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Laparoscopic Hysterectomy Outcomes: Hospital vs Ambulatory Surgery Center

  • The Center for Innovative GYN Care

Abstract and Figures

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.
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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
Background and Objective: Compare operative out-
comes of laparoscopic hysterectomy in an outpatient hos-
pital setting versus freestanding ambulatory surgery cen-
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.
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.
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.
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.
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.
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:
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
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
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.
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
and Roman et al
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.
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.
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.
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).
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
. 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
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
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
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.
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
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
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.
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
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 Setting
N (%)
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
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
250 468 (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
)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
arotomy to rule out bowel perforation, which was ex-
cluded. The patient recovered without further compli-
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
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
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,
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.
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
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).
half of eligible hospital surgeries were moved to ASCs, the
savings could amount to $2.5 billion per year.
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
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.
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
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.
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.
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
1. Frack B, Grabenstatter K, Williamson J. Ambulatory surgery
centers: Becoming big business. L.E.K. Consulting. 2017;XIX(25).
Available from:
2. Report to the Congress: Medicare payment policy. 2016.
Ambulatory surgical center services. MEDPAC. Available from:
sfvrsn0. Accessed October 2017.
3. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team be-
haviors and patient outcomes. Am J Surg. 2009;197(5):678685.
4. Lingard L, Regehr G, Orser B, et al. Evaluation of a preop-
erative checklist and team briefing among surgeons, nurses, and
anesthesiologists to reduce failures in communication. Arch
Surg. 2008;143(1):12–7; discussion 18.
5. Hair B, Hussey P, Wynn B. A comparison of ambulatory
perioperative times in hospitals and freestanding centers. Am J
Surg. 2012;204(1):23–27.
6. Trentman TL, Mueller JT, Gray RJ, Pockaj BA, Simula DV.
Outpatient surgery performed in an ambulatory surgery center
versus a hospital: Comparison of perioperative time intervals.
Am J Surg. 2010;200(1):6467.
7. Grisel J, Arjmand E. Comparing quality at an ambulatory
surgery center and a hospital-based facility: Preliminary findings.
Otolaryngol Head Neck Surg. 2009;141(6):701–709.
8. Munnich EL, Parente ST. Procedures take less time at ambu-
latory surgery centers, keeping costs down and ability to meet
demand up. Health Aff (Millwood). 2014;33(5):764–769.
9. Centers for Medicare and Medicaid Services. Calendar year
2008 revised ambulatory surgical center payment system. Avail-
able from:
pdf. Accessed October 13, 2013.
7January–March 2019 Volume 23 Issue 1 e2018.00076 JSLS
10. Moawad G, Liu E, Song C, Fu AZ. Movement to outpatient
hysterectomy for benign indications in the United States, 2008
2014. PLoS One. 2017;12(11):e0188812.
11. Nezhat C, Main J, Paka C, Soliemannjad R, Parsa MA. Ad-
vanced gynecologic laparoscopy in a fast-track ambulatory sur-
gery center. JSLS. 2014;18(3).
12. OR Manager. Adding new business to the ASC, one proce-
dure at a time—Part 1. January 18, 2017. Available from: http://
dure-time-part-1/. Accessed May 5, 2017.
13. Ko¨hler C, Hasenbein K, Klemm P, Tozzi R, Schneider A.
Laparoscopic-assisted vaginal hysterectomy with lateral transsec-
tion of the uterine vessels. Surg Endosc. 2003;17(3):485–490.
14. Roman H, Zanati J, Friederich L, Resch B, Lena E, Marpeau
L. Laparoscopic hysterectomy of large uteri with uterine artery
coagulation at its origin. JSLS. 2008;12(1):25–29.
15. Peters A, Stuparich MA, Mansuria SM, Lee TT. Anatomic
vascular considerations in uterine artery ligation at its origin
during laparoscopic hysterectomies. Am J Obstet Gynecol. 2016;
16. Volpi E, Bernardini L, Angeloni M, Cosma S, Mannella P.
Retroperitoneal and retrograde total laparoscopic hysterectomy
as a standard treatment in a community hospital. Eur J Obstet
Gynecol Reprod Biol. 2014;172:97–101.
