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Preoperative Evaluation/Patient Issues/Outpatient Vaginal Hysterectomy

QUESTION:

We are considering doing vaginal hysterectomies at our outpatient ambulatory center. Concerns are related to potential blood loss and post-op pain management. Are there any guidelines regarding doing vaginal hysterectomies at an ASC? This includes both laparoscopic assisted and regular vaginal hysterectomy, and would include a 24 hour stay.

At our facility, 95% of our cases are done as outpatients, being discharged directly from the facility, usually within one hour of their surgery. However, on occasion we do a case that requires the patient stay overnight in the facility, where they are monitored and attended to by an RN, with the backup of a physician available by phone. This is usually procedures such as laparoscopic cholecystectomy and shoulder surgery. The patient usually stays overnight for pain management, especially if they live a distance from the center. There is also an occasional patient that has uncontrolled nausea and/or vomiting, and they also stay until that is controlled.

Therefore, I would predict that a high percentage of vaginal hysterectomy patients would require 24 hour stay to observe for bleeding and/or pain control with the option of transferring to the hospital (which is just across the street) if necessary.

-- From William E. Strong, M.D., Provo, UT

REPLY:

You have mentioned that your group is considering doing laparoscopic assisted and regular vaginal hysterectomy at your ambulatory surgical center and that it would include keeping the patient at your facility for 24 hours after surgery. As you have correctly pointed out, postoperative monitoring and observation by a registered nurse, with physician back-up would be necessary. I am not aware of any guidelines for doing vaginal hysterectomy at an ASC facility. However, I know of gynecologists who work out of private hospitals and send their patients home the day after undergoing laparoscopic assisted/regular vaginal hysterectomy, if the patients are stable. Obviously, you have to ensure that the patient does not have any ongoing or anticipated bleeding, is hemodynamically stable, is comfortable with adequate pain control, does not have any nausea/vomiting, is preferably voiding urine voluntarily, and is awake, alert, and oriented before discharge from your ASC facility the morning after surgery. It is reassuring that you have the option of transferring patients to the hospital, across the street, if needed.

-- From Ashu Wali, M.D., F.F.A.R.C.S.I., Houston, TX

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