Assessing Perioperative Risk According to Surgical Route in Hysterectomy for Very Large Uteri.

Background and Objectives: The benefits of minimally invasive hysterectomy are widely recognized. However, laparoscopic hysterectomy is more technically difficult in patients with enlarged uteri. In this study, we sought to compare surgical outcomes for patients with large uteri (greater than 1 kg) undergoing laparoscopic versus open hysterectomy.

This was a retrospective cohort study performed at a tertiary-care academic center, including all patients who underwent laparoscopic or open hysterectomy for a benign indication between January 1, 2009 and December 31, 2024. The primary outcome was a composite measure of intraoperative and postoperative complications, readmissions, and reoperations.

A total of 509 patients underwent hysterectomy for uteri larger than 1 kg: 268 via laparotomy and 241 via laparoscopy. After controlling for confounding variables, the risk of any complication, readmission or reoperation was similar in the laparoscopy and laparotomy groups (OR 1.09 [0.68–1.77], P = .7119). Median estimated blood loss was lower in the laparoscopy group as compared to the laparotomy group (100 vs 300 mL, P < .001). Mean operative time was longer in the laparoscopy group by 24 minutes (188 vs 164 minutes, P < .001). The median length of stay was 0 days for the laparoscopy group, versus 2 days for the laparotomy group (P < .001).

Our results suggest that laparoscopic hysterectomy is feasible even for patients with uterine weight exceeding 1 kg. While operative time was longer in the laparoscopy group, this increase in operative time was not associated with an increase in perioperative complications.

Gynecologic surgical procedures, Hysterectomy, Laparoscopy, Laparotomy, Leiomyoma, Minimally invasive surgical procedures

Hysterectomy is among the most common gynecologic surgeries performed in the United States, with a lifetime prevalence of up to 20–25% in people with uteri.1 Hysterectomy may be performed via a minimally invasive approach (vaginal, laparoscopic or robot-assisted surgery), or via an open technique. Minimally invasive options for hysterectomy are associated with shorter hospitalization, and may be associated with a myriad of clinical benefits including faster return to activity, decreased pain, less blood loss, and fewer incisional complications.2,3 Given these advantages, the American College of Obstetricians and Gynecologists (ACOG) recommends a minimally invasive approach where feasible.4 While the rate of minimally invasive hysterectomy has steadily increased over time, laparoscopic hysterectomy may remain less accessible for patients with larger uteri given the technical challenges presented by manipulation, visualization and specimen extraction.5 Various authors have suggested 16 to 18-week size or estimated specimen weight >700 g as exclusion criteria for laparoscopic hysterectomy in the research context.6–8 However, with advances in surgical technique, laparoscopy may be an option even for significantly enlarged uteri: multiple case series have demonstrated the feasibility of minimally invasive hysterectomy for uteri greater than 1 kg, and case reports have been published of laparoscopic hysterectomy for uteri exceeding 5 kg.9–12 Kondo et al (2011) compared outcomes in 23 patients undergoing laparoscopic hysterectomy and 15 patients undergoing laparotomy for uteri weighing over 1 kg, finding reduction in complications and length of hospital stay for those undergoing laparoscopy.13 Uccella et al (2018) conducted a retrospective analysis of 258 patients undergoing hysterectomy for uteri weighing more than 1 kg, similarly finding a lower overall complication rate for patients undergoing laparoscopic hysterectomy versus laparotomy.14 A 2018 analysis of the National Surgical Quality Improvement Program (NSQIP) database found that while overall complications increased with uterine size, abdominal hysterectomy remained consistently associated with increased complication rates as compared to laparoscopic hysterectomy for similarly sized uteri, with over 30% increased odds of complication for abdominal versus laparoscopic hysterectomy for uteri weighing over 500 g.3 This analysis did not include data on surgeon training or patient surgical or medical history, which may impact route of surgery as well as complication rates. The current study aims to compare outcomes for laparoscopic versus abdominal hysterectomy for uteri weighing over 1 kg, including detailed data on surgeon training, surgical indication, and patient medical and surgical history. This represents the largest single-institution retrospective cohort study of surgical route for very large uteri conducted to date. We hypothesized that a composite measure of the rate of any complication, readmission or reoperation would be lower in the group undergoing laparoscopic hysterectomy as compared to the group undergoing laparotomy.

