Funding: This study was funded by The Center for Innovative GYN Care.
Acknowledgments: We would like to thank Frank Egan, Laila Kazi, Nilofar Kazi,
June Kyrk, Sandra Staicu, and Kim Williams for their diligent data abstraction. We
would also like to thank Holy Cross Hospital and The Center for Innovative GYN
Care for their commitment to excellence in research. Dr. van der Does and Ms.
Haworth had full access to all the data in the study and take responsibility for the
integrity of the data and the accuracy of the data analysis.
Conflicts of Interest: All authors declare no conflict of interest regarding the
publication of this article.
Informed consent: Dr. van der Does declares that written informed consent was
obtained from the patient/s for publication of this study/report and any accompa-
nying images.
Address correspondence to: Louise van der Does, PhD, The Center for Innovative
GYN Care, 3206 Tower Oaks Blvd, Suite 200, Rockville, MD 20852, USA. Tele-
phone: 703-568-5628, Fax: 301-669-3053, E-mail: lvanderdoes@innovativegyn.com
DOI: 10.4293/JSLS.2018.00076
© 2019 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
1January–March 2019 Volume 23 Issue 1 e2018.00076 JSLS www.SLS.org
SCIENTIFIC PAPER

is paralleled by a substantial increase in minimally inva-
sive surgery, including laparoscopic hysterectomy. This
changing landscape of gynecologic surgery has set the
stage for further migration to the ASC setting.
Nezhat et al
11
published a retrospective review of 134
patients who underwent advanced gynecologic laparo-
scopic surgery at 3 freestanding ASCs over a year-long
period in 2010–2011, which demonstrated that these pro-
cedures could be safely performed with a high rate of
same-day discharge and low unplanned readmission rate.
Although laparoscopic hysterectomy is commonly per-
formed as outpatient surgery, only an estimated 1% of all
hysterectomies are performed at an ASC.
12
As the proce-
dure involves the extensive vascular network inside the
peritoneal cavity, the main concerns about performing
hysterectomy at an ASC without hospital support are the
risk of bleeding complications, visceral injury, and post-
operative hospitalization.
During laparoscopic hysterectomy, the uterine vessels are
typically identified and cauterized at the isthmo-cervical
region of the uterus. However, pelvic pathology such as
fibroids, endometriosis, adhesions from previous pelvic
surgeries, or ovarian remnants can distort anatomy and
pose additional technical challenges during laparoscopic
hysterectomies. A retroperitoneal laparoscopic approach,
with early ligation of the uterine artery at its origin at the
anterior branch of the internal iliac artery, was originally
described by Ko¨hler et al
13
and Roman et al
14
as a tech-
nique to control blood loss and protect the ureter, even in
cases with large uteri. The retroperitoneal dissection re-
quired for this technique may also help prevent other
visceral injuries by allowing full visualization and lateral-
ization of the ureters.
15–17
A randomized study of 400
patients showed shorter operative time and significantly
less blood loss in patients who underwent uterine artery
ligation at the origin versus the isthmo-cervical region.
18
The laparoscopic retroperitoneal hysterectomy (LRH) per-
formed in this study is a variation of a total laparoscopic
hysterectomy, with the distinguishing aspect of a standard
retroperitoneal dissection, lateralization of the ureters, and
early ligation of the uterine artery at its origin from the
anterior division of the internal iliac artery.
19–21
Our ob-
jective was to compare patient characteristics and opera-
tive outcomes of women undergoing LRH in a hospital
outpatient department (Hospital) versus a freestanding
ambulatory surgery center (ASC).
MATERIALS AND METHODS
A retrospective review of all outpatient LRH cases per-
formed at a high-volume community hospital by a single
private-practice gynecology group from January 1, 2011
through December 31, 2014 was compared to all LRH
cases performed by the same practice at a freestanding
ASC from October 1, 2013 through October 1, 2017. This
practice consists of a fellowship-trained minimally inva-
sive gynecologist and a gynecologic oncologist, who in-
dividually performed each the procedures evaluated in
the study. The ASC in this review first opened on October
1, 2013, dictating the commencement date of the ASC data
collection. The ASC is Medicare certified and is accredited
by the Accreditation Association for Ambulatory Health
Care. Distribution of patients to either ASC or Hospital was
determined solely by patients’ insurance. On the rare
occasion, cases were scheduled at the Hospital for pa-
tients with high-risk comorbidities, including severe ane-
mia and body mass index ⬎60 kg/m
2
. All women in this
study were 18 years or older, nonpregnant, with benign
indications for surgery. The type of hysterectomy per-
formed in all cases was an LRH, performed by one of the
two surgeons, as described in detail below.
