Physician Risk Estimation of Operative Time: A Comparison of Risk Factors for Prolonged Operative Time in Robotic and Conventional Laparoscopic Hysterectomy Jose Carugno, MD, Anthony Gyang, MD, Frederick Hoover, MD, Kelly Taylor, RN, and Georgine Lamvu, MD, MPh Abstract Objective: The Physician Risk Estimation of Operative Time (PREOpT) project is an effort to identify patient characteristics associated with prolonged operative time in patients undergoing robotic or conventional lapa- roscopic total hysterectomy. Methods: A retrospective cohort study of 1290 cases of robotic and conventional laparoscopic total hysterectomy was performed over 2 years. Univariate, bivariate, and predictive analysis were performed to determine associations between patient characteristics and prolonged operative time. Setting: The study was performed in urban gynecologic practices in a tertiary care teaching hospital. Results: Of 1290 patients who underwent minimally invasive hysterectomy, 732 patients had conventional laparoscopic hysterectomy (TLH) and 558 had robotic hysterectomy (RTH). Prolonged operative time was defined as ‡ 180 minutes. Mean operative time for all cases was 115.79 minutes (standard deviation [SD] – 60.37). Obesity was associated with increased operative time (odds ratio [OR] = 2.33, 95% confidence interval [CI] 1.40–3.89). Patients with history of myomectomy had 2.77 increased odds of prolonged operative time (95% CI 1.42–5.4; p = 0.003). If the myomectomy was performed laparoscopically, the OR was 3.76 (95% CI 1.30–11.01; p = 0.015), but if it was performed via laparotomy, the odds increased to 4.15 (95% CI 1.40–12.32; p = 0.01. This effect disappeared when a surgeon with a high volume of patients performed the surgery. ‘‘High volume’’ surgeons had a 56% reduced risk of long operative time OR = 0.44 (95% CI 0.31–0.63). Conclusions: Obesity, large uterine size, previous history of myomectomy, and lack of surgeon experience were associated with long operative time in patients undergoing laparoscopic or robotic hysterectomy for benign disease. ( J GYNECOL SURG 30:15) Introduction H ysterectomy is the most common major gynecologic surgical procedure performed in the United States, with almost 600,000 cases performed each year. 1,2 By the age of 70, *45% of women have undergone hysterectomy. 3 Although the rate of abdominal hysterectomy has been decreasing, more than two thirds of hysterectomies are still being performed through an abdominal incision, despite this being the most in- vasive modality. 2 Many studies have demonstrated that when performing a hysterectomy for benign disease, and the vaginal route is not feasible, a minimally invasive approach is associ- ated with lower perioperative morbidity, shorter hospital stay, faster postoperative recovery, and earlier return to normal activities when compared with abdominal hysterectomy. 4–8 Unfortunately, the general gynecologic community has not embraced laparoscopic hysterectomy. The limitations in performing total laparoscopic hysterectomy (TLH) mainly relate to the learning curve associated with this procedure, as laparoscopic techniques require extensive training. 9,10 Difficult hand–eye coordination, a restricted range of motion with non-articulated instruments, two-dimensional vision, and a steep learning curve can make the procedure cum- bersome, and in some cases, time consuming. Also, mayor complications such as vascular injury, or intestinal or uro- logic complications may occur. Robotic-assisted laparoscopy was introduced to improve the shortcomings of conventional laparoscopy. Although this system does not eliminate the need for energy devices, it offers features such as high-resolution three-dimensional (3D) view, and a wrist-like motion of the robotic arm, which provides finer and more dexterous movements. Improved ergonomics may result in faster learning curves, enabling more surgeons to offer a minimally invasive approach to a broader patient population and potentially reducing the rate of abdominal hysterectomies. 11–13 Division of Advanced & Minimally Invasive Gynecology, Department of Graduate Medical Education, Florida Hospital, Orlando, FL. JOURNAL OF GYNECOLOGIC SURGERY Volume 30, Number 1, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/gyn.2013.0037 15