advanced laparoscopic procedures are increasingly being used as an alternative to laparotomy in gynecologic surgery . a recent meta - analysis of 34 prospective randomized trials proves the benefits of minimally invasive surgery ( mis ) compared with abdominal gynecologic surgery , including decreased pain , decreased surgical - site infections , decreased hospital stay , quicker return to activity , and fewer postoperative adhesions . despite the improved outcomes with mis , most hysterectomies are still performed by a laparotomy . per the centers for disease control and prevention 's national discharge survey in 2009 , 60% of the 497,000 hysterectomies performed in the united states in that year used an abdominal approach . the predominance of a laparotomy approach to hysterectomy is mirrored by data from the residency review committee that showed that a 2010 obstetrics and gynecology residency graduate in the 50th percentile for operative experience will complete 64 abdominal hysterectomies ( 61% ) , 18 vaginal hysterectomies ( 17% ) , and 23 laparoscopic hysterectomies ( 22% ) during his or her residency . in 2009 a division of mis was established in our obstetrics and gynecology residency program with 2 experienced full - time faculty members ( g.h . and m.d . ) , with the emphasis placed on a minimally invasive approach to gynecologic surgery . the purpose of this study is to evaluate the safety and surgical outcomes of minimally invasive hysterectomy in a residency training program . the penn state college of medicine institutional review board approved the study design and methods for the protection of the study participants . from january 1 through december 31 , 2010 , 537 patients underwent hysterectomy for benign indications at penn state milton s. hershey medical center with or without concomitant surgery . these patients were identified by use of international classification of diseases , ninth revision codes for hysterectomy types ( total abdominal , abdominal supracervical , total vaginal , laparoscopy - assisted vaginal , laparoscopic supracervical , and total laparoscopic ) . no patients were excluded . in a retrospective fashion , demographic characteristics , surgical outcomes , and follow - up data were collected from the electronic medical record by the primary author and entered into a confidential database . the obstetrics and gynecology resident physician was the primary surgeon with an attending as the first assistant , or vice versa . residents performed port placement , half of the hysterectomy , laparoscopic and/or vaginal colpotomy , morcellation , or closure of the vaginal cuff as needed . the attending physician for most hysterectomies ( 81% ) was 1 of the 2 minimally invasive surgeons . the decision to proceed with a specific type of mis hysterectomy ( vaginal , laparoscopy - assisted , total laparoscopic , or laparoscopic supracervical ) was dependent on vaginal access and the presence of an adnexal mass , as well as surgeon and patient preference . using an abdominal approach was only intended from the outset in a paucity of situations ( 11 of 537 ) , as discussed later . patients underwent a preoperative bowel preparation with either 1 bottle of magnesium citrate , saline laxative enema , or bisacodyl suppository . patients were admitted on the day of surgery , received a single dose of prophylactic antibiotics and pneumatic compression stockings , and underwent early ambulation postoperatively . unless contraindicated , the postoperative pain management protocol consisted of ketorolac , 30 mg intravenously , at the completion of surgery ; morphine , 2 to 4 mg intravenously every 2 hours as needed ; and oxycodone , 5 to 10 mg orally every 4 hours . an orogastric tube was inserted at the start of the case and then removed at the end of surgery . patients were positioned in the dorsolithotomy position by use of ultrafin stirrups ( alten medical , acton , ma , usa ) in the maximal trendelenburg position ( approximately 30 ) for any laparoscopic portion of the surgery . for laparoscopic hysterectomy , a 3-port ( 5- to 10-mm ) transperitoneal approach was used : intraumbilical , right lower quadrant , and left lower quadrant . harmonic ace curved shears ( ethicon endo - surgery , cincinnati , ohio)or , rarely , plasmakinetic cutting forceps ( gyrus acmi , southborough , massachusetts ) per surgeon preference  were used to ligate the triple pedicle ( fallopian tube , round ligament , and utero - ovarian ligament ) , skeletonize the uterine artery , ligate the uterine artery , ligate the cardinal and uterosacral ligaments , and incise the vaginal colpotomy if necessary . if morcellation was necessary ( eg , during laparoscopic supracervical hysterectomy ) , the gynecare morcellex tissue morcellator ( ethicon , cincinnati , ohio ) or storz rotocut g1 tissue morcellator ( karl storz , tuttlingen , germany ) was used per surgeon preference . for total hysterectomy , the vaginal cuff was closed laparoscopically , including vaginal cuff fixation to the uterosacral ligaments , with v - loc 180 no . 20 polyglactin 910 with lapra ty ii ( ethicon ) . for vaginal cuff closure during laparoscopy - assisted vaginal hysterectomy , no . 0 polyglactin 910 was used in 3 layers for vaginal cuff fixation to the uterosacral ligaments , reperitonealization , and reapproximation of the anterior cuff edge to its posterior counterpart . complications were noted from the electronic medical record at hospital discharge , at office follow - up , on readmission , at emergency department visits , at unscheduled postoperative visits , and based on morbidity and mortality data . the median age was 45 years ( range , 2290 years ) , the median body mass index was 30 kg / m ( range , 1660 kg / m ) , the median estimated uterine size was 11 cm ( range , 630 cm ) , and 22% of patients had prior cesarean delivery . patient demographic characteristics of the 537 hysterectomies , 526 ( 98% ) were initiated with a minimally invasive approach and 517 ( 96% ) were completed in that fashion ; thus only 9 conversions ( 2% ) were required . of the cases in which a minimally invasive approach was used , 16% were vaginal and 84% were laparoscopic . vaginal hysterectomies were primarily performed for pelvic organ prolapse or incontinence diagnoses , whereas laparoscopic hysterectomies were performed for more varied preoperative diagnoses including abnormal uterine bleeding , fibroids , endometriosis , and pelvic pain . the indications