Movement to outpatient hysterectomy for benign indications in the United States, 2008-2014

Same-Day Discharge is Safe, Feasible Following Vaginal Hysterectomy with Apical Suspension

Purpose

Studies involving minimally invasive hysterectomy and robotic sacrocolpopexy have demonstrated safety and feasibility of same-day discharge. There are limited data, however, on same-day discharge outcomes for vaginal hysterectomy and pelvic reconstruction. This study aimed to compare 30 and 90-day surgical outcomes between same-day discharge versus overnight stay following vaginal hysterectomy and apical suspension.

Patients and Methods

This retrospective study evaluated surgeries performed over two time periods. Overnight stay was standard between December 2018 and February 2020. Same-day discharge was standard from December 2020 to February 2022. All patients who underwent vaginal hysterectomy with apical suspension were included. The primary outcome was to determine if there was an increase in 30-day readmission rates. Secondary outcomes included emergency department visits and reoperations within 30 days, the previous variables at 90 days, and the rate for successful same-day discharge.

Results

A total of 324 patients were analyzed over the 30 months: 149 (46%) in the overnight stay group and 175 (54%) in the same-day discharge group. At 30 days, no difference was found between groups for readmissions (2.7% vs 4.0%, p = 0.56), emergency department visits (14.8% vs 14.9%, p = 1.0), or reoperations (2.0% vs.1.7%, p = 1.0). At 90 days, outcomes were also similar. Same-day discharge as standard practice was successful in 80% of patients.

Conclusion

In this retrospective two cohort study, the safety of same-day discharge following vaginal hysterectomy with apical suspension was demonstrated with no increased risk of 30 or 90-day readmissions, emergency visits, or reoperation rates. The majority (80%) of patients were discharged on the day of surgery, suggesting feasibility of this model.

First report of robotic-assisted total hysterectomy using the Hugo™ RAS system

This study describes the first reported treatment of a benign gynecological disease with the Medtronic's Hugo™ RAS System, the first robot-assisted device used in the field of gynecology in Japan. Patients who underwent robot-assisted total laparoscopic hysterectomy with the Hugo™ RAS System at the Tottori University Hospital between March 2023 and June 2023 were included in this study. In the first case, the patient was in her 40 s and had uterine fibroids. We describe our experience and compare the device with the conventional da Vinci surgical system. We discuss the key features of the Hugo system (including the independent arms, open console, and pistol-shaped handle), the convenience of robotic surgery, the potential to improve quality of life, and how this technology could revolutionize the field of surgery.

Beyond Sterilization: A Comprehensive Review on the Safety and Efficacy of Opportunistic Salpingectomy as a Preventative Strategy for Ovarian Cancer

Ovarian cancer (OC) is Canada's third most common gynecological cancer, with an estimated 3000 new cases and 1950 deaths projected in 2022. No effective screening has been found to identify OC, especially the most common subtype, high-grade serous carcinoma (HGSC), at an earlier, curable stage. In patients with hereditary predispositions such as BRCA mutations, the rates of HGSC are significantly elevated, leading to the use of risk-reducing salpingo-oophorectomy as the key preventative intervention. Although surgery has been shown to prevent HGSC in high-risk women, the associated premature menopause has adverse long-term sequelae and mortality due to non-cancer causes. The fact that 75% of HGSCs are sporadic means that most women diagnosed with HGSC will not have had the option to avail of either screening or prevention. Recent research suggests that the fimbrial distal fallopian tube is the most likely origin of HGSC. This has led to the development of a prevention plan for the general population: opportunistic salpingectomy, the removal of both fallopian tubes. This article aims to compile and review the studies evaluating the effect of opportunistic salpingectomy on surgical-related complications, ovarian reserve, cost, and OC incidence when performed along with hysterectomy or instead of tubal ligation in the general population.

Patient and Surgery Characteristics of Inpatient Hysterectomies Among Transgender Individuals

Purpose: The purpose of this study is to estimate population-based rates of inpatient hysterectomy and accompanying bilateral salpingo-oophorectomy by indication and evaluate surgical patient characteristics by indication, year, patient age, and hospital location. Methods: We used 2016 and 2017 cross-sectional data from the Nationwide Inpatient Sample to estimate the hysterectomy rate for individuals aged 18-54 years with a primary indication for gender-affirming care (GAC) compared to other indications. Outcome measures were population-based rates for inpatient hysterectomy and bilateral salpingo-oophorectomy by indication. Results: The population-based rate of inpatient hysterectomy for GAC per 100,000 was 0.05 (95% confidence interval [CI] = 0.02-0.09) in 2016 and 0.09 (95% CI = 0.03-0.15) in 2017. For comparison, the rates per 100,000 for fibroids were 85.76 in 2016 and 73.25 in 2017. Rates of bilateral salpingo-oophorectomy in the setting of hysterectomy were higher in the GAC group (86.4%) than in comparison groups (22.7%-44.1% for all other benign indications, 77.4% for cancer) across all age ranges. A higher rate of hysterectomies performed for GAC was done laparoscopically or robotically (63.6%) than other indications, and none was done vaginally, as opposed to comparison groups (0.7%-9.8%). Conclusion: The population-based rate for GAC was higher in 2017 compared to 2016 and low compared to other hysterectomy indications. Rates of concomitant bilateral salpingo-oophorectomy were more prevalent for GAC than for other indications at similar ages. The patients in the GAC group tended to be younger, insured, and most procedures occurred in the Northeast (45.5%) and West (36.4%).

Pathologic Profile of Hysterectomy Cases in Saudi Arabia: A Tertiary Center Experience

Background

Hysterectomies are increasingly being replaced by more conservative management modalities and are now only used for limited clinical indications. The agreement between these indications and the final pathology is understudied.

Objectives

This study aimed to correlate the preoperative clinical diagnoses with the pathological findings detected in hysterectomies in Saudi women of different age groups.

Materials and Methods

This retrospective study analyzed the preoperative clinical indications and the subsequent clinical and pathological data of all hysterectomies conducted at a single tertiary care hospital in the Eastern Province of Saudi Arabia between January 2010 and December 2021.

