Intraoperative Complications During Minimally Invasive Hysterectomy for Gynecologic Malignancy: An ACS-NSQIP Study

INTRODUCTION: Ambulatory surgical centers (ASCs) offer reduced costs, quicker services, and higher patient satisfaction. Given resource limitations, patient and surgical risks must be carefully assessed when selecting ASC cases. Data on the risk profile of minimally invasive hysterectomies (MIH) performed for gynecologic oncology indications is limited, which is necessary to guide decisions about their suitability for an ASC setting. OBJECTIVE: To identify the rate of intraoperative complications during MIH for gynecologic oncology indication. METHODS: We performed a retrospective observational study utilizing the 2022 and 2023 American College of Surgeons National Surgical Quality Improvement Program database to identify the rate of intraoperative complications during MIH for gynecologic oncology indications. Women undergoing MIH were identified using the CPT codes. Gynecologic oncology indications were identified using ICD-10 codes and included prophylactic, ovarian mass/cyst, endometrial hyperplasia, cervical dysplasia, borderline ovarian tumor, endometrial cancer, ovarian cancer, cervical cancer, fallopian tube cancer, and peritoneal cancer. The primary objective was to determine the rate of intraoperative complications during MIH for gynecologic oncology indications. Intraoperative complications included an unplanned conversion to laparotomy and/or a blood transfusion within 24 hours of surgery. Factors associated with intraoperative complications were analyzed as secondary objectives. RESULTS: Twenty-two thousand seven hundred seventy-nine women underwent MIH for a gynecologic oncology indication. One hundred seventy-nine (0.8%) patients experienced an intraoperative complication: 83 (0.4%) occurrences of unplanned conversion to laparotomy and 102 (0.5%) cases of blood transfusion within 24 hours of surgery (Table 1). Certain patient demographics and clinical characteristics were associated with an intraoperative complication (Table 2). Patients with an intraoperative complication were more likely to have class 3 obesity (13.0% vs 2.9%, p < 0.001); however, class 2 obesity was at lower risk of an intraoperative complication (10.1% vs 16.7%, p = 0.02). Patients with American Society of Anesthesiologists (ASA) functional class 2 were less likely to have an intraoperative complication (22.9% vs 43.0%, p < 0.001). Higher ASA functional status (class 3 and 4) was associated with higher risk of an intraoperative complication (Class 3 61.5% vs 52.5%, p = 0.01; Class 4 14.0% vs 2.9%, p < 0.001). Patients with preoperative medical comorbidities like congestive heart failure (7.8% vs 1.8%, p < 0.001), ascites (3.5% vs 0.2%, p < 0.001), acute kidney injury (2.2% vs 0.02%, p < 0.001), dialysis (1.7% vs 0.2%, p = 0.01), disseminated cancer (5.0% vs 1.7%, p = 0.004), bleeding disorder (6.7% vs 1.2%, p < 0.001), and receiving a preoperative blood transfusion within 72 hours of surgery (7.8% vs 0.2%, p < 0.001) were at higher risk of an intraoperative complication. Gynecologic oncology indications that were associated with a higher risk of intraoperative complication included ovarian cancer (10.1% vs 2.3%, p < 0.001), fallopian tube cancer (2.8% vs 0.5%, p = 0.002), and peritoneal cancer (1.1% vs 0.1%, p = 0.01). Women who underwent surgery for a prophylactic indication were less likely to have an intraoperative complication (2.2% vs 7.0%, p = 0.02). Median operative time was longer in the intraoperative complication cohort (178 minutes vs 122, p < 0.001). CONCLUSIONS: Intraoperative complications during MIH for gynecologic oncology indications occur at a low rate of 0.8%. This low risk supports further considering of performing these procedures in ASCs.Table 1Table 2