Original Research

Association Between Obesity and the Trends

of Routes of Hysterectomy Performed for
Benign Indications
Emad Mikhail, MD, Branko Miladinovic, PhD, Vic Velanovich,
Stuart Hart, MD, and Anthony N. Imudia, MD
OBJECTIVE: To estimate the association between obesity
and the recent trends of routes chosen for hysterectomy
performed for benign indications in the United States.
MATERIALS AND METHODS: Using the American College of SurgeonsNational Surgical Quality Improvement
Projects database, patients who underwent hysterectomy
for benign indications from 2005 to 2011 were identified
by International Classification of Diseases, 9th Revision
codes and were categorized into total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), laparoscopically assisted vaginal hysterectomy (LAVH), and total
laparoscopic hysterectomy (TLH). The patients were
divided into four subgroups according to body mass index
(BMI) (less than 25, 2529.9, 3039.9, and 40 or greater).
The data were analyzed using Students t test or x2 and
Fishers exact test.
RESULTS: A total of 18,810 patients underwent hysterectomy for benign indications during the study period:
9,852 (52.4%) were TAH, 5,146 (27.4%) TVH, 2,296
(12.2%) LAVH, and 1,516 (8.0%) TLH. The rates of TAH
From the Departments of Obstetrics and Gynecology, Internal Medicine, and
General Surgery, University of South Florida, Morsani College of Medicine,
Tampa, Florida; and the Division of Gynecologic Oncology, University of South
Alabama, Mitchell Cancer Institute, Mobile, Alabama.
Presented as a poster at the American College of Obstetricians and Gynecologists
Annual Clinical and Scientific Meeting, April 2630, 2014, Chicago, Illinois.
The American College of Surgeons National Surgical Quality Improvement Program
(ACS NSQIP) and the hospitals participating in the ACS NSQIP are the source of the
data used herein; they have not verified and are not responsible for the statistical
validity of the data analysis or the conclusions derived by the authors.
Corresponding author: Emad Mikhail, MD, Department of Obstetrics and
Gynecology, University of South Florida/Morsani College of Medicine, 2 Tampa
General Circle, Suite 6031, Tampa, FL 33606; e-mail: emikhail@health.usf.edu.
Financial Disclosure
Dr. Hart has been a speaker and consultant for Covidien and Boston Scientific.
He has received research support from Covidien, Stryker, and Cooper Surgical.
The other authors did not report any potential conflicts of interest.
2015 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/15

912

VOL. 125, NO. 4, APRIL 2015

MD,

Michael A. Finan,

MD,

increased from 45.7% in patients with ideal body weight

to 62% in morbidly obese patients (P,.001). The rate of
TVH and LAVH decreased from 32.7% and 13.3% in patients with ideal body weight to 17.1% and 11.7% in
morbidly obese patients, respectively (P,.001 and 0.04).
The rate of TLH performed was independent of BMI
(P5.61). Higher BMI was associated with longer operative
time (P,.001) in all routes of hysterectomy. The rates of
superficial and deep wound infections were higher with
increasing BMI in patients undergoing TAH (P,.001) but
not with TVH (P5.26), LAVH (P51.0), or TLH (P5.48).
CONCLUSION: Regarding hysterectomy performed for
benign indications, increasing BMI was associated with
increased rate of TAH and decreased rate of TVH and
LAVH, but not the rate of TLH. Increasing BMI was
associated with increased operative time for all subgroups
and increased surgical site infection in the TAH group.
(Obstet Gynecol 2015;125:9128)
DOI: 10.1097/AOG.0000000000000733

LEVEL OF EVIDENCE: II

ysterectomy is one of the most frequently performed surgical procedures in the United States.1
There are three approaches to hysterectomy; abdominal
hysterectomy, vaginal hysterectomy, and laparoscopic
hysterectomy with or without robotic assistance.1,2
A minimally invasive approach for hysterectomy is
more favorable as a result of its well-known benefits
including less blood loss, fewer perioperative complications, less postoperative pain, shorter hospital stay,
quicker recovery time, and better cosmesis.2,3
Different factors affect the surgeons decision on
the route chosen for hysterectomy, including safety
and cost-effectiveness.1 The American College of Obstetricians and Gynecologists considers the vaginal
approach to be the ideal route for performance of
benign hysterectomy when feasible.1 Additionally, the
American Association of Gynecologic Laparoscopists

