The following is a summary of “Is total laparoscopic hysterectomy with longer operative time associated with a decreased benefit compared with total abdominal hysterectomy?,” published in the FEBRUARY 2023 issue of Obstetrics and Gynecology by Chakraborty, et al.

The general difference between total laparoscopic and total abdominal hysterectomy in perioperative morbidity is well known. But total laparoscopic hysterectomy also has longer operating times, which is a separate predictor of morbidity. Therefore, it was unclear whether a total laparoscopic hysterectomy offered a diminishing return and a higher risk of morbidity than a shorter abdominal hysterectomy. For a study, researchers sought to ascertain whether there is a maximum amount of time that can pass during surgery before the advantages of total laparoscopic hysterectomy start to outweigh those of total abdominal hysterectomy, which is less invasive.

Patients undergoing total laparoscopic hysterectomy and total abdominal hysterectomy for benign indications between the years of 2014 and 2018 were identified using targeted hysterectomy-specific data from the National Surgical Quality Improvement Project. Generalized linear models were used to examine the length of stay following surgery as well as any significant morbidity. The models took into account demographics, comorbidities, and data unique to hysterectomy, like uterine weight, endometriosis, and pelvic inflammatory disease at the time of operation. Multiple imputation analysis was used to deal with missing data. To evaluate the impact of selection bias and nonlinear interactions between covariates and the outcomes, respectively, sensitivity analyses employing propensity score matching and generalized additive models were carried out. In order to identify the women who underwent total abdominal hysterectomy (n=58,152) or total laparoscopic hysterectomy (n=58,570–58,573), Common Procedural Terminology codes were employed. As there was no method for doing so under the National Surgical Quality Improvement Project, conventional laparoscopy and robotic surgery could not be distinguished from one another. Consequently, a comprehensive laparoscopic hysterectomy also involved robotic surgery. Any surgery lasting >360 minutes was also excluded because it represented a significant outlier in the data and clinical practice. Other exclusion criteria included pelvic reconstructive surgery, anti-incontinence surgery, lymphadenectomy, radical hysterectomy, cytoreductive surgery, a pre-or postoperative diagnostic code for gynecologic malignancy, preoperative sepsis or renal failure, emergency surgery, and any concurrent non-gynecologic surgery. Patients who underwent ureteral stenting as part of the treatment but experienced no other urologic procedures were also included because it could be done in conjunction with a hysterectomy or to treat ureteral injury.

With 129±60 minutes for total laparoscopic hysterectomy and 129±64 minutes for total abdominal hysterectomy, respectively, the mean operating time was comparable for both approaches (P=.45). The median length of stay was longer following total abdominal hysterectomy (2 [interquartile range, 2-3] days vs 1 [interquartile range, 0-1] days; P<.001) and the complication rate was higher (16.6% vs 7.7%; P<.001) than following total laparoscopic hysterectomy. The risk of a major morbidity increased by 45% (95% CI, 41%-49%) for every hour more spent performing a hysterectomy after controlling for confounders. Additionally, total abdominal hysterectomy was linked to an additional time penalty, increasing the risk of major morbidity by an additional 61% (95% CI, 53%-68%) for every hour spent performing the procedure. Although total laparoscopic hysterectomy was much longer than total abdominal hysterectomy, there was never a time point at which total abdominal hysterectomy was linked with decreased morbidity or a shorter length of stay. Both the generalized additive model analysis and the propensity-matched analysis came to the same findings.

According to the research, total laparoscopic hysterectomy did not have a greater rate of complications or a longer hospital stay than a total abdominal hysterectomy at any feasible point in the surgical procedure.

Reference: ajog.org/article/S0002-9378(22)00797-9/fulltext