Results

There was no decline in the frequency of hysterectomies across the study period. Abnormal uterine bleeding was the most common clinical indication across all age groups, followed by symptomatic fibroid and uterine prolapse in women aged <50 and ≥50 years, respectively. A total of 9.2% of the cases were indicated for therapeutic reasons, either as an emergency procedure for peripartum hemorrhage or for suspected uterine premalignant and malignant lesions. Besides these, 41.2% of patients had more than one pathology, with the most common combination being leiomyoma and adenomyosis (43.4%). The difference in age between malignant and benign cases (52.3 vs. 48.8 years, respectively) was not statistically significant (P = 0.109).

Conclusions

Most of our cohort had benign lesions. Perceptible misuse of the procedure in this cohort was unlikely, as a large proportion of the patients had more than one pathology corresponding to each clinical indication.

Ice-POP: Ice Packs for Postoperative Pain: A Randomized Controlled Trial

STUDY OBJECTIVE

To evaluate the benefit of ice packs as a supplement to standard pain management following laparoscopic hysterectomy (LH).

DESIGN

This Institutional Review Board-approved randomized controlled trial involved patients undergoing LH for benign conditions. Subjects were randomized to receive standard enhanced recovery after surgery pain management or standard enhanced recovery after surgery plus ice packs.

SETTING

Two academic tertiary care centers PATIENTS: Patients undergoing planned outpatient LH with the minimally invasive gynecologic surgery team between February 2019 and November 2020 were considered. Patients with chronic pain, current opioid use ≥1 week, or planned overnight hospitalizations were excluded. Primary outcome data were available for 51 subjects (24 control, 27 intervention).

INTERVENTIONS

Ice packs were placed on the abdomen in the operating room.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed at multiple time points throughout the study using a visual analogue scale (VAS). Opioid requirement was assessed using morphine milligram equivalent. There was no difference between the groups on any demographic variables. Morphine milligram equivalent requirements were also not different between the groups (p = .63). Postoperative day 1 (POD#1) VAS scores were not different (p = .89). Eighty-five percent of subjects reported feeling that their pain was controlled. Subjects who reported that they did not feel their pain was controlled did not use more opioids on POD#1 (p = .37), nor did they have higher POD#1 VAS scores (p = .55). Eighty-seven percent of the intervention subjects said they would use ice again, and 82.6% of them said they would recommend ice to others. There were no adverse events related to ice. All subjects were prescribed 20 tablets oxycodone and averaged 2.9 (SD 3.4) tablets used after discharge.

CONCLUSION

Ice packs are an acceptable supplement for postoperative pain control, but they do not reduce postoperative pain or opioid usage compared to standard pain management without ice packs.

Cost drivers for benign hysterectomy within a health care system: Influence of patient, perioperative, and hospital factors

OBJECTIVE

To identify patient, perioperative, and hospital factors that drive total hospital charges for benign hysterectomy.

METHODS

The authors conducted a retrospective cohort study between July 2014 and February 2019 at five academic and community hospitals within an integrated healthcare system in the state of Maryland with a Global Budget Revenue methodology for hospital charges. Predictor variables included patient, perioperative and hospital characteristics. One-way analysis of variance was used to compare charges among approaches. A multiple linear regression model was built to account for the interaction between covariates.

RESULTS

A total of 2592 patients underwent hysterectomy via laparoscopic (61%), abdominal (16%), robotic (14%), or vaginal (9%) approaches. Before adjusting for covariates, laparoscopic and vaginal approaches had similar charges ($11 637 and $12 229, respectively), while robotic and open approaches had higher charges ($17 535 and $19 099, respectively). After adjusting, charges for open, laparoscopic, and robotic approaches were higher than the vaginal approach ($692, $712, and $1279, respectively). Each operating room minute resulted in an increased cost of $46. Length of stay >23 h was associated with an increase of $865. Year, uterine size, body mass index, additional procedures, and transfusion influenced charges.

CONCLUSION

Perioperative and hospital characteristics significantly influence hospital charges for benign hysterectomy, more so than nonmodifiable patient characteristics. This provides opportunities to reduce healthcare expenditures, such as improving operating room efficiency and reducing length of stay.

Effects of hysterectomy on pelvic floor function and sexual function-A prospective cohort study

INTRODUCTION

Hysterectomy is one of the most common major surgical procedures in women. The effects of hysterectomy on pelvic floor and sexual function are uncertain. Our objective was to investigate the effects of hysterectomy for benign indications on pelvic floor and sexual function and to compare different modes of surgery.

MATERIAL AND METHODS

We performed a prospective clinical cohort study. In all, 260 women scheduled for hysterectomy answered validated questionnaires (Pelvic Floor Impact Questionnaire, Pelvic Floor Distress Inventory and Female Sexual Function Index). Participants were followed 6 months and 1 year after surgery. Data were analyzed using nonparametric statistics and mixed effect models.

RESULTS

Women with subtotal hysterectomy, vaginal hysterectomy, laparoscopic assisted vaginal hysterectomy, and previous prolapse/incontinence surgery were excluded from further analysis, leaving the remaining cohort to 242 patients. The response rate at 6 months and 1 year follow-up was 180/242 (74.3%) and 169/242 (69.8%), respectively. There was an improvement of pelvic floor function at both follow-ups; mean score of Pelvic Floor Impact Questionnaire at baseline was 42.5 (51.7), at 6 months 19.9 (42.2) and at 1 year 23.7 (50.3) (p < 0.001). The mean score of Pelvic Floor Distress Inventory at baseline was 69.6 (51.1), at 6 months 49 (43.2) and at 1 year 49 (43.2) (p < 0.001). There was an improvement of sexual function after 6 months (mean score of Female Sexual Function Index at baseline 17.9 [SD 11.7] and at 6 months 21.0 [SD 11.7]) (p < 0.001). There was no difference in pelvic floor or sexual function when comparing surgical techniques.

CONCLUSIONS

Robotic assisted laparoscopic hysterectomy, laparoscopic hysterectomy and abdominal hysterectomy improve pelvic floor function to the same extent at 6 months and 1 year after surgery. There was an overall improvement of sexual function 6 months after hysterectomy, but this did not persist after 1 year.

