title: Safely Increase the Minimally Invasive Hysterectomy Rate: A Novel Three-Tiered Preoperative Categorization System Can Predict the Difficulty for Benign Disease.
abstract: BACKGROUND
  A nonlaparotomic route is recommended for hysterectomy for benign indications.
  
  
  OBJECTIVE
  1) Predict the difficulty of hysterectomy to treat benign disease as measured by operative time and risk of laparotomy, 2) confirm the safety and quality of increasing our minimally invasive hysterectomy (MIH) rate, and 3) determine whether the assistant's experience affected the likelihood of an MIH being performed in equally difficult hysterectomies.
  
  
  METHODS
  All hysterectomies for benign disease performed at the Kaiser Permanente Fontana Medical Center in Fontana, CA, in 2012 were reviewed for length of surgery, length of stay, complications, and readmissions. A three-tiered category system was developed from four preoperative parameters (body mass index, number of vaginal deliveries, clinical uterine size, and history of major abdominal surgery) to anticipate length and difficulty of surgery.
  
  
  METHODS
  Rates of MIH, complications, and readmissions as well as length of surgery and length of stay for similarly difficult hysterectomies. These outcomes were compared with surgeons' and assistants' experience.
  
  
  RESULTS
  Of 576 hysterectomies performed for benign disease, 89% were MIH with a 3% complication rate and 4% readmission rate. An increase in the hysterectomy category was statistically significantly associated with longer surgery times and a higher percentage of laparotomy. With the most experienced assistants, the MIH rate was 98%.
  
  
  CONCLUSIONS
  Using 4 preoperative parameters, the average operating time for hysterectomy for benign disease can be predicted. A higher hysterectomy category predicts a more difficult surgery. Our center has increased its MIH rate to 89% while maintaining safety.
authors.affiliation: Obstetrician/Gynecologist at the Fontana Medical Center in CA. esteban.a.andryjowicz@kp.org.
authors.forename: Esteban
authors.initials: E
authors.lastname: Andryjowicz
authors.affiliation: Former Regional Chief of Obstetrics and Gynecology for the Southern California Permanente Medical Group at the Fontana Medical Center in CA and the present Chief of Obstetrics and Gynecology at the Fontana Medical Center in CA. teresa.b.wray@kp.org.
authors.forename: Teresa B
authors.initials: TB
authors.lastname: Wray
authors.affiliation: Obstetrician/Gynecologist at the Fontana Medical Center in CA. reinaldo.v.ruiz@kp.org.
authors.forename: V
authors.initials: V
authors.lastname: Reinaldo Ruiz
authors.affiliation: Obstetrician/Gynecologist at the Fontana Medical Center in CA. james.d.rudolf@kp.org.
authors.forename: James
authors.initials: J
authors.lastname: Rudolf
authors.affiliation: Obstetrician/Gynecologist at the Fontana Medical Center in CA. sara.x.noroozkhani@kp.org.
authors.forename: Sara
authors.initials: S
authors.lastname: Noroozkhani
authors.affiliation: Obstetrician/Gynecologist at the Fontana Medical Center in CA. sandra.c.crowder@kp.org.
authors.forename: Sandra
authors.initials: S
authors.lastname: Crowder
authors.affiliation: Research Manager of Biostatistics for the Southern California Permanente Medical Group in Pasadena. jeff.m.slezak@kp.org.
authors.forename: Jeff M
authors.initials: JM
authors.lastname: Slezak
mesh_terms: D015992:Body Mass Index; D002985:Clinical Protocols; D036861:Delivery, Obstetric; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D007902:Length of Stay; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D061646:Operative Time; D009929:Organ Size; D010359:Patient Readmission; D011183:Postoperative Complications / Q000453:epidemiology