This retrospective cohort study included patients undergoing hysterectomy at 2 affiliated tertiary-care academic hospitals. The study was deemed exempt by the Institutional Review Board. Surgical cases were identified from an internal database of all hysterectomies performed at these hospitals. The inclusion criteria were patients undergoing laparoscopic and open abdominal hysterectomy between January 1, 2009 and December 31, 2024. The exclusion criteria were cases with uterine weight below 1 kg on final pathologic report, and cases with preoperative histologic diagnosis of malignancy through endometrial sampling. Patient and procedure characteristics were collected via thorough review of the electronic medical records. This included demographic information, prior abdominal procedures, indications for the procedure as documented in the preoperative office visit, hysterectomy subtype, surgeon subspecialty, operative time, estimated blood loss (EBL), length of hospitalization, and the occurrence of any major intraoperative complication (defined as an EBL greater than 1000 mL, organ injury, or conversion to an open procedure). Postoperative complications occurring within 60 days were categorized by Clavien-Dindo classification.15 The primary outcome was a composite measure of any perioperative complication, readmission, or reoperation. Secondary outcomes were intraoperative and postoperative complications, operative time, EBL, and length of inpatient stay. All data were compared for the 2 groups using Student’s t test for parametric variables, Wilcoxon rank-sum tests for nonparametric variables, and χ2 or Fisher’s exact test for categorical variables. Multivariable regression modeling was performed for primary outcome, controlling for: age, body mass index (BMI), race, prior surgical history, uterine weight, hysterectomy subtype and group. Statistical significance was determined as P-value less than .05 and all P-values were 2-sided. Statistical analysis was performed using SAS, version 9.4 (SAS Institute, Cary, NC).

During the study period, a total of 509 patients underwent hysterectomy for uteri larger than 1 kg, 241 via laparoscopy and 268 via laparotomy. Baseline patient characteristics are summarized in Table 1. Groups were overall similar with respect to age, parity, race, and history of prior surgery. BMI was slightly higher in the laparoscopy group, with mean BMI of 31.4 +/− 7 kg/m2 versus 29.7 +/− 6.7 kg/m2 (P = .0058). Laparoscopic procedures became more prevalent over time, with the total number of laparoscopies exceeding laparotomies from 2017 onward (147 vs 133; Supplemental Figure S1). American Society of Anesthesiologists Physical Status Classification (ASA class) was overall similar between the 2 groups (P = .165). The likelihood of adnexal surgery differed between the 2 groups (P < .001), with patients undergoing laparotomy more likely to undergo salpingo-oophorectomy (22.0% vs 8.3%). The 2 groups differed in presence and stage of endometriosis (P = .002); patients in the laparoscopy group were more likely to have no endometriosis (89.6% vs 82.1%) or Stage IV endometriosis (4.6% vs 1.9%), while patients in the laparotomy group were more likely to have Stage I endometriosis (14.9% vs 5.4%). Table 1. | Laparoscopic (n = 241) | Open (n = 268) | P-Value | | |---|---|---|---| | Age | 47.4 (5.8) | 48.2 (7) | .147 | | BMI (kg/m2) | 31.4 (7) | 29.7 (6.7) | .0058 | | Parity (number of births) | ||| | 0 | 104 (43.2%) | 102 (38.1%) | .240 | | 1 | 51 (21.2%) | 40 (14.9%) | | | 2 | 54 (22.4%) | 72 (26.9%) | | | 3+ | 31 (12.9%) | 37 (13.8%) | | | Missing | 1 (0.4%) | 17 (6.3%) | | | Race | ||| | White | 127 (52.7%) | 135 (50.4%) | .433 | | Black | 79 (32.8%) | 85 (31.7%) | | | Hispanic | 7 (2.9%) | 8 (3.0%) | | | Asian | 17 (7.1%) | 24 (9.0%) | | | Other | 6 (2.5%) | 3 (1.1%) | | | Unknown | 5 (2.1%) | 13 (4.9%) | | | Prior surgery* | ||| | Prior laparoscopy or laparotomy | 109 (45.2%) | 125 (46.6%) | .720 | | Prior laparoscopy | 66 (27.4%) | 58 (21.6%) | .138 | | Prior laparotomy | 70 (29.1%) | 92 (34.3%) | .191 | | Year of procedure | ||| | 2009 | 5 (2.1%) | 23 (8.6%) | .047 | | 2010 | 10 (4.2%) | 20 (7.5%) | | | 2011 | 13 (5.4%) | 8 (3.0%) | | | 2012 | 17 (7.1%) | 11 (4.1%) | | | 2013 | 10 (4.2%) | 19 (7.1%) | | | 2014 | 12 (5.0%) | 14 (5.2%) | | | 2015 | 8 (3.3%) | 16 (6.0%) | | | 2016 | 19 (7.9%) | 24 (9.0%) | | | 2017 | 22 (9.1%) | 17 (6.3%) | | | 2018 | 22 (9.1%) | 19 (7.1%) | | | 2019 | 14 (5.8%) | 13 (4.9%) | | | 2020 | 16 (6.6%) | 17 (6.3%) | | | 2021 | 21 (8.7%) | 13 (4.9%) | | | 2022 | 14 (5.8%) | 16 (6.0%) | | | 2023 | 20 (8.3%) | 21 (7.8%) | | | 2024 | 18 (7.5%) | 17 (6.3%) | | | ASA class | ||| | Missing | 2 (0.8%) | 1 (0.4%) | .165 | | 1 | 16 (6.6%) | 22 (8.2%) | | | 2 | 177 (73.4%) | 174 (64.9%) | | | 3 | 46 (19.1%) | 69 (25.8%) | | | 4 | 2 (0.8%) | || | Adnexal surgery | ||| | None | 49 (20.3%) | 61 (22.8%) | <.001 | | One ovary removed | 7 (2.9%) | 31 (11.6%) | | | Salpingectomy | 165 (68.5%) | 117 (43.7%) | | | Salpingo-oophorectomy | 20 (8.3%) | 59 (22.0%) | | | Endometriosis | ||| | None | 216 (89.6%) | 220 (82.1%) | .002 | | Stage I | 13 (5.4%) | 40 (14.9%) | | | Stage II | 0 | 2 (0.8%) | | | Stage III | 1 (0.4%) | 1 (0.4%) | | | Stage IV | 11 (4.6%) | 5 (1.9%) | | | Surgeon training | ||| | General OBGYN | 19 (7.9%) | 108 (40.3%) | <.001 | | Gynecologic Oncology | 7 (2.9%) | 94 (35.1%) | | | MIGS | 206 (85.5%) | 1 (0.4%) | | | Urogynecology | 3 (1.1%) | || | REI | 9 (3.7%) | 62 (23.1%) | | | Hysterectomy subtype | ||| | Total | 162 (67.2%) | 201 (75.0%) | .053 | | Supracervical | 79 (32.8%) | 67 (25.0%) | | | Indication(s) for surgery* | ||| | Pain | 86 (35.7%) | 65 (24.3%) | .005 | | Bleeding | 95 (39.4%) | 84 (31.3%) | .057 | | Fibroids | 236 (97.9%) | 239 (89.2%) | <.001 | | Other | 6 (2.5%) | 40 (14.9%) | <0.001 | Data displayed as mean ± standard deviation or number (%). *Categories are not mutually exclusive. Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; MIGS, minimally invasive gynecologic surgery; REI, reproductive endocrinology and infertility. With regard to perioperative characteristics (Table 1), most laparoscopic surgeries were done by fellowship trained minimally invasive gynecologic surgeons (85.5%), while laparotomies were performed largely by general obstetrician-gynecologists (OBGYNs), gynecologic oncologists, and reproductive endocrinologists (40.3%, 35.1%, and 23.1%, respectively; P < .001). There was a high proportion of supracervical hysterectomy in both groups (32.8% in laparoscopy group vs 25.0% in laparotomy group, P = .053). Indications for hysterectomy were recorded based on the preoperative visit documentation rather than on imaging or postoperative pathology, and multiple indications for surgery could be documented. Patients undergoing laparoscopic hysterectomy were more likely to have a documented indication of pain (35.7% vs 24.3%, P = .005) or fibroids (97.9% vs 89.2%, P < .001). Notably, with the exception of one patient with enlarged adenomyotic uterus without discrete mass, all patients were confirmed to have fibroids on preoperative imaging and/or pathology report. Intraoperative and postoperative outcomes