Pain Characteristics after Total Laparoscopic Hysterectomy

Paracervical block before laparoscopic total hysterectomy: A randomized controlled trial

OBJECTIVE

To test the hypothesis that paracervical block with 0.5 % bupivacaine decreases postoperative pain after total laparoscopic hysterectomy (TLH).

MATERIALS AND METHOD

This randomized double-blind placebo control trial included 152 women. We injected 10 mL 0.5 % bupivacaine (study group, n = 75) or 10 mL normal saline (control group, n = 77) at the 3 and 9 o'clock positions of the uterine cervix. The primary outcome was the visual analog scale score (VAS) determined 1 h (h) postoperatively.

RESULTS

The 152 patients did not differ in their baseline demographics or perioperative characteristics. The mean VAS 1 h postoperatively was significantly lower in the study group than in controls (5.7 ± 1.2 vs. 6.8 ± 1.1, P < 0.001). The average VAS at 30 min, 3 h, and 6 h postoperatively was also significantly lower in the study group. Patients in the study group had a significantly lower analgesic requirement than did controls during the first 24 h postoperatively (6 [7.8 %] vs. 16 [21 %], P = 0.021). Total QoR-40 questionnaire scores were higher in patients who received bupivacaine.

CONCLUSION

Paracervical bloc with 0.5 % bupivacaine just before TLH is an effective and safe method to reduce pain and lower postoperative analgesic requirement. URL LINK THAT LEADS DIRECTLY TO THE TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT05341869?cond=NCT05341869&draw=2&rank=1.

Comparison of Quality of Recovery between Modified Thoracoabdominal Nerves Block through Perichondrial Approach versus Oblique Subcostal Transversus Abdominis Plane Block in Patients Undergoing Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial

Modified thoracoabdominal nerves block through a perichondrial approach (M-TAPA) provides a wide analgesic range. Herein, we examined the quality of recovery (QoR) of M-TAPA for total laparoscopic hysterectomy (TLH) compared with oblique subcostal transversus abdominis plane block (OSTAPB) and measured plasma levobupivacaine concentrations (PClevo). Forty female patients undergoing TLH were randomized to each group. Nerve blocks were performed bilaterally with 25 mL of 0.25% levobupivacaine administered per side. The primary outcome was changes in QoR-15 scores on postoperative days (POD) 1 and 2 from the preoperative baseline. The main secondary outcomes were PClevo at 15, 30, 45, 60, and 120 min after performing nerve block. Group differences (M-TAPA-OSTAPB) in mean changes from baseline in QoR-15 scores on POD 1 and 2 were -11.3 (95% confidence interval (CI), -24.9 to 2.4, p = 0.104; standard deviation (SD), 22.8) and -7.0 (95% CI, -20.5 to 6.6, p = 0.307; SD, 18.7), respectively. Changes in PClevo were similar in both groups. The post hoc analysis using Bayesian statistics revealed that posterior probabilities of M-TAPA being clinically more effective than OSTAPB were up to 22.4 and 24.4% for POD 1 and 2, respectively. In conclusion, M-TAPA may not be superior to OSTAPB for TLH.

Clinical analysis of acute postoperative pain after total laparoscopic hysterectomy for adenomyosis and uterine fibroids - a prospective observational study

OBJECTIVE

To investigate the outcome of total laparoscopic hysterectomy (TLH) and postoperative pain characteristics and compare the pain severity after TLH for adenomyosis or uterine fibroids.

METHODS

This prospective observational study collected 101 patients received TLH for adenomyosis (AD group) including 41 patients were injected goserelin (3.6 mg) 28 days before TLH, while other adenomyosis patients received TLH without preoperative treatment, and 113 patients received TLH for uterine fibroids (UF group). Pain scores were evaluated at different time sites from operation day to postoperative 72 h using the numeric rating scale. Clinical data were collected from clinical record.

