Do Long Operating Times Reduce the Benefit of Total Laparoscopic Hysterectomy Compared to Abdominal Hysterectomy?
BACKGROUND AND PURPOSE:
Chakraborty et al. (AJOG, 2022) sought to determine whether there is an operative time limit beyond which the benefits of total laparoscopic hysterectomy (TLH) diminished compared with shorter total abdominal hysterectomy (TAH)
Retrospective cohort study
National Surgical Quality Improvement Project
2014 to 2018
Patients undergoing total hysterectomy for benign indications
Exclusion included >360 minutes as surgeries beyond this time frame considered outliers
TLH, including robotic-assisted surgery
Outcomes were analyzed using linear models, controlled for
Demographic data | Comorbidities | Hysterectomy-specific information (e.g., uterine weight, endometriosis, PID)
Selection bias was assessed using propensity score matching
Any major morbidity
Length of stay after surgery
TAH: 58,152 | TLH: 58,570
Mean operating time was similar for both routes (P=0.45)
Laparoscopic: 129 ± 60 minutes
Abdominal: 129 ± 64 minutes
The complication rate was higher for total abdominal hysterectomy than total laparoscopic hysterectomy (P<0.001)
Median length of stay was longer for TAH (P<0.001)
Laparoscopic: 1 (IQR, 0 to 1) days
Abdominal: 2 (IQR, 2 to 3) days
An increase of 1 hour in operative time for hysterectomy was associated with a 45% increase in the risk of major morbidity (95% CI, 41 to 49)
Increased risk was greater with TAH
Each hour of operative time was associated with a 61% greater risk of major morbidity (95% CI, 53 to 68)
At no time point was total abdominal hysterectomy associated with less morbidity or a shorter length of stay than total laparoscopic hysterectomy
No change in result even if total laparoscopic hysterectomy was significantly longer than total abdominal hysterectomy
No matter how long total laparoscopic hysterectomy took, the risk of morbidity was never higher than it was for total abdominal hysterectomy
The authors state
We found that TLH at any operating time, up to 360 minutes, was associated with less major morbidity and shorter hospital stay than TAH, even if TAH is hours shorter than TLH
…as long as laparoscopy is considered feasible, it should be offered as the preferred route to minimize adverse events
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