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Among patients who underwent a hysterectomy for benign indications, a later surgical start time lengthened hospital stay and increased blood loss, according to a retrospective cohort study.

Compared with patients whose operations started in the morning, those who underwent a hysterectomy with an afternoon start time had a longer length of stay (difference of 0.3 days, P<0.001) and a lower likelihood of same-day discharge (24% vs 13%, respectively), reported Tara Brah, MD, of the Johns Hopkins School of Medicine in Baltimore.

Additionally, hysterectomies performed in the afternoon had higher levels of blood loss (218 mL vs 181 mL, P<0.001), Brah said in a virtual presentation at the American Association of Gynecologic Laparoscopists annual meeting.

Hysterectomies performed in the afternoon had lower costs, by around $1,400 -- driven mainly by laparoscopic procedures, Brah noted.

"Later start time was associated with increased length of stay and decreased same-day discharge, which has previously been reported in the literature," Brah said. "We did not see any increase in mortality or morbidity associated with surgical start time."

While increased blood loss was observed among hysterectomies that started in the afternoon, this group did not have a higher transfusion rate, Brah added. For this reason, she said that while findings on increased blood loss are statistically significant, they are likely not clinically significant.

"While the underlying mechanism remains unclear, utilization of this information can help with surgical planning to personalize risk reduction and increase same-day discharge," Brah and her colleagues wrote in the abstract of their study. "Further analysis is underway to elucidate the time-of-day cost discrepancies."

The team aimed to analyze whether surgical start time for hysterectomies was associated with perioperative outcomes, and included all hysterectomies performed for benign indications at five hospitals within the Johns Hopkins system from July 2014 to February 2019.

The researchers grouped patients into two groups -- a.m. and p.m. -- based on the start time of their surgery. The investigators evaluated postoperative outcomes and adverse events associated with the procedures, including estimated blood loss, length of stay, blood transfusion, organ injury, and surgical site infections. Hospital costs were also included in the analysis.

Brah's group controlled for confounding factors including year, age, body mass index, race, comorbidities, uterine size, surgical indication, and surgeon subspecialty.

Overall, the researchers included around 2,900 patients; approximately 1,900 hysterectomies were performed before noon, and 984 were performed after noon. Among all hysterectomies, length of stay was 1.2 days, and 20% of patients were discharged on the day of their procedure. The median cost of a hysterectomy was $13,232.

Demographic and perioperative characteristics were similar between the two groups. However, the afternoon group had a higher proportion of hysterectomies performed for fibroids and abnormal uterine bleeding, while the morning group had a higher proportion of endometriosis, pelvic organ prolapse, and prophylactic hysterectomy.

When stratifying hysterectomies by surgical approach, a later start time increased length of stay among open, laparoscopic, and robotic surgeries, but not vaginal procedures. Afternoon start time was associated with higher estimated blood loss only among laparoscopic procedures, and lower costs only in the laparoscopic group as well.

No association was seen between operative time and adverse perioperative events, Brah and co-authors noted.

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