RESULTS

Operative time and anaesthetic time were longer in the AD group than those in the UF group (66.88 ± 8.65 vs. 64.46 ± 7.21, p = 0.04; 83.95 ± 10.05 vs. 79.77 ± 6.88, p < 0.01), severe endometriosis was quite more common in AD group (23.76% vs. 2.65%, p < 0.01). Postoperative usage of Flurbiprofen in AD group were more than that of UF group (15.48 ± 38.00 vs. 4.79 ± 18.16, p = 0.02). Total pains and abdominal visceral pains of AD group were more severe compared with UF group in motion and rest pattern at several time sites, while incision pain and shoulder pain were similar. The total postoperative pains after goserelin preoperative treatment in AD group were less than that without goserelin preoperative treatment (p < 0.05). The levels of serum NPY, PGE2 and NGF after laparoscopic hysterectomy of adenomyosis reduced with GnRH agonist pretreatment.

CONCLUSIONS

Acute postoperative pain for adenomyosis and uterine fibroids showed considerably different severity, postoperative total pain and abdominal visceral pains of TLH for adenomyosis were more severe compared with uterine fibroids. While patients received goserelin before laparoscopic hysterectomy of adenomyosis suffered from less severity of postoperative total pain than that without goserelin preoperative treatment.

Anterior Quadratus Lumborum Block for Total Laparoscopic Hysterectomy: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVES

This study aimed to investigate the perioperative analgesic effects of anterior quadratus lumborum block (QLB) for total laparoscopic hysterectomy (TLH).

MATERIALS AND METHODS

One hundred patients undergoing TLH were randomized to receive an anterior QLB or placebo before general anesthesia. The primary and secondary outcomes were postoperative sufentanil consumption, intraoperative remifentanil demand, time to first opioid demand, numeric rating scale (NRS) pain scores, heart rate, mean arterial pressure, and complications within 24 hours after surgery.

RESULTS

No significant intergroup differences were observed in sufentanil consumption within 24 hours after surgery. Remifentanil consumption during surgery was lower in the QLB group than in the placebo group. At 1 hour after surgery, the NRS scores of abdominal visceral pain at rest and during activity were 1.26 and 1.41 points lower than those in the placebo group. In other time points, the differences in abdominal visceral pain were neither statistically significant nor clinically significant (pain difference <1) or both. No significant differences in NRS scores of shoulder pain, abdominal incisional pain, and perineal pain were observed between the 2 groups, at rest or during activity. There were no significant differences in other secondary outcome variables between the 2 groups.

DISCUSSION

Preoperative bilateral anterior QLB only reduced intraoperative opioid demand and postoperative abdominal visceral pain scores at 1 hour after surgery. Thus, the clinical significance of anterior QLB in TLH may be limited.

Laparoscopic administration of bupivacaine at the uterosacral ligaments during benign laparoscopic and robotic hysterectomy: a randomized controlled trial

BACKGROUND

Postoperative pain continues to be an undermanaged part of the surgical experience. Multimodal analgesia has been adopted in response to the opioid epidemic, but opioid prescribing practices remain high after minimally invasive hysterectomy. Novel adjuvant opioid-sparing analgesia to optimize acute postoperative pain control is crucial in preventing chronic pain and minimizing opioid usage.

OBJECTIVE

This study aimed to determine the effect of direct laparoscopic uterosacral bupivacaine administration on opioid usage and postoperative pain in patients undergoing benign minimally invasive (laparoscopic and robotic) hysterectomy.

