Postoperative complications after abdominal, laparoscopic, and vaginal hysterectomy for uteri weighing 250 grams or less

Background: The objective of this study is to assess if route of hysterectomy impacts 30-day postoperative complications in patients with uterus weighing 250 grams or less for benign indications. Methods: This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2018. Women who underwent hysterectomy for benign disease with uterus weight 250 grams or less were selected. Patients were stratified into three groups: abdominal hysterectomy (AH; via laparotomy), laparoscopic hysterectomy (LH; either conventional or robotic-assisted laparoscopy), and vaginal hysterectomy (VH; vaginal approach without laparotomy or laparoscopy). The primary outcomes were the rates of composite 30-day postoperative complications for each group. We compared patient demographics, clinical, and surgical characteristics using ANOVA for continuous variables, Kruskal Wallis for nonparametric variables, and chi-square for categorical variables across all three groups. We then used multivariate regression to identify independent factors associated with increased 30-day postoperative complications in this total cohort. Results: From 2014 to 2018, a total of 38,429 cases were identified. There were 5,585 (14.5%) AH, 27,196 (70.8%) LH, and 5,648 (14.7%) VH. LH and AH had similar operative time [113 minutes (IQR, 85-150 minutes) and 111 (IQR, 83-154 minutes), respectively, P=0.870) while VH has the shortest when compared to LH (96 minutes (IQR, 68-137 minutes), P<0.001]. AH had the most composite complications when compared to LH and VH (10.1% versus 5.3% and 6.4%, respectively, P<0.001). After multivariable logistic regression, black race (aOR 1.13, 95% CI: 1.01-1.26), ASA class 2 (aOR 1.25, 95% CI: 1.06-1.49), ASA class 3 (aOR 1.79, 95% CI: 1.48-2.17), smoker (aOR 1.20, 95% CI: 1.08-1.33), vaginal hysterectomy (aOR 1.38, 95% CI: 1.22-1.55), abdominal hysterectomy (aOR 1.96, 95% CI: 1.771-2.18), and uterine weight 201-250 g (aOR 1.35, 95% CI: 1.09-1.68) were associated with increased odds of 30-day postoperative complications. Conclusions: In a modern cohort of women undergoing hysterectomies for benign indications, laparoscopic hysterectomy has lower rates of complications than vaginal hysterectomy for uteri weighing 250 grams or less. This finding challenges the older analyses and confers laparoscopic hysterectomy with lower odds of 30-day postoperative complications.