title: Longer Operative Time During Benign Laparoscopic and Robotic Hysterectomy Is Associated With Increased 30-Day Perioperative Complications.
abstract: OBJECTIVE
  The relationship between operative time and perioperative morbidity has not been fully characterized in gynecology. We aimed to determine the impact of operative time on 30-day perioperative complications after laparoscopic and robotic hysterectomy.
  
  
  METHODS
  Patients undergoing laparoscopic and robotic hysterectomy for benign disease from 2006 to 2011 within the National Surgical Quality Improvement Program (NSQIP) database were identified by Current Procedural Terminology code. Operative times were stratified into 60-minute intervals and complication rates analyzed. Primary outcomes included 30-day overall, medical, and surgical complications. Bivariate analyses using χ(2), Fisher's exact, and one-way analysis of variance tests were performed to compare clinical and procedural characteristics associated with longer operative time and complications. Multivariable logistic regression analyses were then performed to determine the independent association between operative time and perioperative complications.
  
  
  METHODS
  Canadian Task Force classification II-2 (Evidence obtained from well-designed cohort or case-control studies preferably from more than 1 center or research group).
  
  
  METHODS
  American College of Surgeons NSQIP.
  
  
  METHODS
  Patients who underwent laparoscopic or robotic hysterectomy for benign disease from 2006 to 2011 at any institution participating in NSQIP.
  
  
  METHODS
  None, retrospective database study.
  
  
  RESULTS
  Of the 7630 laparoscopic and robotic hysterectomies identified, 399 patients (5.2%) experienced complications, most commonly urinary tract infection (UTI; 2.1%), superficial surgical site infection (1.0%), and blood transfusion (1.0%). Return to the operating room was required in 97 patients (1.3%), and there were 4 deaths, for a mortality rate of .05%. Complications increased steadily with longer operative time. Operative time ≥ 240 minutes was associated with increased overall complications (13.8% vs 4.6%, p < .001), surgical complications (5.4% vs 1.5%, p < .001), medical complications (10.4% vs 3.2%, p < .001), return to the operating room (2.7% vs 1.2%, p = .002), deep venous thrombosis (.5% vs .06%, p = .011), pulmonary embolism (.7% vs .1%, p = .012), and blood transfusion (3.4% vs .8%, p < .001). These associations remained statistically significant after multivariable regression analysis. Based on continuous regression modeling, each additional hour of operative time would be expected to increase odds of overall complications (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.28-1.54; p < .001), medical complications (OR, 1.42; 95% CI, 1.28-1.57; p < .001), surgical complications (OR, 1.32; 95% CI, 1.17-1.49; p < .001), venous thromboembolism (OR, 1.47; 95% CI, 1.12-1.92; p = .005), UTI (OR, 1.20; 95% CI, 1.05-1.36; p = .006), blood transfusion (OR, 1.42; 95% CI, 1.18-1.71; p < .001), and return to the operating room (OR, 1.25; 95% CI, 1.08-1.45; p = .003).
  
  
  CONCLUSIONS
  We demonstrated a direct, independent association between operative time and 30-day complications after laparoscopic and robotic hysterectomy. Future research should aim to further delineate risk factors for prolonged operative time and morbidity in laparoscopic hysterectomy to allow surgeons to maximize preoperative planning and optimize patient selection for minimally invasive hysterectomy.
authors.affiliation: Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Electronic address: tcatanza@gmail.com.
authors.forename: Tatiana
authors.initials: T
authors.lastname: Catanzarite
authors.affiliation: Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Sujata
authors.initials: S
authors.lastname: Saha
authors.affiliation: Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Pilecki
authors.affiliation: Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: John Y S
authors.initials: JY
authors.lastname: Kim
authors.affiliation: Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Magdy P
authors.initials: MP
authors.lastname: Milad
mesh_terms: D000368:Aged; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D016022:Case-Control Studies; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000009:adverse effects / Q000379:methods; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D061646:Operative Time; D059035:Perioperative Period; D058996:Quality Improvement; D012189:Retrospective Studies; D012307:Risk Factors; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000379:methods; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000209:etiology; D013997:Time Factors; D014552:Urinary Tract Infections / Q000453:epidemiology* / Q000209:etiology
keywords: Gynecologic surgery; Laparoscopic hysterectomy; Operative time; Perioperative complications