STUDY DESIGN

This was a single-blinded, triple-arm, randomized controlled trial at an academic medical center between March 15, 2021, and April 8, 2022. The inclusion criteria were patients aged >18 years undergoing benign laparoscopic or robotic hysterectomy. The exclusion criteria were non-English-speaking patients, patients with an allergy to bupivacaine or actively using opioid medications, patients undergoing transversus abdominis plane block, and patients undergoing supracervical hysterectomy or combination cases with other surgical services. Patients were randomized in a 1:1:1 fashion to the following uterosacral administration before colpotomy: no administration, 20 mL of normal saline, or 20 mL of 0.25% bupivacaine. All patients received incisional infiltration with 10 mL of 0.25% bupivacaine. The primary outcome was 24-hour oral morphine equivalent usage (postoperative day 0 and postoperative day 1). The secondary outcomes were total oral morphine equivalent usage in 7 days, last day of oral morphine equivalent usage, numeric pain scores from the universal pain assessment tool, and return of bowel function. Patients reported postoperative pain scores, total opioid consumption, and return of bowel function via Qualtrics surveys. Patient and surgical characteristics and primary and secondary outcomes were compared using chi-square analysis and 1-way analysis of variance. Multiple linear regression was used to identify predictors of opioid use in the first 24 hours after surgery and total opioid use in the 7 days after surgery.

RESULTS

Of 518 hysterectomies screened, 410 (79%) were eligible, 215 (52%) agreed to participate, and 180 were ultimately included in the final analysis after accounting for dropout. Most hysterectomies (70%) were performed laparoscopically, and the remainder were performed robotically. Most hysterectomies (94%) were outpatient. Patients randomized to bupivacaine had higher rates of former and current tobacco use, and patients randomized to the no-administration group had higher rates of previous surgery. There was no difference in first 24-hour oral morphine equivalent use among the groups (P=.10). Moreover, there was no difference in numeric pain scores (although a trend toward significance in discharge pain scores in the bupivacaine group), total 7-day oral morphine equivalent use, day of last opioid use, or return of bowel function among the groups (P>.05 for all). The predictors of increased 24-hour opioid usage among all patients included only increased postanesthesia care unit oral morphine equivalent usage. The predictors of 7-day opioid usage among all patients included concurrent tobacco use and mood disorder, history of previous laparoscopy, estimated blood loss of >200 mL, and increased oral morphine equivalent usage in the postanesthesia care unit.

CONCLUSION

Laparoscopic uterosacral administration of bupivacaine at the time of minimally invasive hysterectomy did not result in decreased opioid usage or change in numeric pain scores.

Efficacy of nonopioid analgesics and regional techniques for perioperative pain management in laparoscopic gynecological surgery: a systematic review and network meta-analysis

BACKGROUND

The optimal approach for perioperative pain management in laparoscopic gynecological surgery is unclear due to a lack of comprehensive analysis, which limits the development of evidence-based enhanced recovery after surgery protocols. This study aimed to conduct a systematic review and network meta-analysis to support clinical decision-making for optimal analgesia.

MATERIALS AND METHODS

This study conducted a systematic literature search in PubMed, Embase, CENTRAL, Web of Science, and CINAHL from inception to 3 December 2021, and updated on 19 August 2022. Randomized controlled trials comparing the perioperative use of nonopioid analgesics and regional techniques in adults undergoing elective laparoscopic gynecological surgery under general anesthesia were included in the analysis, either alone or in combination. The co-analgesic interventions during the perioperative period for the intervention and control groups of each eligible study were also considered. We assessed the risk of bias using the Risk of Bias 2 tool and evaluated the certainty of evidence using the Confidence in Network Meta-Analysis (CINeMA) approach. A Bayesian network meta-analysis was used to estimate the efficacy of the analgesic strategies. The primary outcomes were pain score at rest and cumulative oral morphine milligram equivalents at 24 h postoperatively.

RESULTS

Overall, 108 studies with 9582 participants and 35 different interventions were included. Compared with inert treatments, combinations of two or more interventions showed better efficacy and longer duration in reducing postoperative pain and opioid consumption within 24 h than monotherapies, and showed stepwise enhanced effects with increasing analgesic modes. In combination therapies, regional techniques that included peripheral nerve blocks and intraperitoneal local anesthetics, in combination with nonopioid systemic analgesics, or combining local anesthetics with adjuvant drugs, were found to be more effective. Monotherapies were found to be mostly ineffective. The most effective peripheral nerve blocks were found to be ultrasound-guided transversus abdominis plane block with adjuvant and ultrasound-guided quadratus lumborum block.

