PMID- 30222939
OWN - NLM
STAT- In-Data-Review
LR  - 20181116
IS  - 1097-6868 (Electronic)
IS  - 0002-9378 (Linking)
VI  - 219
IP  - 5
DP  - 2018 Nov
TI  - The impact of surgeon volume on perioperative adverse events in women undergoing 
      minimally invasive hysterectomy for the large uterus.
PG  - 490.e1-490.e8
LID - S0002-9378(18)30751-8 [pii]
LID - 10.1016/j.ajog.2018.09.003 [doi]
AB  - BACKGROUND: There are currently sparse data on the relationship between surgeon- 
      and patient-related factors and perioperative morbidity in the setting of
      elective hysterectomy for the larger uterus. OBJECTIVE: We sought to evaluate the
      impact of surgeon case volume on perioperative adverse events in women undergoing
      minimally invasive hysterectomy for uteri >250 g. STUDY DESIGN: This is a
      retrospective cohort study of all women who underwent total vaginal, total
      laparoscopic, laparoscopic-assisted vaginal, or robotic-assisted total
      laparoscopic hysterectomy from January 2014 through July 2016. Hysterectomy was
      performed for: fibroids, pelvic pain, abnormal uterine bleeding, or prolapse.
      Patients were identified by Current Procedural Terminology codes and the
      systemwide electronic medical record was queried for demographic and
      perioperative data. Perioperative adverse events were defined a priori and
      classified using the Clavien-Dindo scale. Surgeon case volume was defined as the 
      mean number of minimally invasive hysterectomy cases performed per month by each 
      surgeon during the study period. RESULTS: In all, 763 patients met inclusion
      criteria: 416 (54.5%) total laparoscopic hysterectomy, 196 (25.7%)
      robotic-assisted total laparoscopic hysterectomy, 90 (11.8%) total vaginal
      hysterectomy, and 61 (8%) laparoscopic-assisted vaginal hysterectomy. Mean
      (+/-SD) age was 47.3 +/- 6.1 years, and body mass index was 31.1 +/- 7.4 kg/m(2).
      In all, 66 surgeons performed minimally invasive hysterectomy for uteri >250 g
      during the study period, and the median rate of minimally invasive hysterectomy
      cases for large uteri per month was 3.4 (0.4-3.7) cases/month. The median (IQR)
      uterine weight was 409 (308-606.5) g. The rate of postoperative adverse events
      Dindo grade >2 was 17.8% (95% confidence interval, 15.2-20.7). The overall rate
      of intraoperative adverse events was 4.2% (95% confidence interval, 2.9-5.9). The
      rate of conversion to laparotomy was 5.5% (95% confidence interval, 4.0-7.4).
      There was no significant difference in adverse event rates between the routes of 
      minimally invasive hysterectomy cases (25.6% vs 17.5% vs 18.0% vs 14.8% for total
      laparoscopic hysterectomy, robotic-assisted laparoscopic hysterectomy, total
      vaginal hysterectomy, and laparoscopic-assisted vaginal hysterectomy,
      respectively, P = .2). In a logistic regression model controlling for age, body
      mass index, uterine weight, operating time, and history of laparotomy, higher
      monthly minimally invasive hysterectomy volume was significantly associated with 
      the likelihood that a patient would experience a postoperative adverse event
      (adjusted odds ratio, 1.1 for each additional minimally invasive hysterectomy
      case for large uteri per month; 95% confidence interval, 1.0-1.3). When
      controlling for the same variables, a higher incidence of intraoperative
      complications was significantly associated with monthly minimally invasive
      hysterectomy case volume (adjusted odds ratio, 1.5 for each additional minimally 
      invasive hysterectomy case for large uteri per month; 95% confidence interval,
      1.20-2.08). Increasing age was associated with a lower incidence of complications
      (adjusted odds ratio, 0.9 for each additional year; 95% confidence interval,
      0.8-0.9). Higher monthly minimally invasive hysterectomy volume was associated
      with a lower rate of conversion from a minimally invasive approach to laparotomy 
      (adjusted odds ratio, 0.4 for each additional minimally invasive hysterectomy
      case for large uteri per month; 95% confidence interval, 0.2-0.5). CONCLUSION:
      The overall rate of serious adverse events associated with minimally invasive
      hysterectomy for uteri >250 g was low. Higher monthly minimally invasive
      hysterectomy case volume was associated with a higher rate of intraoperative and 
      postoperative adverse events but was associated with a lower rate of conversion
      to laparotomy.
CI  - Copyright (c) 2018 Elsevier Inc. All rights reserved.
FAU - Bretschneider, C Emi
AU  - Bretschneider CE
AD  - Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics,
      Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
      Electronic address: emibrets@gmail.com.
FAU - Frazzini Padilla, Pamela
AU  - Frazzini Padilla P
AD  - Section of Minimally Invasive Gynecologic Surgery, Cleveland Clinic, Weston, FL.
FAU - Das, Deepanjana
AU  - Das D
AD  - Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics,
      Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
FAU - Jelovsek, J Eric
AU  - Jelovsek JE
AD  - Department of Obstetrics and Gynecology, Duke University, Durham, NC.
FAU - Unger, Cecile A
AU  - Unger CA
AD  - Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics,
      Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
LA  - eng
PT  - Journal Article
DEP - 20180914
PL  - United States
TA  - Am J Obstet Gynecol
JT  - American journal of obstetrics and gynecology
JID - 0370476
OTO - NOTNLM
OT  - hysterectomy
OT  - morbidity
OT  - surgeon volume
EDAT- 2018/09/18 06:00
MHDA- 2018/09/18 06:00
CRDT- 2018/09/18 06:00
PHST- 2017/12/14 00:00 [received]
PHST- 2018/08/27 00:00 [revised]
PHST- 2018/09/06 00:00 [accepted]
PHST- 2018/09/18 06:00 [pubmed]
PHST- 2018/09/18 06:00 [medline]
PHST- 2018/09/18 06:00 [entrez]
AID - S0002-9378(18)30751-8 [pii]
AID - 10.1016/j.ajog.2018.09.003 [doi]
PST - ppublish
SO  - Am J Obstet Gynecol. 2018 Nov;219(5):490.e1-490.e8. doi:
      10.1016/j.ajog.2018.09.003. Epub 2018 Sep 14.