OB/Gyn

Episode 11.1 Smarter Hysterectomies, Lower Costs

Jamie Perry joins this episode as we share ten standout women’s health breakthroughs from 2025 and then get practical about value in endoscopic hysterectomy. The focus is simple: cut waste, save time, protect quality, and expand access through better selection, technique, and team flow.

• Key 2025 breakthroughs shaping care and counseling
• Why OR time outweighs device price
• Preference cards as a lever to reduce waste
• Three-arm robotics and smarter instrument choices
• Laparoscopic tips: barbed suture, simulation, quadrant workflow, vessel skeletonization
• Robotic tips: patient selection, docking discipline, turnover efficiency, data tracking
• Same-day discharge and ERAS as non-negotiables
• When vaginal route is truly better and why referrals matter

Links Discussed

Transcript

ANNOUNCER: 0:01

Welcome to Thinking About OBGYN. Today’s episode features Howard Herrell and Jamie Perry discussing endoscopic hysterectomy.

JAMIE: 0:15

Howard?

HOWARD: 0:16

Jamie?

JAMIE: 0:17

What are we talking about on today’s episode?

HOWARD: 0:20

Well, we’re going to talk a little bit about robotic and laparoscopic hysterectomy.

JAMIE: 0:25

Oh, for you to beat up on them.

HOWARD: 0:27

No. No. For our guests, let me introduce Jamie Perry, who does robotic and laparoscopic hysterectomies. We’re not going to debate the merits of laparoscopic robotic hysterectomy compared to the gold standard vaginal hysterectomy. I realize that not everyone does vaginal hysterectomy. It pains me. I cry at night many times as I lay there thinking about it. But if folks are going to do laparoscopic or robotic hysterectomies, then it can we can at least talk about some ways of being more cost efficient and environmentally sustainable and improving their techniques a little bit, can’t we?

JAMIE: 1:06

Oh, you’re really serious, aren’t you?

HOWARD: 1:08

Yes. We’re going to talk about laparoscopic and robotic hysterectomy.

JAMIE: 1:11

Okay.

HOWARD: 1:12

Now Antony and I talked about this article that had 12 steps towards sustainability in gynecologic surgery, and they had an accompanying video that was in the Green Journal on the last episode, and that starting point for talking about sustainability and cost effectiveness in laparoscopic and robotic surgery. So I thought we would work on that and build on that. I realized over the last couple of years that quality and environmental sustainability and then value and cost effectiveness, as well as access to care and economic sustainability, they’re all actually parallel ideas and they walk hand in hand with each other.

JAMIE: 1:52

Okay. I am all here for this. However, you’re not allowed to mention vaginal hysterectomy this entire episode.

HOWARD: 2:00

Okay. I can do that. I won’t say anything about vaginal hysterectomy being the cheapest and most environmentally sustainable, cost-effective method of hysterectomy.

JAMIE: 2:10

Okay, there it is. Do you feel better now?

HOWARD: 2:13

A little bit. Okay, but first we’re starting 2026, and I thought we could do a quick little review. There’s like a David Letterman top 10 list. The listeners are too young to know who David Letterman was. But the ten most important scientific discoveries that relate to women’s health of 2025 as selected by us randomly.

JAMIE: 2:34

In no particular order.

HOWARD: 2:36

Yeah. Well, time will tell how they actually rank in the future and which ones we missed. And listeners can let us know which big things we missed.

JAMIE: 2:44

Okay, let’s do this.

HOWARD: 2:46

Would you like to go first?

JAMIE: 2:48

I would.

HOWARD: 2:49

Alrighty.

JAMIE: 2:50

First on our top 10 list is dual receptor inhibition from menopause. The FDA approval of LNZENITANT in October 2025 represents a major scientific shift in treating vasomotor symptoms, particularly hot flashes. Unlike traditional hormone therapy, this drug is the first to target both the NK1 and the NK3 receptors in the hypothalamus. By modulating the brain’s temperature-regulating neurons directly, it provides a highly effective but non-hormonal alternative for women who can’t take estrogen.

HOWARD: 3:21

Okay, so this is different than VIOSA that we’ve had for two, three years now.

JAMIE: 3:25

Right. VIOSA or phesolinatin only antagonizes the NK3 receptor. And this new drug targets both NK1 and NK3.

HOWARD: 3:36

And how much does it cost?

JAMIE: 3:38

You are such a tight wad. So VIOSA is about$675 a month retail. Linquit is about$775 a month retail. And estradiol is$10 a month retail. So of course the vast majority of patients should still use estradiol, but for ones that have true contraindications and severe vasomotor symptoms, it’s nice to have alternatives.

HOWARD: 4:00

All right. And do we know if targeting both receptors, the NK1 and NK3, is that better than just targeting NK3 or is it high?

JAMIE: 4:09

We don’t know for sure yet. There aren’t any head-to-head studies at this time. But there was an article in the March 2025 Green Journal that made the case that dual receptor blockade provides superior benefit to patients and also just makes biologic sense that it would. Okay, your turn.

HOWARD: 4:26

All right. Well, number two is non-hormonal targets for endometriosis. And specifically, if you’re looking for this drug, it’s called HMI 115. So research into HMI 115 is it’s actually an antibody that targets a prolactin receptor, and it’s shown that it can shrink endometriosis lesions and reduce pain without suppressing sex hormones. It’s non-hormonal, at least in the in the sex hormone sense. There was a phase two trial published in Lancet obstetrics and gynecology in Women’s Health Journal in November of 2025 that used this human monoclomal antibody to block the prolactin receptor in patients who had endometriosis. And the study involved just 108 women, it’s a phase two trial, but they were randomized to different doses of this antibody versus placebo. And they found significant relief for women with moderate to severe endometriosis. Sounds like a commercial. So this is potentially exciting because it would be a completely non-hormonal treatment and a treatment that doesn’t interfere with the ovary or natural sex hormones or have any of the side effects of a pseudomenopausal state. So we’ll undoubtedly see three phase three trials very soon.

