Do hysterectomy patients fare better with high-volume surgeons?

A single-institution retrospective study published in JSLS, The Journal of the Society of Laparoendoscopic Surgeons suggests that operative times may be shorter and blood loss lower when hysterectomy is done by high-volume surgeons. The analysis, however, found no difference between them and intermediate- or low-volume surgeons in terms of conversion to laparotomy, readmission rates, or incidence of intraoperative or postoperative complications, whereas hospital stays were slightly longer for the patients whose surgeons performed the most procedures.

The results are based on analysis of a database of hysterectomies performed at Brigham and Women’s Hospital in 2006, 2009, and 2010. A total of 1914 procedures-644 abdominal, 393 vaginal, and 877 laparoscopic or robotic-were included but hysterectomies performed for oncologic or obstetric indications were excluded. Surgeons were classified as low-volume (<11 hysterectomies per year), intermediate volume (11-50 hysterectomies per year), or high-volume (>50 procedures per year). Because the hospital is an academic institution, most of the surgeries were completed with resident or fellow assistance.

Of the 85 gynecologic surgeons represented in the database, 67 were low-volume, 10 were intermediate-volume, and 8 were high-volume and they performed 43.8% (838), 35.6% (682), and 20.6% (394) of the procedures, respectively. A trend toward more laparotomies was seen in the high-volume group (36.75% vs 31.7% for low- and intermediate volume groups; P=.061). A laparoscopic approach was most common among intermediate-volume surgeons (57.92%) compared with abdominal for both low- and high-volume surgeons (42.64% and 19.65%, respectively). Uterine fibroids were the most common indication for the procedures done by low- and intermediate-volume surgeons (64.47% and 69.65%, respectively), versus 49.4% for the high-volume group, which had more varied indications.

Editorial Board member Jon Einarsson on morcellation and hysterectomy

Information on age, length of hospital stay, and operative time was taken from medical records and charts were reviewed for factors such as body mass index, parity, prior abdominal surgeries, and estimated blood loss during surgery. Blood loss ≥1000 mL, vessel or visceral organ injury, and major cardiac/pulmonary events were the intraoperative complications reviewed. Continuous variables were compared with a one-way analysis of variance test and categorical variables were compared with the X² of Fisher exact test.

Operative time was significantly lower in the high-volume group versus the intermediate- and low-volume surgeons (155.11 minutes, 199.19 minutes, and 203.35 minutes, respectively; P<.001). Blood loss also was significantly lower among the high-volume surgeons versus the other two groups (161.09 mL vs 205.58 mL and 237.96 mL, respectively; P<.001). Mean length of hospital stay, however, was slightly higher for hysterectomies performed by the high-volume group (2.06 days vs 1.35 days and 1.8 days for the intermediate- and low-volume groups, respectively; P<.001).

Their findings, the authors said, “confirm a strong relationship between operator surgical volume and both shorter operative time and lower estimated blood loss.” Greater complexity of cases handled by the high-volume surgeons, they theorized, might explain the increased length of stay associated with procedures performed by that group.

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