LRH Technique
We provide here the most important technical principles
of the LRH technique for benign gynecologic surgery as
described in the operative reports. First, a uterine manip-
ulator is inserted to allow for mobility. The hysterectomy
is initiated by transecting the round ligament and entering
the retroperitoneal space. The paravesical and pararectal
spaces are completely developed and the vital structures
are identified. The uterine artery is then ligated at its origin
using the Harmonic Scalpel. A defect is made in the
posterior leaf of the broad ligament, which lateralizes the
ureter and aids in isolating the infundibulopelvic ligament.
The anterior leaf of the broad ligaments is then opened on
each side to create a bladder flap that is carried through to
the midline along the vesicouterine peritoneum. The an-
terior vaginal fornix is delineated using a simple sponge
stick, and a colpotomy is created using the Harmonic
Scalpel. The uterus is then extracted vaginally, and if
needed in cases of large specimen, via extraperitoneal
vaginal debulking techniques using sharp dissection. No
electric morcellation is used. The vaginal cuff is closed
transvaginally.
Prior to surgery, postoperative instructions were reviewed
in detail with the patient. After surgery, patients in the ASC
were discharged home within 2–3 hours of the end of
Laparoscopic Hysterectomy Outcomes: Hospital vs Ambulatory Surgery Center, MacKoul P et al.
2January–March 2019 Volume 23 Issue 1 e2018.00076 JSLS www.SLS.org

their procedure. Pain management regimen included pre-
operative acetaminophen, Intravenous (IV) narcotics in-
traoperatively and in the post-anesthesia care unit, and
patients were discharged home with oral narcotics and
ibuprofen.
Patients requiring transfer from the ASC to the hospital are
transported via local medical transport company, with
which the ASC has an agreement, at the expense of the
ASC. The emergency department is contacted before
transport to alert of the incoming patient, and patients are
transported directly to one of 3 local hospitals, all located
within 10 miles of the ASC.
Postoperative phone calls were made by Hospital and
ASC staff on the day after discharge. If the patient was not
able to be reached, a follow-up phone call was made until
the patient was reached or until postoperative day 7. All
patients were scheduled for a 2-week postoperative visit.
Cases with concomitant procedures frequently performed
during a hysterectomy were included in the study, such as
adnexal surgery (salpingectomy, oophorectomy, ovarian
cystectomy), adhesiolysis, cystoscopy, or other (ureterol-
ysis, repair of incidental minor surgical injuries). Cases
with major concomitant pelvic or abdominal surgery un-
related to the hysterectomy, such as appendectomy, cho-
lecystectomy, hernia repair, and pelvic support proce-
dures were excluded from the analysis. Patients with
malignant indications for surgery were also excluded.
Clinical characteristics analyzed included age, race,
weight, body mass index, prior medical/surgical history,
uterine weight, and uterine pathology. The Elixhauser
Comorbidity Index was used to identify and record co-
morbid conditions that have been shown to have a po-
tential impact on clinical outcomes.
22
Clinical outcomes evaluated included estimated blood
loss, operative times, laparotomy conversion rate, and
intraoperative and postoperative complications. Compli-
cations were categorized as intraoperative when they oc-
curred and were recognized at the time of the procedure
(intestinal injury, bladder injury, ureteral injury, vascular
injury, and other operative injury). Complications that
presented within 60 day of the hysterectomy were cate-
gorized as postoperative (wound complications, vaginal
cuff dehiscence, pelvic abscess, venous thromboembo-
lism, bacteremia/sepsis, blood transfusion, and emer-
gency department visits for pain). Intraoperative compli-
cations and conversion to standard abdominal laparotomy
(incision size greater than 5 cm) or minilaparotomy (inci-
sion size ⬍5 cm) were identified from the operative notes.