JAMIE: 5:37

But why prolactin is the target?

HOWARD: 5:40

Well, yeah, there’s a lot of background interesting research there, but patients with endometriosis have dysregulation of prolactin signaling, and they have augmented endometrial prolactin synthesis and aberrant prolactin receptor activation. So we think that these are some key issues related to the pathogenesis of endometriosis as we learn more, and so they decided to look at this as a therapeutic target. So, all right, your turn.

JAMIE: 6:05

Okay, so number three is the four biological subtypes of PCOS. In a breakthrough study published in Nature Medicine, researchers identified four distinct subgroups of polycystic ovarian syndrome, PCOS. Using machine learning to analyze clinical data, they categorize the condition into four subtypes. One hyperandrogenic PCOS with high risk of second trimester pregnancy loss and dyslipidemia. The second being PCOS with obesity with the most severe metabolic complications and lowest life birth rates. Third is PCOS with high sex hormone binding globulin, which had the most favorable reproductive outcomes and the lowest incidence of diabetes and hypertension. And the fourth being PCOS with high luteinizing hormone or antimalarian hormone with the greatest risk of ovarian hyperstimulation and the lowest remission rate. This discovery moves PCOS treatment away from the one-size-fits-all approach often used and allows us to predict IVF success and metabolic risk more accurately for individual patients. It’s been clear to all of us that PCOS is not one disease, but this research will likely lead to individualization and categorization and treatment and risk assessments. So we may be changing the entire conversation around PCOS in the next few years. Number four?

HOWARD: 7:25

All right. So we’ve gone back and forth over the effects of hormone replacement therapy on dementia, things like that. So a new analysis from major trials this year validated what people call the timing hypothesis. And the science seems to be clear that the neuroprotective benefits of hormone therapy are heavily dependent on when you start it. So starting therapy during perimenopause or early postmenopause significantly lowers biomarkers, at least, for Alzheimer’s and reduces cardiovascular risk. But waiting to start it until later in life doesn’t offer the same protection. So this discovery emphasizes that timing is critical for long-term cognitive and heart health. The elite trial and then a subsequent 2025 analysis provided definitive evidence that the benefits of hormone replacement therapy, or menopausal hormone therapy is a new buzzword in the menopause journal, are highly dependent on timing. So it confirms that starting it during perimenopause or early menopause will lower these risks, and starting it later, either doesn’t offer the same neuroprotective effects or at least in the case of heart disease may increase your risk. So this is where we’ve been heading for a long time that starting hormones at around the time of menopause or perimenopause is a completely different thing than starting at, say, 65. So more confirmation, at least, about the neuroprotective benefits. Number five?

JAMIE: 8:55

Number five is a discovery that is all about empowering women and increasing access. The widespread clinical validation and FDA approval of the at-home self-collection kits for HPV testing has really changed cervical cancer prevention. Studies in 2025 proved that a swab you collect yourself in the privacy of your own home is just as accurate as one collected by a doctor. So that’s removing a huge barrier to many patients, the pelvic exam for just an accurate sample that the doctor could have collected. This is a massive step forward in privacy and is expected to drastically reduce cancer mortality rates by making screening accessible to so many more people. There are, of course, self-collection swabs, and our guidelines are shifting towards HPV primary screening. So we are witnessing the end of the PAP smear, perhaps, as we traditionally understood it for cervical cancer screening. Number six.

HOWARD: 9:49

I will say that the current guideline about these self-collected swabs is every three years if it’s self-collected, and every five years if it’s clinician collected. So for the next little while, women will have a choice of getting it collected with a speculum, essentially, or doing it for themselves. And it’s invern for now, it’s three years if self-collected. So still something that people can do potentially at home or just for themselves in the office.

JAMIE: 10:16

Right.

HOWARD: 10:17

All right. Number six is a brilliantly simple concept that goes back to endometriosis again and could end years of suffering without a diagnosis. So the establishment of the Amber Bank, this is the Australian Menstrual Fluid Biobank, has led to a lot of things, but it led to the discovery of specific metabolic markers and stem cells in menstrual fluid that can identify endometriosis without surgery. So by analyzing menstrual fluid, they were able to find specific markers, stem cells, that can indicate that patient has endo, and that, of course, will pave the way for a simple non-invasive diagnostic test without surgery. And then could finally end the agonizing average seven-year delay that many women face before getting a diagnosis. So we may soon be at a time where you have both a non-surgical diagnosis for endometriosis available and then treatment for endometriosis that’s perhaps non-hormonal and non-surgical. And so both of those could be very common in five to ten years, let’s say. Number seven?

JAMIE: 11:22

Number seven, we have innovation and advice that really hasn’t changed much in decades, the copper IUD. For many women, the trade-off for having reliable hormone-free birth control was heavier bleeding and cramping. Material science has finally solved this with the approval of MyUDELA by using a super flexible nitinol frame that’s a nickel titanium alloy and significantly less copper. This new IUD is designed to be far more comfortable. It addresses the big complaints about traditional copper IUDs, giving a modern, long-term, but non-hormonal option that many women can actually tolerate. And this will be used in the near future as well, potentially for hormonal IUDs. Number eight.

HOWARD: 12:21

So this isn’t just a standard screen. It looks at thousands of RNA messages from the placenta floating in the maternal blood and identifies the molecular signature of preeclampsia with pretty good accuracy. And it was able to determine 91% of patients who would go on to develop preeclampsia months before they would. This is different than some of the tests that you’re seeing being marketed now that are helpful for a week or two. This is months in advance. So is there a benefit to that? Well, it can lead to exciting new research opportunities. If you know that a person is very likely to get preoclampsia in the future, there’ll be all sorts of interventions that can be tested to help prevent preocclampsia, but also it can help divide patients truly into a low and high-risk cohort so that lower risk patients have less visits, less interventions, things like that than they currently might. Most of our prenatal care system is still built around screening for hypertension, and this might help us discern who needs more intensive prenatal care and who needs less intensive prenatal care. Number nine.

