Increasing Access to Minimally Invasive Large Specimen Hysterectomy in a Community-Focused Academic Center

INTRODUCTION: Hysterectomies can be performed via different routes with minimally invasive surgery (MIS) preferred over laparotomy. Expert gynecologic surgeons have demonstrated the feasibility of MIS for large uterine specimens, even exceeding 1,000 grams (g). Despite data supporting the safety of this procedure, uterine size continues to be cited as a common indication for abdominal hysterectomy. OBJECTIVE: A quality improvement (QI) project was undertaken. Our objective was to assess if the quality intervention increases access to minimally invasive hysterectomy and if it decreases the current laparoscopy to laparotomy conversion rate. METHODS: In this before-and-after single-phase QI project, we included women aged 18 years or older undergoing hysterectomy. Patients with malignant pathology, concomitant urogynecologic procedures, and those with missing data were excluded. Within our institution, a group approach has been adopted in which the surgeon who determines the route may not be the surgeon who performs the procedure, which creates opportunities for discrepancy between preoperative planning and the actual surgical route. This may also contribute to a high conversion rate if the surgeon is not comfortable performing MIS for large uteri. Pilot data collected at our institution demonstrated a low percentage of MIS hysterectomy and high conversion rate compared to the national average. To address this, the QI intervention consisted of a bundle of preoperative assessment and surgery performed by faculty with MIS expertise for uteri larger than 16 weeks’ size. The primary outcome was the percentage of hysterectomies that were successfully completed through MIS. Secondary outcomes included the conversion rate from MIS to laparotomy, the rate of same-day discharge, and the rate of surgical complications. Variables were collected before and after the QI intervention. Outcomes were followed for 12 months after the implementation of the quality initiative. A 15% increase in the rate of MIS was considered significant. RESULTS: A total of 906 patients underwent hysterectomy during the study period. Of these, 724 (79.9%) had surgery before, and 182 (20.1%) after the QI. Patient characteristics did not significantly differ between cohorts, except for race, ethnicity, and uterine size. Following the QI, a significantly higher proportion of patients underwent MIS (78% vs 92%, P<0.0001). Importantly, in the cohort of patients with uteri >500 g/16 weeks, the rate of MIS increased from 37% to 82%, p<0.001. The rate of same-day discharge significantly increased (57% vs 76%, P<0.001). There was no significant difference in complication rate (19% vs 16%, P=0.47). The total conversion rate from MIS to laparotomy decreased from 6% to 0.5%, p=0.002, and from 11% to 0, p=0.01, for the large uteri cohort. After adjusting for confounders, the intervention was still associated with a significant decrease in laparotomy, OR: 0.18 [0.09–0.355], p<0.001. This was maintained if uterine weights were categorized by weight as <500 g, 500–1000 g, and >1000 g. CONCLUSIONS: A QI bundle aligning surgeons with MIS expertise with preoperative planning and execution of large specimen hysterectomies increased access to MIS and decreased the conversion rate to laparotomy for patients with large uteri. This intervention may lead to sustainable and significant improvements in surgical outcomes in this population (Tables 1 and 2).