Postoperative pain relief following laparoscopic tubal sterilization with silastic bands

Reducing postoperative pain after tubal ligation with rings or clips: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of using local anesthesia during interval laparoscopic tubal ligation to control postoperative pain.

DATA SOURCES

We searched MEDLINE, PubMed, and Cochrane databases and found additional articles from bibliographies of relevant studies.

METHODS OF STUDY SELECTION

We included only randomized, double-blind, placebo-controlled trials reporting postoperative pain after interval laparoscopic tubal ligation under general anesthesia (n=20). The trials compared the application of topical or injectable local anesthetic with placebo and used a visual analog scale (VAS) (scores 0-100) or the Modified McGill Pain Intensity Scale (subsequently converted to a VAS) to assess pain.

TABULATION, INTEGRATION, AND RESULTS

Pain scores were evaluated at the following times after extubation: 30 minutes, 1 hour, 2 hours, 4 hours, 8 hours, and 24 hours. The meta-analysis was based on random-effects methods for pooled data using RevMan. Postoperative pain decreased with the use of local anesthetic compared with placebo as follows (mean VAS decrease in millimeters, 95% confidence interval): 30 minutes 18.6 (11.7-25.5); 1 hour 16.6 (9.3-24.0); 2 hours 17.4 (9.6-25.2); 4 hours 12.5 (5.1-19.9); 8 hours 11.9 (6.7-17.1); and 24 hours 3.9 (-1.4 to 9.2). There was moderate heterogeneity in the data across studies (I statistic ranging from 55% to 75%). The effect size was similar for the following subgroups: pain scores reported as means or medians and use of McGill compared with VAS pain scales. A stratified analysis of trials including ring tubal ligation compared with clip tubal ligation showed the use of local anesthetic decreased pain substantially for both. No eligible studies assessed tubal ligation with cautery.

CONCLUSION

Use of local anesthetic during laparoscopic tubal ligation substantially reduces postoperative pain up to 8 hours after surgery.

Systematic review and metaanalysis of intraperitoneal instillation of local anesthetics for reduction of pain after gynecologic laparoscopy

We reviewed the effectiveness of intraperitoneal instillation of local anesthetic on pain after gynecologic laparoscopic surgery. Sources included the Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, EMBASE, and Ovid MEDLINE In-Process & Other Non-Indexed Citations databases, and abstracts, reference lists, and randomized controlled trial (RCT) registries. The 7 included RCTs compared pain scores after administration of intraperitoneal analgesics or placebo/control during gynecologic laparoscopic surgery with benign indications. Outcome measures were pain scores (per visual analog scale) at 1 to 2, 4 to 6, and 24 hours postoperatively. Pain scores were significantly lower in the groups receiving local anesthesia at 1 to 2 hours (weighted mean difference [WMD], -1.82; 95% confidence interval [CI], -2.55 to -1.08]) and 4 to 6 hours postoperatively (WMD, -2.00; 95% CI, -3.64 to -0.35), but were similar at 24 hours (WMD, -1.43; 95% CI, -1.15 to 0.96). Local analgesia instilled intraperitoneally significantly decreased pain during a 6-hour interval after gynecologic laparoscopy.

Effect of Gabapentin on morphine demand and pain after laparoscopic sterilization using Filshie clips. A double blind randomized clinical trial

Background

A considerable number of patients require opioids during recovery after laparoscopic sterilization. This implies nausea, dizziness and sedation and increases the number of unplanned admissions. Gabapentin has shown excellent postoperative analgesic effect in a number of recent studies with few side effects. This study was designed to test whether gabapentin given preoperatively can reduce the number of patients needing morphine in the recovery period.

Methods

80 females scheduled for laparoscopic sterilization using Filshie clips were randomized to two treatment groups (Gaba group and control group).

All patients received lornoxicam 8 mg p.o. 30 min. before the procedure. Patients in the Gaba group received gabapentin 1200 mg p.o. and patients in the control group received placebo capsules prior to the procedure. All patients were anesthetized according to a protocol, using remifentanil and propofol.

Postoperative analgesia was obtained with patient controlled infusion of morphine. Pain, nausea, dizziness and sedation were scored at 2 and 4 hours after end of anesthesia. The expenditure of morphine was the primary measure for the effect of analgesia and the number of patients demanding morphine was the primary endpoint.