The medical charts were reviewed to identify postopera-
tive complications that were reported when the patient
was seen, evaluated, or admitted to the emergency de-
partment, hospital, or the office.
Statistical Analysis
Prior to inferential analyses, data were checked for
potential outlier and aberrant measurements. Patient’s
demographic and clinical characteristics measured on a
nominal or ordinal scale were summarized as counts
and percentages, and compared between surgical set-
tings using Pearson’s
␹
2
tests, whereas variables mea-
sured in the interval scale were summarized as means
and standard deviations and compared across surgical
settings using Student t-test.
Operative outcomes were compared between surgical set-
tings with and without patient demographic and case
complexity adjustments. We used median regression to
model estimated blood loss and operative times because
of concerns about non-normality of the dependent vari-
able. Lengths of stay and the number of ports were com-
pared using negative binomial regression. Dichotomous
operative outcomes (intra-operative complications, post-
operative complications, and conversions) were com-
pared using Pearson’s
␹
2
tests.
The operative outcomes were also adjusted for age, race,
number of previous abdominal surgeries, body mass in-
dex, number of comorbidities, weight, uterine size, and
number of additional procedure. Logistic regression was
used to model intra-operative, postoperative complica-
tions, and conversions. Negative binomial regression was
used to model length of stay and number of ports. All
statistical analyses were conducted with SPSS 21 (IBM
Inc., Armonk, NY, USA). All statistical tests were 2-tailed at
the P⬍.001 level.
RESULTS
A total of 1210 patients underwent LRH at the ASC and 821
patients at the Hospital. Age, weight, and body mass index
were comparable between the groups. White patients
were more likely to have surgery at the ASC (48.3%) than
Black patients (29.5%). This difference did not exist in the
Hospital group (46.4% White; 45.6% Black). No significant
differences were noted in the Other group, which in-
cluded Asian and Hispanic women (Table 1).
No statistically significant differences in mean uterine
weights were noted between the surgical settings (ASC,
349.4 g; Hospital, 329.7 g). The largest uterus in the ASC
3January–March 2019 Volume 23 Issue 1 e2018.00076 JSLS www.SLS.org

setting was 3500 g, compared to 2489 g in the Hospital
(Table 1). Uterine pathology was also similar in both
groups, except for endometriosis, which was more prev-
alent at the ASC (Table 2).
There was no difference in the number of comorbidities
between the ASC and Hospital settings, but the ASC group
had a larger number of patients with 2 or more previous
abdominal surgeries (Table 1). The ASC group had sig-
nificantly shorter average anesthesia and surgery times
(85.8 and 53.7 minutes, respectively) compared with
the Hospital (97.4 and 61.3 minutes, P⬍.001) (Table 3
and Table 4). The rate of intra-operative and postop-
erative complications between settings was not signifi-
cantly different (ASC, 2.2% and 3.3%; Hospital, 2.1%
and 3.4%). There was one postoperative blood transfu-
sion in each group. There was one conversion to stan-
dard abdominal laparotomy in the ASC group, and no
conversions in the Hospital. In the former case, there
were extensive bowel adhesions to uterus with injury to
bowel during removal of fibroids, thus a laparotomy
was required for a small-bowel resection and large-
bowel repair (Table 3). This patient was discharged
home the same day, but she was seen in the emergency
department 3 days later for postoperative pain, and was
admitted for a pelvic abscess requiring exploratory lap-
Table 2.
Pathology
Pathology Setting
Hospital
N (%)
ASC
N (%)
N 821 1210
Leiomyoma 587 (71.5) 927 (76.6)
Adenomyosis 376 (45.8) 679 (56.1)
Endometriosis 69 (8.4) 223 (18.4)
Endometrial polyp 98 (11.9) 114 (9.4)
Ovarian cyst 114 (13.9) 172 (14.2)
Ovarian neoplasm 41 (5) 18 (1.5)
Endometrial intraepithelial neoplasia 12 (1.5) 19 (1.6)
Cervical intraepithelial neoplasia 6 (0.7) 14 (1.2)
Cervical cancer 2 (0.2) 2 (0.2)
Uterine sarcoma 0 (0) 0 (0)
Endometrial cancer 4 (0.5) 21 (1.7)
Fallopian tube cancer 1 (0.1) 0 (0)
ASC, Ambulatory Surgery Center.