for laparotomy included concomitant bowel malignancy surgery ( n = 4 ) , uterine size > 16 cm ( n = 3 ) , nulliparous patients with minimal pelvic descent cared for by a surgeon not trained in total laparoscopic hysterectomy ( n = 3 ) , significant prior abdominal surgeries ( n = 2 ) , and vaginal agenesis and vater association ( presence of [ me]3 of the following congenital malformations : vertebral defects , anal atresia , cardiac defects , tracheoesophageal fistula , renal anomalies , and limb abnormalities ) ( n = 1 ) . nine cases required conversion because of lack of visualization , adhesive disease , repair of bowel / urinary tract injury , or control of bleeding . the median operative time was 86 minutes ( range , 31396 minutes ) , the median blood loss was 95 ml ( range , 201250 ml ) , the median hospital stay was 1 day ( range , 022 days ) , and the median uterine weight was 199 g ( range , 252900 g ) . a concomitant procedure was performed in 11% of laparoscopic hysterectomy cases and 82% of vaginal hysterectomy cases . the overall complication rate was 11% , comprising major complications in 5% of patients and minor complications in 6% ( table 3 ) . there were 3 bowel injuries , 3 urinary tract injuries , and 12 reoperations for either cuff abscess or cuff dehiscence . lavh = laparoscopy - assisted vaginal hysterectomy ; lsh = laparoscopic supracervical hysterectomy ; tlh = total laparoscopic hysterectomy ; tvh = total vaginal hysterectomy . proven benefits of minimally invasive hysterectomy include decreased pain , decreased surgical - site infections , decreased intestinal complications , fewer postoperative adhesions , decreased hospital stay , and quicker return to activity . despite these clear benefits , a minimally invasive approach is used in only 40% of hysterectomies performed in the united states and in only 39% of hysterectomies performed by obstetrics and gynecology residents . in our study 96% of hysterectomies were completed with a minimally invasive approach , which represents a 2.4-fold increase over the national average . in a pubmed review , we located very few studies on minimally invasive hysterectomies for benign disease at a residency teaching institution . abdelmonem et al reported on 177 hysterectomies at a residency teaching institution where 72% were completed with a minimally invasive approach . however , their review spanned a 5-year period , the number of patients excluded was not reported , and data retrieval was biased . to our knowledge , our 96% minimally invasive approach is the highest rate reported from an obstetrics and gynecology residency program . in the nonresidency setting , 99% and 100% minimally invasive approaches have been reported . the abdominal approach was used in 5 of 11 patients in our study for a uterine size > 16 cm and significant prior abdominal surgeries , neither of which is a contraindication to a laparoscopic approach . in a residency training program , complication rates for hysterectomy would be expected to be increased compared with those of practicing gynecologic surgeons . a review in the cochrane database of systematic reviews ( cdsr ) of 34 randomized controlled trials with 4,495 women reported on minimally invasive hysterectomies for benign disease performed by practicing gynecologic surgeons . our operative time of 86 minutes compares favorably with the cdsr time of 121 minutes . our reported blood loss was 95 ml versus 311 ml in the cdsr , and our hospital stay was 1 day versus 3 days in the cdsr . thus our operative time , blood loss , and hospital stay appear similar to those of practicing gynecologic surgeons . in our study although the cdsr did not report the overall major complication rate , it did report on specific complications . our urinary tract injury rate was 1% versus 3% in the cdsr , our vaginal cuff infection rate was 2% versus 4% in the cdsr , and our urinary tract infection rate was 2% versus 6% in the cdsr . thus our complication rate appears similar to or better than that reported for a wide variety of practicing gynecologic surgeons . our residency training institution completed 96% of 537 hysterectomies using a minimally invasive approach while maintaining an acceptable operative time , amount of blood loss , hospital stay , and complication rate . these findings support a minimally invasive approach for hysterectomy for benign disease at an academic resident teaching facility . because of the proven benefits of a minimally invasive approach , it is our opinion that residency training institutions should emphasize a minimally invasive approach for hysterectomy . our division of minimally invasive surgery has now begun robotic training in the residency training program , and this will be reviewed in the future .
background and objectives : to evaluate the feasibility of a minimally invasive approach for hysterectomy for benign disease at a university teaching hospital.methods:five hundred thirty - seven consecutive patients underwent hysterectomy for benign disease at penn state milton s. hershey medical center in 2010 . 
 no cases were excluded . 
 minimally invasive approaches included total vaginal hysterectomy , laparoscopy - assisted vaginal hysterectomy , total laparoscopic hysterectomy , and laparoscopic supracervical hysterectomy . 
 all surgeries were completed with the resident as the primary surgeon or first assistant.results:the median age was 45 years , the median body mass index was 30 kg / m2 , the median estimated uterine size was 11 cm , and 22% of patients had a prior cesarean section . 
 of the 537 hysterectomies , 526 ( 98% ) were started with a minimally invasive approach and 517 ( 96% ) were completed in that fashion ; thus only 9 conversions ( 2% ) were required . of the cases in which a minimally invasive approach was used , 16% were vaginal and 
 84% were laparoscopic . 
 the median operative time was 86 minutes , the median blood loss was 95 ml , the median hospital stay was 1 day , and the median uterine weight was 199 g. for the minimally invasive hysterectomies , there was a 5% major complication rate.conclusion:our residency training institution completed 96% of 537 hysterectomies using a minimally invasive approach while maintaining an acceptable operative time , amount of blood loss , hospital stay , and complication rate . 
 thus our study supports that a minimally invasive approach for hysterectomy for benign disease at an academic resident teaching facility is feasible .