are listed in Table 2. The primary outcome, a composite measure including any complication, reoperation or readmission, was similar between the 2 groups (47 [19.5%] vs 54 [20.2%], P = .855). Mean operative time was 24 minutes longer for laparoscopic surgery, and this difference was statistically significant (188 +/− 72.4 minutes vs 164 +/− 59.3 minutes, P < .001). OR time exceeded 4 hours for 20.8% of laparoscopic hysterectomies, versus 10.1% of abdominal hysterectomies (P = .001). Given subjectivity of EBL and the tendency to estimate round numbers, EBL is presented as median rather than mean. Median EBL was significantly lower for laparoscopy versus laparotomy (100 mL [interquartile range (IQR) 50–300] versus 300 [IQR 150–500], P < .001). Median uterine weight was greater in the laparotomy group (1266 g [1093–1550] vs 1488 g [1226–2001], P < .001), with uterine weight exceeding 2 kg in 25% of the laparotomy group versus 8.7% in the laparoscopy group. The range of uterine weights was 1003–13,170 g in the laparotomy group and 1000–4096 g in the laparoscopy group, with both groups exhibiting right skew. There were fewer intraoperative complications in the laparoscopy group (5.8% vs 10.8%, P = .042). The distribution of complications differed between the 2 groups (P = .010); there were more intraoperative blood transfusions in the laparotomy group (21 [7.8%] vs 7 [2.9%]). In a separate analysis, holding other factors equal, increasing uterine weight was associated with higher EBL (geometric mean EBL 184.5 mL for uterine weight 2000 g, P < .001; Supplemental Table S1).The rate of conversion from laparoscopic to open surgery was 5.8%, with all cases reviewed to confirm conversion for surgical indications rather than for specimen extraction. Table 2. | Laparoscopic (n = 241) | Open (n = 268) | P-Value | | |---|---|---|---| | Any perioperative complication, reoperation, or readmission | 47 (19.5%) | 54 (20.2%) | .855 | | Intraoperative outcomes | ||| | Mean operative time (minutes) | 188 (72.4) | 164 (59.3) | 4 hours | 50 (20.8%) | 27 (10.1%) | .001 | | Median EBL (ml) | 100 (50–300) | 300 (150–500) | <.001 | | Median uterine weight (g) | 1266 (1093–1550) | 1488 (1226–2001) | <.001 | | Uterine weight | ||| | 1000–1500 | 174 (72.2%) | 135 (50.4%) | <.001 | | 1501–2000 | 46 (19.1%) | 66 (24.6%) | | | 2000+ | 21 (8.7%) | 67 (25.0%) | | | Any intraoperative complication | 14 (5.8%) | 29 (10.8%) | .042 | | Intraoperative complications by category | ||| | Bowel injury | 1 (0.4%) | 1 (0.4%) | .010 | | Bladder injury | 6 (2.5%) | 2 (0.7%) | | | Ureteral injury | 0 (0%) | 3 (1.1%) | | | Transfusion or EBL >1L | 7 (2.9%) | 21 (7.8%) | | | Other intraoperative complication | 0 (0%) | 2 (0.7%) | | | Conversion to laparotomy | 14 (5.8%) | NA | NA | | Postoperative outcomes | ||| | Median length of stay (days) | 0 (0–1) | 2 (2–3) | <.001 | | Any postoperative complication | 37 (15.4%) | 33 (12.3%) | .320 | | Postoperative complications by category | ||| | Missing data | 1 (0.4%) | 9 (3.4%) | .002 | | OTC medication | 6 (2.5%) | 9 (3.4%) | | | UTI | 0 (0.0%) | 4 (1.5%) | | | Superficial SSI | 23 (9.5%) | 7 (2.6%) | | | Infection requiring hospitalization | 1 (0.4%) | 4 (1.5%) | | | Infection requiring intervention | 2 (0.8%) | 2 (0.7%) | | | VTE | 2 (0.8%) | 2 (0.7%) | | | Postoperative transfusion | 0 (0.0%) | 1 (0.4%) | | | Reoperation | 3 (1.2%) | 4 (1.5%) | | | Postoperative complications: Clavien-Dindo classification | ||| | Missing data | 1 (0.4%) | 9 (3.4%) | .109 | | None | 203 (84.2%) | 226 (84.3%) | | | 1 | 6 (2.5%) | 9 (3.4%) | | | 2 | 26 (10.8%) | 