An Exploration of Hysterectomy Procedures: A Focus on Minimally Invasive Approaches

Objective: To compare intra-operative and post-operative outcomes of total abdominal hysterectomy, total vaginal hysterectomy, total laparoscopic hysterectomy, and total robotic hysterectomy for benign conditions, as well as to conduct a cost approximation of each. Methods: Retrospective chart review of all hysterectomies by two surgeons between January 2017 and January 2019. For each patient, the following metrics were recorded and analyzed: age, BMI, medical history, abdominal/pelvic surgical history, surgical indication, route of hysterectomy, intra-operative complications, total operative time, time to discharge, estimated blood loss, post-operative complications, pain status, return to activities of daily living, and return to employment. Results: A total of 521 patients who underwent total abdominal hysterectomy (n=40), total vaginal hysterectomy (n=55), total laparoscopic hysterectomy (n=131), and total robotic hysterectomy (n=292) were analyzed. There were no significant differences among the groups in age, BMI, or surgical history. The total vaginal hysterectomy category included the highest percentage of pre-existing medical history (p=0.043, p=0.011). Of the four categories, total robotic and total laparoscopic hysterectomies involved shorter operative times (p=0.026, p=0.044), shorter inpatient stays (p= <0.001), fewer intra-operative complications (p= <0.001), decreased pain status (p= <0.001), and quicker return to both employment (p=0.039, 0.044) and activities of daily living (p=0.002). Total robotic hysterectomy showed less estimated blood loss (p= <0.001) and fewer post-operative complications (p=0.022, p=0.046) when compared to laparoscopic hysterectomy. Robotic hysterectomy was noted to have the highest OR-specific costs and total encounter costs. Conclusions: The two minimally invasive routes to hysterectomy, robotic and laparoscopic, appear to both be comparable in terms of intra-operative and post-operative outcomes, and are associated with improved outcomes when compared to abdominal and vaginal routes to hysterectomy. However, due to the high cost of robotic surgery, it may not be the most cost-effective approach.