17. Kale A, Aksu S, Terzi H, Demirayak G, Turkay U, Sendag F.
Uterine artery ligation at the beginning of total laparoscopic
hysterectomy reduces total blood loss and operation duration. J
Obstet Gynaecol. 2015;35(6):612–615.
18. Trivedi PH, Parekh NA, Trivedi SP, Gandhi AC. Tackling
uterine artery at the origin is safe and effective for TLH. J Minim
Invasive Gynecol. 2015;22(6S):S106.
19. Sinha R, Sundaram M, Nikam YA, Hegde A, Mahajan C. Total
laparoscopic hysterectomy with earlier uterine artery ligation. J
Minim Invasive Gynecol. 2008;15(3):355–359.
20. Poojari VG, Bhat VV, Bhat R. Total laparoscopic hysterec-
tomy with prior uterine artery ligation at its origin. Int J Reprod
Med. 2014;2014:420926.
21. Lii SJ, Becker SF, Danilyants NE, Mackoul PJ. A novel ap-
proach to total laparoscopic hysterectomy using only two 5mm
ports: initial clinical experience. J Minim Invasive Gynecol. 2010;
22. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity
measures for use with administrative data. Med Care. 1998;36(1):
23. Mowat A, Maher C, Ballard E. Surgical outcomes for low-
volume vs high-volume surgeons in gynecology surgery: A sys-
tematic review and meta-analysis. Am J Obstet Gynecol. 2016;
24. Medicare Payment Advisory Commission. Report to the Con-
gress: Medicare Payment Policy. March 2018; pp. 127–152. Avail-
able from:
Laparoscopic Hysterectomy Outcomes: Hospital vs Ambulatory Surgery Center, MacKoul P et al.
8January–March 2019 Volume 23 Issue 1 e2018.00076 JSLS
... Advances in technology and more emphasis on laparoscopic techniques in residency have resulted in a shift in gynecological surgery from the inpatient to the outpatient setting. 1 This changing landscape of gynecologic surgery promotes further migration to ambulatory surgery centers (ASCs), freestanding outpatient facilities that allow for same-day surgeries and patient discharge. Ambulatory surgery centers have demonstrated advantages of greater efficiency, patient convenience and lower costs than the hospital-based outpatient surgery model. ...
... (3) No limitations in timing of scheduling LAM cases. Intraoperative (1) No blood transfusion capability. ...
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Aim: To compare the safety protocols and operative outcomes of women undergoing laparoscopic-assisted myomectomy (LAM) by the same surgeons at a freestanding ambulatory surgery center (ASC) versus a hospital outpatient setting. Methods: Retrospective chart review of all women ≥18 years old with symptomatic leiomyoma, who underwent LAM with uterine artery occlusion or ligation for blood loss control, at a freestanding ASC between 2013 and 2017, and an outpatient hospital setting between 2011 and 2013, both serving the metropolitan Washington, DC area. The procedures were performed by two minimally invasive gynecologic surgical specialists from a single practice. The safety protocols of each setting were reviewed to identify similarities and differences. Results: A total of 816 LAM cases were analyzed (ASC = 588, hospital = 228). The rate of complications was comparable across settings, as was the average myoma weight (ASC = 396.2 g; hospital = 461.5 g; P = 0.064). Operative time was significantly shorter at the ASC: 68 min (95% CI 66-70) versus 80 min at hospital (95% CI 76-84), P < 0.0001. Ambulatory surgery center and hospital protocols differed in limits of preoperative hemoglobin (minimum 9.0 g/dL, 7.5 g/dL respectively), lower nurse/patient ratio in PACU, and were similar in intraoperative surgical safety standards. Conclusion: Laparoscopic-assisted myomectomy can be performed safely and effectively by skilled surgeons at a freestanding ASC, even in patients with morbid obesity or large leiomyoma.
