Improving Access to Minimally Invasive Hysterectomy for Large Uteri in a Community-Focused Academic Center
Background: Despite the benefits of laparoscopic hysterectomy, uterine size remains a common indication for abdominal hysterectomy.
Objective: This study aims to assess whether a quality improvement (QI) intervention to increase alignment of pre-operative evaluation and the ultimate surgical route improves access to laparoscopic hysterectomy and reduces conversion from laparoscopy to laparotomy.
Methods: A before-and-after single-center, single-phase QI project was conducted. Women aged ≥18 years undergoing hysterectomy for benign indications from 2019– 2024 were included. Patients with malignant pathology, concomitant urogynecologic procedures, and those with missing data were excluded. At our institution, a group approach was employed in which the route-deciding surgeon may differ from the operating surgeon, leading to discrepancies in surgical feasibility and high conversion rates. The QI intervention consisted of routing all patients with uteri ≥16 weeks to a group of surgeons with minimally invasive surgery (MIS) expertise for both pre-operative planning and operative management. Data collected included demographics, comorbidities, prior surgeries, surgical routes, complications, and length of hospital stay. Cases were stratified by uterine weight.
Results: Of 906 total hysterectomies, 724 (79.9%) occurred pre-intervention and 182 (20.1%) post-intervention. Following the QI, the overall rate of planned MIS significantly increased from 78% to 92% (p < 0.001). Among patients with uteri weighing >500 g (approximately 16-week size), MIS rose from 37% to 82% (p < 0.001). Same-day discharge significantly increased from 57% to 76% (p < 0.001). No significant difference in complication rates was observed. The overall laparoscopy to laparotomy conversion rate declined from 5.9% to 0.5% (p = 0.002), and from 10.8% to 0% (p = 0.01) in patients with large uteri.
Conclusion: The involvement of MIS-trained surgeons in both planning and execution was associated with increased access to laparoscopic hysterectomy and a reduced conversion rate to laparotomy, particularly in patients with large uteri. This QI study provides Class III evidence.
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