Table 1.
Patient Characteristics
Setting PValue
Hospital ASC
N 821 1210
N (%) N (%)
Age group (years) ⬍.001
⬍40 150 (18.3) 280 (23.2)
40–50 431 (52.5) 660 (54.6)
51–60 174 (21.2) 220 (18.2)
61–70 40 (4.9) 45 (3.7)
⬎70 26 (3.2) 4 (0.3)
Race ⬍.001
Black 374 (45.6) 357 (29.5)
White 381 (46.4) 584 (48.3)
Other 55 (6.7) 153 (12.7)
Unknown 11 (1.3) 115 (9.5)
No. of previous Ab
surgeries
.0014
None 263 (32.0) 364 (30.1)
1 278 (33.9) 365 (30.2)
2 171 (20.8) 239 (19.8)
⬎2 109 (13.3) 241 (19.9)
No. of comorbidities .120
None 205 (25.0) 278 (23.0)
1 233 (28.4) 359 (29.7)
2 158 (19.2) 287 (23.7)
3 225 (27.4) 285 (23.6)
Uterine size categories .7817
ⱕ250 468 (57.0) 681 (56.4)
⬍250–500 176 (21.4) 260 (21.5)
⬎500–750 79 (9.6) 131 (10.9)
⬎750–1000 55 (6.7) 68 (5.6)
⬎1000 43 (5.2) 67 (5.6)
Mean (SD) Mean (SD)
Age (years) 47.5 (9.4) 45.6 (7.7) ⬍.0001
Weight (kg) 79.9 (21.0) 79.8 (21.9) .9006
BMI (m/k
2
)29.8 (7.3) 29.4 (7.8) .3218
Uterine weight (g) 329.7 (335.9) 349.4 (364.8) .2139
Ab, Abdominal; ASC, Ambulatory Surgery Center.
Laparoscopic Hysterectomy Outcomes: Hospital vs Ambulatory Surgery Center, MacKoul P et al.
4January–March 2019 Volume 23 Issue 1 e2018.00076 JSLS www.SLS.org

arotomy to rule out bowel perforation, which was ex-
cluded. The patient recovered without further compli-
cation.
The average length of stay in the outpatient Hospital
group was 0.2 days, with 88% of patients discharged the
same day of surgery. Postoperative pain was the pri-
mary reason for admission, followed by case delays, and
inability to void. Other reasons for postoperative admission
in order of frequency were patient request, postoperative
nausea/vomiting, dizziness/sleepiness, postoperative ane-
mia, abnormal electrocardiogram (EKG), hypotension, vag-
inal bleeding, incisional bleeding, and low oxygen satura-
tion. There were two transfers to the hospital from the ASC;
one was for blood transfusion, and the other for observation
for low oxygen saturation, secondary to a history of obstruc-
tive sleep apnea. Both cases had uncomplicated resolutions.
Table 3.
Operative Outcomes (Unadjusted Analysis)
Setting PValue
Hospital ASC
N Mean (SD) N Mean (SD)
Estimated blood loss (mL) 783 128.8 (141.7) 1178 121.3 (135.2) .99
Length of stay (days) 821 0.2 (0.8) 1090 0.0 (0.0) ⬍.001
Total surgery time (minutes) 818 61.3 (30.4) 1185 53.7 (23.3) ⬍.001
Total anesthesia time (minutes) 819 97.4 (32.7) 1175 85.8 (31.3) ⬍.001
Number of ports 818 2.2 (0.5) 1192 2.3 (0.5) .29
No. (%) No. (%)
Intra-operative complications 821 18 (2.19) 1209 27 (2.23) .95
Post-operative complication 821 28 (3.41) 1209 40 (3.31) .90
Conversion to minilaparotomy 821 10 (1.22) 1209 22 (1.82) .16
Conversion to laparotomy 821 0 (0.0) 1209 1 (.08) N/A
ASC, Ambulatory Surgery Center.
Table 4.
