Document Type : Short Communication


Department of Obstetrics, Gynecology and Reproductive Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada


Background: Minimally invasive hysterectomy is generally preferable to abdominal hysterectomy. The technicity index (TI) is the proportion of hysterectomies performed by minimally invasive surgery. Many centers globally have started to audit local TI as a quality indicator, but only a handful have published their results to help define international standards of care.
Objective: In this study, TI was examined in Winnipeg and Canada to determine consistency between local and national patterns of practice, audit expected changes, and contribute to the growing body of literature defining international standards of care.
Methods: A retrospective cross-sectional database review of hysterectomies performed in the Winnipeg Regional Health Authority (WRHA) from 2008 to 2015 was conducted. Mixed effects linear regression models were generated primarily to analyze TI and account for surgeon and hospital characteristics. The Canadian Institute for Health Information (CIHI) database was accessed to estimate the average national TI from 2009 to 2014. One-sample t tests compared annual WRHA and CIHI TI.
Results: In Winnipeg, 1363±32 hysterectomies were performed annually for all indications with an average TI of 34% independent of time (P=0.09). The CIHI database recorded approximately 27 000 hysterectomies annually with increasing TI (41%-52%, 3.5±1.8%/year, P=0.025). WRHA TI differed from national TI every year (P<2.2x10-16).
Conclusion: Over the study period, WRHA TI was below the Canadian average and static despite national increases. The importance of local audits to identify underperformance and stimulate initiatives for quality improvement is highlighted in this study.


  1. Health Care in Canada 2010. Canadian Institute for Health Information (CIHI) website. 2010. Accessed October 20, 2017. Published 2010. 
  2. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2009(3):Cd003677. doi:10.1002/14651858.
  3. Donnez O, Jadoul P, Squifflet J, Donnez J. A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG. 2009;116(4):492-500. doi:10.1111/j.1471-0528.2008.01966.x.
  4. Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ. 2005;330(7506):1478. doi:10.1136/bmj.330.7506.1478.
  5. Thiel JA, Kamencic H. Assessment of costs associated with outpatient total laparoscopic hysterectom. J Obstet Gynaecol Can. 2006;28(9):794-798. doi:10.1016/S1701-2163(16)32258-7.
  6. Jonsdottir GM, Jorgensen S, Cohen SL, et al. Increasing minimally invasive hysterectomy: effect on cost and complications. Obstet Gynecol. 2011;117(5):1142-1149. doi:10.1097/AOG.0b013e3182166055.
  7. Gale J, Cameron C, Chen I, Guo Y, Singh SS. Increasing Minimally Invasive Hysterectomy: A Canadian Academic Health Centre Experience. J Obstet Gynaecol Can. 2016;38(2):141-146. doi:10.1016/j.jogc.2015.12.004.
  8. Lefebvre G, Allaire C, Jeffrey J, et al. SOGC clinical guidelines. Hysterectomy. J Obstet Gynaecol Can. 2002;24(1):37-61; quiz 74-36.
  9. ACOG Committee Opinion No. 444: choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2009;114(5):1156-1158. doi:10.1097/AOG.0b013e3181c33c72.
  10. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol. 2011;18(1):1-3. doi:10.1016/j.jmig.2010.10.001.
  11. McCracken G, Lefebvre GG. Vaginal hysterectomy: dispelling the myths. J Obstet Gynaecol Can. 2007;29(5):424-428. doi:10.1016/S1701-2163(16)35494-9.
  12. Chen I, Bajzak KI, Guo Y, Singh SS. A national survey of endoscopic practice among gynaecologists in Canada. J Obstet Gynaecol Can. 2012;34(3):257-263. doi:10.1016/S1701-2163(16)35186-6.
  13. Laberge PY, Singh SS. Surgical approach to hysterectomy: introducing the concept of technicity. J Obstet Gynaecol Can. 2009;31(11):1050-1053. doi:10.1016/S1701-2163(16)34350-X.
  14. Renaud MC, Plante M, Roy M. The technicity index: a useful performance indicator for minimally invasive surgery in the management of endometrial cancer. J Obstet Gynaecol Can. 2012;34(12):1180-1183. doi:10.1016/S1701-2163(16)35466-4.
  15. Makinen J, Brummer T, Jalkanen J, et al. Ten years of progress--improved hysterectomy outcomes in Finland 1996-2006: a longitudinal observation study. BMJ Open. 2013;3(10):e003169. doi:10.1136/bmjopen-2013-003169.
  16. Lim PC, Crane JT, English EJ, et al. Multicenter analysis comparing robotic, open, laparoscopic, and vaginal hysterectomies performed by high-volume surgeons for benign indications. Int J Gynaecol Obstet. 2016;133(3):359-364. doi:10.1016/j.ijgo.2015.11.010.
  17. Andryjowicz E, Wray T. Regional expansion of minimally invasive surgery for hysterectomy: implementation and methodology in a large multispecialty group. Perm J. 2011;15(4):42-46. doi:10.7812/TPP/11-093.
  18. Chen I, Lisonkova S, Allaire C, Williams C, Yong P, Joseph KS. Routes of hysterectomy in women with benign uterine disease in the Vancouver Coastal Health and Providence Health Care regions: a retrospective cohort analysis. CMAJ Open. 2014;2(4):E273-280. doi:10.9778/cmajo.20130080.
  19. Bernatchez-Laflamme SM, Bujold E, Roberge S, Laberge PY. [Development of technicality indices of hysterectomies in Quebec]. J Obstet Gynaecol Can. 2013;35(2):144-148. doi:10.1016/S1701-2163(15)31019-7.
  20. Grant-Orser A, El Sugy R, Singh SS. Does laparoscopy safely improve technicity for complex hysterectomy cases? J Obstet Gynaecol Can. 2014;36(3):248-252. doi:10.1016/S1701-2163(15)30633-2.
  21. R_Core_Team. R Development Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing; 2015.
  22. Bates D, Mächler M, Bolker B, Walker S. Fitting Linear Mixed- Effects Models Using lme4. J Stat Softw. 2015;67(1):48. doi:10.18637/jss.v067.i01.
  23. Bogani G, Cromi A, Serati M, et al. Laparoscopic and vaginal approaches to hysterectomy in the obese. Eur J Obstet Gynecol Reprod Biol. 2015;189:85-90. doi:10.1016/j.ejogrb.2015.02.035.
  24. Manitoba Health. Annual Statistics 2010-2011. Manitoba: Manitoba Health, Healthy Living and Seniors Health Information Management; 2010.
  25. Manitoba Health. Annual Statistics 2013-2014. Manitoba: Manitoba Health, Healthy Living and Seniors Health Information Management; 2013.