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VIEWPOINT
Implementing an
Outpatient Laparoscopic Hysterectomy Program:
8 Steps Toward Success
Richard Rosenfield, MD
Laparoscopic hysterectomy can be performed
in a completely outpatient environment with discharge home within
4 hours of surgical completion. There is no need for an expensive
robot, overnight stay, or a hospital environment. This approach can
yield profound cost savings and enormous patient satisfaction.
The merits of laparoscopic hysterectomy over abdominal hysterectomy
have been described widely in literature, including improved quality
of life postoperatively. Despite evidence validating the safety and
shortened recovery of minimally invasive surgery, fewer than 40% of
women are aware of minimally invasive options as alternatives to traditional
hysterectomy.
Ambulatory surgery centers (ASCs) are continually required to validate
safety in order for specific surgeries to be deemed appropriate for
outpatient management by the Centers for Medicare and Medicaid Services
(CMS). Hospitals do not respond amicably to the potential loss of revenue,
and proposed legislation can create blockades in the name of patient
safety, when the real issues at hand are economic consideration. As
surgeons, we need to be the stewards of patient safety, and our data
will pave the way to cost-effective transition.
More than 500 laparoscopic hysterectomies have been performed at our
freestanding ASC since October 2005 (patient statistics: age range,
19 to 64; BMI, 18.7 to 48.6; uterine mass, 70 to 2,000 g; operative
time, 36 to 269 minutes; no conversions to laparotomy). All but 2 patients
were sent home within 4 to 6 hours postoperatively. One was transferred
to a local hospital for a nonsurgical anesthesia-related pulmonary
issue that occurred postoperatively and spontaneously resolved, and
a second patient was sent for observation after a large bowel injury
and repair. Our complication rate has remained below 1%, and infection
rates are less than 0.5%. Although we have been fortunate to avoid
conversions to laparotomy and emergent hospital transfer, we are fully
prepared for either eventuality if the need arises.
The fixed cost of performing a laparoscopic hysterectomy exceeds the
fixed cost of the traditional abdominal or vaginal hysterectomy, secondary
to the cost of disposable equipment utilized in the surgery (of course,
this assumes that the start-up cost of the laparotomy equipment has
been paid off over a prolonged amortization). When comparing venue,
the ASC has a very different mechanism of billing when compared to
the hospital. Health care economics are complex, and a review of the
mechanism of hospital billing would be a lengthy article of its own.
There is tremendous dissonance between cost of surgery and billed charges
to patients and payors. The variable costs of surgery include institutional
overhead such heating and cooling, maintenance, leases, tenant improvements,
etc—billed charges from large institutions are not based on simple
calculations of fixed costs of equipment and medication but are calculated
from complex actuarial formulas. The result is variable data on true
costs of surgery. On the contrary, CMS has calculated facility reimbursement
for ASCs based on fixed cost of the surgery alone, with no consideration
for these variable costs, making the reimbursements significantly lower
than those relinquished to large institutions.
Clearly, overnight hospitalization adds significant health care costs
when compared with same-day discharge home. Additional considerations
when exploring cost efficiency include extended time off work, lost
wages, cost to employers, and the cost of management of complications,
including infection rates and delayed wound healing with laparotomy.
The following 8 steps may help facilitate
transition to outpatient hysterectomy:
1. Proceed slowly.
Start with a small uterus in an average-sized patient. Review laparoscopic
anatomy. Recruit someone to precept you through your first several
cases. Find a colleague or partner to work with on a regular basis.
2. Begin at the beginning.
Successful outpatient surgery begins with the office consultation.
Your initial discussion about surgical options with the patient sets
a positive tone for the entire patient experience.
3. Happy preop patients become happy postop patients.
In the preoperative holding area, keep patients warm and calm. Bair
Paws® gowns are a great addition for both preoperative and postoperative
comfort. In the operating room, we add simple creature comforts like
a prewarmed surgical table, dimmed lighting, and a genre of music that
the patient prefers. Our staff members introduce themselves and explain
their roles to the patient.
4. Select your tools and techniques carefully.
There are many techniques available for laparoscopic hysterectomy.
I recommend observing and trying several approaches to find the one
that best suits you. In our series, we have maintained a relatively
consistent surgical technique. We typically use 5 trocars for access,
with primary laparoscope access through the umbilicus and 2 assist
ports on each side.
We have abandoned the suprapubic port, as it is less ergonomic and
provides no strategic advantage for surgical completion of a laparoscopic
hysterectomy. While many surgeons promote a technique with fewer access
ports into the pelvis, we encourage surgeons to consistently operate
with 2 hands, as done in open cases. This will prepare the surgeon
for more complex cases requiring extensive retroperitoneal dissection,
lysis of adhesions, or suturing. Morcellation is performed transumbilically.
We use a Skytron 6500 operating table, with its steep Trendelenberg
and ability to drop to a low position, optimal for advanced laparoscopy.
Unlike robotics, using “straight-stick” laparoscopy allows
the surgeon to use the table as an additional tool for visualization.
5. Surround yourself with competence, and minimize risk.
Operating rooms respond well to a team concept, especially when roles
are defined. Consider the opportunity to observe another surgeon and
note efficiencies or inefficiencies, position of the equipment, and
nuances of technique. Arrange for a proctor if possible. A skilled
scrub technologist and first assistant can dramatically improve your
surgical environment.
6. Become friends with your anesthesia team.
How many times have you heard the anesthesia provider referred to as “Anesthesia” during
a case?
Learning a few names can serve you well as you try to impose the following
recommendations on your anesthesia team.
- Use local anesthetic at trocar sites.
- Avoid
use of long-acting narcotics. Such medications lead to somnolence
and can potentiate urinary retention.
- Aggressively hydrate your patients.
- Preemptively attack pain
and nausea. We prefer a combination of metoclopramide, ondansetron,
ketorolac, and dexamethasone in all patients. Scopolamine (transdermal
patch) is used in patients with a proven history of postoperative
nausea or motion sickness.
7. Practice the art of early discharge.
Discharging your patient home starts with motivation to leave the facility.
While tired from anesthesia, most patients have minimal pain. Remove
the Foley catheter in the operating room, encouraging early ambulation
and voiding. It is imperative to avoid transfer to a postoperative
overnight floor in the hospital, as this typically adds several hours
to a patient’s stay and “floor nurses” are accustomed
to overnight hospitalization in hysterectomy patients. Assuring the
patient, family, and nursing staff that you are available will help
alleviate concerns with early discharge home. Follow up with a nurse
phone call within 24 hours of surgery as a measure of quality and safety
control.
8. Track your data.
Proof of success will reside in your data. Quality assurance protocols
and patient satisfaction surveys can be used to quickly build a resource
for you to enhance your ability to assure patients, your colleagues,
outpatient surgery facilities, and payors that outpatient hysterectomy
is not only feasible but also provides the patient with a safe, painless,
and cost-effective option when compared with traditional hysterectomy.
In a time of uncertain health care reform and reimbursements, a transition
to outpatient hysterectomy might be just what the doctor ordered!
The author reports he is surgical preceptor for Olympus America Inc
and Ethicon, Inc and cofounder and Chief Medical Officer of SURGiVIEW.com.
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Richard Rosenfield, MD, is Executive Medical
Director and Director of Gynecology, Pearl Women’s Center, Portland, OR.
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