Impact of surgeon characteristics on endometriosis surgery outcomes

Objective — This study aimed to evaluate the association between surgeon characteristics and postoperative surgical outcomes, including rates of complications, recurrence of symptoms, fertility outcomes, and need for reoperation for individuals undergoing surgical management of endometriosis.

Design — Population cohort study.

Setting — Ontario, Canada

Patients — 83,787 Ontario patients, who are biologically identified as women, aged 18-50 who had an initial diagnosis of endometriosis (ICD-9-617 or ICD-10-N80) between April 1, 2002, and March 31, 2018.

Interventions — Surgeon volume of endometriosis cases, grouped into four categories: 6 or fewer in the prior year (low volume), 7 – 11 (moderate volume), 12 – 23 (high volume), and 24 or more (highest volume). A modified exposure variable defined by surgeon’s volume of complex endometriosis surgery (based on OHIP billing code) in the year prior to the index surgery was also used.

Measurements — The primary outcome was the rate of re-operation within 30 days of index surgery and over the duration of follow-up in the study. Secondary outcomes were postoperative complications, the rate of infertility consults, and live birth rate following endometriosis surgery.
Main results — The majority of patients (80.3%) underwent surgery with a low volume surgeon. In the 30-day post-operative period, the lowest rate of postoperative complication was noted amongst the highest volume surgeons (5.5%). There was a significantly reduced risk of complications amongst high volume surgeons compared to low volume surgeons (aHR 0.84, 95% CI 0.74 – 0.96). Higher volume surgeons tended to refer patients for fertility assessment and these patients also had higher chance of achieving a livebirth postoperatively.

Patients who underwent surgery with a high volume of complex endometriosis surgeon, were less likely to undergo repeat surgery (17.8% vs. 32.9%, aHR 0.80 (0.72 – 0.88)), including all the surgery types examined.

Conclusion — Our study suggests the majority of patients undergoing surgery for endometriosis have surgery with a low volume surgeon. Postoperative outcomes were impacted by surgeon volume, suggesting that there is a need to define criteria for surgical competency. Ongoing work to define surgeon characteristics and skills required to perform different types of endometriosis surgery is encouraged.