18 (6.7%) | | | 3a | 2 (0.8%) | 2 (0.7%) | | | 3b | 3 (1.2%) | 4 (1.5%) | | | Readmission within 60 days | 10 (4.2%) | 10 (3.7%) | .808 | | Days to readmission* | 12.4 (10.3) | 7.8 (4.9) | .236 | | Postoperative diagnosis of malignancy | 4 (1.7%) | 5 (1.9%) | 1.00 | Data displayed as mean (+/− standard deviation), median (IQR), or number (%). *Applies to patients with readmission within 60 days only. Abbreviations: EBL, estimated blood loss; OTC, over the counter (not requiring a prescription); SSI, surgical site infection; UTI, urinary tract infection; VTE, venous thromboembolism. Given length of stay was recorded as integers, length of stay is presented as median rather than mean; median length of stay was significantly lower in the laparoscopy group (0 days [IQR 0–1] vs 2 days [IQR 2–3], P < .001). The rate of any postoperative complication was similar between the 2 groups (P = .320). The distribution of postoperative complications by Clavien-Dindo score was likewise similar between the laparoscopy and laparotomy groups (P = .109). However, the specifics of postoperative complications differed between the 2 groups (P = .002), with a greater number of superficial surgical site infections in the laparoscopy group (23 [9.5%] vs 7 [2.9%]). The rate of readmission within 60 days was similar between the 2 groups (P = .808), and for patients who were readmitted, the timing of readmission was similar for those undergoing laparoscopy versus laparotomy (12.4 days postsurgery +/− 10.3 vs 7.8 days postsurgery +/− 4.9, P = .236). Finally, the rate of postoperative diagnosis of malignancy was similar in the laparoscopy and laparotomy groups (1.7% vs 1.9%, P = 1.00). The results of multivariable regression for primary outcome of any complication, readmission or reoperation are summarized in Table 3. Covariates were selected a priori based on literature and perceived clinical importance, and retained in the final model if statistical significance level was 0.35 or lower. After controlling for age, BMI, prior surgery, uterine weight, supracervical versus total hysterectomy, ASA class, endometriosis, and adnexal surgery, the risk of any complication remained similar between the laparoscopy and laparotomy groups (OR 1.09 [0.68–1.77], P = .7119). Table 3. | Variable | Adjusted or (95% CI)* | P-Value | |---|---|---| | Group | || | Laparoscopic (reference) | || | Open | 1.09 [0.68–1.77] | .7119 | | Age | 0.99 [0.95–1.03] | .5683 | | BMI | 1.01 [0.98–1.05] | .5483 | | Prior surgery | || | None (reference) | || | Yes | 1.45 [0.93–2.25] | .0992 | | Uterine weight | || | 1000–1500 g (reference) | || | 1500–2000 g | 1.11 [0.63–1.94] | .7205 | | 2000+g | 1.25 [0.68–2.33] | .4733 | | Subtype | || | Total (reference) | || | Supracervical | 0.62 [0.36–1.07] | .0838 | | ASA class | || | 1 (reference) | || | 2 | 1.13 [0.45–2.86] | .7946 | | 3+ | 1.35 [0.47–3.84] | .5745 | | Endometriosis | || | Absent (reference) | || | Present | 1.38 [0.76–2.53] | .2944 | | Adnexal surgery | || | None (reference) | || | One ovary removed | 0.5 [0.18–1.34] | .1683 | | Salpingectomy | 0.83 [0.46–1.49] | .5273 | | Salpingo-oophorectomy | 0.42 [0.17–1.03] | .0572 | *Adjusted for all other factors within model: age, BMI, prior surgery, subtype, uterine weight, ASA class, adnexal surgery, endometriosis and group. **Covariates were selected a priori based on previous literature, availability of data, and perceived clinical importance. These factors were entered into the model in a stepwise fashion and retained in the final model if their statistical significance level was 0.35 or lower.

