Outcomes of Minimally Invasive Hysterectomy With Exit Incision for Specimen Extraction Versus Abdominal Hysterectomy for Enlarged Uteri

INTRODUCTION: The benefits of a minimally invasive hysterectomy (MIH) over abdominal hysterectomy (AH) have consistently shown fewer perioperative complications, lower hospital length of stays, and decreased blood loss. However, with enlarged uteri, an open technique may be preferred due to perceived case difficulty or to avoid uterine morcellation in cases of possible malignancy. Alternatively, an exit abdominal incision, or mini-laparotomy can be created to allow for specimen extraction. We hypothesized that an exit incision with or without morcellation for specimen removal at time of minimally invasive hysterectomy may confer an even greater benefit as compared to an exclusively abdominal approach. OBJECTIVE: To compare the surgical outcomes of minimally invasive hysterectomy with exit specimen extraction to abdominal hysterectomy. METHODS: This was a retrospective cohort study of 960 patients undergoing hysterectomy for benign indications at a single academic institution between January 2017 and December 2023. 753 patients underwent abdominal hysterectomy (AH) and 207 patients underwent minimally invasive hysterectomy (MIH) by laparoscopic or robotic-assisted approach requiring exit incision for specimen extraction with or without morcellation. The primary outcome was a composite rate of both medical and surgical adverse events within 90 days of surgery. Secondary outcomes included operative times (incision time to closing time in minutes), estimated blood loss (mL), hospital length of stay (same-day discharge as 0 days). Outcomes were adjusted for uterine weight (g) when applicable. RESULTS: Demographic and preoperative surgical risk factors were similar between groups except for older age (54.0 years versus 49.9 years, p<0.01) and higher proportion of self-identified White patients (69.2% versus 57.8%, p<0.05) in the abdominal hysterectomy group (Table 1). Patients undergoing AH had a significantly higher proportion of adverse outcomes within 90 days of surgery (15.3% versus 4.8%, p<0.01), maintaining significance when adjusted for uterine weight (Table 2). Longer mean operative times (210 minutes versus 188 minutes, p=0.02), higher estimated blood loss (430 mL versus 270 mL, p=0.01), and increased hospital length of stay (3.9 nights versus 1.3 nights, p<0.01) were seen in the AH group versus MIH with extraction with no differences when adjusted for uterine weight. CONCLUSIONS: Our results support improved perioperative and postoperative outcomes for patients undergoing minimally invasive hysterectomy with exit incision, with or without morcellation for specimen retrieval compared to those undergoing AH. Use of an extraction site for enlarged uteri does not appear to mitigate the improved safety profiles of minimally invasive approaches over open techniques and should be preferentially considered in surgical planning for patients with enlarged uteri.Table 1Table 2