Objective
The purpose of this study was to estimate the incidence of postoperative pulmonary complications after hysterectomy for benign indications.
Study Design
This was a retrospective cohort study of all women who underwent hysterectomy for benign indications at the Cleveland Clinic from Jan. 1, 2001, to Dec. 31, 2009. Exclusion criteria incorporated patients who underwent hysterectomy for premalignant or malignant conditions. Pulmonary complications were defined as postoperative pneumonia, respiratory failure, atelectasis, and pneumothorax based on International Classification of Diseases , Ninth Revision, codes.
Results
In the 9-year study period, 3226 women underwent hysterectomy for benign indications (abdominal, 38.4%; vaginal, 39.3%; laparoscopic, 22.3%). Ten of the 3226 women (0.3%; 95% confidence interval, 0.17–0.57%) who underwent hysterectomy were identified with postoperative pulmonary complications. Among the different types of hysterectomy, the incidence of pulmonary complications was not different (total abdominal hysterectomy, 0.9%; vaginal hysterectomy, 0.12%; laparoscopic hysterectomy, 0.9%; P = .8).
Conclusion
The incidence of postoperative pulmonary complications after hysterectomy for benign indications is low.
Postoperative pulmonary complications are one of the most frequent causes of postoperative morbidity and death. Hospital-acquired pneumonia is one of the major nosocomial infections to be found in postoperative patients and is the third most common nosocomial complication, after surgical site infection and urinary tract infection. When patients undergo general anesthesia, intubation causes the chest motion and shape to change, which leads to alterations in dependent lung regions and results in atelectasis. Although laparoscopy is a relatively safe procedure, patients may experience complications because of insufflation, which include mediastinal emphysema, pneumothorax, and pneumomediastinum. Despite the high frequency of postoperative pulmonary complications and the extensive general surgery literature, the number of publications regarding these events after gynecologic surgery is limited (MEDLINE, January 1966 to June 2012; English language; search terms: pulmonary complications , gynecology , and hysterectomy ). In one study, 2.16% of patients who underwent general open gynecologic surgery experienced postoperative pulmonary complications. Hysterectomy in itself was not assessed specifically, and routes were not compared. In another retrospective study that assessed patients who underwent laparoscopic gynecologic procedures, the rate of postoperative pulmonary complications was 2.3%; however, oncology patients were included in this cohort.
Multiple risk factors, which may increase a patient’s chances of experiencing postoperative pneumonia, include cigarette smoking, advanced age, previous antibiotic exposure, endotracheal intubation, and alcohol consumption. In the early postoperative period, residual anesthesia may cause patients to accumulate oropharyngeal secretions or to experience tissue edema of the upper airway. In addition, general anesthesia patients are placed in the supine position, which increases aspiration risk. After surgery, patients may have difficulty taking deep breaths because of pain that leads to atelectasis. It has been shown that pain scores, lung function tests, and the ability to ambulate are increased in patients who undergo laparoscopic hysterectomy vs abdominal hysterectomy.
The objective of our study was to estimate the incidence of postoperative pulmonary complications after hysterectomy for benign indications and to compare the incidence of pulmonary complications after laparoscopic, vaginal, and total abdominal hysterectomies.
Materials and Methods
After institutional review board approval was obtained, all hysterectomies that were performed by the members of the Women’s Health Institute at the Cleveland Clinic from Jan. 1, 2001, to Dec. 31, 2009, were identified using International Classification of Diseases , Ninth Revision (ICD-9) codes and were then reviewed by the electronic medical record. The electronic medical record was examined to confirm the occurrence of postoperative pulmonary complications. For this analysis, pulmonary complications were defined as a diagnosis of postoperative pneumonia, respiratory failure, atelectasis, or pneumothorax within 365 days of the procedure. Postoperative pneumonia was defined as postoperative fever of >38.0°C, elevated white blood cell count >12.0 k/μL, productive cough, and/or diagnosis of pneumonia by chest x-ray or computed tomography of the chest. The definition of respiratory failure included the requirement ventilator support after surgery or surgical intensive care unit (SICU) admission for respiratory assistance. Symptomatic atelectasis was defined as the requirement of intervention, such as bronchoscopy, respiratory therapy consultation, or SICU admission for a respiratory indication. Pneumothorax was defined as presentation on radiographic findings (chest x-ray or computed tomography of the chest). Although pulmonary embolism is an important postoperative surgical complication, we decided not to include this complication because of the nature of pulmonary embolism starting as a problem of coagulopathy that then is found in the pulmonary system. The other reason we did not include pulmonary embolism in this patient population is that the incidence has been published in the literature by 1 of the authors of this article.
The timeframe for postoperative pulmonary complications was treatment or readmission for 1 of these 4 diagnoses within 365 days after surgery. Among those subjects who experienced postoperative pulmonary complications, inpatient and outpatient diagnoses and radiology reports were reviewed for information on the surgical procedure that had been performed and the patient’s postoperative course. Charts were abstracted through all visits up to Dec. 31, 2009. No charts had incomplete information. The diagnosis of postoperative pulmonary complications that were gathered from ICD-9 codes overestimated the number of pneumonias by 10 patients, atelectasis by 15 patients, pneumothorax by 4 patients, and respiratory failure by 101 patients.