JAMIE: 13:25

At number nine, we have a testament to the incredible advancements in neonatal care. In 2025, the threshold of viability for extremely premature infants or micropremes has been successfully pushed to 22 weeks. Through discovery of novel surfactant therapies and highly specialized ventilation strategies this year, doctors are not just saving babies born at the absolute edge of survival, but significantly improving their long-term health outcomes. You all have talked about this on the podcast sum in the last year, but it’s incredible how far this has come, even in the last three or four years. And of course, now that we have artificial womb technology and clinical trials, can take this even to the next level. I think that it’s not just about the edge of survivability, but in a world where 22-week babies are now able to survive, but even the 23 and 24-week pregnancies are also doing a lot better with these change ventilation strategies, better survival and fewer morbidities. All right, number 10.

HOWARD: 14:27

Well, number 10 is rapid-hole genome sequencing or RWGS for newborns. So genome sequencing, of course, isn’t new, but 2025 saw the clinical integration of rapid-hole genome sequencing as a standard of care for at least critically ill newborns. So this allows geneatologists to diagnose rare genetic disorders, usually in less than 24 hours, compared to sometimes weeks previously, which would enable immediate life-saving intervention and reduce the sort of diagnostic odysse that moms sometimes spend weeks to months on before getting a genetic diagnosis.

JAMIE: 15:02

So I think an honorable mention is partner treatment for recurrent bacterial vaginosis. And the new idea that vaginal microbiome transplantation for recurrent BV. More to come on that in future episodes, maybe though.

HOWARD: 15:14

Yeah, that would be weird if we were doing transplants in the office.

JAMIE: 15:18

It could happen.

HOWARD: 15:20

Not the same kind of transplant.

unknown: 15:23

Yeah.

HOWARD: 15:23

And Tony and I, in the next episode, we’ll probably talk about another New England Journal of Medicine article about this idea and how bacterial vaginosis affects male partners as well. So it’s it is pretty interesting. That’s another major thing, just the idea of expedited or expedited partner treatment for recurrent BV is another thing we’ll look back to 2025 on as something that sort of changed the way we think about bacterial vaginosis after decades of thinking about it differently. So okay, well let’s talk about endoscopic hysterectomy.

JAMIE: 15:56

You sound surprisingly excited.

HOWARD: 15:59

Well, like I said, I realize that people are going to do them. So we might as well talk about how to save money while we’re doing them. We’ve got to create a culture, I think, of value-based care and sustainability in epistrics and gynecology if we want to maintain access to care for our patients. So apart from any other considerations, one of my biggest criticisms of endoscopic hysterectomy is just that it’s expensive, both laparoscopic and robotic, at least compared to vaginal, not compared to abdominal hysterectomy. Obviously, if you’re replacing an abdominal case with an endoscopic case, you’re saving money. But compared to vaginal, it’s more expensive. So as I said on that the last episode, we talked about 12 things that help drive sustainability. And the author’s focus of that paper was on environmental sustainability, but they also are associated with lower cost. And a lot of them are, frankly, common sense. So let’s build on those 12 concepts a little bit and apply them to robotic and laparoscopic hysterectomy.

JAMIE: 16:57

Well, there’s a few ways to think about saving money in this space. And one obvious one is not wasting equipment, utilizing the minimal amount of instruments and tools necessary to do the hysterectomy, but it’s just as important to utilize speed and efficiency because ultimately operating room time is very expensive and contributing to a lot of our cost here. I do hysterectomies by all method, but as you seem stuck with your tried and true vaginal hysterectomy approach, I’ll start by just saying that whatever a person’s skill level is, they should certainly do the hysterectomy in the most minimally invasive way that they’re able to do it. The route a surgeon is most comfortable with is likely to be the safest as well. That’s going to help reduce the cost of postoperative complications. But it’s not only vaginal hysterectomy as the Howard Herrell standard, but even in the ACOG committee opinion about choosing route of hysterectomy for benign disease, does describe vaginal hysterectomy as a recommended first line and then reserving our laparoscopic and robotic hysterectomies as utilized for more difficult patients.

HOWARD: 18:04

I will say, I’ll add to that, that if your most minimally invasive route of hysterectomy is abdominal hysterectomy in 2026, you should refer your patient to someone else.

JAMIE: 18:13

That’s very fair. I think we’ve all been tricked by the comparison of laparoscopic and robotic hysterectomy to abdominal hysterectomy. The laparoscopic or robotic methods, they’re always going to be less invasive and cheaper than abdominal case, but of course, not when compared to a vaginal hysterectomy. So it’s not quite a fair comparison. So there, you don’t have to say anything about vaginal hysterectomy as the gold standard because I did it for you. Well, thank you.

HOWARD: 18:42

Okay. Well, let’s talk about saving money then and being more efficient. So endoscopic hysterectomy is always going to be more expensive than vaginal hysterectomy. I don’t try to be redundant. In fact, it’s more expensive than abdominal hysterectomy, at least in terms of the immediate surgical costs, although you have to think about abdominal hysterectomy, the patient staying in the hospital a day or two or things like that, and then the cost equation goes the other way. But value equals quality divided by cost. So even when you’re very cost efficient, the because of the supplies used in the machinery used in robotic surgery, that part of the equation, the cost, is going to be higher when you compare it certainly to vaginal hysterectomy. So you’ve got to maximize quality and you’ve got to work on efficiency and time saving to justify what you’re spending on those fixed costs of equipment in non-reusable equipment. So for an individual surgeon, someone who still does many abdominal hysterectomies or who may take a very long time in the operating room doing a vaginal laparoscopic hysterectomy or something like that, they might actually, compared to themselves, save money if they can maximize efficiency and increase quality with the robot or with the laparoscope or whatever, if they can decrease the cost of operating room time, which is very expensive. And you hear people talk about operating room time costing$40 to$60 a minute. I will say a lot of times that’s in blocks. The way that it’s billed out, that’s in a block of time. So sometimes making an argument that I reduce the length of my surgery by three minutes or something doesn’t automatically equal 180 bucks or something because you might not have reduced it by a block of 15 minutes, depending on how it’s done. But in any event, operating room time is very expensive.

