at least 430,000 hysterectomies are performed each year in the united states , and more than 80% are for treatment of benign diseases , such as leiomyoma , abnormal uterine bleeding , pelvic organ prolapse , and endometriosis . hysterectomy is the second most common surgery undergone by women and accounts for $ 5 billion dollars annually in u.s . the first laparoscopic hysterectomy was described in 1989 ; however , by 2003 , only about 11% of the nation 's hysterectomies were performed laparoscopically . by 2010 , this number had increased only somewhat , to 20% to 30% . despite consensus statements by both the american association of gynecologic laparoscopists ( aagl ) and the american congress of obstetricians and gynecologists ( acog ) stating that minimally invasive hysterectomy should be the standard of care , more than 50% of hysterectomies for benign indications are still open procedures . from 2003 through 2010 food and drug administration approval of robotic technology for hysterectomy in 2005 brought with it the promise of increased ease of minimally invasive hysterectomy : 3-dimensional optics , wristlike motion with robotic instruments , and shorter learning curves than traditional laparoscopy . despite this new technology , for example in one study at an academic teaching hospital with robotic technology , the percentage of hysterectomies performed with robotic assistance increased from 2.5% to 24.8% between 2007 and 2009 , but despite marketing campaigns in favor of this minimally invasive technique , the rate of open procedures remained virtually unchanged at approximately 45% . the advantages of minimally invasive hysterectomy are well - documented : shorter hospitalization , faster recovery , more rapid return to normal activities , and fewer postoperative infections . a meta - analysis comparing total laparoscopic hysterectomy ( tlh ) with total abdominal hysterectomy ( tah ) showed a reduction in morbidity  specifically , fewer perioperative complications ( pooled odds ratio , 0.31 ) , lower estimated blood loss ( 180 ml ) , and shorter hospital stay . slow adoption of minimally invasive hysterectomy among practicing obstetrician - gynecologists ( ob / gyns ) , specifically conventional  straight - stick  laparoscopic hysterectomy , has been attributed to long learning curves and insufficient laparoscopic training in ob / gyn residencies . notably , a survey of ob / gyn physicians showed that surgeons would prefer the laparoscopic or vaginal route for hysterectomy for themselves ( 40% ) or their spouses ( 55% ) . despite this result , the surveyed group cited limited training , technical difficulty , lack of personal surgical experience , and long operating times as substantial barriers to performing minimally invasive hysterectomy . similarly , the general public 's awareness of laparoscopic hysterectomy has been slow to develop ; however , with the well - documented advantages of this technique , the demand is now increasing rapidly , just as it did for laparoscopic cholecystectomy in the early 1990s . hysterectomy via a laparoscopic approach can be performed safely as an outpatient surgery , as shown in a feasibility study by morrison and jacobs more than 10 years ago . a more recent study comparing outcomes of outpatient ( 40% ) laparoscopic hysterectomies to inpatient ( 60% ) procedures demonstrated significantly fewer 30-day complications in the outpatient group than in the inpatient group ( 4.5% vs. 7.2% ; p < .001 ) . nationwide , from 2006 through 2010 , rates of outpatient hysterectomy have increased from 17.5% to greater than 44% . moreover , same - day discharge protocols have been repeatedly shown to be well - tolerated and safe , with high rates of patient satisfaction . given excellent clinical outcomes and high rates of patient satisfaction , we expected public demand to increase at our community hospital . to accommodate this increase , an informal mentorship program was started by the division of minimally invasive gynecologic surgery ( migs ) to expand the surgical skills of community ob / gyn generalists and increase our rates of laparoscopic hysterectomy without the assistance of robotic technology . the primary objective of this retrospective review is to document the trends in techniques for hysterectomy performed during 8 years for benign indications in a community teaching hospital without robotic technology . all women more than 18 years of age who underwent hysterectomy for benign indications at newton - wellesley hospital ( nwh ) from january 1 , 2004 , through december 31 , 2012 , were included in this retrospective observational study . the patients were identified by international classification of diseases , ninth revision ( icd-9 ) procedure codes in operating room records , and data were collected , including patient age , date of surgery , date of hospital discharge , surgeon , preprocedure icd-9 diagnostic code , and current procedural terminology ( cpt)/icd-9 codes . laparoscopic hysterectomy included both total laparoscopic hysterectomy ( tlh ) and laparoscopic supracervical hysterectomy ( lsh ) . vaginal hysterectomy included both total vaginal hysterectomy ( tvh ) and laparoscopy - assisted vaginal hysterectomy ( lavh ) . preprocedure diagnoses of malignancy were excluded ; however , postprocedure diagnoses of malignancy were included in the analysis . secondary outcomes , including length of stay and factors associated with the