Predictors of Overnight Admission after Minimally Invasive Hysterectomy in the Expert Setting

Minimally invasive outpatient hysterectomy for a benign indication: A systematic review

BACKGROUND

Outpatient surgery in gynaecology may offer advantages including cost reduction, patient convenience and hospital bed optimisation without compromising patient safety and satisfaction. With the continual rise in health costs since 2000, outpatient surgery could be a line of action to improve financial resource utilisation and a solution for continuing to treat patients during crises such as the coronavirus disease 2019 pandemic.

OBJECTIVE

This systematic review provides an overview of the literature on minimally invasive outpatient hysterectomy for benign indications.

METHOD

A focused systematic review of the medical literature between 2018 and 2022 on outpatient gynaecological surgery for a benign indication was conducted using the PubMed and Google Scholar search engines. We then narrowed our selection to articles that referred to hysterectomy. Successful same-day discharge (SDD) was defined as the patient's return home on the day of the procedure without an overnight stay.

RESULTS

Fifteen articles that focused on minimally invasive surgery were included in this review. Most of the studies (n = 11) were conducted in the United States. Outpatient surgery had a mean success rate of 60 % and a mean readmission rate of 3 %. The main reasons for SDD failure were patient choice, failed voiding, the need for pain management, nausea or vomiting, or both and the late timing of surgery. SDD was not associated with more complications and readmissions compared with inpatient care. The three main attribute predictors of SDD were young age, early timing of surgery and short total operative time. Patient satisfaction with SDD was high in absolute terms and relative to satisfaction with hospitalisation.

CONCLUSION

Minimally invasive outpatient hysterectomy for a benign indication is feasible and safe but is associated with a notable risk of failure. To increase the success rate of outpatient management, patients must be well selected and surgery pathways must be planned in advance. The implementation of enhanced recovery protocols may help promote outpatient hysterectomy for a benign indication.

Improving the Rate of Same-Day Discharge in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery-An Enhanced Recovery After Surgery Quality Improvement Initiative

OBJECTIVES

The objectives of our quality improvement (QI) initiative were (1) to increase the rate of same-day discharge (SDD) in eligible gynecologic oncology (GO) patients to 70% and (2) to evaluate the ease with which QI methods demonstrated in one study could be applied at another center.

DESIGN

A pre-/postintervention design was used (50 patients/group).

SETTING

SDD in patients undergoing minimally invasive GO surgery is a recent trend aligned with Enhanced Recovery After Surgery (ERAS) principles. SDD in GO is safe and feasible based on several recent studies, including a QI initiative in Edmonton, Alberta, which resulted in SDD rates >70%.

PATIENTS

A baseline audit of GO patients at our center (Calgary, Alberta) found the SDD rate to be 14%. Given that Edmonton and our center are within the same province, they have similar patient populations and available resources-suggesting that interventions from the Edmonton QI initiative may be translatable.

INTERVENTIONS

Four interventions were designed to address root causes for failed SDD identified after QI diagnostics: (1) SDD as the default discharge plan, including a "Day Surgery" surgical booking; (2 and 3) development and implementation of ERAS SDD preoperative and postoperative order sets; and (4) patient education SDD-specific documents.

MEASUREMENTS AND MAIN RESULTS

Rate of SDD was measured together with patient demographics and surgical outcomes. Process and balancing measures were defined and tracked. SDD in GO increased from 14% (7 of 50) to 82% (41 of 50) after the implementation of the above-mentioned interventions (odds ratio [OR], 28; p <.001; 95% confidence interval [CI], 9.54-82.11). Improved SDD was achieved without negatively affecting postoperative rates of emergency department visits: 8% pre- and 4% postintervention within 7 days (OR, 0.48; p = .678; 95% CI, 0.09-2.74) and 12% pre- and 10% postintervention within 30 days (OR, 0.8148; p = 1.001; 95% CI, 0.2317-2.86).

CONCLUSION

This ERAS QI initiative resulted in a substantial increase in SDD in GO, without a negative impact on balancing measures. We demonstrate that the "spread" of simple, clearly defined QI interventions across centers (where the patient population is similar) is feasible. This suggests that an ERAS SDD program for GO could be a realistic goal for other centers with similar characteristics.