JAMIE: 20:24

Right. That’s fair. So one of the things that you guys talked about on the last episode was looking at your surgeon preference cards periodically. And I’ve gone back and done this and tried to from time to time because every item opened on the preference card but not used during a surgery is complete waste. And there’s an incredible amount of waste that happens in GYN surgery, during all surgery for that matter. But there are also a lot of things that are nice to have, but not absolutely necessary. Maybe advanced ceiling devices or things like that are great to have, but very expensive and maybe only need to be reserved for the most difficult cases. Even things like automatically having a suction irrigator opening or a particular number of trocars set out or bags on plain cases before you’ve even gotten into the abdomen and taken a survey could result in a lot of waste over time. So surgeons really need to standardize and periodically review the preference cards and what they’re actually using.

HOWARD: 21:21

Okay. And for robotic hysterectomy in particular, surgeons need to maximize what people call the three-arm technique. So in the most standard laparoscopic hysterectomy method, traditional laparoscopy, we might use three five millimeter ports to complete the hysterectomy. And one of these is going to be your camera. And the other two are going to be operative ports. And with that, of course, you’ll have a vessel sealer that seals and cuts, and then a grasper, and maybe you’ll have a scissor and a needle driver and the other things that you interchange in there and a suction irrigator. But in with at least the original robotic technique for hysterectomy, there were five ports used, often with four robotic arms installed and then an accessory port.

JAMIE: 22:03

Yeah, that’s very true. With robotic hysterectomies, it’s not common to use a vessel ciller that cuts, but rather most surgeons are using a bipolar grasping device in one hand and a monopolar instrument in the other that will act as their cutting. So choosing which of those instruments a surgeon will have as a standard on their preference card goes a long way in cost difference. For example, with the Da Vinci robotic system, there are three monopolar options. There’s scissors, spatula, and a hook. The monopolar scissors are going to cost about$335 per case, where the other two are closer to$120 per case. And certainly there might be a reason why a surgeon would choose to utilize one energy source over another based on the particular case, but even knowing the difference in that cost is such an important starting place. Also, some surgeons may not realize that not all robotic instruments are multi-use. The ones I mentioned earlier, the forceps and the monopolar instruments, are reused between 10 and 15 times, depending on the product. You mentioned using a vessel sealer for a straight stick laparoscopic hysterectomy. And while there are vessel sealers that can be used robotically, they’re more expensive, around$3,000 to$4,000 each, and they’re single use. And then certainly if you’re needing to trade instruments in and out, say adding in a robotic tenaculum or scissors or a different degree of camera, each time you’re clicking in a new device, that cost is being added. So you can see how those costs would quickly add up, especially if the surgeon isn’t aware of the individual device price differences. So, as you said, one of the simplest things that a robotic surgeon can do is to develop and try to master the three-arm technique, meaning using two robotic arms, one camera, and then you have your accessory port for your assistant. And certainly ensure that you’re using the most cost-effective instruments for your case’s needs.

HOWARD: 23:57

Okay, and then so for your robotic history setup, then what instruments, what arms are you using?

JAMIE: 24:04

I prefer to have the monopolar spatula and bipolar forceps. The spatula is a little bit cheaper and I can achieve cutting with it. Certainly, if I’m going to do a difficult endometriosis case, I may use scissors instead, but that’s not my standard.

HOWARD: 24:23

And then you’ll also need a needle driver to sew the cut. Correct. So so roughly speaking, it’s actually cheaper to use a monopolar spatula and the bipolar forceps. Those combined are cheaper than the monopolar scissors.

SPEAKER_03: 24:38

Yes.

HOWARD: 24:39

If you look at it. So the to th these prices, if we cite prices, they’re going to range widely by your hospital and your hospital’s contracting. But the spatula can be reused 10 times and is about$1,200. The monopolar scissors is about$330 a case. The bipolar forceps can be reused 14 times-ish. There’s some ish in there, but that’s about$207 a case. The needle driver can be reused 15 times, so it’s about$186 per case. The progress forceps about$14 times and to come out to$200 a case. So you gotta that will those prices will vary with your own individual contracting, but as you said, just being aware of it and thinking about what combination of instruments you’re using or where it might make sense to use a reusable instrument through the assistant support or something like that, you may end up making a huge price difference with all those things added together. I think people get frustrated sometimes when we talk about f cost savings, because in a lot of these costs, if you look at your preference card, they’re not that high. For example, a robotic arm drape might be$30. So saving one drape by doing three arms instead of four or something doesn’t feel like you’ve saved a lot of money. But you’re also saving the instrument that you didn’t use if you’re figuring out a way to use one less instrument that you didn’t click in. And so now it’s 330 bucks. And if you do 200 robotic hysterectomies a year at your facility, that’s$72,000 for your department. And in a world where we’re losing OBGYN units and rural care and even urban care centers are closing, that$72,000 might be an OB nurse, for example,’s whole salary. So when I do a vaginal laparoscopic hysterectomy, thinking about every little dollar of cost, I don’t place in a dwelling foli catheter, and I don’t think they’re necessary, but they’re$37 a piece. So again, for 200 cases a year, well, that’s$7,400. But it’s also the time that I didn’t place placing the foley or having the nurse place the foley. And it may even save a few UTIs or ER visits related to a possible UTI postoperatively. So if the time is$60 a minute and you save three minutes by not placing the catheter and dealing with it postoperatively, then you saved$180 for the case. And now that’s$36,000 a year if you do a couple hundred cases. When we did our episodes on value-based care and obstetrics, you can see how a CBC here and a typing screen there and all these little things, they really do add up. And every dollar you save, every minute of OR time you save is going to add up a lot over the course of a facility. It may be the difference in whether your service line is viewed as profitable and favorable to the bottom line of the hospital and sustainable or whether it isn’t. So the real cost savings, it many times is not even the instrument, it’s the time. I think about that with the bove during C-section. I, of course, never have a bovey on C-section, and okay, what’s a bovey cost? Three bucks, I don’t know. It’s not much of anything. But I don’t spend 10 or 15 minutes boveing. It’s also the time element of it. So so you got to think about each of these prices. And there could be that there’s a particular product that saves you adequate time that that enhances your speed and efficiency enough that even though it might be a little bit expensive, it could be worth using.