... In obstetrics and gynecology procedures and surgeries, like other kinds of surgeries, the proportion of ambulatory surgery has been increasing [1,2,13]. Initially, it was limited to simple procedures, but now even laparoscopic surgery is actively performed in ambulatory patients [14]. This is because, along with the development of surgical equipment and surgical techniques, the quality of management of ambulatory patients has been improved. ...
Background: There has been a steady increase in outpatient-based ultra-short duration gynecology surgeries. However, there are no detailed studies on anesthesia regimens for these surgeries. The aim of this study was to compare the effects of low-dose rocuronium and fentanyl single bolus for their suitability with these patients. Methods: A total of 60 patients were randomly divided into three groups: a control group (group C, n = 20) that received 3 mL of normal saline; a fentanyl group (group F, n = 19) that received 1 mcg/kg of fentanyl; and a low-dose rocuronium group (group R, n = 20) that received 0.3 mg/kg of rocuronium. We collected hemodynamic data during anesthetic induction and the intraoperative period. We also investigated supraglottic airway (SGA) insertion condition, patient’s gross movements, and surgeon’s satisfaction. In addition, we evaluated the incidence of postoperative nausea and vomiting, pruritus, first voiding time and discharge time from the postanesthetic care unit. Results: Systolic, diastolic, and mean blood pressure were significantly lower in group F after SGA insertion (p = 0.031, p = 0.046 and p = 0.048). SGA insertion conditions scores were significantly worse in group C than in group F and group R for total score (p < 0.001). Also, the number of patient movements during surgery and the number of rescue fentanyl injections were significantly higher in group C than group F and group R (p = 0.005 and p < 0.001). Conclusion: Fentanyl administration at 1 mcg/kg has advantages compared with rocuronium and is a more suitable single agent regimen for outpatient-based ultra-short duration gynecology surgeries.
... 7 An important point is different reports of early years of laparoscopy with longer procedures in comparison to the open method. 20 Three characters are regarded for learning curve assessment including the duration of surgery, rate of complications, and the number of conversions to open surgery. In a study, in the learning curve of laparoscopic hysterectomy, the first 10 procedures were done in a mean time of 180 minutes and decreased to 75 minutes in the 90-100th patients. ...
... Con el perfeccionamiento del abordaje mínimamente invasivo, se han publicado estudios que muestran que la vía laparoscópica podría acompañarse de una política de egreso temprano (primeras 12 a 24 horas de la histerectomía) dada la seguridad de este procedimiento. Por ejemplo, MacKoul et al. comparan dos instituciones en las que se dio salida temprana, una con manejo ambulatorio con alta temprana en el 98% de las pacientes y otra con hospitalización con salida temprana en 88%, sin diferencia en la frecuencia de complicaciones (7). Estas observaciones han llevado a un incremento de la frecuencia del alta temprana en pacientes con histerectomía laparoscópica de un 13% en el 2008 a un 57% en el 2014 en centros quirúrgicos ambulatorios de Estados Unidos (8). ...