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Unauthorized reproduction of this article is prohibited.

concludes that most hysterectomies for benign disease

should be performed either vaginally or laparoscopically.4 Because obesity is now considered a pandemic5
with increasing prevalence, surgeons must consider its
effects on perioperative complications and surgical
decision-making. It has been shown that patients who
are obese experience some of the greatest differential
benefit from minimally invasive techniques.6 It has been
suggested that if the vaginal route was deemed unsuitable for any reason, the laparoscopic route is more
favorable compared with the abdominal approach.7
The objective of this study is to estimate the
association between obesity and the trends toward
minimally invasive approaches of hysterectomy
performed for benign indications and to describe
the perioperative outcomes in each group using the
American College of SurgeonsNational Surgical
Quality Improvement Projects database.

MATERIALS AND METHODS

After obtaining exempt status from the University of
South Floridas institutional review board, the American College of SurgeonsNational Surgical Quality
Improvement Project database from 2005 to 2011
was queried for all patients who underwent hysterectomy using appropriate International Classification of
Diseases, 9th Revision (ICD-9); codes (Appendix 1).
The American College of SurgeonsNational Surgical
Quality Improvement Project database, which is publically available and deidentified, is a quality improvement initiative originally developed by the Veterans
Health Administration in 1991 and adopted by the
American College of Surgeons in 2001.8 The database
includes more than 300 participating hospitals nationwide, both community and academic. Data entry
points include but are not limited to demographics,
comorbidities, laboratory values, operative variables,
and 30-day postoperative outcomes, complications,
mortality, reoperation, and length of stay.9 Routine
auditing and the use of specially trained surgical nurses
to record patient variables ensure high-quality data.8,10
The National Surgical Quality Improvement Project
provides a highly reliable data system to compare
risk-adjusted outcomes that surgeons can have confidence in, but it also provides robust data to allow for
intensive quality improvement efforts at the local
level.11 A random 8-day sampling method is used to
ensure a diverse range of surgical procedures is captured.12 It is believed that a random sample is better
because a sample would provide knowledge about different types of operations and their outcomes performed by the different surgical subspecialties and the
surgical service as a whole.9,11

VOL. 125, NO. 4, APRIL 2015

Only those patients with a benign indication for

the hysterectomy procedures were included. The list
of International Classification of Diseases, 9th Revision diagnostic codes used to query the database and
flow chart of the inclusion criteria is shown in Appendix 1 and Figure 1, respectively. The National Surgical Quality Improvement Project database does not
identify robotically assisted laparoscopic hysterectomy separately from total laparoscopic hysterectomy
(TLH); therefore, these groups are both denoted as
TLH for the purposes of this study.
Patients were divided into four groups according
to body mass index (BMI, calculated as weight (kg)/
[height (m)]2) as follows: normal and underweight
(less than 25), overweight (2529.9), obese (class I
and II; 3039.9), and morbid obesity (class III) (40
or greater). Patients were subcategorized using Current Procedural Terminology codes into the following
subgroups: 1) total abdominal hysterectomy (TAH)
58150, 2) total vaginal hysterectomy (TVH)58260,
3) TLH58570, and 4) laparoscopically assisted vaginal hysterectomy (LAVH)58550.
The trends of hysterectomy during the study period
were determined and the proportion of patients who
underwent hysterectomy through different routes each
year were compared for each BMI category. For each
hysterectomy route, certain perioperative outcomes
such as operative time, total length of hospital stay,
rates of superficial infection, wound infection, pneumonia, pulmonary embolism, urinary tract infection,
peripheral nerve injury, blood transfusion, deep venous
thrombosis, and reoperation were compared and analyzed for each BMI group.
Data were analyzed using Stata 13.1. For univariate
normally distributed continuous data, we applied the
Students t test. For skewed data we used the Wilcoxon
rank-sum test. x2 or Fishers exact test was used for
categorical data. We used the test for trend13 or a nonparametric k-sample test on the equality of medians to
assess the differences across categories of interest as
appropriate. The Strengthening the Reporting of
Observational studies in Epidemiology guidelines for
reporting observational studies were strictly followed.14