JAMIE: 28:08

I think a stratifix suture to close the cuff could be a good example of that.

HOWARD: 28:13

Yeah, exactly. So yeah, they’re like$30 this suture compared to a couple dollars for a regular suture, a Vicral or something. So if you’re doing particularly if you’re doing a straight stick laparoscopic surgery, you’re gonna save yourself plenty of time using that stratifix, and I would recommend it. But I don’t know if that argument is as compelling with robotic hysterectomy. One of the chief advantages of robotic hysterectomy is the ability to sew and tie quickly. And I think in many people, at least early on, adopted a robotic system purely for that benefit, because they were in in the pre-stratifix era in particular, they’re pretty frustrated by having to sew and tie laparoscopically. But even very good surgeons with straight stick laparoscopy are probably going to save time with stratifix at laparoscopic hysterectomy. And if you saved again, if you save 30 seconds, you’ve paid for the suture. Now, the devil’s in the details, it might be that if your surgery takes 32 minutes with stratifix and it takes 42 minutes without, it might be the same time depending on how your time is blocked out. So we shouldn’t take that too literally, but but the point is that$30 is probably a good investment.

JAMIE: 29:26

Sure. So it’s clear that managing OR time well is critical. But this also does include your non-operating time, like the amount of time it takes to dock the robot, and particularly your turnover time between click cases. One of the criticisms that I know that you’ve made is the traditional way that we think about the length of surgery is from incision to closing. And that doesn’t take into account the length of turnover time, the equipment setup. So another way to look at it might be how many cases can you do in a particular block of time? Because then that includes all those variables. I pulled the data for one of my robotic hysterectomies, and it took 22 minutes from the time the patient was brought into the room until first incision was made. After the incisions were all closed, it took 14 minutes for the patient to leave the room. So the patient was in the room for 36 minutes additionally that were not part of the surgery. And then, of course, the room had to be cleaned and turned over, and that takes a little bit longer with robotics than it would for a room doing straight stick laparoscopic cases, and certainly would for a room compared to one that was doing vaginal hysterectomy, just because there’s more stuff to move in and out, changing the drapes and such. So when you include the operating room time and include the turnover time, setup time for the next patient, a lot of these cases are two and a half to three hours long, even though your surgery time may have been closer to an hour.

HOWARD: 30:47

Right. And I’m not going to say anything by agreement, by contract with you today. I’m not going to say anything about vaginal hysterectomy. But for the purposes of patient access and cost, that’s a huge point. The most expensive part of a surgery is ultimately time. So a good surgeon should focus on reducing those non-operative times. There’s often more gains there than there are in the surgery time itself. For the case of robotics and laparoscopic surgeries, this includes standardizing your team and the room layout. And that has been shown to save about 15 to 30 minutes fairly routinely, which can add up to thousands of dollars of cost savings, but also more importantly allow for you to do more cases in the same block of time or during the day or during the course of a year. And that increases access to care. It also increases utilization of your robot or your equipment that you have these fixed prices on, which helps to lower those fixed costs of investment in advanced robotic platforms or endoscopic equipment because it’s amateurized over how many cases you’re going to do a year, like the contracts and things like that for service. So I like to focus for me how many cases can I do in a block of time. If I have a six-hour OR block, can I get four hysterectomies done? I usually can pretty easily, even when the hysterectomies have other add-on case procedures like slings or things like that. But for a lot of robotics programs, that same amount of time might only allow for two cases. And that’s the biggest price gap that we have some control over in working on building efficiency around turnover time and things like that.

JAMIE: 32:24

That’s very true. Another cost savings goal should be same-day discharge. And I know that you’ve always done that with vaginal hysterectomy. And I think that most people are doing it now with endoscopic hysterectomies, but this is an essential cost savings. If providers are still routinely keeping these patients overnight, they have to focus on eliminating that for the majority of patients. This includes thinking about our enhanced recovery strategies after surgery to minimize postoperative pain and nausea, but also focusing on shorter duration of surgeries with less anesthesia exposure. So we still get the necessity of having relatively quick surgeries to make this goal happen. But then you save a hospital bed and a night in the hospital, and that’s going to lower costs and open up access for other patients who might need the facility. That’s one of the main promises of minimally invasive surgery to begin with. So if you’re doing a minimally invasive approach, but keeping the patient in the hospital, you’re really missing out on a big important step there.

HOWARD: 33:24

Right. So we need to standardize the whole process, including pre- and post-operative care, make sure we’re doing same-day discharge every time it’s appropriate. Focus on speed and precision to reduce your operating room time. Use the fewest number of instruments possible and think about the cost mix of those instruments and what you’re doing with them. And then choose, as you said, the least expensive energy sources that you can when it’s appropriate. And we didn’t discuss the manipulator or the uterine manipulator, but obviously you want to use something that’s inexpensive and reusable and be aware of what you’re spending there too.

JAMIE: 34:01

So should we do four tips for laparoscopic and robotic assisted hysterectomy? Tips that can help with speed and efficiency, but of course are cost effective.