Impact of type of minimally invasive approach on open conversions across ten common procedures in different specialties

BACKGROUND

Conversion rates during minimally invasive surgery are generally examined in the limited scope of a particular procedure. However, for a hospital or payor, the cumulative impact of conversions during commonly performed procedures could have a much larger negative effect than what is appreciated by individual surgeons. The aim of this study is to assess open conversion rates during minimally invasive surgery (MIS) across common procedures using laparoscopic/thoracoscopic (LAP/VATS) and robotic-assisted (RAS) approaches.

STUDY DESIGN

Retrospective cohort study using the Premier Database on patients who underwent common operations (hysterectomy, lobectomy, right colectomy, benign sigmoidectomy, low anterior resection, inguinal and ventral hernia repair, and partial nephrectomy) between January 2013 and September 2015. ICD-9 and CPT codes were used to define procedures, modality, and conversion. Propensity scores were calculated using patient, hospital, and surgeon characteristics. Propensity-score matched analysis was used to compare conversions between LAP/VATS and RAS for each procedure.

RESULTS

A total of 278,520 patients had MIS approaches of the ten operations. Conversion occurred in 5% of patients and was associated with a 1.77 day incremental increase in length of stay and $3441 incremental increase in cost. RAS was associated with a 58.5% lower rate of conversion to open surgery compared to LAP/VATS.

CONCLUSION

At a health system or payer level, conversion to open is detrimental not just for the patient and surgeon but also puts a significant strain on hospital resources. Use of RAS was associated with less than half of the conversion rate observed for LAP/VATS.

Introduction of the day case total laparoscopic hysterectomy (TLH) protocol

BACKGROUND

Traditionally total laparoscopic hysterectomy (TLH) patients are admitted for 1-2 days post-operatively. Day case TLH has been proven to be feasible and safe in other countries; however, this tertiary Queensland hospital is one of the first Australian institutions to introduce a day case TLH protocol.

AIM

To pilot the implementation of our day case TLH protocol assessing the feasibility, safety and patient satisfaction of same-day discharge.

MATERIALS AND METHODS

A retrospective audit of the implementation of our day case TLH protocol at a tertiary Queensland hospital was conducted. Primary outcome was length of post-operative hospital stay. Secondary outcomes included perioperative complications and post-operative re-presentation rates. Patient satisfaction was assessed through a patient questionnaire.

RESULTS

Seventy-seven patients were included in the study. There were 94.81% patients who went home on the same day. Their average length of post-operative hospital stay was 7.72 (SD ± 3.36) hours. Of the patients who did achieve same-day discharge, the average length of stay was 7.05 (SD ±1.46) hours. There were no significant differences in perioperative complications or re-presentation rates compared to previously published literature. Patients reported they were extremely satisfied with day case TLH.

CONCLUSION

The implementation of our day case TLH protocol is feasible, safe and well received by patients in our tertiary Australian hospital. These results can have multimodal effects in healthcare: decrease in hospital costs by reducing length of stay and overnight admissions, improved theatre efficiency and patient flow, while maintaining patient safety and satisfaction.

[Feasibility and security of laparoscopic (± robotic) total hysterectomy in outpatient surgery: A French multicenter retrospective study]

OBJECTIVE

To assess the feasibility and safety of total hysterectomy by laparoscopic approach (± robot assisted) in ambulatory.

MATERIALS AND METHODS

French three-center retrospective study including 165 patients who had laparoscopic (± robot assisted) total hysterectomy scheduled as outpatients from January 2016 to December 2020. Clinical and perioperative data were collected. Factors associated with outpatient failure and rehospitalization were evaluated.

RESULTS

The outpatient success rate was 92.7%. Factors associated with outpatient failure were incision time>13:00, large volume of blood loss, intraoperative complications with Oslo score≥2, uterine weight≥250g, indication for benign pathology, and robot-assisted approach. Among patients managed as outpatients, 7.2% were rehospitalized at a mean of 10 days from surgery. The factors associated with rehospitalization were the use of an effective antiaggregant or anticoagulant treatment and the use of intraoperative adhesiolysis. Four patients (2.6%) underwent revision surgery.

CONCLUSION

Minimally invasive hysterectomy can be performed as an outpatient procedure even in cases of malignant pathology. Age and body mass index are not associated with an increased risk of failure or re-hospitalization within one month.

Total Hysterectomy by Low-Impact Laparoscopy to Decrease Opioids Consumption: A Prospective Cohort Study

Our objective was to evaluate postoperative pain and opioid consumption in patients undergoing hysterectomy by low-impact laparoscopy and compare these parameters with conventional laparoscopy. We conducted a prospective study in two French gynecological surgery departments from May 2017 to January 2018. The primary endpoint was the intensity of postoperative pain evaluated by a validated numeric rating scale (NRS) and opioid consumption in the postoperative recovery unit on Day 0 and Day 1. Thirty-two patients underwent low-impact laparoscopy and 77 had conventional laparoscopy. Most of the patients (90.6%) who underwent low-impact laparoscopy were managed as outpatients. There was a significantly higher consumption of strong opioids in the conventional compared to the low-impact group on both Day 0 and Day 1: 26.0% and 36.4% vs. 3.1% and 12.5%, respectively (p = 0.02 and p < 0.01). Over two-thirds of the patients in the low-impact group did not require opioids postoperatively. Two factors were predictive of lower postoperative opioid consumption: low-impact laparoscopy (OR 1.38, 95%CI 1.13−1.69, p = 0.002) and a mean intraoperative peritoneum below 10 mmHg (OR 1.25, 95%CI 1.03−1.51). Total hysterectomy by low-impact laparoscopy is feasible in an outpatient setting and is associated with a marked decrease in opioid consumption compared to conventional laparoscopy.

Initiation and feasibility of a multi-specialty minimally invasive surgical programme using a novel robotic system: A case series

INTRODUCTION

There are a number of small case series examining new robotic surgical systems, but this is the first large case series assessing the feasibility of the Versius® system from CMR Surgical (1 Evolution Business Park, Cambridge, UK) in a multi-specialty setting.

