Hysterectomy enters the outpatient portfolio at MEDARVA Stony Point Surgery Center

Since last spring, the Richmond, Va.-based MEDARVA Stony Point Surgery Center has been providing patients with an unexpected outpatient procedure — uterine removal.

"We were doing a few of these hysterectomies a week, where patients were spending the night in the hospital," says Keith Berkle, MD, a gynecologic surgeon at the center, who is also on staff at the medical center Virginia Women's Center. "We send patients home after almost every other laparoscopic procedure we do — so why do these patients have to stay in the hospital?"

Today, Dr. Berkle performs same-day hysterectomies to treat patients with chronic pelvic pain, endometriosis, uterine fibroids and severe vaginal bleeding. "The question wasn't 'why should we do this as an outpatient procedure?'" Dr. Berkle says. "The question was: 'why aren't we?'"

Hysterectomy is the second most common surgery among women in the United States, according to the U.S. Department of Health and Human Services' Office on Women's Health. It's standard for a patient to spend one to two days in the hospital after the procedure, with an additional three to six weeks of recovery time. But by using a mix of minimally invasive surgery, pain management and comprehensive patient care, Dr. Berkle has been able to send patients on their way home in fewer than four hours. He even says many women he treats are able to return to work within two weeks of the procedure.

"We're not cavalier about these surgeries at all, and we know not every patient is going to be a candidate for an ASC," says Bruce Kupper, CEO of MEDARVA Stony Point Surgery Center. "But as patients are becoming better consumers and more knowledgeable about things like exposure to infectious diseases in the hospital setting, we're finding patients are saying, to put it in a crude way: 'I'd rather be home with my own germs than be commingled with somebody else's.'"

To lay the groundwork for outpatient hysterectomy, staff at MEDARVA Stony Point Surgery Center ensured the center had proper instrumentation on hand, confirmed CPT codes for the procedures were authorized in insurance contracts and "trusted the judgement of their gynecologists," according to Mr. Kupper.

"Our gynecologists make the judgement of who they think is appropriate for the outpatient procedure," Mr. Kupper says. "And they do it well."

The shift into the outpatient setting begins with surgical technique — gynecologists at the center use minimally invasive laparoscopic incisions, which allow them to remove the uterus using a few centimeter-long incisions in strategic spots on a patient's abdomen. This method contrasts abdominal hysterectomy, which uses one large vertical incision.

"Being able to do laparoscopic hysterectomies really accelerates healing and removes a lot — not all, but a lot — of the infection complications, the bleeding complications and the wound breakdown complications that come with the large, C-section-type incisions used in abdominal hysterectomy," Dr. Berkle says.

Following the roughly two-hour procedure, patients spend about an hour in the center's recovery room. "The nice thing about doing the procedure at an ambulatory surgery center, as opposed to a hospital, is that nurses in recovery are really sharing in the goal of doing an outpatient procedure," Dr. Berkle says. "They're not scared to manage pain aggressively and to take patients a little out of their comfort zone in terms of getting up and walking around.

"In hospitals, we oftentimes see if things aren't going quite perfect, patients can be pressured from the recovery room staff to 'just spend another night' in the hospital," he continues. "There's really a shift in thinking about what we're able to accomplish at an ambulatory surgery center."

While surgical technique is important, staff at MEDARVA Stony Point Surgery Center stress that one often overlooked aspect of patient care is key: expectation management. "It's making sure that the patient knows what the experience is going to be like," Dr. Berkle says. "Saying, 'listen, you're going to have some discomfort when you go home — this is surgery.'

"But you can go home after you get our wisdom teeth out, you can go home after you get your tubes tied; there's no reason you can't go home after a hysterectomy," he concludes. "You just have to manage expectations and make sure the patient knows you're with them every step of the way."

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