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    Should you offer outpatient hysterectomy?

    Minimally invasive approaches to hysterectomy—performed vaginally, laparoscopically, or with robotic assistance—offer faster postoperative recovery with lower healthcare costs. Same-day discharge in appropriate cases can further enhance these benefits.

    Dr. W. has practiced obstetrics and gynecology for 10 years. Three years ago, she attended courses to learn laparoscopic hysterectomy (LH) techniques. With the help of some of her more experienced colleagues, she began to incorporate these techniques into her practice. She has been successful with her cases and now routinely considers laparoscopy as the first-line method for hysterectomy in appropriate patients. Currently, Dr. W. admits her patients to the hospital overnight and discharges them on postoperative day 1 after LH. She has read that some gynecologists are discharging patients home on the day of surgery and some are completing minimally invasive hysterectomies on a completely outpatient basis. She is interested in the idea of same-day discharge (SDD), but is unsure of how to make this work in her practice.

    This scenario describes an emerging trend in the practice of obstetrics and gynecology. In this article, we explore the safety and efficacy of SDD after minimally invasive hysterectomy for benign disease and review tips to help you offer early discharge to your patients.

    History of minimally invasive hysterectomy

    Hysterectomy remains the most common major gynecologic surgery performed in women in the United States, with approximately 600,000 women undergoing this procedure each year.1 A nationwide review of hysterectomies performed from 1997 through 2005 showed that about two thirds of hysterectomies were performed via laparotomy.2

    However, this year the American Academy of Gynecologic Laparoscopists published a position paper stating that a minimally invasive approach to hysterectomy is the method of choice for benign disease.3 A 2009 publication by the American College of Obstetricians and Gynecologists (Committee Opinion no. 444) specifically recommended vaginal hysterectomy (VH) as the preferred route whenever feasible.4 Others have suggested that robotically assisted LH techniques may provide an easier learning curve, thereby enabling more surgeons to adopt a minimally invasive approach to hysterectomy.5 These position papers likely represent the beginning of a fundamental change in the methods by which hysterectomy is performed in the US and abroad.

    Minimally invasive hysterectomy procedures include those completed vaginally (VH), laparoscopically (LH), or via a robot-assisted laparoscopic route. These techniques also can be used in combination, such as laparoscopy-assisted VH. A recent survey of US gynecologists suggested that although they would overwhelmingly prefer LH or VH for themselves or their spouses, a number of barriers prevent them from achieving this goal for their patients. These include perceived technical difficulty and, particularly for laparoscopic surgery, a lack of adequate training during residency.6

    Minimally invasive hysterectomy offers several benefits, and recent studies of laparoscopic and robotic procedures for benign or malignant indications have documented less pain, less blood loss, fewer complications, shorter hospital stays, faster recovery and return to normal activities, as well as improved cosmesis compared with abdominal hysterectomy.7-12

    Shorter hospital stays associated with these less-invasive procedures also reduce costs.13,14 A 2005 report showed that the costs associated with outpatient VH were 20% to 25% lower than those for inpatient VH.15 Investigators from Denmark calculated that performing vaginal-wall repair on an outpatient basis rather than having patients stay overnight in the hospital reduced total costs by more than one-third.16 Clearly, hospitalization significantly increases healthcare costs compared with SDD. Given the increasing scrutiny on healthcare spending, decreasing the length of stay after hysterectomy, where safe and feasible, will likely become more important.

    Bruce S. Kahn, MD, FACOG
    Dr Kahn is Director, Scripps Fellowship in Minimally Invasive Gynecologic Surgery, and practices Female Pelvic Medicine and ...


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