Results

Three patients were excluded because of procedural errors and one because of conversion to open surgery. 38 patients completed the study in each group.

32 (84%) patients in the gabapentin group and 37 (97%) patients in the control group did require morphine in the recovery period. (p = 0,049).

There was no significant difference between mean morphine consumption, pain scores and frequency of adverse effects (nausea, dizziness, sedation and vomiting)

Conclusion

The postoperative analgesic effect of gabapentin given preoperatively was confirmed in this study. For this procedure, with pain predominantly in the immediate recovery period, and of less intensity than after major surgical procedures, the effect demonstrated is much less pronounced than in similar studies of major surgery. General use of gabapentin as analgesic for laparoscopic sterilization is not supported by this study.

Trial Registration

Current Controlled Trials ISCRTN39209275

Effect of topical bupivacaine on postoperative pain after laparoscopic tubal sterilization with Filshie clips

OBJECTIVE

The purpose of this study was to evaluate postoperative pain after the administration of topical bupivacaine during laparoscopic sterilization with Filshie clips.

STUDY DESIGN

Sixty-three women who underwent laparoscopic tubal sterilization with Filshie clips were assigned randomly to receive topical bupivacaine or placebo. Presence of pain, pain intensity, nausea, vomiting, timing of request for pain medication, and pain medication requirements were assessed postoperatively.

RESULTS

Patient demographics were similar between the 2 groups. Topical bupivacaine decreased the incidence (P=.005) and intensity (P=.028) of postoperative pain at 30 minutes. No differences in incidence or severity of pain were seen at hospital discharge or on postoperative day 1.

CONCLUSION

Topical bupivacaine that is applied to the fallopian tubes at the time of laparoscopic tubal sterilization with the Filshie clip decreases immediate postoperative pain.

Female sterilization. Evidence

The literature review herein reveals substantial information regarding the safety, efficacy, short-term complications, long-term complications, and noncontraceptive benefits of sterilization. This information should be helpful for providers and potential sterilization candidates. The review also reveals areas where the data are unclear. Points to keep in mind during counseling include the following: The vast majority of women are satisfied with the decision to undergo sterilization. The fact that regret occurs underscores the importance of counseling and adequate individual deliberation before the procedure. In addition to the difficulty and expense associated with sterilization reversal, the woman should thoroughly understand the permanence of the procedure. Although failure is a rare event, it can occur many years after the procedure. Although evidence suggests that hysterectomy rates are higher in sterilized women aged less than 30 to 35 years, it is unlikely that there is a plausible biologic effect of sterilization on hysterectomy risk. An association between tubal sterilization and menstrual cycle changes does not seem valid for changes noted up to 2 years after the procedure. Data are unclear and inconsistent among studies observing women more than 2 years after the procedure. Evidence consistently shows that sterilization is associated with a reduced incidence of ovarian cancer and pelvic inflammatory diseases. Most studies show no effect or improvement of sexual satisfaction after sterilization. Complications during and postprocedure are rare. Sterilization provides no protection against the acquisition of sexually transmitted disease. Patients and their physicians should recognize that sterilized women may need more targeted preventive efforts for health screening and to reduce high-risk behavior than women who use other contraceptive methods. The surgeon's experience and the woman's preferences should govern the ultimate decision regarding the approach and occlusion method. Level II-2 evidence indicates comparable safety between interval laparoscopy and minilaparotomy. Data consistently show that in experienced trained hands, tubal sterilization is safe and highly effective regardless of the approach or occlusive method. Attention to the subtleties of technique seems to be most important in ensuring procedure safety and efficacy. Reanalysis of the CREST data shows that the cumulative failure rate of bipolar coagulation is comparable with the failure rate of unipolar coagulation if a substantial length of tube is adequately coagulated. The data discussed herein can be used to guide management decisions that may increase accessibility and reduce cost of the procedure. Low-resource settings and office settings have maintained an excellent safety record for this procedure through performance of sterilization under local anesthesia. The use of local anesthesia enables a change in procedure location from an inpatient operating room to a free-standing surgical clinic or adequately equipped office. Local anesthesia, with or without preoperative medication, is an excellent option associated with a lower complication risk, reduced cost, and shorter, easier recovery. The surgeon should have specific training in the effective use of local anesthetics, preoperative medications, and management of rare complications in low-resource settings. Little additional research is needed regarding the safety and efficacy of standard sterilization approaches and occlusion methods. There is a need for continued development of nonsurgical methods of sterilization, microlaparoscopic approaches performed in the office setting, and the feasibility and acceptance of service provision by nonspecialist health care providers. The evidence indicates that female sterilization can be performed safely in a variety of resource settings ranging from rural sterilization camps in developing countries to high-tech, resource-rich operating rooms in developed c