need for an open procedure , were investigated . an outpatient was defined as having a length of stay of 0 days ( ie , date of admission and date of discharge were the same ) . nwh is a 313-bed academic community hospital and a member of the partners healthcare network . at nwh , our gynecology department includes 42 community - based generalist ob / gyns and , starting in 2002 , a gynecology division devoted to migs . the migs department expanded from 1 full - time surgeon to 2 full - time surgeons in 2005 , with the goals of making nwh a referral center for challenging gynecologic laparoscopy and hysteroscopy cases and of expanding the surgical skills of interested generalist ob / gyn physicians at the hospital . in 2004 , at nwh , only 24 ( 8% ) of the 292 hysterectomies performed for benign indications were laparoscopies . this number increased to more than 50% ( 189/365 ) by 2008 , and , in 2012 , 72% ( 316/439 ) of benign - indication hysterectomies were performed by laparoscopy . more than 93% ( 411/439 ) of all hysterectomies by 2012 were minimally invasive , including tlh , lsh , tvh , and lavh . the number of lavhs and tvhs combined did not change significantly from 2004 through 2012 , with an average of 98 tvhs+lavhs performed annually , accounting for 22% to 33% of the volume of hysterectomies . there was , however , a transient downward trend during 2007 and 2008 , with only 64 and 68 vaginal procedures performed in those years , respectively ( figure 1 ) . from 2004 through 2012 , the annual number of total hysterectomies performed for benign indications at nwh gradually increased from 292 to 439 . the rate of open hysterectomy declined by year while the rate of laparoscopic hysterectomy increased and vaginal hysterectomy ( lavh+tvh ) remained relatively constant at newton - wellesley hospital . the average age of patients who underwent hysterectomy was 41.3 years . the most frequent icd-9 preprocedure diagnostic codes were leiomyoma , uterine endometriosis , and excessive menstruation or menstrual disorder not otherwise specified . factors associated with open hysterectomy in 2011 and 2012 included intraoperative suspicion of malignancy , large fibroid uterus ( greater than at 18 weeks ' gestation ) , extensive intra - abdominal adhesions due to endometriosis , or a history of prior surgeries , the most common being cesarean delivery . by 2011 , the surgeon 's preference or lack of expertise was rarely cited as a factor leading to an open procedure . in 2004 , only 2 of 194 laparoscopic hysterectomies were performed on an outpatient basis . by 2010 , 60% ( 163/269 ) were outpatient , and by 2012 , the frequency grew to more than 85% ( 293/344 ; figure 2 ) . increasing rate of outpatient laparoscopic hysterectomy compared to declining inpatient laparoscopic hysterectomy by year at newton - wellesley hospital . this retrospective observational study clearly demonstrates the ability of a large diverse gynecologic surgery department to transform its surgical practice from primarily open hysterectomies to a majority ( 72% ) performed via a traditional laparoscopic route and a large majority ( 93% ) via a minimally invasive technique ( tlh , lsh , tvh , lavh ) in less than 8 years . this rate of laparoscopic hysterectomy is far higher than rates reported in the current literature . the study results show a drastic increase in the adoption of laparoscopic hysterectomy in our community hospital , even without the use of robotic technology . the implementation of a robust migs department should be given credit for the transformation to a greater than 72% laparoscopic hysterectomy rate at nwh . the migs department was started in 2002 and expanded in scope in 2004 , with the additional of an aagl migs fellowship program . the migs expert laparoscopic surgeons have mentored interested generalist gynecologic surgeons in an effort to improve the latter 's laparoscopic surgical skills . this voluntary mentorship program has allowed interested generalist ob / gyns who were inadequately trained or needed further experience in performing laparoscopic procedures to gain confidence and hone their skills . one or 2 generalists from each private practice group at nwh chose to participate in the informal mentorship program . after these surgeons felt confident in their skills , they began to schedule surgeries with members of their own groups acting as surgical assistants . as a result , by 2012 nearly all of our generalist gynecology groups had practitioners who were able to offer and safely perform minimally invasive hysterectomies . with an migs mentorship program and fellowship , similar rapid increases in laparoscopic hysterectomy rates have been achieved in other hospital systems without the use of robotic technology . an increase in traditional laparoscopic hysterectomy was demonstrated by the kaiser permanente southern california group . among more than 300 surgeons , rates of laparoscopic hysterectomy increased from 38% to 78% over a 5-year period with the use of a structured program of didactics and surgical mentorship . likewise , the same evolution has occurred at brigham & women 's hospital in boston , where most hysterectomies are performed via a traditional laparoscopic route . as patients become more vocal about their desire for laparoscopic hysterectomy , their expectation of having an outpatient surgery should increase in parallel . in 3 large - scale studies , outpatient