RESULTS
During the study period, the total number of patients
who underwent hysterectomy for benign indications
who met our inclusion criteria was 18,810. The
number of TAH was 9,852 (52.4%), TVH was 5,146
(27.4%), LAVH was 2,296 (12.2%), and TLH was
1,516 (8.0%). The distribution of these cases during
the study period is shown in Table 1. Between 2007
and 2011, there was a more than 20% decline in the

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913

American College of Surgeons National

Surgical Quality Improvement
Program database
(N=1,777,036)
Records without a benign
indication for hysterectomy
(n=1,758,226)

Study sample
(n=18,810)
Records with missing body
mass index values
(n=57)

Body mass index,

normal weight
(n=4,951)

Body mass index,

overweight
(n=5,537)

Body mass index,

obese
(n=6,397)

Body mass index,

morbidly obese
(n=1,868)

Subdivided using CPT codes

TAH (n=2,241, 45.3%)

TVH (n=1,618, 32.7%)
LAVH (n=660, 13.2%)
TLH (n=432, 8.8%)

TAH (n=2,797, 50.5%)

TVH (n=1,674, 30.2%)
LAVH (n=646, 11,7%)
TLH (n=420, 7.6%)

TAH (n=3,623, 56.6%)

TVH (n=1,520, 23.8%)
LAVH (n=767, 12.0%)
TLH (n=487, 7.6%)

TAH (n=1,158, 62.0%)

TVH (n=320, 17.1%)
LAVH (n=218, 11.7%)
TLH (n=172, 9.2%)

Fig. 1. Flowchart of inclusion criteria. ICD-9, International Classification of Diseases, 9th Revision; CPT, Current Procedural
Terminology; TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; LAVH, laparoscopically assisted vaginal
hysterectomy; TLH, total laparoscopic hysterectomy.
Mikhail. Obesity and Surgical Trends for Hysterectomy. Obstet Gynecol 2015.

proportion of TAHs performed in the United States

(Table 1). Although the proportion of TVH and
LAVH remained stable over the entire study period,
the proportion of TLH increased by almost 10%
between 2008 and 2011 (Table 1).
Stratification of the number of different routes for
hysterectomy performed by BMI during the 7-year
period showed that the rates of TAH significantly
increased from 45.7% in patients with ideal body
weight to 62% in morbidly obese patients (P,.001).

Between each BMI category, approximately 5%

increase in the proportion of TAH was noted (Fig. 2;
Table 2) and the overall increase in the rate of TAH
between patients with normal body weight and
morbid obesity was 16.3% (Table 2). On the contrary,
the rates of both TVH and LAVH significantly
decreased from 32.7% and 13.3% in patients with ideal
body weight to 17.1% and 11.7% in morbidly obese
patients, respectively (P,.001 and .04) (Table 2). For
LAVH, the decline was across all BMI categories

Table 1. Number of Different Types of Hysterectomy Performed From 2005 to 2011

Hysterectomy Route
TAH
TVH
LAVH
TLH
Total

20052006

2007

2008

2009

2010

2011

94 (69.6)
41 (30.4)
0
0
135

510 (69.3)
226 (30.7)
0
0
736

1,400 (57.6)
672 (27.6)
290 (11.9)
69 (2.8)
2,431

1,905 (53.7)
1,012 (28.5)
421 (11.9)
212 (5.9)
3,550

2,432 (51.2)
1,315 (27.7)
643 (13.5)
358 (7.5)
4,748

3,511 (48.7)
1,880 (26.1)
942 (13.1)
877 (12.2)
7,210

Total
9,852
5,146
2,296
1,516
18,810

(52.4)
(27.4)
(12.2)
(8.0)
(100)

TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; LAVH, laparoscopically assisted vaginal hysterectomy; TLH, total
laparoscopic hysterectomy.
Data are n (%).

