Identifying the Rate-Limiting Step in Total Laparoscopic Hysterectomy in a Training Hospital.
OBJECTIVE
To identify the lengthiest step of total laparoscopic hysterectomy (TLH) in a teaching hospital and to determine which clinical factors affect the duration of this step.


METHODS
The University of Louisville Hospital.


METHODS
Single institution retrospective case series.


RESULTS
This is a retrospective chart and video review that included 135 benign, elective TLHs performed at The University of Louisville. TLH was divided into 5 steps: (1) insertion of laparoscopic ports and adhesiolysis to restore normal anatomy; (2) identification of the ureter and resection of adnexal structures to transection of the round ligament; (3) transection of the round ligament to transection of the uterine artery; (4) lateralization of the uterine vessel pedicle to completion of colpotomy; and (5) completion of vaginal cuff closure. The random intercept and slope model was used to identify the lengthiest step of TLH, and the backward elimination procedure was used to evaluate which clinical factors affected this step. Mean ± SD total length of TLH was 81 ± 30 min. The lengthiest step was colpotomy, with a mean duration of 24 ± 13 min. Uterine weight significantly increased the length of time required for colpotomy (p = .001). The primary energy source (ultrasonic scalpel vs monopolar hook) used to perform colpotomy did not influence the length of time (p = .539 vs p = .583). Uterine weight (p < .001) and adhesiolysis (p = .003) significantly increased the total time of TLH.


CONCLUSIONS
At a teaching institution where surgeries are performed by residents and fellows, colpotomy is the lengthiest step of TLH and is influenced by uterine weight. This finding may reflect the training levels of the surgeons performing these cases and the learning curve associated with a challenging surgical skill. Further research should focus on simulation models and/or tools for colpotomy that may result in greater efficiency in the operating room.
Department of Obstetrics, Gynecology, and Women's Health, The University of Louisville, Louisville, Kentucky.
Diogo
D
Torres
Department of Obstetrics, Gynecology, and Women's Health, The University of Louisville, Louisville, Kentucky.
Thomas G
TG
Lang
Department of Obstetrics, Gynecology, and Women's Health, The University of Louisville, Louisville, Kentucky. Electronic address: resad.pasic@louisville.edu.
Resad
R
Pasic
Department of Obstetrics, Gynecology, and Women's Health, The University of Louisville, Louisville, Kentucky.
Shan
S
Biscette
Department of Bioinformatics and Biostatistics, The School of Public Health and Information, The University of Louisville, Louisville, Kentucky.
Bakeerathan
B
Gunaratnam
Department of Obstetrics, Gynecology, and Women's Health, The University of Louisville, Louisville, Kentucky.
Linda-Dalal J
LD
Shiber
D000328:Adult; D000368:Aged; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007045:Hysterectomy, Vaginal / Q000379:methods*; D007629:Kentucky; D010535:Laparoscopy / Q000379:methods*; D059032:Learning Curve; D008875:Middle Aged; D011183:Postoperative Complications; D011247:Pregnancy; D012189:Retrospective Studies; D013529:Surgical Wound Dehiscence / Q000209:etiology; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery; D014599:Uterus / Q000601:surgery*
Colpotomy; TLH; Total laparoscopic hysterectomy; Uterine weight