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Objetivo: Describir la seguridad del alta en las primeras 12 horas del posoperatorio en mujeres cometidas histerectomía por laparoscopia por patología benigna de útero. Materiales y métodos: Estudio de cohorte histórica descriptiva. Se incluyeron todas las mujeres llevadas a histerectomía laparoscópica por patología benigna, quienes fueron dadas de alta después de 12 horas del procedimiento en un hospital de alta complejidad en Bogotá, Colombia, entre enero del 2013 y abril del 2019. Se excluyeron pacientes con comorbilidades (diabetes, enfermedad cardiovascular y pulmonar obstructiva crónica), limitaciones para la movilización y aquellas que presentaron complicaciones intraoperatorias. Se realizó un muestreo consecutivo. Se evaluaron variables demográficas, y como variables de seguridad, el reingreso por urgencias y complicaciones clasificadas según la escala de Dindo a los 15 días del postoperatorio. Se hace análisis descriptivo. Resultados: Durante el período de estudio se realizaron 860 histerectomías por laparoscopia, de estas, 67 (7,8%) cumplieron con los criterios de selección. Once pacientes (16,4%) reingresaron por el servicio de urgencias, de las cuales, siete (63,6%) acudieron por dolor, una (9%) por sangrado activo, una (9%) por fiebre, y dos (18%) por síntomas urinarios. Se presentaron seis (8,9%) complicaciones postoperatorias de las cuales dos pacientes (2,9%) tuvieron hematoma de cúpula vaginal, dos (2,9%) hemoperitoneo, una (1,4%) infección urinaria y una (1,4%) lesión ureteral; cuatro pacientes (5,9%) requirieron hospitalización, estas últimas se clasificaron en el estadio IIIb de Dindo. Conclusiones: El alta temprana surge como alternativa al cuidado hospitalario para este tipo de población. Se requieren estudios con grupo control y asignación aleatoria para aportar mejor evidencia respecto a este manejo.
... Postoperative complication rate of laparoscopic hysterectomy is around 4-5% in literature [12]. A study from Denmark declared complication rate of 15% for general hospitals, and 7% for minimal invasive surgery hospitals [13]. ...
Objective: The objective of this retrospective observational study is to analyse the properties of laparoscopic hysterectomy cases that are performed for benign indications and also endometrial cancer indications. Operation time, postoperative complicaton rate, blood transfusion need, and hospitalization time are compared according to benign and malign indications and also body mass index of the patients. Material and methods: Patients who were operated between September 2012 and December 2017 are included in this study. Patients' age, body mass index, medical histories, operation indications, operation time, pathology reports, pre and postoperative hemoglobine values and postoperative complications are obtained from medical records.Body mass index is classified as underweight for <19 ; normal for 19-25 ; overweight for 25-30 and obese for ≥30. Results: Operation and hospitalization times were significantly higher for high BMI and malign gynecologic indication groups than lower BMI and benign gynecologic indication groups (p:0.0001). Complication rates and transfusion needs were similar in between malign and benign gynecologic disease groups (p :0.443; P:0.670 respectively) and also in between high and lower BMI groups (P:0.813 ; P:0.468 respectively). Conclusion: Laparoscopic approach for hysterectomy operations in high BMI patients and endometrial cancer patients seem to be safe in terms of postoperative complication and bleeding that necessitate transfusion.
Study Objective(s) In this study, we describe trends of all three routes of hysterectomy, patient demographics, and perioperative morbidity among women undergoing surgery for benign indications between 2007-2017. We also sought to compare the rates of ELOS and readmission rates among the laparoscopic, abdominal, and transvaginal routes. Study design Retrospective cohort study Study Setting National Database study Patients American College of Surgeons- National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients who underwent an elective hysterectomy for benign indication between 2007-2017. Interventions Patients were identified using Current Procedural Terminology (CPT) codes and excluded if their indication for surgery included cancer and pelvic organ prolapse diagnoses based on International Classification of Disease (ICD) codes. Collected variables of interest included age, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) classification, uterine weight > 250 grams, and operative time. Our outcomes of interest included ELOS and readmission within thirty days. ELOS was defined as a hospital admission of two days or more after laparoscopic and transvaginal hysterectomy, and greater than three days for an abdominal hysterectomy. Summary statistics were used to evaluate shifts in patient characteristics and postoperative outcomes by hysterectomy route and year of surgery. Multivariable logistic regression analysis, stratified by year, comparing laparoscopic to transvaginal and abdominal hysterectomies, was performed. Measurements and Main Results 224,357 patients that met the inclusion and exclusion criteria. Of those, 132,567 (59.1%) underwent a laparoscopic hysterectomy; 30,105 (13.4%) a vaginal hysterectomy; and 61,685 (27.5%) an abdominal hysterectomy. The rate of laparoscopic hysterectomy increased by more than 200% between 2007-2017, while the rates of transvaginal and abdominal hysterectomies steadily decreased (-58%, -42%, respectively]). The mean age, median obesity, and ASA classification increased amongst women undergoing hysterectomy across all routes with the sharpest increase within the laparoscopic hysterectomy group (% increase in mean age [2.1%, 1.3%, 0.7%] and mean BMI [9.1%, 4.3%, 3.7%] for laparoscopic, transvaginal and abdominal routes, respectively). In 2017 the odds of ELOS were 29% lower for those who received laparoscopic compared to those who received abdominal hysterectomy (P<0.001). Comparing the rates of readmission between the laparoscopic and abdominal hysterectomy groups shows that the odds of readmission is significantly lower for patients who receive a laparoscopic hysterectomy across all eleven years (P<0.001). Conclusion(s) The rates of laparoscopic hysterectomy have been steadily increasing over the past eleven years. This large retrospective study confirms the lowest rates of readmission and extended length of stay within the laparoscopic hysterectomy group despite the rising medical complexity of the patients.