Minimally invasive surgery offers numerous benefits including shorter hospitalization, rapid return to baseline level of function, and decreased blood loss.2,3 Our study demonstrates that even for patients with very large uteri, laparoscopic hysterectomy is feasible. In our dataset, laparoscopic hysterectomy was associated with a similar risk of overall complications, a lower rate of intraoperative complications, a similar rate of postoperative complications, lower EBL, and shorter hospitalizations. The rate of conversion to open surgery was low at 5.8%. BMI was slightly higher in the laparoscopy group, but was not associated with differences in complication rate on multivariable regression. The rate of adnexal surgery differed between the 2 groups, with more patients in the laparotomy group undergoing salpingo-oophorectomy; this may be reflective of difference in practice based on surgeon training, with gynecologic oncologists being more likely to remove ovaries. In multivariable logistic regression, adnexal surgery was not associated with differences in rate of complication, readmission or reoperation. Laparoscopy was associated with a statistically significant increase in operating time. This is consistent with the results of a prior analysis by Uccella et al (2018), who reported a 35-minute difference in median operative time between laparoscopic and open hysterectomy.14 The noted increase of 24 minutes in mean operative time in our study may be due to the increased difficulty of laparoscopic surgery with an enlarged uterus, or may represent the time needed to extract the specimen in a minimally invasive fashion. Increased operative time has been associated with an increased risk of venous thromboembolism (VTE), with Moulder et al finding a 35% increase in the odds of VTE for every 60-minute increase in operative time. Notably, when stratified by surgical approach, this increase in risk of VTE was greatest amongst patients undergoing abdominal hysterectomy compared with laparoscopic hysterectomy.16 In our dataset, there was no increase in the rate of VTE or in the risk of overall postoperative complications associated with laparoscopic hysterectomy, suggesting any complications associated with the increased time required for laparoscopy and specimen extraction may have been balanced by the overall decrease in complications associated with a minimally invasive approach. Our data suggest a somewhat higher rate of superficial surgical site infection in patients undergoing laparoscopic rather than abdominal hysterectomy, which is unexpected given the existing literature indicates that the rate of incisional complications is lower with laparoscopic hysterectomy.2 While this finding bears further investigation, it is possible that it may be reflective of differing provider thresholds for treatment for superficial surgical site infection. While prior work by Kondo et al (2011), Uccella et al (2018), and Louie et al (2018) demonstrated a reduction in overall complications for patients with large uteri undergoing laparoscopic versus abdominal hysterectomy, our data suggest no difference in overall complications. It is possible our available number of cases was not sufficient to detect a difference, or that other unmeasured patient factors influenced the rates of complication in our study. We did note a decreased risk of intraoperative complications, and similarly to Uccella et al (2018) and Louie et al (2018), found that laparoscopy was associated with decreased EBL and decreased length of hospitalization.3,14 Notably, the rate of supracervical hysterectomy in this study was high, at 32.8% in the laparoscopy group and 25.0% in the laparotomy group. At our institution, patients are offered the choice of cervical retention or removal after counseling regarding the advantages and disadvantages of each approach. A 2012 Cochrane review, and ACOG’s 2017 update to the relevant Committee Opinion, suggest there is no clinical benefit to retaining the cervix at the time of hysterectomy for benign disease.4,17 The vast majority of the supracervical hysterectomies in our dataset were performed prior to 2019, suggesting practice and counseling have evolved along with the evidence. Multiple studies have demonstrated racial disparities in access to minimally invasive hysterectomy.18–23 Disparities often persist despite controlling for fibroid burden.24 While the proportion of Black patients in the laparoscopy and laparotomy groups was similar in our study, our results also demonstrate that Black patients remain at elevated risk of having significant fibroid burden and very large uteri at the time of hysterectomy as compared to other groups: over 30% of patients in our study identified as Black, as compared to 