914

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Obesity and Surgical Trends for Hysterectomy

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35
Estimated percent
(95% confidence interval)

Estimated percent
(95% confidence interval)

70
65
60
55
50

30

25

20

15
45
Ideal

Overweight

Obese

Morbidly obese

Body mass index

Ideal

Obese

Morbidly obese

Body mass index

14

10
Estimated percent
(95% confidence interval)

Estimated percent
(95% confidence interval)

Overweight

13
12
11
10

6
Ideal

Overweight

Obese

Morbidly obese

Body mass index

Ideal

Overweight

Obese

Morbidly obese

Body mass index

Fig. 2. Trends of different route of hysterectomy performed between 2005 and 2011 stratified by body mass index. Total
abdominal hysterectomy (A), total vaginal hysterectomy (B), laparoscopically assisted vaginal hysterectomy (C), total laparoscopic hysterectomy (D).
Mikhail. Obesity and Surgical Trends for Hysterectomy. Obstet Gynecol 2015.

(P,.001) and was more pronounced in the obese and

morbid obesity group (Fig. 2). The overall percent
decline in the rate of TVH between patients with normal body weight and morbid obesity was 15.6%
(Table 2). The rate of LAVH was only negatively
influenced by morbid obesity when compared with
patients with normal body weight (Table 2). There
were no significant differences in the rate of TLH with
increasing BMI (P5.61).

In patients who underwent TAH, a statistically

significant difference was found in the mean operative
time and the rate of wound infection (defined as
superficial and deep surgical site infections) among
the different BMI groups (P,.001). It was uniformly
noted that more time was needed to complete the
TAH with increasing BMI. Approximately 33
more minutes were needed to complete the TAH in
the class III obesity group as compared with patients

Table 2. Number of Hysterectomies Performed Between 2005 and 2011 Classified by Route and Body
Mass Index
BMI Classification
Hysterectomy Route
TAH
TVH
LAVH
TLH

Ideal Body Weight

2,241
1,618
660
432

(45.7)
(32.7)
(13.3)
(8.7)

Overweight
2,797
1,674
646
420

(50.5)
(30.2)
(11.7)
(7.6)

Obese
3,623
1,520
767
487

Morbid Obesity

(56.6)
(23.8)
(12.0)
(7.6)

1,158
320
218
172

(62.0)
(17.1)
(11.7)
(9.2)

OR (95% CI)
1.257
0.773
0.952
0.986

(1.2191.295)
(0.7470.799)
(0.9100.997)
(0.9331.041)

,.001
,.001
.04
.61

BMI, body mass index; OR, odds ratio; CI, confidence interval; TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; LAVH,
laparoscopically assisted vaginal hysterectomy; TLH, total laparoscopic hysterectomy.
Ideal body weight, BMI less than 25; overweight, BMI 2529.9; obese, BMI 3039.9; morbid obesity, BMI 40 or greater.
P is for Wilcoxon test for trend.

VOL. 125, NO. 4, APRIL 2015

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915

Table 3. Selected Perioperative Outcomes of Patient Stratified by Body Mass Index and Route of
Hysterectomy
BMI Classification
Hysterectomy Route
TAH (n59,852)

TVH (n55,146)

LAVH (n52,296)

TLH (n51,516)

Variable

Ideal Body Weight

Overweight

Obese

Morbid Obesity

Operative time (min)

Superficial infection
Wound infection
Operative time (min)
Superficial infection
Wound infection
Operative time (min)
Superficial infection
Wound infection
Operative time (min)
Superficial infection
Wound infection

101.9652.7
18 (0.8)
4 (0.2)
91.2654.3
6 (0.4)
2 (0.1)
117.4660.2
3 (0.5)
1 (0.2)
134.7661.9
1 (0.2)
0 (0.0)

108.6658.6*
41 (1.5)*
6 (0.2)
99.4659.5*
8 (0.5)
1 (0.1)
120.0657.4
7 (1.1)
1 (0.2)
145.0658.9*
5 (1.2)
0 (0.0)

117.7662.9*
102 (2.8)*
25 (0.7)*
100.0657.7*
14 (0.9)
5 (0.3)
128.3661.9*
7 (0.9)
1 (0.1)
146.8658.2*
3 (0.6)
2 (0.4)

134.3670.9*
75 (6.5)*
24 (2.1)*
102.9656.6*
4 (1.3)
0 (0.0)
141.8667.3*
4 (1.8)
0 (0.0)
166.4674.5*
1 (0.6)
0 (0.0)

BMI, body mass index; TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; LAVH, laparoscopically assisted vaginal
hysterectomy; TLH, total laparoscopic hysterectomy.
Data are mean6standard deviation or frequency (%) of occurrence.
The distribution of the data were tested for normality.
Ideal body weight, BMI less than 25; overweight, BMI 2529.9; obese, BMI 3039.9; morbid obesity, BMI 40 or greater.
* P,.001 compared with ideal body weight.

with normal or underweight body weight (Table 3).