hysterectomy rates have been as high as 44% to 52% . in our experience , the paradigm shift from inpatient to outpatient laparoscopic hysterectomy is fueled by excellent patient education regarding patients ' postoperative expectations of the surgeon and ancillary staff such as clinic personnel and surgical nurses . patients are medicated before surgery with the goals of preventing postoperative nausea and vomiting and reducing pain . medications are tailored to the individual and may include a scopolamine patch , oral acetaminophen , and pregabalin . postoperative pain management includes the use of nonsteroidal anti - inflammatory drugs and limited narcotics . the safety of outpatient hysterectomy is ensured by applying strict postanesthesia care unit discharge criteria . although not specifically investigated in this study , our anecdotal experience confirms high rates of patient satisfaction , similar to those reported in the literature . this study documents a paradigm shift in route of hysterectomy over an 8-year span at our hospital . we argue that this increase in rates of laparoscopic hysterectomy can happen on a larger scale , irrespective of the availability of robotic surgical technology , fueled largely by patients ' demand for minimally invasive surgery and by mentorship programs to broaden the skills of less experienced laparoscopists . we have demonstrated the ability to teach laparoscopic hysterectomy techniques to interested generalist gynecologists with the goal that these providers will offer minimally invasive hysterectomy to their patients . the creation of an migs department with the addition of two migs surgeons to the nwh staff made this mentorship program possible . this is our department 's greatest strength , as other groups or physician organizations can emulate similar mentorship techniques . as steege and einarsson asserted in their recent editorial ,  physicians and patients would be better served by retraining programs for practicing gynecologists who have sufficient surgical volume to maintain and enhance their skills .  of note , the reputation of the migs department made nwh a community referral center for cases requiring difficult laparoscopy , thus accounting for the increase in the volume of hysterectomies from 2004 through 2012 . despite the presence of the migs department , non  fellowship - trained generalist ob / gyns continue to perform more than 55% of all laparoscopic hysterectomies at nwh . similarly , we were not privy to patients ' characteristics such as body mass index or surgical history because of the way cases were queried with icd-9 codes , billing data , and operating room records alone . perspective bias also can not be completely eliminated from a retrospective , single - center study . although we attempted to address all confounding factors , it is possible that some confounders were not identified . a heterogeneous group of general - practice gynecologists can perform a majority ( > 72% at nwh ) of hysterectomies laparoscopically without the use of robotic technology and a larger majority ( > 93% at nwh ) of hysterectomies with minimally invasive techniques . the transformation from open surgery to conventional laparoscopic hysterectomy at nwh was fueled by informal migs department mentorship , as well as the presence of an migs fellowship . with this setup , barriers to laparoscopic hysterectomy
background and objective : despite the prevalence of hysterectomy for treatment of benign gynecologic conditions , providers nationwide have been slow to adopt minimally - invasive surgical techniques . our objective is to investigate the impact of a department for minimally invasive gynecologic surgery ( migs ) on the rate of laparoscopic hysterectomy at an academic community hospital without robotic technology.methods:this retrospective observational study included all patients who underwent hysterectomy for benign indications from january 1 , 2004 , through december 31 , 2012 . 
 the primary outcome was route of hysterectomy : open , laparoscopic , or vaginal . 
 secondary outcomes of interest included length of stay and factors associated with an open procedure.results:in 2004 , only 24 ( 8% ) of the 292 hysterectomies performed for benign conditions at newton - wellesley hospital ( nwh ) were laparoscopic . 
 the rate increased to more than 50% ( 189/365 ) by 2008 , and , in 2012 , 72% ( 316/439 ) of hysterectomies were performed via a traditional laparoscopic approach . by 2012 , more than 93% ( 411/439 ) of all hysterectomies were performed in a minimally invasive manner ( including total laparoscopic hysterectomy [ tlh ] , laparoscopic supracervical hysterectomy [ lsh ] , total vaginal hysterectomy [ tvh ] , and laparoscopy - assisted vaginal hysterectomy [ lavh ] ) . 
 more than 85% of the hysterectomies at nwh in 2012 were outpatient procedures . by this time 
 , the surgeon 's preference or lack of expertise was rarely cited as a factor leading to open hysterectomy.conclusions:a large diverse gynecologic surgery department transformed surgical practice from primarily open hysterectomy to a majority ( > 72% ) performed via the traditional laparoscopic route and a large majority ( > 93% ) performed in a minimally invasive manner in less than 8 years , without the use of robotic technology . 
 this paradigm shift was fueled by patient demand and by migs department surgical mentorship for generalist obstetrician / gynecologists .