A total of 517 cases were identified and included in the analysis. Table 1 outlines the demographic information of the patients, including body mass index (BMI) and pre-operative hemoglobin. Forty-seven patients (9.09 %) received a perioperative blood transfusion. The need for blood transfusion according to route of hysterectomy was as follows: Total abdominal hysterectomy (TAH): 34/263 (12.92 %), Total laparoscopic hysterectomy (TLH): 5/119 (4.2 %), Laparoscopic assisted vaginal hysterectomy (LAVH): 3/35 (8.57 %), and Vaginal hysterectomy (VH): 5/100 (5.0 %) (Table 2). The mean estimated blood loss (EBL) in a total abdominal hysterectomy was 327.17 cc ± 306.30, which is 187.8 cc, 42 cc, and 128.8 cc greater than the mean EBL noted in TLH, LAVH, and VH, respectively. Hysterectomies performed with the abdominal laparotomy route was a significant risk factor for perioperative blood transfusion (p = 0.012) (Table 2).
Table 1
Demographic characteristics
|
TAH
(n = 263)
|
TLH
(n = 119)
|
LAVH
(n = 35)
|
VH
(n = 100)
|
Age ± SD
|
46.31 ± 9.40
|
46.58 ± 9.41
|
47.2 ± 9.46
|
58.19 ± 9.42
|
BMI in kg/m2 ± SD
|
30.9 ± 7.08
|
28.63 ± 7.13
|
31.44 ± 7.24
|
27.76 ± 7.11
|
Race n (%)
|
|
|
|
|
Hispanic
|
135 (51.5%)
|
81 (68.0%)
|
20 (57.1%)
|
66 (66%)
|
African American
|
84 (31.8%)
|
25(21.0%)
|
7 (20%)
|
15 (15%)
|
Caucasian
|
44 (11.7%)
|
7 (5.8%)
|
7 (20%)
|
14 (14%)
|
Preop Hemoglobin (g/dl)
|
11.17 ± 1.89
|
11.66 ± 1.88
|
11.81 ± 1.90
|
12.29 ± 1.88
|
Preop Hematocrit (%)
|
35.72 ± 5.12
|
36.32 ± 5.10
|
36.98 ± 5.16
|
38.08 ± 5.10
|
Mean uterine weight (g)
|
578.70 ± 795.49
|
279.87 ± 800.85
|
182.26 ± 817.16
|
110.38 ± 797.35
|
Mean post op Hb (g/dl)
|
10.34 ± 1.65
|
10.53 ± 1.65
|
10.79 ± 1.67
|
11.03 ± 1.65
|
Mean post op Hct (%)
|
32.93 ± 4.48
|
32.86 ± 4.50
|
32.66 ± 4.54
|
34.07 ± 4.49
|
Mean EBL cc (SD)
|
327.17 ± 306.30
|
139.38 ± 307.55
|
285 ± 314.22
|
198.35 ± 307.284
|
Received transfusion n (%)
|
34 (12.9%)
|
5 (4.2%)
|
3 (8.5%)
|
5 (5%)
|
Converted to open n (%)
|
-
|
5 (4.2%)
|
3 (8.6%)
|
1 (1%)
|
Intra-op complications n(%)
|
5 (1.9%)
|
1 (0.84%)
|
0 (0%)
|
1 (1%)
|
TAH: Total abdominal hysterectomy, TLH: Total laparoscopic hysterectomy, LAVH: Laparoscopic assisted vaginal hysterectomy, VH: Vaginal hysterectomy. BMI: Body mass index Hb: Hemoglobin, Hct: Hematocrit, EBL: Estimated blood loss
|
Table 2
Type of hysterectomy and the risk of receiving a perioperative blood transfusion.
