Open vs minimally invasive hysterectomy outcomes with enhanced recovery after surgery


Discover how immediate postoperative symptom burden varies between open and minimally invasive hysterectomies under enhanced recovery after surgery protocols, shedding light on recovery disparities in gynecologic surgery.

Open vs minimally invasive hysterectomy outcomes with enhanced recovery after surgery | Image Credit: © N F/ - © N F/ -

Open vs minimally invasive hysterectomy outcomes with enhanced recovery after surgery | Image Credit: © N F/ - © N F/ -

Open hysterectomy leads to increased symptom burden in the immediate postoperative period when utilizing enhanced recovery after surgery (ERAS), according to a recent study published in the American Journal of Obstetrics & Gynecology.


  1. Open hysterectomy, despite utilizing enhanced recovery after surgery (ERAS) protocols, leads to increased symptom burden immediately after surgery compared to minimally invasive hysterectomies (MIS). This includes higher pain levels, fatigue, lack of appetite, and other discomforts.
  2. MIS is associated with various benefits such as reduced pain, shorter hospital stays, lower readmission rates, decreased complication rates, and cost savings compared to open hysterectomies. These benefits align with the implementation of laparoscopic surgery and ERAS protocols.
  3. While ERAS has shown improved outcomes in both open and minimally invasive surgeries, there's a scarcity of data comparing patient-reported outcomes between MIS and open gynecologic procedures using ERAS protocols.
  4. The study evaluated differences in post-surgical recovery between MIS and open hysterectomy utilizing ERAS surgical care. Data collection spanned from November 2014 to April 2020, involving various parameters including patient demographics, intraoperative factors, and postoperative measures.
  5. The study included 646 patients, with 254 in the open cohort and 392 in the MIS cohort. Patients undergoing MIS had lower BMI and Charlson Comorbidity Index scores, and a higher incidence of previous chemotherapy. Additionally, differences in tumor type, surgical procedures, and duration were observed between the cohorts.

Minimally invasive hysterectomies, which are associated with reduced pain, shorter hospital stays, less readmissions, reduced complication rates, and cost savings, have become more common following the implementation of laparoscopic surgery. Outcomes have also been improved through utilization of ERAS plans.

While ERAS has been associated with improved outcomes in open and minimally invasive surgery (MIS), there is little data comparing patient-reported outcomes among patients receiving MIS to those receiving open gynecologic procedures using ERAS protocols.

Investigators conducted a study to evaluate differences in postsurgical recovery after MIS compared to open hysterectomy when using ERAS surgical care. Participants received either open surgery starting November 4, 2014, or MIS surgery starting February 1, 2017, with an end data for data collection of April 22, 2020.

A Research Electronic Data Capture database was used to collect and manage data, including body mass index (BMI), age, race and ethnicity, tumor type, primary tumor site, previous chemotherapy or radiation, and previous laparotomy or laparoscopy. Comorbidities were evaluated using the Charlson Comorbidity Index (CCI).

Intraoperative data included hysterectomy type, surgery duration, additional procedures, and intraoperative morphine equivalent daily dose. Thirty days after surgery, hospital length of stay, complications, and readmissions were also reported.

Patients receiving ERAS underwent preoperative carhobydrate loading, skin preparation, and premedication with acetaminophen, celecoxib, tramadol, pregabalin, and venothromboembolic prophylaxis with heparin. Intraoperative measures included goal-directed fluid therapy, normothermia, and weight-based injection of local anesthetic.

Postoperative measures included opioid-sparing, multimodal analgesia with scheduled acetaminophen and ibuprofen, early ambulation, and feeding on postoperative day (POD) 0. Patients receiving laparotomy had urinary Foley catheters removed on POD 1, while they were removed at the end of surgery in patients receiving MIS.

The MD Anderson Symptom Inventory (MDASI) ovarian-cancer module was used in patients with ovarian cancer who received surgery from November 4, 2014, to June 30, 2018, to determine symptom burden. Patients who underwent surgery after July 1, 2018, completed the MDASI-PeriOP-GYN module. Symptoms were graded on a scale from 0 to 10, with a higher number indicating worse symptom burden.

The open cohort received the survey at the preoperative visit, daily during postoperative hospital admission, days 3 and 7 after discharge, and once per week for up to 9 weeks postoperatively. The MIS cohort received the survey at the preoperative visit, once per day until POD 7, and once per week for up to 8 weeks postoperatively.

There were 646 patients included in the final analysis, 254 in the open cohort and 392 in the MIS cohort. A traditional laparoscopy was provided to 76.8% of patients in the MIS cohort and robotic-assisted laparoscopic surgery to 23.2%. A significantly lower BMI, lower CCI score, and higher previous chemotherapy incidence was reported in the open surgical cohort.

Tumor type and site of disease also differed between cohorts. Omentectomy was more common in the open hysterectomy cohort, lymphadenectomy less common, and duration of surgery longer.

The median length of hospital stay was 3 days in the open surgical cohort vs 0 in the MIS cohort, while 30-day remission rates were 2.5% vs 1.2%, respectively. The overall complication rate was also increased in the open surgical cohort.

Higher preoperative scores for pain, fatigue, nausea, lack of appetite, vomiting, numbness or tingling, abdominal and back pain, bloating, constipation, difficulty concentrating, urinary symptoms, leg cramps, and indigestion were reported in the open surgical cohort vs the MIS cohort.

Postoperatively, the open surgical cohort had higher mean symptom severity scores for pain, lack of appetite, fatigue, abdominal pain, dry mouth, constipation, bloating, and indigestion. In the MIS cohort, memory problems, distress, vomiting, and urinary symptom scores were increased.

When comparing scores between the open surgical and MIS cohorts, overall pain scores were 54.1% vs 28%, abdominal pain 34.5% vs 7.2%, fatigue 45% vs 30.6%, lack of appetite 23% vs 11.8%, bloating 18.7% vs 6.6%, and constipation 25.4% vs 11.2%. A higher mean interference in physical functioning was also reported in the open surgical cohort.

These results indicated immediate postoperative outcomes are worse in patients receiving open hysterectomy vs MIS hysterectomy when utilizing the ERAS pathway. However, symptomatic and functional improvement was reported within 8 weeks of surgery.


Huepenbecker SP, Iniesta MD, Wang XS, et al. Longitudinal perioperative patient-reported outcomes in open compared with minimally invasive hysterectomy. Am J Obstet Gynecol. 2024;230:241.e1-18. doi:10.1016/j.ajog.2023.10.012

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