Blog

Pedro T Ramirez, Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, Houston, TX

One of the major advantages of laparoscopic surgery is that patients are able to undergo major surgery while at the same time return to normal daily activities much sooner when compared to open surgery. Although there is a higher cost of the instrumentation and technology used in laparoscopic surgery, this cost is counterbalanced by the fact that patients are discharged earlier. However, there are a number of patients that even after laparoscopy will stay in the hospital the same amount of time that they would have if having the surgery through laparotomy. This deviation from the norm of minimally invasive surgery can certainly increase cost at multiple levels. Given this dilemma, it would be ideal for surgeons to determine preoperatively which patients are at an increased risk of staying longer in the hospital despite undergoing minimally invasive surgery.

We recently completed a retrospective study (1) evaluating perioperative risk factors for prolonged hospitalization after gynecologic laparoscopic surgery. In that study, we included a total of 807 patients who underwent laparoscopic surgery for either benign (57%) or malignant disease (43%). In our analysis, we found that 78 (9.7%) patients had prolonged hospitalization defined as a hospital stay >48 hours after surgery. We noted that the predictors of prolonged hospitalization were age >54 years, blood loss >120 mL, intraoperative or postoperative blood transfusion, and postoperative complications. We then developed a clinical scoring system that was used to estimate the probability of prolonged hospitalization.

Interestingly and unexpectedly, we found that medical history, surgical history, body mass index, or social factors, such as ethnicity or smoking, were not associated with a prolonged hospitalization.

Our study identified risk factors that are associated with surgery or the postoperative period rather than preoperative factors. One might ask then, how do our findings translate into tangible information that will help surgeons with clinical decision-making? We believe that by recognizing these risk factors and by using a clinical scoring system, surgeons may be able to predict the risk associated with a prolonged hospitalization despite undergoing a minimally invasive surgery. This is important as it may help surgeons strategize on the surgical approach and also on the postoperative management.

As an example, if a surgeon is debating whether to perform the procedure open to minimize time under anesthesia or in order to decrease complexity of the procedure and through a clinical scoring evaluation indications suggest that the patient will stay longer despite a minimally invasive approach, then such surgeon may be more inclined to do the case open. Another potential benefit of the clinical scoring system, as proposed by our group is that by estimating a prolonged hospitalization, surgeons may be more likely to prescribe anticoagulation prophylaxis to prevent deep venous thromboembolism or more aggressive incentive spirometry to prevent atelectasis.

In summary, not all patients who undergo laparoscopic surgery for gynecologic indications will gain the benefit of the minimally invasive approach by a faster hospital discharge. We must continue to strive to identify factors that may help us predict postoperative outcomes in minimally invasive surgery. Future studies should aim to validate clinical scoring systems and outcomes algorithms in order to provide better patient care and counseling.

Also, this study has shown us the importance of striving to achieve “blood-less” surgery. Next week’s blog will focus on a little known strategy to decrease intraoperative blood loss.

1. Zand B, Frumovitz M, Jofre MF, Nick AM, Dos Reis R, Munsell MF, Sangi-Haghpeykar H, Levenback C, Soliman PT, Schmeler KM, Ramirez PT. Risk factors for prolonged hospitalization after gynecologic laparoscopic surgery. Gynecol Oncol. 2012 Sep;126(3):428-31.