Operative Outcomes (Adjusted Analysis)
Setting PValue
Hospital ASC
Estimated blood loss (mL), Adj. Medians (95% CI) 105.4 (97.8–113.1) 89.6 (83.6–95.6) .004
Length of stay (days), Adj. Medians (95% CI) 0.2 (0.2–0.3) 0.0 (0.0–0.0) ⬍.001
Total surgery time (min), Adj. Medians (95% CI) 56.5 (55.0–58.0) 48.8 (47.6–50.0) ⬍.001
Total anesthesia time (min), Adj. Medians (95% CI) 92.7 (91.0–94.4) 80.4 (79.1–81.7) ⬍.001
Number of ports, Adj. counts (95% CI) 2.3 (2.2–2.4) 2.2 (2.1–2.3) .44
Intra-operative complications, % (95% CI) 4.0 (2.1–6.0) 2.7 (2.1–3.4) .061
Post-operative complications, % (95% CI) 4.8 (2.8–6.8) 3.7 (2.8–4.6) .077
Conversion to minilaparotomy, % (95% CI) 1.8 (0.7–3.0) 3.2 (2.2–4.1) .10
Adjusted for age, race, number of previous abdominal surgeries, body mass index, number of comorbidities, weight, uterine size, and
number of additional procedures.
Adj, Adjusted.
5January–March 2019 Volume 23 Issue 1 e2018.00076 JSLS www.SLS.org

All other ASC patients were discharged the same day of
surgery (99.8%).
In the 60-day postoperative period for the ASC group,
there were 4 visits to the emergency department for pain
versus 6 visits for the Hospital group. There were 2 visits
to the emergency department from the ASC group for
nausea/vomiting. There were 22 ASC patients who were
admitted to the hospital in the 60-day postoperative pe-
riod, and 16 patients who were readmitted from the Hos-
pital group. Reasons for hospital admission were similar
between settings and included vaginal cuff dehiscence,
abdominal wall hematoma, ileus, infection, pelvic ab-
scess, pulmonary embolism, deep-vein thrombosis, and
ureteral obstruction.
When the operative results were adjusted for age, race,
number of previous abdominal surgeries, body mass in-
dex, number of comorbidities, weight, uterine size and
number of additional procedures, there was only one
difference from the unadjusted results (Table 4). The
unadjusted average estimated blood loss between the ASC
and Hospital was not significantly different (128.8 mL vs
121.3 mL; P⫽.99, respectively). However, the adjusted
average estimated blood loss showed a statistically signif-
icant difference (ASC, 89.6 mL vs Hospital, 105.4 mL; P⫽
.004).
DISCUSSION
The patient characteristics were similar in both groups,
supporting the idea that LRH can be safely performed in a
freestanding ASC where subspecialty backup and imme-
diate blood transfusion capabilities do not exist. The low
average estimated blood loss and transfusion rate across
settings is evidence that the techniques inherent to LRH
provide hemostasis, especially in patients who require
extensive adhesiolysis, multiple concomitant procedures,
and who are at higher surgical risk with comorbid condi-
tions such as diabetes, hypertension, Chronic obstructive
pulmonary disease (COPD), and obesity.
LRH also allows for the safe removal of large uteri. While
the average uterine weight in each setting was not signif-
icantly different, the largest uteri removed at the ASC was
over 1000 g larger than at the Hospital (3500 g vs 2489 g,
respectively).
Surgeon experience remains an important factor in
achieving successful clinical outcomes. Many studies
show an association between high-volume surgeons and
lower surgical complications, which is also linked to
same-day discharge.
23
Unlike past studies emphasizing
the feasibility of ASCs with proper patient selection, our
data support the idea that laparoscopic hysterectomy can
be performed safely in the hands of skilled surgeons using
advanced laparoscopic techniques, even in patients with
complex cases.
In addition, there was a significant difference in average
anesthesia and operating times at the ASC compared to
the Hospital. Anesthesia times at the ASC were 12 minutes
shorter on average, and surgeons performed LRH 7 min-
utes faster than at the Hospital (P⬍.001). The faster times
may be attributed in part to highly efficient surgical teams
and processes at the ASC. Indeed, a retrospective study by
Hair et al
5
across surgical specialties found significantly
shorter perioperative times at freestanding ASCs com-
pared to hospital-based outpatient surgery centers, and
concluded the difference could be attributed to efficiency
and patient selection. The shorter operative times at the
ASC in our study may also reflect improvement in surgical
practice over time, as the commencement of the Hospital
data began 2 years before the opening of the ASC, with a
subsequent overlap of 2 years from the respective settings.