MATERIALS AND METHODS

All patients undergoing Versius®-assisted surgery in a previously robot-naïve centre were consented for collection of data on demographics, pre-, intra-, and postoperative outcomes. Data collection was performed prospectively from the start of the robotic surgical programme.

RESULTS

160 operations were performed over a 19-month period, including 68 colorectal, 60 gynaecology, and 32 general surgery cases. The conversion rate to open surgery was 4.4% for colorectal, and 0% for gynaecology and general surgery. Median length of stay was 6 days for colorectal, 1 day for gynaecology, and 0 days for general surgery. Other outcomes were comparable to existing literature for robotic assisted surgery.

CONCLUSION

The Versius® system is safe and feasible for use in a multi-specialty minimally invasive surgery programme, including colorectal, general surgical & gynaecological cases, and operative volume can be safely and easily scaled up in a district general hospital setting without prior robotic surgical experience.

Short stay laparoscopic hysterectomy: An evaluation of feasibility and patient satisfaction

Background

Short-stay total laparoscopic hysterectomy (TLH) could lead to reduced hospital costs and decrease complications associated with hospitalisation such as hospital acquired-infection and venous thromboembolism.

Objective

To evaluate the feasibility, safety and patient satisfaction of a novel short ‘less than 23-hour’ stay TLH protocol.

Material and Methods

Prospective cohort study, at Birmingham Women’s Hospital, United Kingdom including eligible women undergoing TLH for benign indications or early stage cervical/endometrial cancer.

Main outcome measures

Feasibility of discharge within 23-hours following TLH. Surgical complications and readmission rates were collected within 30-days of hysterectomy and patient’s satisfaction was assessed at 6-weeks.

Results

Of the 128 eligible women, 104/128 women (81%) were discharged within 23-hours of admission, of which 62/104 or 60% (48.4% of the whole cohort) were discharged on the same day. Adenomyosis/fibroids, and previous caesarean sections were associated with a greater likelihood of stay beyond 23-hours (P<0.05). The overall complications rate was 13/128 (10%) with two grade-3 Clavien-Dindo intraoperative complications; one serosal bowel injury oversewn and one ureteric injury requiring reimplantation. The readmissions rate was 5/128 (4%). 94% of patients were ‘happy’ or ‘very happy’ with the pathway, although satisfaction was higher in short-stay patients (RR 1.2; 95% CI 0.95–1.94).

Conclusion

Hospital discharge within 23-hours of TLH appears to be safe, feasible and acceptable to patients where a standardised, multidisciplinary care protocol is used.

What is new?

Our study is the first prospective case series in the UK reporting the safety and acceptability for performing laparoscopic hysterectomy as a 23-hour day case procedure.

Trends in the Use of Minimally Invasive Adnexal Surgery in the United States

OBJECTIVE

To examine the utilization of minimally invasive adnexal surgery, including ovarian cystectomy and oophorectomy, among women with benign gynecologic diseases and compare the associated morbidity and mortality of minimally invasive and open surgery.

METHODS

Women with benign ovarian pathology who underwent an ovarian cystectomy or oophorectomy from 2016 through 2018 in the Nationwide Ambulatory Surgery Sample and Nationwide Inpatient Sample databases were included. Patients with a diagnosis of gynecologic malignancy or concurrent hysterectomy were excluded. Population-level weighted estimates were developed, and perioperative morbidity, mortality, and hospital charges were examined based on surgical approach for each procedure.

RESULTS

The cohort included 351,207 women who underwent oophorectomy and 220,893 women who underwent cystectomy, when weighted representing 547,836 and 328,408 patients, respectively, nationwide. A minimally invasive surgical approach was used in 294,190 (89.6%) patients who underwent ovarian cystectomy, and in 478,402 (87.3%) of patients who underwent oophorectomy. Use of minimally invasive surgery for cystectomy increased from 88.7% in 2016 to 91.0% in 2018, and the rate of minimally invasive surgery for oophorectomy increased from 85.8% to 88.7% over the same time period (P<.001 for both). The complication rates for ovarian cystectomy were 2.7% for minimally invasive surgery and 8.8% for laparotomy (P<.001); for oophorectomy the complication rate was 3.1% for minimally invasive surgery and 22.9% for laparotomy (P<.001).

CONCLUSION

Minimally invasive surgery is used in the majority of women who are undergoing oophorectomy and ovarian cystectomy for benign indications. Compared with laparotomy, minimally invasive surgery is associated with fewer complications.

Bladder Backfilling versus Standard Catheter Removal for Trial of Void after Outpatient Laparoscopic Gynecologic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the rate of postoperative urinary retention and time to discharge between bladder backfilling and standard catheter removal for trial of void (TOV) after outpatient laparoscopic gynecologic surgery. Our secondary objectives were to compare the time to void, postoperative complications, and patient satisfaction.

DATA SOURCES

We searched the PubMed, Ovid MEDLINE, Embase, Cochrane Library databases, and relevant reference lists of eligible articles up to March of 2021.

METHODS OF STUDY SELECTION

This review included randomized controlled trials (RCTs) of TOV after outpatient laparoscopic gynecologic surgery. Odds ratios (ORs) with 95% confidence interval (CI) and weighted mean differences (WMDs) were reported. The quality of the studies was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. Data were analyzed with Review Manager 5.4 software (RevMan 5.4.1; Cochrane Collaboration, London, United Kingdom).

TABULATION, INTEGRATION, AND RESULTS

Five RCTs (N = 488) were included. The bladder backfilling group had a significantly shorter time to void than the standard TOV group (WMD, -25.19 minutes; 95% CI, -44.60 to -5.77; p = .01). Successful TOV was not significantly different between the 2 (OR, 0.92; 95% CI, 0.51 to -1.65; p = .77), without significant heterogeneity (I² = 24%). There was also no significant difference in the time to discharge between the 2 TOV techniques (WMD, -25.19 minutes; 95% CI, -44.60 to -5.77; p = .01). There was no significant difference in complication rates or patient satisfaction between the 2 groups.