Robotic-assisted Gynecological Surgery in Older Patients - a Comparative Cohort Study of Perioperative Outcomes

Study design Because of current demographic developments, a hypothesis was proposed whereby older female patients aged > 65 years can be safely operated using minimally invasive, robotic-assisted surgery, despite having more preoperative comorbidities. A comparative cohort study was designed to compare the age group ≥ 65 years (older age group, OAG) with the age group < 65 years (younger age group, YAG) after robotic-assisted gynecological surgery (RAS) in two German centers. Patients and methods Consecutive RAS procedures performed between 2016 and 2021 at the Women's University Hospital of Jena and the Robotic Center Eisenach to treat benign or oncological indications were included in the study. The age groups were compared according to their preoperative comorbidities (ASA, Charlson comorbidity index [CCI], cumulative illness rating scale - geriatric version [CIRS-G]) and perioperative parameters such as Clavien-Dindo (CD) classification of surgical complications. Analysis was performed using Welch's t -test, chi ² test, and Fisher's exact test. Results A total of 242 datasets were identified, of which 63 (73 ± 5 years) were OAG and 179 were YAG (48 ± 10 years). Patient characteristics and the percentage of benign or oncological indications did not differ between the two age groups. Comorbidity scores and the percentage of obese patients were higher in the OAG group: CCI (2.7 ± 2.0 vs. 1.5 ± 1.3; p < 0.001), CIRS-G (9.7 ± 3.9 vs. 5.4 ± 2.9; p < 0.001), ASA class II/III (91.8% vs. 74.1%; p = 0.004), obesity (54.1% vs. 38.2%; p = 0.030). There was no difference between age groups, even grouped for benign or oncological indications, with regard to perioperative parameters such as duration of surgery (p = 0.088; p = 0.368), length of hospital stay (p = 0.786; p = 0.814), decrease in Hb levels (p = 0.811; p = 0.058), conversion rate (p = 1.000; p = 1.000) and CD complications (p = 0.433; p = 0.745). Conclusion Although preoperative comorbidity was higher in the group of older female patients, no differences were found between age groups with regard to perioperative outcomes following robotic-assisted gynecological surgery. Patient age is not a contraindication for robotic gynecological surgery.

Changes to same day discharge after minimally invasive hysterectomy throughout COVID-19 pandemic

BACKGROUND

Minimally invasive hysterectomy is a common gynecologic procedure. Numerous studies have found that a same day discharge (SDD) is safe following this procedure. Research has found that SDDs decrease resource strain, nosocomial infections, and financial burden for both the patient and healthcare system. Due to the recent COVID-19 pandemic, the safety of hospital admissions and elective surgeries was called into question.

OBJECTIVE

To assess the rates of SDD among patients who underwent a minimally invasive hysterectomy before and during the COVID-19 pandemic.

STUDY DESIGN

A retrospective chart review was performed from September 2018 to December 2020 on 521 patients, who met inclusion criteria. Descriptive analysis, chi-square tests of association, and multivariable logistic regression were used for analysis.

RESULTS

There was a significant difference between rate of SDDs pre-COVID-19 (12.5%) versus during the COVID-19 period (28.6%) (p < 0.001). Surgical complexity was predictive of not being discharged the same day of surgery (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 2.2-8.8), as was surgical completion time after 4 p.m. (OR = 5.2, 95% CI = 1.1-25.2). There was no difference in readmissions (p = 0.209) and emergency department (ED) visits (p = 0.973) between SDD and overnight stay.

CONCLUSION

Rates of SDD for patients undergoing minimally invasive hysterectomy were significantly increased during the COVID-19 pandemic. SDDs are safe; the number of readmissions and ED visits did not increase among patients who were discharged on the same day.

Prevalence of and Risk Factors for Emergency Department Visits After Outpatient Gynecologic Surgery

STUDY OBJECTIVE

To identify the prevalence of and risk factors for emergency department (ED) visits within 30 days of outpatient gynecologic surgery.

DESIGN

Retrospective cohort study.

SETTING

Tertiary academic medical institution.

PATIENTS

Adult patients who underwent outpatient surgery (≤1 midnight in the hospital) between January 2018 and September 2019 (N = 2373).

INTERVENTIONS

Scheduled outpatient gynecologic surgery for a benign indication.