CONCLUSIONS

These results provide robust evidence for the routine use of regional techniques in combination with nonopioid analgesics in perioperative pain management. However, further better quality and larger trials are needed, considering the low confidence levels for certain interventions.

Ultrasound-guided anterior quadratus lumborum block at the L2 level for postsurgical analgesia in patients undergoing laparoscopic gynaecological surgery: a single-centre, randomised, double-blinded trial at a university-affiliated hospital in China

OBJECTIVE

This study aimed to investigate the analgesic effect of an ultrasound-guided anterior quadratus lumborum block (QLB) at the L2 level on postoperative pain after laparoscopic gynaecological surgery.

DESIGN

Prospective single-centre randomised double-blind trial.

SETTING

University-affiliated hospital.

PARTICIPANTS

Sixty patients aged between 18 and 65 years scheduled for laparoscopic gynaecological surgery.

INTERVENTIONS

Before surgery, bilateral anterior QLB was performed with 20 mL of 0.375% ropivacaine injected on each side in the QLB group, whereas equal amount of saline was administered in the placebo group.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was the cumulative morphine dose in the first 24 hours, and the secondary endpoints were morphine consumption at each time interval, area under the curve (AUC) of the numeric rating scale (NRS) for pain, maximum pain intensity, incidence of moderate-to-severe pain (NRS>3), sedation score, adverse events, and time to home-readiness.

RESULTS

Cumulative morphine consumption in the first 24 hours after surgery was significantly lower in the QLB group than in the placebo group (mean difference, 14.2; 95% CI 6.3 to 22.1; p<0.001). The AUCs of NRS pain intensity scores, including visceral and incisional pain at rest and on movement, were significantly lower in the QLB group than in the placebo group (all p<0.001). The time to home-readiness was significantly shorter in the QLB group than in the placebo group (p<0.05).

CONCLUSION

Ultrasound-guided anterior QLB at the L2 level significantly reduced morphine consumption and relieved visceral and incision pain intensity after laparoscopic gynaecological surgery, which was beneficial for enhanced recovery.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR-IOR-17011960).

The Effect of Caudal Ropivacaine and Morphine on Postoperative Analgesia in Total Laparoscopic Hysterectomy: A Prospective, Double-Blind, Randomized Controlled Trial

Purpose

Multiple regional nerve blocks proved no additional benefit in total laparoscopic hysterectomy in multimodal analgesia, as postoperative pain may mainly originate from the vaginal cuff. Theoretically, caudal block can relieve pain from the vaginal cuff by a sacral spinal nerve block. We aimed to verify whether a caudal block with ropivacaine and morphine can achieve an analgesic effect without additional adverse effects after a total laparoscopic hysterectomy.

Patients and Methods

Forty-eight patients undergoing total laparoscopic hysterectomy were randomly allocated to receive preoperative caudal block with 20 mL of mixture including 0.25% ropivacaine and 2 mg morphine (caudal block group) or sham block (sham group). The primary outcome was the postoperative 24 h cumulative sufentanil consumption.

Results

Median (IQR) sufentanil consumption in the first 24 postoperative hours of the caudal block group and the sham group was 0.00 (0.00 to 0.05) μg/kg vs 0.13 (0.04 to 0.21) μg/kg, respectively, p < 0.001. The majority of patients felt that visceral pain was more intense than incisional pain at 1, 6, 12, and 24 h post-surgery in the sham group (95.8% at 1 h, 95.8% at 6 h, 95.8% at 12 h, and 75% at 24 h post-surgery). Compared to the sham group, the caudal block reduced visceral pain scores at rest and during movement at 1 h (p < 0.001), 6 h (p < 0.001), 12 h (p < 0.001), and 24 h (p < 0.001) post-surgery. Intraoperative remifentanil consumption was significantly lower in the caudal block group than in the sham group (p = 0.004). There were no significant differences in other secondary outcomes between the two groups.