CONCLUSION

The bladder backfilling technique of TOV after outpatient laparoscopic gynecologic surgery may reduce the time to first spontaneous void without affecting patient satisfaction or postoperative complications, but it does not significantly affect the time to discharge or urinary retention.

The association between douching, genital talc use, and the risk of prevalent and incident cervical cancer

While human papillomavirus is the primary cause of cervical cancer, other factors may influence susceptibility and response to the virus. Candidates include douching and talcum powder applied in the genital area. We used Cox proportional hazards models to estimate confounder-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) in the Sister Study (2003-2009), a US cohort of women aged 35-74. We considered pre-baseline (n = 523) and incident (n = 31) cervical cancers. Douching at ages 10-13 was positively associated with pre-baseline cervical cancer (HR 1.32, 95% CI 0.86-2.03), though the association was not statistically significant. We did not observe an association between adolescent talc use and pre-baseline cervical cancer (HR 0.95, 95% CI 0.76-1.19). Douching in the year before enrollment was positively associated with incident cervical cancer (HR 2.56, 95% CI 1.10-5.99). The association between recent genital talc use and incident cervical cancer was positive, but not statistically significant (HR 1.79, 95% CI 0.78-4.11). The observed positive association between douching and incident cervical cancer is consistent with previous retrospective case-control studies. In the first study to examine genital talc use and cervical cancer, we did not see evidence of an association.

Robotic Hysterectomy for Benign Indications: What Have We Learned from a Decade?

Background and Objectives

Robotic surgery data need a setback on many years of practice with high-volume surgeons to evaluate its real value. Our main objective was to study the impact of a decade of robotic surgery on minimally-invasive hysterectomies for benign indications. Our secondary objectives were to evaluate our results for high-volume surgeons and complex cases.

Methods

In this retrospective cohort study, we reviewed medical records at Foch Hospital, from 2010 to 2019, to evaluate the outcomes of robotic hysterectomies for benign disease. We compared the trends of benign hysterectomies done by laparoscopy and laparotomy during this period. We analyzed the proficiency group (≥ 75 cases per surgeon) and complex cases including obese patients and large uteri (>250 g).

Results

495 hysterectomies were performed by robotic, 275 by laparotomy, and 130 by laparoscopy. The laparotomy approach decreased from 62% to 29%, whereas the robotic approach increased from 26% to 61%. The operating room (OR) time decreased in the proficiency group (157.3 ± 43.32 versus 178.6 ± 48.05, P = 0.005); whereas the uterine weight was higher (194.6 ± 158.6 versus 161.3 ± 139.4, P = 0.04). Lower EBL and shorter OR time were seen with uteri ≤ 250 g subgroup (64.24 ± 110.2 ml versus 116.63 ± 146.98 ml, P = 0.0004) (169.62 ± 47.50 min versus 192.44 ± 45.82 min, P = 0.0001). The estimated blood loss (EBL) was less in the BMI ≤ 30 subgroup (68.83 ± 119.24 ml versus 124.53 ± 186.14 ml, P = 0.0005).

Conclusion

A shift was observed between the laparotomy and robotic approaches. High-volume surgeons were more efficient and showed a decrease in OR time after 75 cases despite an increase in uterine weight.

Malnutrition is Associated with Poor Postoperative Outcomes Following Laparoscopic Hysterectomy

Background:

Malnutrition continues to be pervasive among the general population, with rates as high as 50% of patients undergoing surgical procedures. Data is limited about women undergoing surgery for non-malignant gynecologic indications (generally elective laparoscopic hysterectomies, after failed conservative measures). With the significant increase in benign gynecologic surgery, it is of the upmost importance that surgeons optimize modifiable risk factors for patients undergoing laparoscopic hysterectomy. The purpose of this study is to identify the impact of malnutrition on postoperative outcomes in patients undergoing laparoscopic hysterectomy for benign conditions.

Methods:

A retrospective cohort study was conducted utilizing data that was collected through the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP) Database. All patients that underwent laparoscopic hysterectomy for benign indications were identified. Patients with malnutrition were identified by either low albumin (≤ 3.5 g/dL), low body mass index (≤ 18.5), or 10% weight loss within 6 months. The frequency of postoperative complications was evaluated with univariate and multivariate analyses where appropriate.

Results:

Following adjustment, multivariate analysis illustrated pre-operative malnutrition to be a risk factor for the following complications: any complication, death, bleeding requiring transfusion, wound, cardiac, pulmonary, renal, thromboembolic, sepsis complications, extended length of stay, and reoperation (p ≤ 0.05 for all).

Conclusion:

Malnourished patients were at significantly higher risk of developing postoperative complications during the acute postoperative period. With elective laparoscopic hysterectomies, pre-operative evaluation and intervention for malnutrition should be considered to improve nutritional status.

Outpatient Hysterectomy versus Inpatient Hysterectomy: A Systematic Review and Meta-analysis

OBJECTIVE

The aim was to investigate whether outpatient hysterectomy (OH) has benefits when compared with inpatient hysterectomy (IH) regarding postoperative complications, readmissions, operative outcomes, cost, and patient quality of life.

DATA SOURCES

A systematic search for studies comparing OH with IH was conducted through PubMed, SAGE, and Scopus from January 2010 to March 2020, without limitations regarding language and study design.

METHODS OF STUDY SELECTION

Studies reporting on the differences between same-day discharge and overnight stay after hysterectomy were included. The study outcomes were overall complication rate, type of complication, readmission after discharge, surgery duration, estimated blood loss, payer savings, hospital savings, and health-related quality of life (HrQoL). Median and range are used to describe non-normal data, while mean ± SD and confidence interval are used to descibe data with normal distribution. A meta-analysis with sensitivity analysis and subgroup analyses was performed.