13.7% in the general United States population.25 Previous work has found uterine weight to be a frequently cited contributor to disparities in access to minimally invasive hysterectomy.26 Our study underscores that disparities in access to minimally invasive hysterectomy may be reduced by offering laparoscopy equitably to all groups, regardless of uterine size. The strengths of our study include relatively large number of cases as compared to previously published work; controlling for multiple confounders including BMI, prior surgery, ASA class, adnexal surgery and the presence of endometriosis; and thorough documentation of intraoperative and postoperative complications. However, this is a single-institution study performed at an academic medical center housing multiple OBGYN surgical subspecialty divisions, which may limit generalizability to other settings. Although we controlled for surgeon subspecialty, which may serve as a proxy for operative volume and surgical training, we did not classify individual surgeons according to their operative volume. Undergoing surgery with a high- versus low-volume provider may impact the risk of complications and choice of surgical route. The retrospective nature of our study also introduces the potential for misclassification and reliance on incomplete or erroneous clinical documentation. The estimation of blood loss is generally performed by surgeons with some degree of subjectivity. Finally, our study cannot fully account for patient selection bias, including underlying differences in patients who are booked for laparoscopic surgery versus laparotomy: patients who are booked for laparotomy may have contraindications to Trendelenburg position or intraabdominal insufflation which are not fully captured in these data. Likewise, patients who seek out minimally invasive surgery with a specialist may differ in insurance status and educational background from patients who do not. Our study underscores the utility of postresidency training in minimally invasive surgical techniques; in our study, most laparoscopic hysterectomies for uteri >1 kg were performed by MIGS-trained surgeons, with laparoscopic hysterectomy performed successfully for uteri weighing up to 4096 g. While not all providers have the expertise to comfortably perform laparoscopic hysterectomy for very large uteri, patients should be counseled that they have the option for referral to providers who do have this capability—and should be assisted in surmounting any barriers to accessing this specialized care.

Our results suggest that laparoscopic hysterectomy is feasible even for patients with uterine weight exceeding 1 kg. As compared to laparotomy, the laparoscopic approach is associated with similar overall complications, reduced blood loss, and a reduction in length of stay despite somewhat longer mean operating time. Our data suggest that no patient should be denied candidacy for minimally invasive surgery on the basis of uterine size over 1 kg alone. Supplemental Table S1. | Uterine Weight ≤1500 g | Uterine Weight 1501–2000 g | Uterine Weight >2000 g | P-Value | | |---|---|---|---|---| | Geometric mean estimated blood loss* (mL) (95% CI) | 184.5 (152.3–223.5) | 228.7 (180.5–289.8) | 294.8 (225.2–386.0) | <.001 | *Adjusted for age, BMI, prior surgery, subtype, ASA class, adnexal surgery, endometriosis and group. Footnotes

We would like to express our gratitude to Ms. Xiangmei Gu, MSc, for her invaluable contribution to the statistical analysis in this manuscript. This study was presented as an abstract at the SGS 50th Annual Scientific Meeting, Orlando, FL, March 24–27, 2024. Conflict of interests: none. Disclosure: none. Funding sources: none. IRB approval: This study was deemed exempt by the Mass General Brigham Institutional Review Board (Protocol 2021P001003). Data availability statement: Data will be made available from the authors on request upon approval from IRB. Contributor Information Alison C. Fitzgerald, Brigham and Women’s Hospital, Boston, Massachusetts, USA. (Drs. Fitzgerald, Maghsoudlou, King, Einarsson, and Ajao). Parmida Maghsoudlou, Brigham and Women’s Hospital, Boston, Massachusetts, USA. (Drs. Fitzgerald, Maghsoudlou, King, Einarsson, and Ajao). Shabnam Gupta, Arizona Gynecology Consultants, Phoenix, Arizona, USA. (Dr. Gupta). Louise P. King, Brigham and Women’s Hospital, Boston, Massachusetts, USA. (Drs. Fitzgerald, Maghsoudlou, King, Einarsson, and Ajao). Jon I. Einarsson, Brigham and Women’s Hospital, Boston, Massachusetts, USA. (Drs. Fitzgerald, Maghsoudlou, King, Einarsson, and Ajao). Mobolaji O. Ajao, Brigham and Women’s Hospital, Boston, Massachusetts, USA. (Drs. Fitzgerald, Maghsoudlou, King, Einarsson, and Ajao).

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