MEASUREMENTS AND MAIN RESULTS

A total of 109 patients (5%) visited the ED within 30 days of surgery. Patients who visited the ED were significantly younger (median age 37 years vs 42 years, p = .02) and had a higher prevalence of abdominal surgical history (67% vs 56%, p = .02) and cardiopulmonary comorbidities (53% vs 40%, p = .007). They were more likely to have undergone a hysterectomy (26% vs 20%) and less likely to have undergone prolapse surgery (4% vs 12%, p = .05). Pain related to the surgical site (42% of ED visits), nausea and/or vomiting (14%), and fever (12%) were the most common surgery-related reasons for ED visits. Medical issues not directly related to surgery accounted for 31% of ED visits. A total of 36% of ED visits resulted in admission. When adjusted for age, insurance status, American Society of Anesthesiologists class, chronic pain and cardiopulmonary comorbidities, abdominal surgical history, primary procedure performed, and surgical route, the following factors were associated with significantly increased risk of visiting the ED: decreasing age (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 1.1-1.3, p <.001), history of abdominal surgery (aOR 1.7, 95% CI 1.1-2.6, p = .017), cardiopulmonary comorbidities (aOR 1.9, 95% CI 1.2-3.0, p = .003), undergoing hysterectomy (aOR 2.0, 95% CI 1.1-3.8, p = .032), and a vulvovaginal surgical route as opposed to abdominal surgical route (aOR 2.4, 95% CI 1.2-5.1, p = .015).

CONCLUSION

ED visits after outpatient gynecologic surgery were uncommon, although approximately one-third of visits resulted in admission. Strategies that target our identified risk factors of younger patient age and cardiopulmonary comorbidities may help reduce the ED burden generated by patients undergoing gynecologic surgery.

Same-day Discharge after Robotic Hysterectomy for Benign Conditions: Feasibility and Safety

STUDY OBJECTIVE

To investigate the feasibility and predictive factors for same-day discharge (SDD) after robotic hysterectomy (RH) for benign indications to optimize patient selection by incorporating preoperative, intraoperative, and postoperative variables.

DESIGN

A single-center retrospective cohort study.

SETTING

Tertiary academic hospital.

PATIENTS

Patients undergoing RH for benign indications.

INTERVENTIONS

Patients were designated for SDD by implementing enhanced recovery after surgery protocol.

MEASUREMENTS AND MAIN RESULTS

The study included 890 patients who underwent RH for benign indications between the years 2016 and 2021. Of these, 618 (69.4%) were discharged the same day and 272 (30.5%) were admitted for overnight stay. Both groups had similar age (46.4 vs 46.2 years), body mass index (28.3 vs 28.9), and indications for surgery. In multivariable logistic regression, factors that were significant for overnight stay were American Society of Anesthesiologists score 3, Charlson comorbidity index, previous laparotomy, and operative time. Other factors such as surgery start time and preoperative hemoglobin levels were not statistically significant. Postoperative outcomes were comparable for both groups with similar readmission and reoperation rates.

CONCLUSION

The likelihood of SDD after RH in this cohort after implementing enhanced recovery after surgery protocol was almost 70%, and most of the predictive factors for overnight stay were nonmodifiable. Importantly, both groups had similar outcomes after surgery.

Same-day dismissal for endometrial cancer robotic surgery: feasibility factors

The aim of this study was to investigate the factors in feasibility and safety of same-day dismissal (SDD) of endometrial cancer patients undergoing robotic hysterectomy and staging. A single-institution retrospective chart review of endometrial cancer patients who underwent robotic hysterectomy and staging between 2012 and 2021 was performed. Patient demographics, medical and surgical history, intra- and postoperative events were examined as possible factors related to non-SDD. These factors were analyzed using univariate (chi-square test) and multivariate logistic regression analysis. Of the 292 patients, 117 (40%) had SDD, and 175 (60%) had non-SDD. The SDD rate increased from 13.8% to 88% over the 10-year study period. The factors significantly associated with non-SDD (p < 0.05) were surgery in the first 5 years after the introduction of the SDD and ERAS protocols (2012-2016), age > 75 years, and comorbidities such as cardiovascular diseases, anemia (Hb < 11 g/dl), and anticoagulant therapy. Extensive adhesiolysis, the performance of complete pelvic and/or aortic lymphadenectomy, operating time > 180 min, and PACU discharge after 2:00 p.m. were significant factors for non-SDD. Sentinel lymph node sampling was significantly associated with SDD (OR 0.050; CI 0.273-0.934, p = 0.029). We reported no significant difference in the number, setting and timing of any unscheduled postoperative contacts, complications, and readmissions between SDD and non-SDD groups. SDD after robotic hysterectomy and staging for endometrial cancer is feasible and safe. There are patient and surgery factors for the failure of SDD. The sentinel lymph node sampling was significantly associated with achieving SDD. Trial registration: Institutional Review Board approved the study protocol (#: 1764-05).

