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Reduced Complications Following Implementation of Laparoscopic Hysterectomy: A Danish Population-based Cohort Study
Annette Settnes1, Märta Fink Topsoee1, Charlotte Moeller1
1Department of Gynecology and Obstetrics, North Zealand University Hospital, Hilleroed (Drs. Settnes, Topsoee, and Norrbom); Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus (Drs. Moeller and Dueholm); The Danish Clinical Registries (RKKP), Frederiksberg Hospital, Frederiksberg (Drs. Kopp and Froeslev); Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Copenhagen (Drs. Rasmussen and Dreisler); Department of Gynecology and Obstetrics, Aalborg University Hospital, Aalborg (Dr. Joergensen); Department of Gynecology and Obstetrics, Zealand University Hospital, Roskilde (Dr. Gimbel), Denmark.
Study Objective:
To monitor and report nationwide changes in the rates of and complications after different methods for benign hysterectomy, operative hysteroscopy, myomectomy, and embolization in Denmark. To report the national mortality after benign hysterectomy DESIGN: National prospective, observational cohort study.
Setting:
The Danish Hysterectomy and Hysteroscopy Database.
Patients:
Women undergoing surgery for benign gynecologic diseases: 64 818 hysterectomies, 84 175 hysteroscopies, 4016 myomectomies, and 1209 embolizations in Denmark between 2004 and 2018.
Interventions:
National meetings with representatives from all departments, annual working reports of institutional complication rates, workshops, and national guideline initiative to improve minimally invasive surgical methods.
Measurements And Main Results:
Rates of the different methods and complications after each method with follow-up to 5 years as recorded by the database directly in the National Patient Registry. Nationwide, a decline in the use of hysterectomy, myomectomy, embolizations, and endometrial ablation. The total short-term complications were 9.8%, 7.5%, 8.9%, and 2.7% respectively, however, with a persistent risk of approximately 20% for recurrent operations within 5 years after endometrial ablation. Initially, we urged for increased use of vaginal hysterectomy, but only reached 36%. From 2010, we urged for reducing abdominal hysterectomies by implementing laparoscopic hysterectomy and reached 72% laparoscopic and robotic procedures. Since 2015, we used coring or contained morcellation for removal of large uterus at laparoscopic hysterectomy. The major and minor complication rates (modified Clavien-Dindo classification) were reduced significantly from 8.1% to 4.1% and 9.9% to 5.7% respectively. Mortality after benign hysterectomy was 0.27‰. The odds ratio for major complications after abdominal hysterectomy was 1.66 (1.52-1.81) compared to minimally invasive hysterectomy independent of the length of stay, high-volume departments, indications, comorbidity, age, and calendar year.
Conclusion:
Fifteen years with a national database has resulted in a marked quality improvement. Denmark has 85% minimally invasive hysterectomies and has reduced the number of major complications by 50%.
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