The mean operative time in patients who underwent
TVH, LAVH, and TLH was significantly longer with
increasing BMI (P,.001). An additional 12, 24, and
32 minutes were required to complete TVH, LAVH,
and TLH, respectively, in patients with morbid obesity as compared with patients with ideal body weight
(Table 3). The rates of superficial and deep surgical
site infections were not affected by increasing BMI in
patients who underwent TVH (P5.26), LAVH
(P51.0), or TLH (P5.48) (Table 3). Other perioperative outcomes analyzed and compared in the different
groups of hysterectomy routes were total length of
hospital stay (days), rates of pneumonia, pulmonary
embolism, urinary tract infection, peripheral nerve
injury, blood transfusion, deep venous thrombosis,
and reoperation. As a result of the rare occurrence
of these events, the study was underpowered to find
any significant difference across BMI groups.

DISCUSSION
In this study, it was found that minimally invasive
hysterectomy procedures such as TVH, LAVH, and
TLH are being performed less frequently in patients
with increased BMI. Obesity is associated with
increased rate of TAH despite a national trend that
shows an overall decline in the rate of TAH between
2007 and 2011. As a result of the known benefits
of minimally invasive gynecologic surgery and the
increasing prevalence of obesity in the general U.S.
population, gynecologic surgeons should be trained and

916

Mikhail et al

encouraged to adopt minimally invasive approaches in

general and specifically for this group of patients.
Evidence in the medical literature supports the
opinion that, when feasible, vaginal hysterectomy is the
safest and most cost-effective route by which to remove
the uterus.1,2 Some authors have proposed certain factors as a contraindication for vaginal hysterectomy
including: a narrow vagina, an undescended immobile
uterus, nulliparity, prior cesarean delivery, and an
enlarged uterus.1 Others have set criteria for candidacy
for vaginal hysterectomy including adequate pubic
arch greater than 90, adequate operative space in the
lateral pelvic floor, and uterine size less than 16 cm.15
Many factors influence the route chosen for hysterectomy. These factors include uterine size, shape of the
vagina and uterus, accessibility to the uterus, the need
for concurrent procedures, patient characteristics, and
surgeon training and experience (surgical volume).1,16
Obesity can make vaginal hysterectomy more technically challenging.17 This is in agreement with the findings of our data, which show a steady decline in the rate
TVH performed with increasing BMI.
Obesity has been shown to increase the risk of
perioperative complications after elective procedures.18
The risks associated with increased BMI were dependent on the route of surgery and were mainly seen in
patients undergoing TAH.19 This observation is supported by the findings of the current study. Because
obesity is an independent risk factor for perioperative
complications from hysterectomy, every effort should

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be made to perform a less morbid procedure in these