Same-day Discharge vs Planned Admission after Surgical Treatment for Apical Prolapse

STUDY OBJECTIVE

Same-day discharge (SDD) after surgery is becoming more common, with studies supporting the safety of this practice in gynecologic surgeries. The aim of this study was to compare short-term outcomes of SDD with planned admission in patients undergoing apical pelvic organ prolapse repair, through 30-day complications and 30-day unanticipated healthcare encounters.

SETTING

Female pelvic medicine and reconstructive surgery practice at a university-affiliated tertiary medical center.

PATIENTS

Patients with apical prolapse who underwent surgical treatment during the study period were eligible for inclusion. Excluded were patients under the age of 18, cases planned for SDD with an unexpected admission, cases with a planned open procedure, and those performed in combination with another surgical service.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 296 patients were included in the final analysis. A total of 154 patients had a planned admission, and 142 were discharged on the day of surgery (SDD group). There were no differences in reoperations, development of venous thromboembolism, and blood transfusions between the 2 groups. Patients in the SDD group were more likely to have no postoperative complications (95% vs 88.3%, p = .037). Number of unanticipated urogynecology office visits, urgent/immediate care visits, readmissions, or unplanned phone calls were also similar between the 2 groups. There was a statistically significant difference observed in mean emergency department (ED) visits (0.16 ± 0.40 in the planned admission group vs 0.06 ± 0.27 in the SDD group, p = .02); however, this number was low in both groups.

CONCLUSION

This comparative study suggests that SDD after apical prolapse repair is safe and may be considered for patients interested in this option.

Risk factors for unplanned admission following surgical repair of apical prolapse

Introduction and hypothesis

Same-day discharge (SDD) is increasing in popularity following surgical repair of pelvic organ prolapse. The aim of this study was to evaluate factors associated with unplanned admission (UA) in women undergoing apical prolapse repair.

Methods

This retrospective, observational cohort study included patients who underwent apical prolapse repair and planned same-day discharge (SDD) between March 2019 and December 2021. The cohort was divided into two groups: patients who were discharged on the same day as surgery (SDD group) and patients who had an unplanned admission (UA group). Demographic, pre-, intra-, and post-operative data were collected. Risk factors associated with unplanned admission were evaluated using univariate and multivariate analyses.

Results

One-hundred and eighty-four cases of apical prolapse repair met the criteria for inclusion in the final analysis; this included 142 in the SDD group and 42 in the UA group. Patients in the UA group had significantly increased estimated blood loss, longer total operative time, later time arriving to the Post-Anesthesia Care unit (PACU) and longer overall stay in the PACU. No differences were observed in the 30-day complication rate, or 30-day unanticipated healthcare encounters, between groups. Multivariate analysis revealed that receiving ketorolac post-operatively was associated with a higher likelihood of SDD (OR=2.6, 95% CI 1.032–6.580, p=0.043).

Conclusions

Among women undergoing apical prolapse repair, same-day discharge was associated with comparable immediate and 30-day complication rates. Within our cohort, post-operative treatment with ketorolac was associated with greater likelihood of SDD.

Trends and Perioperative Outcomes across Elective Benign Hysterectomy Procedures from the ACS-NSQIP 2007-2017

STUDY OBJECTIVE

In this study, we describe trends of all 3 routes of hysterectomy, patient demographics, and perioperative morbidity among women undergoing surgery for benign indications between 2007 and 2017. We also sought to compare the rates of extended length of stay (ELOS) and readmission rates among the laparoscopic, abdominal, and transvaginal routes.

STUDY DESIGN

A retrospective cohort study.

STUDY SETTING

National database study.

PATIENTS

The American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent an elective hysterectomy for benign indication between 2007 and 2017.

INTERVENTIONS

Patients were identified using Current Procedural Terminology codes and excluded if their indication for surgery included cancer and pelvic organ prolapse diagnoses based on International Classification of Diseases codes. The collected variables of interest included age, body mass index, American Society of Anesthesiologists classification, uterine weight of >250 grams, and operative time. Our outcomes of interest included ELOS and readmission within 30 days. ELOS was defined as a hospital admission of 2 days or more after laparoscopic and transvaginal hysterectomy and greater than 3 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 with transvaginal and abdominal hysterectomies was performed.