HOWARD: 34:12

Let’s do it. I think some of the tips will obviously be true for robotic and laparoscopic hysterectomy. But again, I can think of at least one that I want to give for laparoscopic hysterectomy that I don’t think necessarily applies to robotic hysterectomy.

JAMIE: 34:27

Okay, then why don’t we do four tips for laparoscopic hysterectomy first, and you can start with your oddball tip.

HOWARD: 34:59

But it does prevent the surgeon from spending several minutes struggling to throw knots, and that adds up. So it it probably saves between five and ten minutes, even for decently skilled surgeons. And there of course are surgeons who can tie knots laparoscopically very fluidly and quickly, and for them, maybe it’s not worthwhile. This is also why I think it’s not worthwhile necessarily for the robot, because in theory, you should be able to tie knot very quickly with the robot. And at that point, then you might just be wasting money with your barbed suture. But the average person is going to save five to ten minutes and therefore a few hundred dollars potentially of operating room time for using a suture that costs maybe$30 now as prices have come down.

JAMIE: 35:46

So Okay, well your point is that you should use it if it saves you time, but that might even be true for some people with a robot, of course. But we don’t need to use it for any benefit other than time saving. So what’s your next tip?

HOWARD: 35:59

Okay, number two, I also think that another tip is to learn to suture and perhaps even not tie lacroscopically using a simulator or maybe taking a course. So it’s not just not tying in terms of suturing the cuff, it’s also sewing. It’s taking the bites, it’s reloading the suture, it’s reloading the needle, taking the next bite, and doing all of these repetitive steps, and people are slow with it. So even if you use a barbed suture, you still need to be able to efficiently sew the cuff in a minute or two and not struggle with reloading the needle constantly and fighting it and having the needle turn on you and all that, and spending several minutes sewing. So this historically, I think, has been the hardest part, the hard the highest learning curve for folks. And I really do believe that this is a big reason why people have moved to the robot early on, is because it makes all of that so much easier. But if you get really good at it, you might use the robot less and you might shave several minutes of length off of your laparoscopic hysterectomy, but you should be practicing this in a simulation or a dry lab, not in patients, not spending 45 minutes learning how to sew on a patient. And so you can very inexpensively get good at sewing and maybe not time.

JAMIE: 37:14

Okay. Number three.

HOWARD: 37:16

All right. Well, for both laparoscopic and robotic hysterectomy, you should use a quadrant-based standardized workflow to move through your case. So maybe quadrant’s not the right word, but what I mean by this is complete all of the surgical steps that you can on one side in one quadrant of the uterus before you move on to the other side. So take the right infandibular pelvic ligament or the uterovarian ligament and the right round ligament and go down the right broad ligament and get the right uterine artery and do the whole right side of your bladder flat bisection and whatever you’re going to do before you switch over and move to the left side. And this minimizes the need for if you have a bedside assistant using the moving the uterus back and forth with the manipulator, or if you’re doing a laparoscopy hysterectomy and you’re changing instruments a lot, or you’ve got a grasper, a tenaculum pulling the uterus to one side with your assistant, like you’re just doing that stuff once, you’re using your energy sealing device, and you’re just zipping down. And honestly, that should just take two or three or four minutes to do the side, and then set up, flip everything to the other side. And this sounds like common sense, and I’m sure most people do this, but folks don’t always. And instead, they it’s almost like an abdominal hysterectomy where, okay, you get your round and I’ll get my round, and we’ll like you’re just replicating that side-to-side stuff, and it just wastes a lot of time moving the instrument, moving the uterus around for no reason, lots of flipping and flopping. That’s a waste of time.

JAMIE: 38:47

Agree. I really like that one. Okay, number four.

HOWARD: 38:50

She didn’t like the one about learning to sew, by the way. She stopped. Because she’s already good at it, probably. But okay, number four. I guess my fourth tip is to get good at skeletonizing the uterine vessels before sealing them. So most laparoscopic hysterectomies should be relatively bloodless. If, but you need to be good at skeletonizing the uterine vessels before you seal them because you’ll often have excessive bleeding if you try to coagulate or seal the thicker bundle of tissue that overlies the vessels, the peritoneum and the areolar tissues. This is probably even more true at robotic hysterectomy because you’re not using the same kind of vessel sealing devices with robotic hysterectomy. But even when you’re using a laparoscopic vessel sealing device, you’re limited to how thick that tissue can be around the vessel and get a good seal and a seal over it. So ideally, you’ll have the vessel isolated and visualized before you coagulate it. And this likely also reduces your risk of ureter injury, but more to the point, it saves a lot of time because you’re not chasing bleeding. I think that’s also why people sometimes flop back and forth, is they’re worried about backbleating and a lot of things like that. It’s not back bleeding, you just didn’t get the vessel that well. And so you need to skeletonize to see it. And I think the skeletonization doesn’t reduce the risk of ureter injury because somehow you’re visualizing the ureter where it crosses by the uterine artery. That’s not the point of benign hysterectomy, but it does decrease the number of kind of lateral burns you end up taking because you’re bleeding, and you just get more lateral and more lateral. And every time you do, because you’re bleeding, you’re increasing your risk of thermal injury or direct injury to the ureter. So you’re also, if you get good control of the vessel and you’re doing a three-port laparoscopic hysterectomy, you’re going to need your suction irrigator a lot less frequently because you’re not dealing with bleeding. These should be relatively bloodless. In fact, a suction irrigator might be something that you don’t routinely open up for your laparoscopic hysterectomy if you’re good at sealing these vessels and not chasing bleeding. The key is skeletonizing the vessel and knowing where it’s at and getting a good seal on it and avoiding the waste of time tracing back bleeding and all that. Okay. Well, what tips many of those things are true for both robotics and laparoscopic, obviously. What tips do you have specifically for robotic hysterectomy? Especially things that save time or money or save having to use instrument arms redundantly.