TABULATION, INTEGRATION, AND RESULTS

Eight studies published between 2011 and 2019 with 104,466 patients who underwent hysterectomy were included in this systematic review and meta-analysis. All included studies except 1 were found to have a high risk of bias. OH in comparison with IH had a lower overall complication rate (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.60-0.82) and lower rates of wound infection (OR 0.60; 95% CI, 0.43-0.84), urinary tract infection (OR 0.64; 95% CI, 0.52-0.78), need for transfusion (OR 0.36; 95% CI, 0.22-0.59), sepsis (OR 0.33; 95% CI, 0.17-0.64), uncontrolled pain (OR 0.79; 95% CI, 0.66-0.95), and bleeding requiring medical attention (OR 0.82; 95% CI, 0.73-0.94). In addition, patients who underwent OH had a lower readmission rate (OR 0.81; 95% CI, 0.75-0.87), surgery duration (standardized mean difference -0.35; 95% CI, -0.61 to -0.08), and estimated blood loss (standardized mean difference -0.63; 95% CI, -0.93 to -0.33) than those who underwent IH. A qualitative analysis found that OH had a poorer patient HrQoL and a lower cost for the hospital as well as the payer.

CONCLUSION

OHs present fewer complications and have a lower readmission rate and estimated blood loss as well as a shorter surgery duration than IHs. OHs also have a cost benefit in comparison with IHs. But patients seem to have a worse HrQoL in the first postoperative week after OH. The high risk of bias of the included studies indicates that well-designed clinical trials and standardization of surgical complication reporting are essential to better address this issue.

Safety of early discharge in patients undergoing laparoscopic hysterectomy in a high complexity center in Bogotá, Colombia, 2013 - 2019. Historical cohort

Objective: To describe the safety of early discharge in the first 12 hours of the postoperative period in women undergoing laparoscopic hysterectomy for benign uterine disease. Materials and methods: Descriptive historical cohort study. The study included all women undergoing laparoscopic hysterectomy due to benign disease and discharged after 12 hours of the procedure in a high complexity hospital in Bogota Colombia, between January 2013 and April 2019. Patients with comorbidities (diabetes, cardiovascular disease and chronic obstructive pulmonary disease) mobility limitations and intraoperative complications were excluded. Consecutive sampling was used. The variables assessed included demographics and safety variables such as readmission through the emergency service and complications classified according to the Dindo scale on the fifteenth postoperative day. A descriptive analysis is made. Results: Of 860 laparoscopic hysterectomies performed during the study period, 67 (7.8%) met the selection criteria. Eleven patients (16.4%) were readmitted through the emergency service, one (9%) due to active bleeding, and two (18%) because of urinary symptoms. There were six (8.9%) postoperative complications, including vaginal vault hematoma in two patients (2.9%), hemoperitoneum in two cases (2,9%), one (1.4%) urinary infection and one (1.4%) ureteral injury; four patients (5.9%) required hospitalization and were classified as stage IIIb on the Dindo scale. Conclusions: Early discharge emerges as an alternative to in-hospital care for this type of population. Randomized controlled studies are needed to produce additional evidence regarding this management approach.

The shift from inpatient to outpatient hysterectomy for endometrial cancer in the United States: trends, enabling factors, cost, and safety

OBJECTIVE

To evaluate trends in outpatient versus inpatient hysterectomy for endometrial cancer and assess enabling factors, cost and safety.

METHODS

In this retrospective cohort study, patients aged 18 years or older who underwent hysterectomy for endometrial cancer between January 2008 and September 2015 were identified in the Premier Healthcare Database. The surgical approach for hysterectomy was classified as open/abdominal, vaginal, laparoscopic or robotic assisted. We described trends in surgical setting, perioperative costs and safety. The impact of patient, provider and hospital characteristics on outpatient migration was assessed using multivariate logistic regression.

RESULTS

We identified 41 246 patients who met inclusion criteria. During the time period studied, we observed a 41.3% shift from inpatient to outpatient hysterectomy (p<0.0001), an increase in robotic hysterectomy, and a decrease in abdominal hysterectomy. The robotic hysterectomy approach, more recent procedure (year), and mid-sized hospital were factors that enabled outpatient hysterectomies; while abdominal hysterectomy, older age, Medicare insurance, black ethnicity, higher number of comorbidities, and concomitant procedures were associated with an inpatient setting. The shift towards outpatient hysterectomy led to a $2500 savings per case during the study period, in parallel to the increased robotic hysterectomy rates (p<0.001). The post-discharge 30-day readmission and complications rate after outpatient hysterectomy remained stable at around 2%.

CONCLUSIONS

A significant shift from inpatient to outpatient setting was observed for hysterectomies performed for endometrial cancer over time. Minimally invasive surgery, particularly the robotic approach, facilitated this migration, preserving clinical outcomes and leading to reduction in costs.

Postoperative Urinary Retention after Benign Gynecologic Surgery with a Liberal versus Strict Voiding Protocol

STUDY OBJECTIVE

Surgeons employ various methods for evaluating what is considered a common occurrence after gynecologic operations, postoperative urinary retention (POUR). Few have reported the incidence of POUR with a liberal voiding protocol (no requirement to void before discharge). The primary objective of this study was to evaluate the risk of POUR after benign gynecologic surgery, comparing a liberal voiding protocol with more strict voiding protocols. Secondary outcomes included length of hospital stay (LOS) and urinary tract infection (UTI).

DESIGN

Retrospective cohort study.

SETTING

Quaternary-care academic hospital in the United States.

PATIENTS

Patients undergoing hysterectomy or myomectomy at Cedars-Sinai Medical Center from August 2017 through July 2018 (n = 652). Cases involving incontinence operations, correction of pelvic organ prolapse, malignancy, or peripartum hysterectomy were excluded.

INTERVENTIONS

Hysterectomy, myomectomy.