Background The definitive treatment for erectile dysfunction is the surgical implantation of a penile prosthesis, of which the most common type is the 3-piece inflatable penile prosthesis (IPP) device. IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs. Aim To evaluate IPP surgical outcomes in an ASC as compared to contemporaneously-performed hospital surgeries. Methods A database of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States, from January 1, 2013 to August 1, 2019, was prospectively compiled and retrospectively reviewed. Cohorts of patients having IPP implantation performed in the hospital vs ASC setting were compared. Main Outcome Measure The primary outcome measure was to compare surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups. Results A total of 923 patients were included for this analysis, with 674 (73%) having ASC-based surgery and 249 (27%) hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs 120 minutes, P < .001) and surgical (68 vs 75 minutes, P < .001) times were significantly shorter in the ASC. While the risk for device erosion and need for surgical revision were similar between groups, there was no higher risk for prosthetic infection when surgery was performed in the ASC (1.7% vs 4.4% [hospital], P = .02), corroborated by logistic regression analysis (odds ratio 0.39, P = .03). The risk for postoperative transfer of an ASC patient to the hospital was low (0.45%). The primary reason for mandated hospital-based surgery was medical (51.4%), though requirement as a result of insurance directive (39.7%) was substantial. Clinical Implications IPP implantation in the ASC is safe, has similar outcomes compared to hospital-based surgery with a low risk for need for subsequent hospital transfer. Strengths & Limitations The strengths of this study include the large patient population in this analysis as well as the real-world nature of our practice. Limitations include the retrospective nature of the review as well as the potential for residual confounding. Conclusion ASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk. Weinberg AC, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020;XX:XXX–XXX.
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Introduction: The past decade has witnessed adoption of conservative gynecologic treatments, including minimally invasive surgery (MIS), alongside steady declines in inpatient hysterectomies. It remains unclear what factors have contributed to trends in outpatient benign hysterectomy (BH), as well as whether these trends exacerbate disparities. Materials and methods: Retrospective cohort of 527,964 women ≥18 years old who underwent BH from 2008 to 2014. BH surgical approaches included: open/abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), and robotic-assisted hysterectomy (RH). Quarterly frequencies were calculated by care setting and surgical approach. We used multilevel logistic regression (MLR) using the most recent year of data (2014) to examine the influence of patient-, physician-, and hospital-level preoperative factors and surgical approaches on outpatient migration. Results: From 2008-2014, surgical approaches for LH and RH increased, which coincided with decreases in VH and AH. Overall, a 44.2% shift was observed from inpatient to outpatient settings (P<0.0001). Among all outpatient visits MIS increased, particularly for RH (3.6% to 41.07%). We observed increases in the proportion of non-Hispanic Black and Medicaid patients who obtained MIS in 2014 vs. 2008 (P<0.001). Surgical approach (51.8%) and physician outpatient MIS experience (19.9%) had the greatest influence on predicting outpatient BH. Compared with LH, RH was associated with statistically significantly higher likelihood of outpatient BH overall (OR 1.23; 95% CI, 1.16-1.31), as well as in sub-analyses of more complex cases and hospitals that performed ≥1 RH (P<0.05). Conclusion: From 2008-2014, rates of LH and RH significantly increased. A significant shift from inpatient to outpatient setting was observed. These findings suggest that RH may facilitate the shift to outpatient BH, particularly for patients with complexities. The adoption of MIS in outpatient settings may improve access to disadvantaged patient groups.