Conclusion

A caudal block with ropivacaine and morphine could provide a satisfactory analgesic effect for 24 h postoperatively without additional adverse effects after total laparoscopic hysterectomy.

Effect of an early mobilisation programme on pain intensity after laparoscopic surgery: a randomised clinical trial

BACKGROUND

Pain is a common complication after laparoscopic surgery. This study aimed to examine the effect of an early mobilisation programme on postoperative pain intensity after laparoscopic surgery.

METHODS

A randomised controlled clinical trial was conducted on 80 patients who underwent laparoscopic surgery in Shahid Beheshti Hospital in Kashan, Iran. The patients were randomly allocated to intervention (n=40) and a control (n=40) group. In the intervention group, an early mobilisation programme was implemented in two rounds. The patient's perceived pain was assessed using a Visual Analogue Scale 15 min before and 30 min after each round of early mobilisation. Data were analysed through the independent samples t, χ2 and Fisher's exact tests and the repeated measures analysis.

RESULTS

The repeated measures analysis showed that the mean pain scores have been decreased over time (F=98.88, p<0.001). Considering the observed interaction between time and the intervention, the t test was used for pairwise comparisons and showed that the mean pain score was not significantly different between the two groups in 15 min before the first round of early mobilisation (p=0.95). However, the mean pain in the intervention group was significantly less than the control group in all subsequent measurements (p<0.05).

CONCLUSION

Early mobilisation programmes such as the one implemented in the current study are easy and inexpensive and can be implemented safely for the reduction of pain after laparoscopic surgeries.

Optimizing Total Laparoscopic Hysterectomy for the Geriatric Population: A Practical Case Study and Comprehensive Literature Review

Elderly patients represent a large cohort of patients requiring gynaecological surgery for benign and malignant indications. In recent years, several conventional gynaecological procedures have shifted towards minimally invasive alternatives such as laparoscopy, hysteroscopy, and robotic surgery. A recent Surveillance, Epidemiology, and End Results (SEER) analysis compared the outcomes of 25,000 women undergoing laparotomy versus laparoscopic approach to hysterectomy and found that laparoscopy is associated with a shorter duration of hospitalization (three days versus five days), less postoperative complications (76%), less requirement for blood transfusion, reduced operational costs, faster recovery, and an overall safer surgical experience. Although geriatric patients are affected by age-related comorbidities, physiologic changes, and altered pharmacodynamics and pharmacokinetics of administered drugs, these patients benefit most from minimally invasive surgery. In this paper, we present a comprehensive account of the interdisciplinary perioperative approaches employed to accomplish a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection in an 82-year-old patient who was diagnosed with grade I endometrial adenocarcinoma and multiple age-related medical comorbidities.

Effect of analgesia nociception index monitor-based nociception control on perioperative stress responses during laparoscopic surgery in Trendelenburg position: a randomized controlled trial

Introduction

The analgesia nociception index (ANI) monitor is a nociception monitoring device based on heart rate variability. We aimed to determine the effect of ANI monitor-based intraoperative nociception control on the perioperative stress response during laparoscopic surgery in the Trendelenburg position.

Methods

Altogether, 72 female patients who underwent total laparoscopic hysterectomy were randomized to either the control or ANI group. Intraoperative nociception was controlled by remifentanil administration in a conventional manner (based on blood pressure and heart rate) in the control group and by ANI monitoring in the ANI group. Perioperative stress responses were estimated by measuring the levels of serum catecholamines and catabolic stress hormones at three timepoints: after loss of consciousness, at the end of surgery, and 1 h after the end of surgery.

Results

The serum cortisol level at the end of surgery was significantly higher in the ANI group than in the control group (p < 0.001), although more remifentanil was administered in the ANI group than in the control group (p < 0.001). Changes in the other estimators' levels were comparable between groups during the perioperative period. The hemodynamic profiles during surgery were also significantly different between the two groups. Phenylephrine use to treat hypotension was more common in the ANI group than in the control group (p = 0.005). However, postoperative clinical outcomes such as pain and nausea/vomiting did not differ between groups.

