Opportunities for change and levelling up: a trust wide retrospective analysis of 8 years of laparoscopic and abdominal myomectomy.

Background: Laparoscopic myomectomy is increasingly considered the gold standard uterine preserving procedure and has well documented benefits over the open approach. Barriers that women have in accessing the most appropriate treatment need to be addressed to ensure optimal patient care and outcomes. Objectives: To analyse rates of open and laparoscopic myomectomy at a large NHS trust and identify how many cases could potentially have been performed laparoscopically, and any variation between sites. Materials and Methods: A retrospective review of preoperative imaging reports and a surgical database containing information for all myomectomies performed between 1st January 2015 and 31st December 2022. Main outcome measures: Number of procedures suitable for alternative surgical approach; length of hospital stay; estimated blood loss; cost differences. Results: 846 myomectomies were performed; 656 by laparotomy and 190 by laparoscopy. 194/591 (32.8%) open myomectomies could have been performed laparoscopically and 26/172 (15.1%) laparoscopic myomectomies may have been better performed via an open approach. Length of hospital stay, and estimated blood loss were significantly higher in the open group. Had cases been performed as indicated by pre-operative imaging, the cost differences ranged from -£115,752 to £251,832. Conclusions: There is disparity in access to the gold standard care of laparoscopic myomectomy. Due to multifactorial reasons, even at sites where the rate of laparoscopic myomectomy is high, there is still underutilisation of this approach. It is clear that there is scope for change and "levelling up" of this imbalance. What is new?: Robust pathways and guidelines must be developed, and more laparoscopic surgeons should be trained to optimise care for women with fibroids.