While these differences in operative time may not be
clinically significant, faster surgical times at the ASC and
faster room turnover allow surgeons to perform a higher
volume of cases. Cumulatively, these efficiencies can have
a significant impact on the “bottom line,” which makes
performing gynecological surgery at ASCs economically
attractive for the provider.
Because of the lower cost structure, ASCs are also able to
provide lower-priced procedures to patients. Patients typ-
ically have lower copays for procedures performed at
ASCs than for the same procedures performed at hospi-
tals. Commercial payors also benefit as they are able to
negotiate more favorable rates compared to the traditional
hospital setting, which lowers their overall costs.
In today’s value-based healthcare environment, the migra-
tion of minimally invasive gynecologic surgery from the
hospital to the ASC setting is a natural step in an effort to
control costs without sacrificing quality. The Government
Accountability Office compared ASC cost data from 2004
with Hospital Outpatient Department (HOPD) costs and
found that costs were, on average, lower in ASCs than in
HOPDs (Government Accountability Office, 2006).
24
If
half of eligible hospital surgeries were moved to ASCs, the
savings could amount to $2.5 billion per year.
24
While the cost savings creates a compelling argument in
favor of the freestanding ambulatory surgery model, the
convenience and personalized care is advantageous to
Laparoscopic Hysterectomy Outcomes: Hospital vs Ambulatory Surgery Center, MacKoul P et al.
6January–March 2019 Volume 23 Issue 1 e2018.00076 JSLS www.SLS.org

both the patient and provider. Surgeons have greater
autonomy in ASCs than in a Hospital, enabling them to
design customized surgical environments and hire spe-
cialized staff. ASCs also provide more expedient and effi-
cient patient scheduling without the interruption of emer-
gency cases, allowing the surgeon to perform a higher
volume of cases in a shorter amount of time.
Limitations
The current study has several limitations. Its retrospective
nature is limited by inherent selection bias. Although tests
were conducted to ensure inter- and intra-rater reliability
among data abstractors, the availability and accuracy of
the medical records, as well as transcription errors, also
remain intrinsic limitations. All hospital data on reopera-
tion and readmittance within 60-day were collected; how-
ever, the total number of postoperative complications may
be underreported, as patients with adverse events may
have been seen in their physician’s office or at a different
hospital.
Additionally, the surgeons involved in this study are ex-
perienced, high-volume laparoscopic gynecologic spe-
cialists, who are especially proficient in the reported tech-
nique and may not represent the general experience of
the surgical community.
Another limitation with the current study is the lack of
data on costs. With the increasing emphasis on the value
in healthcare, future studies comparing the surgical set-
tings should include direct cost comparisons using a mi-
crocosting approach.
Further, while much of the conversation has centered
around outcomes and costs, it is imperative that discus-
sions comparing surgical settings also consider the ex-
perience of the most central player: the patient. Future
studies should incorporate measures of the patient ex-
perience, from the waiting room to the care received
pre- and postoperatively.
Strengths
To our knowledge, this is one of the largest combined
retrospective studies on hysterectomy. It is also the only
study to compare operative outcomes of the LRH ap-
proach across ASC and Hospital settings. This study also
evaluates the outcomes of only 2 surgeons, which mini-
mizes any variations in operative technique and preop/
postop management, allowing for a comparison primarily
based on setting alone.
CONCLUSION
While gynecologic surgery has made a marked shift from
inpatient to outpatient surgery, it is not commonly per-
formed in the freestanding ASC setting. This study adds to
the growing evidence that advanced laparoscopic gyne-
cologic surgery can be safely performed in an ambulatory
surgical center, with no significant difference in compli-
cation rates when compared to patients undergoing the
same procedure by the same surgeons in an outpatient
hospital setting. As more studies confirm the safety of
gynecologic surgery in an ambulatory setting, ASCs are
poised to become the new frontier in minimally invasive
gynecology.
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