MEASUREMENTS AND MAIN RESULTS

POUR, defined as the need for recatheterization within 24 hours of catheter removal, along with UTI and LOS were compared between liberal and strict voiding protocols. A subgroup analysis was performed for those undergoing minimally invasive surgery (MIS). A total of 303 (46.5%) women underwent surgery with a liberal postoperative voiding protocol and 349 (53.5%) women with a strict voiding protocol. Overall, the incidence of POUR was low at 3.8% and not different between the groups (2.6% liberal vs. 4.9% strict, p = .14). UTIs also occurred infrequently (2.8% overall, 2.6% liberal vs. 2.9% strict, p = .86). Similar results were seen specifically among those who underwent MIS: POUR (3.7% overall, 2.8% liberal vs. 5.3% strict, p = .17) and UTI (3.3% overall, 2.4% liberal vs. 4.7% strict, p = .28). The median LOS (interquartile range) was much shorter for MIS patients with a liberal voiding protocol (median 15 hours overall [interquartile range 15 hours], 9 [4] hours liberal vs. 36 [34] hours strict, p <.01). Among those discharged the same day (72.6% of the MIS cases), patients with a liberal voiding protocol had a significantly shorter LOS than those with strict (mean [standard deviation] 9.4 [2.5] hours vs. 10.6 [35] hours, p <.01). Postoperative complications occurred less frequently in those with MIS procedures (11.8% in MIS vs. 20.2% in laparotomies, p <.01) and those with liberal voiding protocols (11.2% liberal vs. 16.9% strict p = .04).

CONCLUSION

Overall, POUR occurs infrequently after major benign gynecologic surgery and does not differ between those with liberal and strict voiding protocols. Our data suggest that same-day discharge after MIS hysterectomy and myomectomy without a requirement to void does not increase the risk of POUR and shortens LOS. Eliminating voiding protocols after these procedures may facilitate greater efficiency in the postanesthesia recovery unit and may contribute to enhanced recovery after surgery protocols.

National trends and outcomes of morbidly obese women who underwent inpatient hysterectomy for benign gynecological disease in the USA

INTRODUCTION

The US population has witnessed an epidemic expansion of obesity in the past several decades; nearly 50% of the population is projected to be obese by 2030 and 25% morbidly obese. This study examined trends, characteristics and outcomes of morbidly obese women who underwent benign hysterectomy.

MATERIAL AND METHODS

This is a population-based retrospective observational study querying the National Inpatient Sample from January 2012 to September 2015. The study population included 509 395 women who underwent hysterectomy for benign gynecological disease: 430 865 (84.6%) non-obese women, 50 435 (9.9%) women with class I-II obesity and 28 095 (5.5%) women with class III obesity. Main outcome measures were (i) cohort-level trends of obesity and perioperative complications assessed by piecewise linear regression with log transformation and (ii) patient-level perioperative complication risk by body habitus assessed with a generalized estimating equation after using a multiple-group generalized boosted model.

RESULTS

The rate of class III obesity increased by 40.4%, higher than the rate of class I-II obesity (22.2%) (both, P < .001). In parallel, cohort-level rates of perioperative complication and prolonged hospitalization for ≥7 days increased by 19.4% and 54%, respectively (P < .001). In a weighted model, class I-II obesity (16.4% vs 14.6%, odds ratio 1.15, 95% confidence interval 1.08-1.21) and class III obesity (19.2% vs 14.6%, odds ratio 1.39, 95% confidence interval 1.28-1.51) had a significantly increased risk of perioperative complications compared with non-obesity. Larger body habitus was associated with higher total charge (median, $35 180, $36 094 and $39 382; all values cited in US dollars) and prolonged admission rate for ≥7 days (2.9%, 3.1% and 3.9%) (both, P < .001).

CONCLUSIONS

The rate of obesity, particularly morbid obesity, has significantly increased among women undergoing benign hysterectomy in the USA. Morbidly obese women had adverse perioperative outcomes, and the increasing number of morbidly obese women resulted in both an increased perioperative morbidity and total charges as a cohort. National and society-based approaches are necessary to reduce the obesity rate and hysterectomy morbidity.

Updates and Controversies of Robotic-Assisted Surgery in Gynecologic Surgery

minimally invasive surgery (MIS) is the standard approach to performance of several gynecologic procedures, including hysterectomy, gynecologic cancer staging procedures, myomectomy, pelvic organ prolapse repair, and select adnexal procedures. Robotic-assisted surgery, a computer-based MIS approach, has been adopted widely in the United States and several other countries. Robotics may offer technological and ergonomic benefits that overcome limitations associated with conventional laparoscopy; however, it is not clear that reported claims of superiority translate into improved gynecologic patient outcomes compared with other MIS approaches. This review critically appraises the evolving role, benefits, limitations, and controversies of robotic-assisted surgery utilization in benign and oncologic gynecology settings.

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.

[Ambulatory minimally invasive hysterectomy: Limiting factors related to health professionals]

OBJECTIVES

The feasibility of minimally invasive hysterectomy for ambulatory benign pathology has been demonstrated in many international studies. France has a considerable delay of multifactorial origin in this field. The objective of this study is to identify the limiting factors related to health professionals to the realization of minimally invasive ambulatory hysterectomy and to determine possible strategies to increase its rate.

METHODS

This is a cross-sectional survey conducted over 2 months using a self-administered questionnaire sent by email to 180 gynecological surgeons in 2 French regions (Grand Est and Bourgogne-Franche Comté).

RESULTS

A total of 22% of health professionals responded to the survey. The vast majority of practitioners (60%) said they did not carry out ambulatory care by habit. The apprehension of the reaction of the patients (47.5%), the fear of delayed diagnosis of complications (12.5%), the management of pain in the postoperative period (42.5%) also participated in brake of the promotion of ambulatory care.

DISCUSSION

Improvement of the organisation of city and hospital management allowing a better continuity of care (70%), the economic valuation (37.5%) and the increase in the hourly amplitude of the ambulatory surgery unit (5%) would improve the rate of ambulatory care of minimally invasive hysterectomies, according to the gynecologist surgeons surveyed. In addition, a prospective study evaluating the quality of life of patients after ambulatory care of minimally invasive hysterectomy would allow better adherence of health professionals and patients to the ambulatory care project in 70% of cases.

CONCLUSION

The change of mentality of health professionals remains a priority for the promotion of ambulatory surgery in gynecology. Information and communication are therefore essential to the expansion of the ambulatory.