MEASUREMENTS AND MAIN RESULTS

There were 224 357 patients who 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 >200% between 2007 and 2017, whereas the rates of transvaginal and abdominal hysterectomies steadily decreased (-58% and -42%, respectively) The mean age, median obesity, and American Society of Anesthesiologists classification increased among 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 body mass index [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 than those who received abdominal hysterectomy (p <.001). Comparing the rates of readmission between the laparoscopic and abdominal hysterectomy groups shows that the odds of readmission are significantly lower for patients who receive a laparoscopic hysterectomy across all 11 years (p <.001).

CONCLUSION

The rates of laparoscopic hysterectomy have been steadily increasing over the past 11 years. This large retrospective study confirms the lowest rates of readmission and ELOS within the laparoscopic hysterectomy group despite the rising medical complexity of the patients.

Factors Associated With Unplanned Admission in Patients Intended for Same Day Discharge After Minimally Invasive Hysterectomy for Endometrial Cancer

Objectives. To identify factors that lead to successful same-day discharge compared with unplanned and planned admission after minimally invasive hysterectomy for endometrial cancer. Methods. Patients undergoing laparoscopic or robotic hysterectomy for endometrial cancer between 2016 and 2019 were retrospectively reviewed. 3 groups were created: same-day discarge (SDD), unplanned admission (UA), and planned admission(PA). Demographic/perioperative factors and encounters after discharge were compared. A multivariable logistic regression was performed. Results. 262 patients were included. By year, the success of SDD increased from 59.1% to 82.5%. Patients who underwent SDD compared with admission were younger (62.2 vs 66.2, P = .003) and had a lower Charlson Comorbidity Index (4 vs 5, P < .001). BMI was not significant. Comparing SDD and UA, shorter operative time (100.3 min vs 130.6 min, P = .037) was associated with SDD. Postoperative pain scores were not significant (3.8 vs 4.7, P = .086). The rate of unscheduled encounters within 30 days of discharge was not significantly different. On multivariable analysis, the odds of SDD decreased by 4% with each 1-year increase in age (OR .96, P = .017). Each 1-minute increase in operative time decreased the odds of SDD by 2% (OR .98, P < .001). Intraoperative acetaminophen (OR 2.78, P = .003) and ketorolac (OR 2.27, P = .031) were predictive of SDD. Conclusion. SDD can be safely incorporated into clinical practice in gynecologic oncology patients undergoing minimally invasive hysterectomy, even for patients older than previously reported. Shorter operative time was associated with SDD. The role of perioperative acetaminophen and ketorolac should be further investigated.

Factors Associated with Same Day Discharge after Laparoscopic Surgery in Gynecologic Oncology

STUDY OBJECTIVE

To identify factors associated with same day discharge (SDD) after laparoscopic surgery in gynecologic oncology.

DESIGN

Retrospective cohort.

SETTING

Teaching hospital.

PATIENTS

Total of 800 patients having minimally invasive surgery in the division of gynecologic oncology during a 20-month period.

INTERVENTION

Minimally invasive surgery cases were reviewed for determinants of SDD to identify factors that could improve the SDD rate.

MEASUREMENTS AND MAIN RESULTS

During the study period, 800 minimally invasive procedures were performed with a 43.0% SDD rate. Patients who had SDD were younger (52.3 years vs 58.0 years; p <.001), had a lower body mass index (31.1 kg/m² vs 33.7 kg/m²; p <.001), were less likely to have a malignancy (28.2% vs 55.5%; p <.001), had a lower estimated blood loss (36 vs 72 mL; p <.001), and were more likely to have received an enhanced recovery after surgery protocol (49.8% vs 39.3%; p <.003). Total surgical time was shorter in women with SDD (156 minutes vs 208 minutes) as was total narcotic use in morphine equivalents (MEq) (milligram intravenous MEq, 23.1 mg MEq vs 28.8 mg MEq). SDD was also associated with earlier start time (p <.001). Laparoscopic cases were most likely to have SDD (51.4%) as compared with robotic assisted surgery (16.1%) or minilaparotomy (10.5%). There was a wide range of SDD among surgeons ranging from 19.8% to 56.2% (p <.001). In a multivariate analysis, the factors predicting SDD in order of predictive factors were surgical time (p <.001), recovery time (p <.001), start time (p <.001), surgeon (p <.001), age (p <.001), estimated blood loss (p <.001), and type of surgery (p = .005).