patients. Our data demonstrate that, on the contrary, as
BMI increases, TAHs are more commonly performed
with more reported perioperative complications.
Laparoscopic hysterectomy seems to be a safe
route for obese patients. In a study by Chopin et al,20
obesity did not increase the complication rate in 1,460
patients who underwent TLH. In a retrospective study
by Kondo et al21 studying 2,271 patients, they have
found that obesity does not have an adverse effect on
the feasibility and safety of laparoscopic hysterectomy.
Similar results were found by Heinberg et al22 and
OHanlan et al.23 It is important to note that obesity
as evidenced by increasing BMI makes any hysterectomy procedure more challenging as demonstrated by
our data. Irrespective of the surgical approach, more
time is required to complete the chosen surgery as the
patients BMI increases. Given that laparoscopy is feasible in patients with a high BMI with fewer reported
perioperative complications compared with open surgery, efforts should be made to streamline techniques
that allow more obese patients to undergo a hysterectomy through a minimally invasive approach.
The strengths of this study include the fact that this is
a multiinstitutional database, which has been verified as
accurate, reproducible, and reliable. Specially trained
surgical clinical nurse reviewers are responsible for data
entry for the National Surgical Quality Improvement
Program database.8,10 An additional advantage and
strength of using American College of Surgeons
National Surgical Quality Improvement Program database is that the selection of cases to be included is based
on random sampling, which minimizes the possibility of
selection bias.9 Weaknesses are that the patients entered
into the National Surgical Quality Improvement Program database are not a complete set of patients undergoing hysterectomy. As of 2012, approximately 382
hospitals were participating in the National Surgical
Quality Improvement Program, which is a significant
improvement since 2006 but is still a small fraction of
all hospitals in the United States. Robotic cases could not
be distinguished from laparoscopic cases based on the
coding of data in the National Surgical Quality Improvement Program. Confounding factors including previous
surgeries, comorbidities, uterine size, and surgeons case
volume could not be controlled for given the unavailability of these variables in the National Surgical Quality
Improvement Program database. It is worth noting that
records with concomitant procedures were not excluded,
and concomitant procedures might be a confounding
factor that affects secondary outcomes, specifically operative time. Despite these aforementioned weaknesses, it
is evident from this study that more open hysterectomies

VOL. 125, NO. 4, APRIL 2015

are being performed in obese patients despite increased

complication rates. Gynecologic surgeons should be
trained and encouraged to perform minimally invasive
procedures in this vulnerable group of patients. If the
vaginal route is found to be technically challenging in
these patients, TLH should be attempted given better
perioperative outcomes when a hysterectomy is successfully completed laparoscopically.
REFERENCES
1. Choosing the route of hysterectomy for benign disease. ACOG
Committee Opinion No. 444. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:11568.
2. Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E,
Garry R, et al. Surgical approach to hysterectomy for benign
gynaecological disease. The Cochrane Database of Systematic
Systematic Reviews 2009, Issue 3. Art. No.: CD003677. DOI:
10.1002/14651858.CD003677.pub4.
3. Jacoby VL, Autry A, Jacobson G, Domush R, Nakagawa S,
Jacoby A. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol
2009;114:10418.
4. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL position statement: route of hysterectomy to treat
benign uterine disease. J Minim Invasive Gynecol 2011;18:13.
5. Korenkov M, Sauerland S. Clinical update: bariatric surgery.
Lancet 2007;370:198890.
6. Siedhoff MT, Carey ET, Findley AD, Riggins LE, Garrett JM,
Steege JF. Effect of extreme obesity on outcomes in laparoscopic
hysterectomy. J Minim Invasive Gynecol 2012;19:7017.
7. Brezina PR, Beste TM, Nelson KH. Does route of hysterectomy
affect outcome in obese and nonobese women? JSLS 2009;13:
35863.
8. Khuri SF, Daley J, Henderson W, Hur K, Demakis J, Aust JB,
et al. The Department of Veterans Affairs NSQIP: the first
national, validated, outcome-based, risk-adjusted, and peercontrolled program for the measurement and enhancement of
the quality of surgical care. National VA Surgical Quality
Improvement Program. Ann Surg 1998;228:491507.
9. Henderson WG, Daley J. Design and statistical methodology of
the National Surgical Quality Improvement Program: why is it
what it is? Am J Surg 2009;198(suppl):S1927.
10. ACS-NSQIP. ACS NSQIP information booklet. Available at:
http://www.acsnsqip.org. Retrieved December 18, 2014.
11. Rowell KS, Turrentine FE, Hutter MM, Khuri SF,
Henderson WG. Use of national surgical quality improvement
program data as a catalyst for quality improvement. J Am Coll
Surg 2007;204:1293300.
12. Hanwright PJ, Mioton LM, Thomassee MS, Bilimoria KY,
Van Arsdale J, Brill ED, et al. Risk profiles and outcomes of total
laparoscopic hysterectomy compared with laparoscopically assisted vaginal hysterectomy. Obstet Gynecol 2013;121:7817.
13. Cuzick J. A Wilcoxon-type test for trend. Stat Med 1985;4:8790.
14. von Elm E, Altman DG, Egger M, Pocock SJ, Gtzsche PC,
Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines
for reporting observational studies. PLoS Med 2007;4:e296.
15. Rezvan A, Pedroso J, Mohajer R, Bhatia NN. Modified
approach to vaginal hysterectomy without initial colpotomy.
Curr Opin Obstet Gynecol 2013;25:4148.