To validate the Current Procedural Terminology codes with the correct diagnosis, we conducted an electronic medical record review on every chart to be certain that the Current Procedural Terminology code that was recorded matched the actual diagnosis within the electronic patient chart. If the patient did undergo hysterectomy, patient demographics and surgical history, type of hysterectomy, type of incision, concomitant procedures, and length of follow-up period at our institution were also collected. The route of hysterectomy was recorded as laparoscopic, vaginal, or abdominal. Laparoscopic hysterectomies included laparoscopic vaginal hysterectomy, laparoscopic supracervical hysterectomy, and total laparoscopic hysterectomy and all robotic-assisted hysterectomy cases. Any procedure that was not intended initially to be performed transabdominally, but was eventually completed by an abdominal incision, was considered an abdominal hysterectomy. Incision type was recorded for the abdominal approach and included Pfannenstiel, Maylard, Cherney, and midline vertical laparotomy incisions. During this chart review, we excluded patients who were <18 years old, who had had gynecologic surgery for malignancy, who had had combined benign gynecology and thoracic operations, who had undergone combined benign gynecology and upper abdominal operations, or who had incomplete medical records.
Using statistical software (JMP, version 9.0; SAS Institute, Cary, NC), we calculated the frequency and 95% confidence interval of postoperative pulmonary complication incidence. Visual evaluation of the data was performed with a histogram and statistician. Skewed data were represented with medians and ranges where appropriate. Fisher exact test was used to evaluate the relationship between postoperative pulmonary complications and categoric variables; the rank-sum Wilcoxon test was performed to evaluate the relationship between postoperative pulmonary complications and continuous variables.
Results
A total of 4435 women underwent hysterectomy at the Women’s Health Institute at the Cleveland Clinic from Jan. 1, 2001, to Dec. 31, 2009. Of these, 3226 women underwent hysterectomy for benign indications (abdominal, 38.4%; vaginal, 39.3%; laparoscopic, 22.3%). A total of 36 surgeons performed the hysterectomies during the 9-year period. Nine of the 3226 patients (0.3%; 95% confidence interval [CI], 0.17–0.57%) who underwent hysterectomy were identified as having experienced a postoperative pulmonary complication. One patient experienced 2 complications. Among hysterectomy types, the incidence of pulmonary complication was not statistically significant: total abdominal hysterectomy, 0.9% (95% CI, 0.03–0.27), vaginal hysterectomy, 0.12% (95% CI, 0.05–0.32), and laparoscopic hysterectomy, 0.9% (95% CI, 0.03–0.27; P = .8). The study population had a mean age of 52.3 ± 12 years in the patients without pulmonary complications vs 54.8 ± 13 years in the patients with pulmonary complications, which was not significant ( Table 1 ). This analysis also included 1244 (38.2%) women who underwent at least 1 prolapse and/or incontinence procedure ( Table 2 ). Most patients who underwent prolapse or incontinence procedures had vaginal hysterectomy (77.2%). The mean length of stay for patients without pulmonary complications was 2.32 ± 1.4 days vs 4.10 ± 2.3 days in the patients with pulmonary complications ( P = .0001; Table 3 ).
| Variable | Patients with no postoperative pulmonary complications (n = 3216) | Patients with postoperative pulmonary complications (n = 10) | P value |
|---|---|---|---|
| Age, y a | 52.3 ± 12 | 54.8 ± 13 | .52 |
| Body mass index, kg/m 2 a | 29.6 ± 7 | 29.5 ± 5 | .97 |
| Race/ethnicity, n (%) | .90 | ||
| African American | 803 (24.9) | 4 (0.5) | |
| Asian/Pacific Islander | 22 (0.68) | 0 | |
| White | 2311 (71.9) | 6 (0.3) | |
| Hispanic | 32 (1.0) | 0 | |
| Other/unknown | 46 (1.4) | 0 | |
| Tobacco use, n (%) | .70 | ||
| Never used | 1679 (52.1) | 5 (0.15) | |
| Never assessed | 271 (8.4) | 0 | |
| Passive | 11 (0.3) | 0 | |
| Quit | 903 (28.0) | 4 (0.12) | |
| Yes | 352 (10.9) | 1 (0.03) | |
| Pack years, n a | 4.1 ± 10 | 8.9 ± 13 | .29 |
| Sexually active, n (%) | .10 | ||
| No | 352 (10.1) | 2 (0.06) | |
| Not asked | 705 (21.85) | 2 (0.06) | |
| Not currently | 475 (14.72) | 4 (0.12) | |
| Yes | 1686 (52.26) | 2 (0.06) |
| Variable | Patients without postoperative pulmonary complications (n = 3116) | Patients with postoperative pulmonary complications (n = 10) | P value |
|---|---|---|---|
| Prolapse procedure, n (%) | |||
| Sacrospinous ligament fixation | 27 (0.84) | 1 (0.03) | .07 |
| Uterosacral vaginal vault suspension | 751 (23.28) | 3 (0.09) | .41 |
| McCall’s | 661 (20.49) | 2 (0.06) | .97 |
| Abdominal sacrocolpopexy | 74 (2.29) | 0 | .50 |
| Anterior/posterior repair | 953 (29.50) | 2 (0.06) | .49 |
| Incontinence procedure, n (%) | |||
| Sling | 560 (17.34) | 1 (0.03) | .51 |
| Burch | 116 (3.60) | 0 | .39 |
| Suprapubic tube | 410 (12.70) | 0 | .10 |
| Adnexectomy, n (%) | 1398 (43.30) | 3 (0.09) | .38 |
| Lysis of adhesions, n (%) | 433 (13.40) | 2 (0.06) | .85 |
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