Closing the Gap: A Decade of Integrating Minimally Invasive Hysterectomy in an Urban Safety-Net Hospital

STUDY OBJECTIVE: To evaluate how the 10-year integration of minimally invasive hysterectomy (MIH) at a safety net hospital impacted surgical approach, perioperative outcomes, and equity of MIH access across racial groups in an underserved patient population. DESIGN: Observational - Retrospective chart review. SETTING: A single, university-affiliated urban safety-net hospital. The institution serves as a primary teaching site for the one of the largest Obstetrics and Gynecology residency programs in the country and provides care to a predominantly underinsured patient population. PATIENTS OR PARTICIPANTS: 3,004 patients undergoing hysterectomy for benign indications between 2010-2020. INTERVENTIONS: Implementation of minimally invasive surgical practices as well as the establishment of a Complex Benign Gynecology fellowship program at an urban safety-net hospital. MEASUREMENTS AND PRIMARY RESULTS: Over the 10-year implementation period, the proportion of laparoscopic hysterectomies increased from 9% to 46% (p<0.05), while abdominal hysterectomies decreased from 68% to 27% (p<0.05). In this time, the proportion of perioperative complications (Clavien-Dindo grades 1 and 2) decreased from 45.4% in 2010 to 26.8% in 2020 (p<0.05). Grade 3 and 4 complications were consistently rare (< 3%). Operating times did not significantly change over time; however, the median blood loss per surgery decreased from 300 to 200 mL and the median hospital stay was reduced by 50%, from 61 to 30 hours (p<.001). The transition to MIH was associated with significantly increased diagnoses of adenomyosis and endometriosis (p < 0.001). CONCLUSION: The systematic implementation of MIH in a safety-net setting is feasible and effective, associated with a decrease in complication rates and hospital stays. The shift to minimally invasive techniques additionally improved the often delayed diagnosis of endometriosis and adenomyosis, which are often associated with significant diagnostic delays. These findings demonstrate that increased access to minimally invasive surgery is essential to quality care in safety net populations.