Mikhail et al

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Unauthorized reproduction of this article is prohibited.

917

16. Boyd LR, Novetsky AP, Curtin JP. Effect of surgical volume on
route of hysterectomy and short-term morbidity. Obstet Gynecol 2010;116:90915.
17. Muffly TM, Kow NS. Effect of obesity on patients undergoing
vaginal hysterectomy. J Minim Invasive Gynecol 2014;21:16875.
18. Choban PS, Flancbaum L. The impact of obesity on surgical
outcomes: a review. J Am Coll Surg 1997;185:593603.
19. Osler M, Daugbjerg S, Frederiksen BL, Ottesen B. Body mass
and risk of complications after hysterectomy on benign indications. Hum Reprod 2011;26:15128.
20. Chopin N, Malaret JM, Lafay-Pillet MC, Fotso A, Foulot H,
Chapron C. Total laparoscopic hysterectomy for benign uterine
pathologies: obesity does not increase the risk of complications.
Hum Reprod 2009;24:305762.
21. Kondo W, Bourdel N, Marengo F, Botchorishvili R, Pouly JL,
Jardon K, et al. Whats the impact of the obesity on the safety of
laparoscopic hysterectomy techniques? J Laparoendosc Adv
Surg Tech A 2012;22:94953.
22. Heinberg EM, Crawford BL III, Weitzen SH, Bonilla DJ. Total
laparoscopic hysterectomy in obese versus nonobese patients.
Obstet Gynecol 2004;103:67480.
23. OHanlan KA, Dibble SL, Fisher DT. Total laparoscopic hysterectomy for uterine pathology: impact of body mass index on
outcomes. Gynecol Oncol 2006;103:93841.

Appendix 1: International Classification of

Diseases, 9th Revision (ICD-9) Codes Used for
Including Patients in the Study (Inclusion Criteria)
The patients with the following ICD-9 codes for benign
indications of hysterectomy were included in the study:

626.8 Abnormal vaginal bleeding

626.2 Menorrhagia
626.6 Metrorrhagia
218, 218.1, 218.2, 218.9 Uterine leiomyoma
220 Benign neoplasm of the ovary
233.1 Cervical carcinoma in situ
616 Cervicitis
618, 618.2, 618.3, 618.4, 618.89 Uterovaginal
prolapse

918

Mikhail et al

625.3 Dysmenorrhea
233.2 Carcinoma in situ nonspecified
614, 614.1, 614.2, 614.4, 614.6 Salpingitis, oophoritis, pelvic adhesions
617 Endometriosis
617.1 Endometriosis of the ovary
617.3 Endometriosis of the pelvic peritoneum
617.9 Endometriosis nonspecified site
618.01 Cystocele
618.1 Uterine prolapse
618.9 Unspecified genital prolapse
620 Ovarian cyst
620.1 Corpus luteum cyst
620.2 Unspecified ovarian cyst
620.5 Ovarian torsion
621 Disorder of the uterus
621.2 Enlarged uterus
621.3 Endometrial hyperplasia
621.31 Simple endometrial hyperplasia without atypia
621.32 Complex endometrial hyperplasia without
atypia
621.33 Endometrial hyperplasia with atypia
621.4 Hematometra
621.8 Nonspecified disorder of the uterus
622.1 Disorder of the cervix
622.11 Mild cervical dysplasia
622.12 Moderate cervical dysplasia
625 Pain associated with female genital organs
625.6 Stress incontinence
625.8 Other specified disorder of female genital organs
625.9 Unspecified disorder of female genital organs
626.4 Irregular menstrual cycle
626.9 Disorder of menstruation
627 Menopausal disorder
627.1 Postmenopausal bleeding

Obesity and Surgical Trends for Hysterectomy

OBSTETRICS & GYNECOLOGY

Copyright by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
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