Downloaded from http://journals.lww.com/greenjournal by BhDMf5ePHKbH4TTImqenVHwXmMsAVI5g6hwYQxiXmrM/W8kbmFuaiF0l6zu4lp2P on 10/13/2020 Original Research Risk Factors for Bowel Injury in Hysterectomy for Benign Indications Cici R. Zhu, MD, Ranjeeta Mallick, PhD, Sukhbir S. Singh, MD, Rebecca Auer, MD, MSc, Jonathon Solnik, MD, Abdul Jamil Choudhry, MBBS, MSc, and Innie Chen, MD, MPH OBJECTIVE: To estimate the incidence and risk factors for bowel injury in women undergoing hysterectomy for benign indications. METHODS: A retrospective cohort study was conducted among women undergoing hysterectomy for benign indications from 2012 to 2016 at institutes participating in the American College of Surgeons National Surgical Quality Improvement Program, including both inpatient and outpatient settings. Bowel injury was identified using Current Procedural Terminology codes as patients who underwent bowel repair at the time of hysterectomy or postoperatively within 30 days. Multivariate logistic regression models were used to control for patient clinical factors and perioperative factors. RESULTS: Bowel injury occurred in 610 of 155,557 (0.39%) included women. After bivariate analysis, factors associated with bowel injury included age, race, body mass index, American Society of Anesthesiologists clas- sification, increased operative time, surgical approach, type of hysterectomy, lysis of adhesions, and operative indication. After adjusting for potential confounders, bowel injury was found associated with older age, surgical indication of endometriosis, and abdominal surgical approach. Compared with the surgical indication of endometriosis (n563/10,625), the surgical indications of menstrual disorder (odds ratio [OR] 0.33, 95% CI 0.23– 0.47; adjusted odds ratio [aOR] 0.33, 95% CI 0.23–0.48; n567/34,168), uterine leiomyomas (OR 0.80, 95% CI 0.61–1.05; aOR 0.44, 95% CI 0.33–0.59; n5243/51,232), and genital prolapse (OR 0.30, 95% CI 0.20–0.45; aOR 0.41, 95% CI 0.25–0.67; n536/20,384) were each associ- ated with lower odds of bowel injury. Compared with the vaginal approach to hysterectomy (n527/27,434), the abdominal approach was found to have significantly increased odds of bowel injury (OR 10.80, 95% CI 7.31– 15.95; aOR 10.49 95% CI 6.42–17.12; n5401/38,106); the laparoscopic approach had smaller but significantly increased odds (OR 2.06, 95% CI 1.37–3.08; aOR 2.03 95% CI 1.24–3.34; n5182/90,017) as well. CONCLUSION: Increased risk of bowel injury is associ- ated with endometriosis and the abdominal surgical approach to hysterectomy. These findings have implica- tions for the surgical care of women with benign uterine disease. (Obstet Gynecol 2020;136:803–10) DOI: 10.1097/AOG.0000000000004007 V isceral injuries have been identified as major intra-operative complications of hysterectomy. 1 Though predictors of urologic and neurologic injuries during hysterectomy and other gynecologic proce- dures have been extensively reported, 2–5 factors asso- ciated with bowel injury have not been sufficiently studied. Iatrogenic bowel injuries are reported in 0.1–1% of women undergoing hysterectomy; and with a large number of hysterectomies performed, total cases become substantial. 4,6–8 Two systematic reviews From the Department of Obstetrics and Gynecology, University of Ottawa, the Ottawa Hospital, the Ottawa Hospital Research Institute, and the Departments of Surgery and Biochemistry, Microbiology, and Immunology, University of Ottawa, the Ottawa Hospital, Ottawa, and the Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada. Innie Chen is supported by the University of Ottawa Clinical Research Chair in Reproductive Population Health and Health Services, the Canadian Institutes for Health Research, and Physicians’ Services Incorporated Foundation to conduct this research. Presented as a poster at the 47th American Association of Gynecologic Laparos- copists (AAGL) Global Congress, November 11–15, 2018, Las Vegas, Nevada, and at the Society of Endometriosis and Uterine Disorders Congress, May 16–18, 2019, Montreal, Canada. Each author has confirmed compliance with the journal’s requirements for authorship. Corresponding author: Innie Chen, MD, MPH, the Ottawa Hospital, Ottawa, Ontario, Canada; email: ichen@toh.ca. Financial Disclosure Dr. Singh reports grants and personal fees from Bayer, AbbVie, Hologic, and Allergan and personal fees from Cooper Surgical, outside the submitted work. Dr. Solnik reports other financial support from Medtronic, Allergan, AbbVie and Hologic, outside the submitted work. The other authors did not report any potential conflicts of interest. © 2020 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/20 © 2020 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. VOL. 136, NO. 4, OCTOBER 2020 OBSTETRICS & GYNECOLOGY 803