JAMIE: 41:26

Okay. Well, how about these? My first tip would be using the least number of robotic arms and instruments needed for the case. So defaulting to three arms instead of four when feasible. The strategy I usually use is enter the abdomen, do my survey of the pelvis, and evaluate before deciding if a fourth pore and arm is going to be necessary for that case. And that means that it’s important to communicate this prior to the start of the procedure to my circulator and to my scrub tech to make sure that we have the instruments that I think I might need in the room, but not necessarily open. So that cost isn’t applied to the patient until I need it. And especially if you have a engaged and well-trained bedside assistant and scrub tech, a lot of benign cases don’t require a fourth arm. And as mentioned before, that also means choosing reusable over single-use instruments and having the awareness of the cost of each device to help guide those instrument choices.

HOWARD: 42:22

Yeah. I tell you, the time you really learn how bad your cards are is when you get a scrub tech that doesn’t normally work with you and they’ve actually opened up all the stuff on your arm and you’re just aghast with how much money was just wasted. Because your tech that you work with all the time, they know, hey, don’t open that. She’s not actually going to use it. But yeah, you need to communicate with them what your plan is.

JAMIE: 42:44

Very true. All right. My second tip is appropriate patient selection. It we’ve talked a lot so far about laparoscopic versus robotic hysterectomies, as if we’re comparing apples to apples and villainizing robotic hysterectomies, but really the problem is just universal over selective robotic use. And in reality, patient characteristics and suspected pathology should be the reason that pushes a surgeon towards the more expensive route, the robotic route, over a vaginal case or straight stick laparoscopy. It is certainly true, though, that the use of robotics can offer clear cost benefit when its use prevents a laparotomy or prevents the necessity for a patient to be admitted, or prevents significant OR time that a challenging straight stick laparoscopic case could take. The 3D visualization, the risk of instruments that the robotic platforms offer can honestly make all the difference sometimes and efficiently completing a case with, say, endometriosis or really enlarged fibroid uterus. They have abdominal pelvic adhesive disease or significant obesity. So that’s helping to achieve our cost effectiveness goals. Conversely, though, with straightforward hysterectomies and a small uterus, choosing vaginal hysterectomy or straight stick laparoscopy should be done to eliminate the cost waste. So be judicious with which cases the robotic actually add value.

HOWARD: 44:14

Yeah. And also be honest about your time. So a lot of people will see after they get through the learning curve, they’ll probably see that their operative time for robotic hysterectomy might be less than their laparoscopic operative time, but they’re not necessarily including that room turnover and all the other stuff. So be honest with how you assess your time. If if you you might think you’re quicker and you’re actually 15 minutes slower because of the robotics turnover time issues, but you can work on those efficiencies too, as we said. What’s your next one?

JAMIE: 44:46

Yeah. Certainly true. All right. Third tip is as we’ve talked about a lot already, reducing OR time is very important for being a cost-effective surgeon. So that can be done with having very consistent docking sequence that your scrub tech is used to, your assistants are used to, the anesthesia team and nursing are used to. And hospitals that have dedicated robotic teams get very good at this. Every 15 minutes of OR time save can offset a pretty big portion of robotic instrument costs. And we have to note that the surgeon learning curve significantly impacts reducing OR time as well. Costs drop pretty substantially after 20 to 40 cases per surgeon, just as their proficiency in that type of surgery increases. So this can also be accomplished through using surgical mentorship, working with a partner, just having that accountability in the OR, particularly on more challenging cases, and utilizing the dual console when it’s available. Also, use of surgical simulations and videos to prepare can reduce our OR time as we become more proficient.

HOWARD: 45:55

I think we also have to appreciate that we’re good at different things, and it’s hard for one person to be good at everything. And this might shock some of the listeners. But I have referred patients for robotic hysterectomies when I thought that they would benefit from it, and it was something I couldn’t accomplish in a minimally invasive way. And we don’t need everybody good at robotics. I think that’s one of my things too, because if everybody gets good at robotics, we’re going to give up on everybody being good at laparoscopy or vaginal surgery. And so I I wish we had a more specialized way of thinking about that, and we referred to each other more than we do, because we can only spend so much of our learning curve living in one place. And I don’t want to give up my skill set in vaginal hysterectomy. And people should refer to me when their patient would benefit from one and they can’t, and people should refer to you and they would benefit from a robotic and they can’t. Like we we should have that culture that puts the patient first.

JAMIE: 46:52

Absolutely.

HOWARD: 46:53

What else you got?

JAMIE: 46:54

All right. My fourth tip is to measure and frequently evaluate your own data. I really appreciate that the institution I work for sends itemized case receipts following each surgery day. And reviewing this has made pretty significant impacts in my instrument choice and made me alter my surgeon preference card numerous times. It helped me reduce my robotic hysterectomy cost to be about$165 below the hospital average and cheaper than the average laparoscopic hysterectomy at my hospital. We also track surgeon data such as patient length of stay, readmission and complication rates, and the average OR times. But it’s important not just to review your own metrics, but comparing it to others within and outside of your institution is a really important way for meaningful behavior change to occur.

HOWARD: 47:47

All right, well, there’s your four. You have a bonus for us?

JAMIE: 47:51

I do, if that’s okay.

HOWARD: 47:52

Yeah, we take bonuses.

JAMIE: 47:54

And this one applies to laparoscopic or robotic hysterectomy, but it’s important to consider ways that we can prevent complications as a cost-saving strategy. So even small reductions in complications have huge financial impact. And like you said earlier, this includes meticulous surgical technique to reduce blood loss, but also having well-prepared patients to go home for same-day discharge. That means utilizing the E-REST protocols to have really efficient discharge processes, knowing what patients to prescribe medical thrombo prophylaxis to, but also making sure patients are well educated on postoperative care restrictions, activity, DVT and infection prevention, and also having easy availability for their follow-up and work and visits can go a long way with reducing the cost of long-term and short-term complications post-op.