A Novel Porcine Stomach Tissue Model for Laparoscopic Colpotomy Simulation

BACKGROUND

Hysterectomies are the most common benign gynecologic surgical procedures performed in the United States. Currently, there are no tissue models that exist to teach trainees the techniques for colpotomy during laparoscopic hysterectomy. To address this educational gap, we have created a laparoscopic colpotomy model using a porcine stomach attached to a uterine manipulator.

METHODS

A segment of a porcine stomach is secured onto a uterine manipulator to simulate the cervicovaginal junction. A uterus model created with craft materials and reused in subsequent sessions is placed above the porcine stomach onto the uterine manipulator tip. Porcine stomach was obtained from a local butcher or meat market costing less than $1.00 per model. The tissue can be refrigerated or frozen for storage, then thawed before each use. This model can be used with any energy device and any laparoscopic platform to teach and perform the colpotomy. Usability survey showed that trainees responded positively to the model and attendings thought it was a useful teaching tool.

EXPERIENCE

Trainees and faculty responded favorably to the model and stated that the use of actual tissue enhanced the realism of a colpotomy simulation.

CONCLUSION

The porcine stomach laparoscopic colpotomy model is an innovative, low-cost teaching tool to add to a gynecologic surgical education simulation toolkit.

Surgical Care for Women with Endometrial Cancer in Florida

Objective: The goal of this research was to analyze if disparities in route of hysterectomy for endometrial cancer exist in Florida. Materials and Methods: In this retrospective cohort study, Florida inpatient and ambulatory surgery databases (2014-2016) were examined to find cases of patients with endometrial cancer who underwent hysterectomy in the state. Logistic regression models were used to compare patient- and hospital-level factors associated with having minimally invasive surgery (MIS) versus open surgery, and complications in patients having open hysterectomy versus MIS. Results: Overall, 6513 patients met the inclusion criteria. MIS was performed in 81.4% of cases. The odds of using a minimally invasive approach to hysterectomy (vaginal, robotic, or laparoscopic) were significantly lower for black women (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.34-0.50) as well as for other non-white patients (OR: 0.64; 95% CI: 0.49-0.84). Patients with Medicaid (OR: 0.42; 95% CI: 0.30-0.59) or Medicare managed care (OR: 0.73; 95% CI: 0.59-0.91), or who received care at a teaching hospital (OR: 0.82; 95% CI: 0.68-0.98) or government hospital (OR: 0.50; 95% CI: 0.38-0.65) were also less likely to receive MIS. Patients receiving care at a high-volume (OR: 1.69; 95% CI: 1.30-2.20) or medium-volume (OR: 3.11; 95% CI: 2.37-4.08) hospital, or patients who were located in the Central (OR: 1.71; 95% CI: 1.17-2.48) or Peninsula (OR: 1.73; 95% CI: 1.17-2.56) regions, compared to the Florida Panhandle, had greater odds of receiving MIS. Conclusions: Although Florida has a high adoption of MIS for treating endometrial cancer, disparities persist. Efforts of state-level entities should focus on improving access to minimally invasive hysterectomy for racial minorities with endometrial cancer.

The Comparison of Outcomes between the "Skeleton Uterus Technique" and Conventional Techniques in Laparoscopic Hysterectomies

Aim

The aim of this study is to compare demographic characteristics, operative data, and complication rates of women who underwent total laparoscopic hysterectomy by the skeleton uterus technique (Skeleton-TLH) with those of women who underwent TLH by the standard technique (Standard-TLH) in a university teaching and research hospital.

Materials and Methods

This retrospective study included 932 laparoscopic hysterectomies in a university teaching and research hospital between January 1, 2013 and December 31, 2017. Clinical characteristics, operative outcomes, and complications were recorded and compared for the two techniques.

Results

In total, 932 laparoscopic hysterectomies were performed, 454 by Skeleton-TLH and 478 by Standard-TLH. The general demographic characteristics of the patients were similar; only gravida and parity were statistically significantly different between the groups (P < 0.001). Based on the primary outcomes (the operative data), total anesthesia time and main operation time were similar in the two groups. Estimated blood loss was statistically significantly lower in the Skeleton-TLH group than in the Standard-TLH group. Hospital stay was longer for the Skeleton-TLH group, and specimen weight was heavier. The secondary outcome was the complication rate. There were no differences between the Skeleton-TLH and Standard-TLH groups in the rates of all minor and major complications.

Conclusion

TLH with the skeleton uterus technique is feasible and safe, especially for advanced pelvic surgeons. This technique not only provides retroperitoneal access to the pelvic spaces and good anatomical visibility; but it also delivers a safer laparoscopic hysterectomy by clamping the uterine arteries and monitoring the ureter throughout the operation.

Laparoscopic Hysterectomy Outcomes: Hospital vs Ambulatory Surgery Center

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.

Outcomes of robotic, laparoscopic, and open hysterectomy for benign conditions in obese patients

Objective:

To compare outcomes of robotic-assisted (RAH), total laparoscopic hysterectomy (LH), and total abdominal hysterectomy (TAH) for benign conditions in obese patients.

Material and Methods:

Retrospective cohort (Class II-2) analysis. All obese patients who underwent RAH, LH or TAH for benign conditions by a single surgeon at the University of Texas Medical Branch between January 2009 and December 2011 were identified and their charts reviewed. The patients’ characteristics, operative data, and post-operative outcomes were collected and statistically analyzed.

Results:

A total of 208 patients who underwent RAH (n=51), LH (n=24) or TAH (n=133) were analyzed. There were no significant differences among the groups in demographic characteristics, indications for surgery or pathologic findings. RAH and LH were associated with lower estimated blood loss (EBL) (p<0.001) and shorter length of hospital stay (LOS) (p<0.001) compared with TAH. In addition, RAH and LH had lower intraoperative and early postoperative (≤6 weeks) complications compared with TAH (p=0.002). However, the procedure time was longer in RAH and LH (p<0.001). No significant differences were noted among the groups for late post-operative complications (after 6 weeks) or unscheduled post-operative visits.

Conclusion:

Minimally invasive hysterectomy appears to be safe in obese patients with the advantages of less EBL, fewer intraoperative complications, and shorter LOS.