Hysterectomy Type
|
|
|
Abdominal Hysterectomy
|
34/263 (12.9%)
|
P = 0.012
|
Laparoscopic Hysterectomy
|
5/119 (4.2%)
|
Laparoscopic Assisted Vaginal Hysterectomy
|
3/35 (8.5%)
|
Vaginal Hysterectomy
|
5/100 (5.0%)
|
* Pearson Chi square |
The average uterine weight of those who did not receive a transfusion was 541.40 g ± 795.93 while the average uterine weight of those who required transfusion was 961.43 g ± 810.881. This difference was found to be statistically significant (p = .001) (Table 3). The mean BMI of patients requiring blood transfusion was 32.82 Kg/m2 ± 7.20, while the BMI in the remainder of the cohort not receiving blood transfusion was 29.59 Kg/m2 ± 7.09. This difference was also statistically (p = 0.003) (Table 3).
Table 3
Risk Factors for blood transfusion
|
Transfusion
|
No Transfusion
|
|
Uterine Weight (grams) ± SD
|
961.43 ± 810.881
|
541.40 ± 795.93
|
p = 0.001
|
Preoperative Hemoglobin (g/dL) ± SD
|
9.45 ± 1.92
|
11.76 ± 1.87
|
p < 0.001
|
BMI (kg/m2) ± SD
|
32.82 ± 7.20
|
29.59 ± 7.09
|
p = 0.003
|
Presence of adhesions
|
24
|
70
|
p = 0.026
|
Personal history of c-section
|
13
|
127
|
p = 0.123
|
SD: Standard deviation |
Total abdominal hysterectomy, BMI and uterine size were all found to be statistically significant risk factors associated with need for perioperative blood transfusions during hysterectomy for benign disease.
The pre-operative mean hemoglobin in patients who did not receive a blood transfusion was 11.76 g/dl +/- 1.87, compared to the mean hemoglobin in those who did receive a transfusion (9.43 g/dl+/- 1.92), which was statistically significant (p < 0.001).
There was a statistically significant difference between the presence of adhesions (p = 0.026) and the need of blood transfusion. There was no association between a personal history of cesarean section (p = 0.123) and receiving a blood transfusion.
We explored the correlation between uterine size and risk of receiving a blood transfusion. In the total abdominal hysterectomy group, the average uterine weight in those who did receive a transfusion was 1,196.63 g, while the average weight in those who did not receive a transfusion was 896.33 g. This was not found to be a statistically significant difference (P = .094). When analyzing the patients who had a minimally invasive approach (TLH + LAVH + VH) the average uterine weight of those that received a blood transfusion compared to those who did not was similar (p = 0.87). Therefore, uterine weight was not identified as an independent risk factor for blood transfusion when controlling for route of hysterectomy.
We also looked at the risk of having a blood transfusion based on patient’s race when controlling for type of hysterectomy. Hispanics patients were 1.21 more likely to receive a blood transfusion compared to Black women (OR 1.12), however the difference was not statistically significant (p = 0.71) (Table 4). When looking at risk of conversion to laparotomy of patients who had a laparoscopic approach (TLH + LAVH) based on race, it was noted that Hispanic women were 0.2 times more likely to undergo conversion to laparotomy, and this value was considered statistically significant ( p = 0.01) (Table 5).
Table 4
Risk of blood transfusion based on patient’s race
|
Transfusion
|
No Transfusion
|
Odds Ratio
|
P value
|
White (as control)
|
5 (10.64%)
|
53 (12.07%)
|
0.14
|
0
|
Black
|
14 (29.79%)
|
114 (25.97%)
|
1.12
|
0.83
|
Hispanic
|
28 (59.57%)
|
114 (25.97%)
|
1.21
|
0.71
|
|
P = 0.84
|
|
|
|
Table 5
Risk of conversion to laparotomy based on patient’s race
|
Number Converted
|
Odds Ratio
|
P value
|
White (n/a no conversion)
|
0
|
--
|
--
|
Black (as control)
|
|
0.07
|
0
|
Hispanic
|
|
0.2
|
0.01
|