Local anesthetic infiltration for postoperative pain relief after laparoscopy: a qualitative and quantitative systematic review of intraperitoneal, port-site infiltration and mesosalpinx block

In a systematic review, we evaluated randomized controlled trials (RCTs) of peripheral local anesthetics (LA) compared with placebo or no treatment in the control of postoperative pain after laparoscopic surgery. A total of 41 trials with data from 2794 patients were considered appropriate for analysis. Of these 41 RCTs, 13 evaluated intraperitoneal LA after cholecystectomy, four RCTs assessed intraperitoneal LA after other procedures, eight RCTs evaluated port-site infiltration after various procedures, 12 RCTs evaluated mesosalpinx or fallopian tube block after sterilization, and four RCTs considered combined LA regimens. Outcome measures were pain scores, analgesic consumption, and time to first analgesic request. Efficacy was estimated by significant difference (P < 0.05), as reported in the original reports, and by calculation of the weighted mean difference of visual analog scale pain scores between treatment groups. Improved pain relief was observed in seven of the 13 RCTs of intraperitoneal LA after cholecystectomy and in four RCTs of other procedures. A statistically significant weighted mean difference of -13 mm visual analog scale (95% confidence intervals [CI]: -20 to -6) in favor of the treatment groups was observed after cholecystectomy. Three of eight trials of port-site infiltration showed significant differences but questionable clinical importance and validity in two; weighted mean difference was not statistically significant between treatment groups (95% CI -9 to 1). All RCTs of mesosalpinx or fallopian tube block after sterilization showed improved pain relief with a statistically significant weighted mean difference of -19 mm (95% CI -25 to -14) in favor of treatment groups. Data of combined regimens were positive, however, sparse. We conclude that there was evidence for a statistically significant but clinically questionable, important effect of intraperitoneal LA for postoperative pain control. There was evidence for a significant but short-lasting effect of mesosalpinx/fallopian tube block after sterilization, but there was a lack of evidence for any important effect of port-site infiltration. Data from combined regimens were too sparse for conclusions.

IMPLICATIONS

A systematic review summarizes, through transparent methodology, available information from randomized, controlled trials to produce the best available evidence-based estimate of a "true" clinical effect of an intervention. This systematic review confirms intraperitoneal and mesosalpinx local anesthetic block, not port-site infiltration, to have some impact on postoperative pain after laparoscopy.

Laparoscopic tubal sterilization. Methods, effectiveness, and sequelae

The following statements summarize the material presented herein. 1. Although laparoscopic tubal ligation remains an effective and widely available form of birth control throughout the world, cumulative failure rates may be higher than previously reported, and patients should be appropriately counseled, with special attention to younger women. 2. Proper surgical technique is important in reducing failure rates, particularly with regard to applying clips or using bipolar cautery. Teaching institutions should employ strict guidelines for instructing residents in the most effective techniques. 3. Although overall rates of ectopic pregnancy are lower after tubal ligation (as is true with any form of birth control), should pregnancy ensure from a failed procedure, there is a 30% to 80% chance of ectopic pregnancy. Consideration should be given to earlier ultrasound and documentation of the location of the pregnancy. 4. There is little evidence to support PTLS from a biologic standpoint. The data on increased hysterectomies in post-tubal patients may be a result of multiple factors, particularly for women aged less than 30 years at the time of occlusion. 5. Although the majority of women report satisfaction with sterilization, thorough counseling for all women cannot be overemphasized. Women aged less than 30 years should be completely aware of all alternatives and possibly encouraged to try another method prior to permanent sterilization.

Extending the limits: minimally invasive surgery

Minimally invasive technology is being applied to an increasing number of surgical procedures. It remains to be seen which techniques will eventually become a 'gold standard' as has the laparoscopic cholecystectomy, and which will fall by the wayside. In the meantime, anesthesiologists must be aware of the unique requirements and complications of laparoscopic surgery.