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We compared the duration of surgery, blood loss, and complications between patients in whom both uterine arteries were ligated at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom ligation was done after cornual pedicle. Using a prospective study in a gynecologic laparoscopic center, a total of 52 women who underwent TLH from June 2013 to January 2014 were assigned into two groups. In group A, uterine arteries were ligated after the cornual pedicles as done conventionally. In group B, TLH was done by ligating both uterine arteries at the beginning of the procedure. All the other pedicles were desiccated using harmonic scalpel or bipolar diathermy. Uterus with cervix was removed vaginally or by morcellation. The indication for TLH was predominantly dysfunctional uterine bleeding and myomas in both groups. In group A, the average duration of surgery was 71 minutes, when compared to 60 minutes in group B . In group A, the total blood loss was 70 mL, when compared to 43#x2009;mL in group B (P value < 0.001). There were no major complications in both groups. To conclude, prior uterine artery ligation at its origin during TLH reduces the blood loss and surgical duration as well as the complications during surgery.
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Background/Objectives: It has been shown that major gynecologic laparoscopy is safe in hospital ambulatory settings, but there is little data to suggest the same in freestanding ambulatory surgery centers. This study evaluates the safety and efficacy of advanced gynecologic laparoscopic surgery using a fast-track model in freestanding ambulatory surgery centers and discusses our institution protocols. Methods: Retrospective, multicenter review was conducted of major gynecologic surgeries from August 1st 2010 to September 30th 2011 in 3 surgical centers with one primary surgeon. All patients were treated for symptomatic uterine leiomyomas and/or endometriosis. Primary outcome measures were unplanned admissions and discharge within 23 hours. Results: One hundred and thirty-four patients underwent major laparoscopic gynecologic surgery with a total of 160 procedures: 77 stage IV endometriosis treatment including 7 disk excisions of endometriosis from the large bowel, 3 ureteroneocystostomies and 1 partial bladder resection, 38 myomectomies, and 34 hysterectomies including 12 modified radical hysterectomies. The overall unplanned admission rate was 4.5%. One hundred and thirty-one patients (97.7%) were discharged within 24 hours after surgery. Three patients (2.2%) were transferred to the hospital postoperatively: 1 patient for observation of postoperative anemia and 2 patients for postoperative fever. Three patients (2.2%) were admitted to the hospital after discharge: 1 patient for postoperative ileus, 1 patient for postoperative fever, and 1 patient with septic pelvic thrombophlebitis. These postoperative issues all resolved without complication, and all patients had an uneventful follow-up. Conclusions: With appropriate resources and an experienced surgeon, advanced laparoscopic surgery can be safely performed in a fast-track ambulatory surgery center with a high rate of discharge within 23 hours and low unplanned readmission rate.
Pelvic pathology such as fibroids, endometriosis, adhesions from previous pelvic surgeries, or ovarian remnants can distort anatomy and pose technical challenges during laparoscopic hysterectomies. Retroperitoneal dissection to ligate the uterine artery at its vascular origin can circumvent these obstacles, resulting in a safer procedure. However, detailed anatomic knowledge of the course of the uterine artery and understanding of vascular variations are essential for optimal dissection. Our video demonstrates a C-shaped uterine artery variation encountered during retroperitoneal dissection. We describe the key steps in identification and isolation of this variant, approaching the uterine artery origin either from the pararectal space or by utilizing the medial umbilical ligament coursing through the paravesical space. We also review other known uterine artery configurations. These techniques allow for safe completion of complex laparoscopic hysterectomies performed for various gynecologic diseases.