CONCLUSION

Multiple factors affect SDD. Modifiable factors for SDD include the start time, surgeon preference, and patient expectations for SDD. Given these data, centers should prioritize surgical order by which patients are more likely to go home, and surgeons should analyze their own data with respect to achieving higher SDD rates.

Same-day discharge after minimal invasive hysterectomy: Applications for improved value of care

OBJECTIVE

Hysterectomy is one of the most common surgical procedures. Same-day discharge (SDD) is increasingly utilized for minimally invasive hysterectomies, but its uptake varies across healthcare systems and surgical specialties. An evidence-based initiative was developed to aid in the incorporation of SDD into the practice of minimally invasive hysterectomy (MIH) in the UPMC Health System. The objective of this study was to identify trends of SDD utilization across various gynecologic specialties at UPMC, as well as evaluate the impact of SDD on length of stay (LOS) and complications after the implementation of SDD initiative.

STUDY DESIGN

We retrospectively identified 5554 patients who underwent MIH between 2014 and 2017 and were eligible for SDD, as determined by physicians and authorized by patients' insurance plans. Multivariable logistic regression models evaluated the trend of SDD utilization among four specialty types (general gynecologists, urogynecologists, specialized minimally invasive surgeons, and oncologists) and trends in complications. Multivariable logistic and linear regression models were applied to compare complications and LOS between patients with SDD vs. those with overnight admissions.

RESULTS

SDD utilization increased from 28.55% to 74.99% during the study period. SDD significantly increased over the study period for all specialty types, with urogynecologists having the highest uptake from 3.9% in 2014 to 95.8% in 2017 (p<.01). After adjusting for year, specialty types, MIH procedure type, and total case time, SDD utilization was associated with shorter mean LOS (p<.01); such that mean LOS was 764.43 min (95% CI: 735.46-793.40) for SDD patients and 2041.84 min (95% CI: 2015.99-2067.70) for patients with overnight admissions. SDD was also associated with 42% lower odds (95% CI: 0.37-0.93, p=.02) of complications compared with patients with overnight admissions.

CONCLUSION

Same-day discharge uptake increased over years and was associated with lower odds of complications and decreased length of stay. More studies are needed to explore same-day discharge process to improve patient outcomes, patient satisfaction, and value of care.

Robotic surgery during the COVID pandemic: why now and why for the future

Health care has changed in unprecedented ways since the first reported cases of COVID-19. With global case rates continuing to rise and government restrictions beginning to loosen, many worry that a second wave in our future. In many hospitals around the world, non-emergent surgeries were put on hold as hospitals were transformed into COVID centers. As surgeons and administrators do their best to reinstate non-emergent procedures, guidance is sought from any and all reliable sources. Robotic surgery has many known and demonstrated benefits over open surgery and often over conventional laparoscopy. In this commentary, we aim to highlight some of the advantages robotic surgery may offer during this uniquely challenging time in health care.

Evaluating unplanned readmission and prolonged length of stay following minimally invasive surgery for endometrial cancer

OBJECTIVE

To evaluate risk factors for 30-day unplanned readmission and increased length of stay (LOS) following minimally invasive surgery (MIS) for endometrial cancer.

METHODS

This was a retrospective, case-control study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Multivariable logistic regression was used to assess perioperative variables associated with readmission and increased LOS after MIS for endometrial cancer.

RESULTS

The study population included 10,840 patients who met the criteria of having undergone MIS with a resultant endometrial malignancy confirmed on postoperative pathology. Common reasons for readmission included organ/space surgical site infection (65 cases), sepsis/septic shock (19 cases), and venous thromboembolism (20 cases). Notable risk factors for readmission included (Odds Ratio, Confidence Interval, p-value): dialysis dependence (6.77, 2.51-17.80, <0.01), increased length of stay (3.00, 2.10-4.10, <0.01), and preoperative weight loss (2.80, 1.06-7.17, 0.03); notable risk factors for increased LOS: ascites (8.51, 2.00-36.33, <0.01), operation duration >5 h (6.93, 5.29-9.25, <0.01), and preoperative blood transfusion (5.37, 2.05-14.04, <0.01).

CONCLUSIONS

Identification of risk factors for adverse postoperative outcomes is necessary to inform and improve standards of care in MIS for endometrial cancer. Using nationally reported data from the ACS NSQIP, this study identifies independent risk factors for unplanned readmission and prolonged LOS, and in doing so, highlights potential avenues for quality improvement.