HOWARD: 48:51

Okay, well, there’s our tips. So I have a friend who has emailed me a couple of times about this topic. And so she’s a good vaginal surgeon and has preferred vaginal hysterectomy for many years in her practice and is as good as anybody. But her hospital, of course, like a lot of hospitals, has a robot and they’ve asked her to use it. And she started using it. And then I actually get these emails a lot where people are like, I like it, begrudgingly. And I asked her, and like, how do you make these decisions? Because again, I I do worry that people get into their pattern and they’re they do all of one thing to the other. And maybe and again, maybe that’s okay. Maybe if you’re just a really great laparoscopic hysterectomist and you’re not good at the other things, maybe you should send them out when the patient needs the other thing, or et cetera. The problem is, of course, the route of hysterectomy that suffers in that approach is always vaginal because you can do virtually every hysterectomy robotically. You can do virtually every hysterectomy laparoscopically, but the average person can’t do virtually, even good vaginal surgeons can’t do every hysterectomy vaginally. So then you get stuck in your way, and every case becomes that. So we were chatting, and I asked her to send me a list of the patients that she would choose to not do a laparoscopic or robotic hysterectomy on, where she actually thought vaginal was preferred. And I thought it was thoughtful, and I wanted to share it and see if you had any thoughts about this. But what I like about it is it forces us to think in the opposite terms. Where should a good laparoscopic hysterectomist send their patient to a good vaginal hysterectomist, for example? Does the patient benefit? So here was her this was her list. This here are times where I believe, I’m quoting from her now, where total vaginal hysterectomy is better than a laparoscopic or robotic approach. All right. She’s got ten of these. Number one, a high normal to small size uterus. So clearly she’s just saying there it’s not a big uterus, it’s like a lot of hysterectomies, it’s just a normal size uterus. Number two, a Paris patient who’s had prior vaginal births. And right there’s a lot of patients, honestly, just in those twos of a lot of folks. Number three, okay, here’s some of the interesting ones. Prior ablation with scarred endometrial cavity, where a uterine manipulator to assist the endoscopic hysterectomy w w might be placed difficultly into the endometrial cavity or perforate them. I thought that was thoughtful. I never really thought about that before.

JAMIE: 51:31

But you’ve learned that from having a bad experience.

HOWARD: 51:33

Yeah, probably. Yeah.

JAMIE: 51:34

So that’s probably in her head. Yeah.

HOWARD: 51:36

Yeah. Number four, an elongated cervix where the uterine manipulator to assist in the endoscopic hysterectomy will end up not getting placed properly. And if the patient otherwise has a normal size uterus. Okay. Number five, an obese or elderly patient who might not tolerate the Trendellenberg and insufflation necessary. She says my BMI cutoff, this is just her opinions, of course, for a GYN surgery is 50. And 46 to 49, I might lean towards vaginal hysterectomy because the laparoscopy will be harder than the vaginal hysterectomy. I will say about that one, I think hard hysterectomies are hard. And the same hysterectomy that might be hard vaginally is hard laparoscopically or hard robotically, but I do get referrals for my BMI cutoff is not 60. I do get referrals for obesity. And it’s interesting, even Howard Kelly, I mentioned in the vaginal hysterectomy book, his one holdout was basically in obese women. And of course, back then he was comparing it to abdominal. But even abdominal hysterectomy is just very difficult, and getting the appropriate level of insufflation and sustaining it and insuflation that you need with that T berg can just be very difficult. So that I like that one. Okay, number six, mesh in the abdomen, in the location where I assume she means where the trochars would normally be placed. I try to avoid going through mesh if I can to avoid infections and other complications. Number seven, prior abdominal plasty andor my multiple prior abdominal surgeries. Number eight, if the patient’s preference is to have a spinal anesthetic for the surgery. I have had that a few times. And for the listeners, you can do a vaginal hysterectomy with a spinal. You actually can do an abdominal hysterectomy with a spinal too, but you can’t do a laparoscopic or robotic hysterectomy with a spinal. Number nine, a patient preference to avoid new scars, although I consent them obviously for emergency laparotomies or laparoscopic rescue. And number 10, any medical reason to avoid laparoscopy, abdominal scars, or general anesthesia. So that’s an interesting list. I’m it th those are just her thoughts. I thought they were very thoughtful. And I wonder what percentage of benign hysterectomies in America fit into her 10 criteria. And I suspect it’s it’s more than 50%.

JAMIE: 54:00

I think that’s absolutely reasonable. Yes.

HOWARD: 54:02

So and our talents are on a bell-shaped distribution. And I guess that was the point of this episode for me too, is I realize that people are it’s unrealistic to expect everybody to do every case vaginally. And so somewhere in there’s a happy medium, and there might be people who approach and they’re able to do 60% or so of their cases vaginally, the ones with the normal size uterus of prior vaginal births that she mentioned in numbers one and two. But then there’s other complications or whatever, and maybe for them they need to refer to somebody who has expertise in robotic surgery or laparoscopic surgery for those more complicated cases rather than be a one-size fits-all. And frankly, some of the folks who only do robotics need to refer to vaginal surgeons for some of their patients too. It goes both ways.

JAMIE: 54:50

Fully agree with that.

HOWARD: 54:52

Do you have any final thoughts? Do you want to sing a song from Wicked?

JAMIE: 54:58

I want to sing a song from Wicked at most points throughout my day. I’m not sure your listeners would be very appreciative of that, though.

HOWARD: 55:07

Well, we’ll have you back on soon.

JAMIE: 55:10

I would love to. Thanks for having me.

HOWARD: 55:12

We won’t talk about robotics.

JAMIE: 55:15

And thanks for going gentle on robotic instructions.

HOWARD: 55:18

This is stressful for me.

JAMIE: 55:20

So I know.

HOWARD: 55:21

Okay, we’ll see you guys in a couple of weeks.

ANNOUNCER: 55:25

Thanks for listening. Be sure to check out thinking about obgyn.com for more information, and be sure to follow us on Instagram. We’ll be back in two weeks.