Objective: The aim of this study was to determine the impact of gynecologic surgeon volumes on patient outcomes. Data sources: Eligible studies were selected through an electronic literature search from database inception up until September 2015 and references in published studies. Search terms included "surgical volume," "surgeon volume," "low-volume OR high-volume," "gynecology OR hysterectomy OR sling OR pelvic floor repair OR continence procedure". Study eligibility: The literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We defined a low volume surgeon (LVS) as one performing the procedure once a month or less and studies were excluded if their definition of LVS was > +/- 33% of our definition. Primary outcomes were total complications, intraoperative complications and postoperative complications. Study appraisal and synthesis methods: All outcome data for individual studies were entered into Review Manager 5.3 systematic review software. When two or more studies evaluated a designated outcome meta-analysis of the entered data was undertaken as per the Cochrane database methodology. Data analysis was entered into GRADEpro, software, which generated a Summary of Findings (SOF) table that included structured and qualified grading (very low to high) of the quality for the evidence of the individual outcomes and provided a measure of effect. Results: Fourteen peer-reviewed studies with 741 760 patients were included in the systematic review. For gynecology the low volume surgeon (LVS) group had an increased rate of total complications; OR 1.3 95% CI 1.2 to 1.5, intraoperative complications; OR 1.6 95% CI 1.2 to 2.1 and postoperative complications; OR 1.4 95% CI 1.3 to 1.4. In gynecologic oncology the LVS group had higher mortality; OR 1.9 95% CI 1.3 to 2.6. In the urogynecology group a single study reported that the LVS group had a higher rate of any complication; RR 1.4 95% CI 1.2-1.6. Another single study found that LVS had higher rates of reoperation for mesh complications after mid-urethral sling procedures; RR 1.4 95% CI 1.2 to 1.5. The evidence is of moderate to very-low quality. Conclusions: Gynecologists performing procedures approximately once a month or less were found to have higher rates of adverse outcomes in gynecology, gynecologic oncology and urogynecology, with higher mortality in gynecologic oncology.
The purpose of this study was to compare the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were ligated by surgical clips and cut using a 5-mm ligature at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom uterine arteries were not ligated at the beginning of TLH. In our prospective study, a total of 60 women underwent TLH. Uterine artery ligation (UAL) was done at the beginning of the procedure. Women were divided into TLH + UAL (n = 30) and TLH (n = 30) groups. In TLH group, TLH was done without ligating the uterine arteries at the beginning of the procedure. In TLH + UAL group, TLH was done with ligation of both uterine arteries at the beginning of the procedure. The mean operating time was longer for the TLH group (99.16 ± 7.01) than TLH + UAL group (63.27 ± 7.16). The median total blood loss was higher in TLH group (109.38 ± 33.03 mL) than TLH + UAL group (47.50 ± 8.12 mL). UAL at the beginning of TLH is a technically feasible procedure. It reduces the total blood loss and decreases the time taken for the procedure and length of hospital stay.
During the past thirty years outpatient surgery has become an increasingly important part of medical care in the United States. The number of outpatient procedures has risen dramatically since 1981, and the majority of surgeries performed in the United States now take place in outpatient settings. Using data on procedure length, we show that ambulatory surgery centers (ASCs) provide a lower-cost alternative to hospitals as venues for outpatient surgeries. On average, procedures performed in ASCs take 31.8 fewer minutes than those performed in hospitals-a 25 percent difference relative to the mean procedure time. Given the rapid growth in the number of surgeries performed in ASCs in recent years, our findings suggest that ASCs provide an efficient way to meet future growth in demand for outpatient surgeries and can help fulfill the Affordable Care Act's goals of reducing costs while improving the quality of health care delivery.