Conclusion

ANI monitor-based nociception control in laparoscopic surgery in the Trendelenburg position did not improve perioperative stress responses, intraoperative opioid consumption, or postoperative clinical outcomes.Clinical trial registration: ClinicalTrials.gov (NCT04343638).

Efficacy of a continuous wound infiltration system for postoperative pain management in gynecologic patients who underwent single-port access laparoscopy for adnexal disease

Introduction

Single-port access (SPA) laparoscopy requires only one incision, unlike conventional laparoscopy. However, its umbilical incision is larger than that of conventional laparoscopy and can be vulnerable to postoperative pain. This study aimed to evaluate whether simultaneous use of a continuous wound infiltration (CWI) system and intravenous patient-controlled analgesia (IV PCA) effectively decreases surgical site pain in patients who underwent SPA laparoscopy due to gynecologic adnexal disease.

Methods

A total of 371 patients who underwent SPA laparoscopy and who received IV PCA or CWI was retrospectively reviewed (combined group [CWI + IV PCA, n = 159] vs. PCA group [IV PCA only, n = 212]). To evaluate postoperative pain management, the numeric rating scale (NRS) pain score after surgery, total amount of fentanyl administered via IV PCA, and additional pain killer consumption were collected.

Results

The NRS scores at 12 h (1.90 ± 1.11 vs. 2.70 ± 1.08, p < 0.001) and 24 h (1.82 ± 0.82 vs. 2.11 ± 1.44, p = 0.026) after surgery were significantly lower in the combined group than in the PCA group. The total amount of PCA fentanyl was significantly smaller in the combined group than in the PCA group (p < 0.001). The total quantity of rescue analgesics was smaller in the combined group than in the PCA group (p < 0.05).

Conclusion

Combined use of the CWI system and IV PCA is an effective postoperative pain management strategy in patient who underwent SPA laparoscopy for adnexal disease.

The comparison of postoperative analgesic requirements between modified thoracoabdominal nerve block through perichondrial approach versus wound infiltration analgesia in patients undergoing gynecological laparoscopic surgery: a retrospective, exploratory study

INTRODUCTION

Recently, modified thoracoabdominal nerve block through perichondrial approach (M-TAPA) has been introduced as a novel trunk block. To date, studies comparing its clinical advantages with those of existing local anesthetic techniques are scarce. We aimed to compare the analgesic efficacy of M-TAPA to that of wound infiltration analgesia (WIA) in patients who underwent gynecological laparoscopic surgeries.

METHODS

We studied medical records from January 2020 to July 2021 at Hokkaido University Hospital. The primary outcome was the number of analgesic requirements in the first 24 h postoperatively. Secondary outcomes were the time until the first analgesic requirement and adverse events regarding local anesthetic techniques. To address confounding, a regression model was used.

RESULTS

Data from 90 of 231 patients were analyzed (M-TAPA group, n = 40; WIA group, n = 50). For the primary outcome, means and 95% confidence intervals for each group and between-group differences were as follows: 2.25 (1.74, 2.76), 2.28 (1.81, 2.75), and -0.03 (-0.72, 0.66), respectively. Adjusted mean difference was 0.39 (-0.32, 1.11). There were no significant differences in means between groups, with or without adjustment for covariates (p = 0.93, 0.28). Furthermore, no significant difference was detected in the time until the first analgesic requirement and adverse events related to local anesthesia.

CONCLUSION

Our results demonstrate that M-TAPA did not reduce postoperative analgesic requirements compared to WIA. In a future clinical trial, sufficient visceral pain control may be required to evaluate the effectiveness of M-TAPA over WIA in patients undergoing laparoscopic gynecological surgery.

A Practical Approach to Total Laparoscopic Hysterectomy in a Morbidly Obese Patient: A Case Report and Literature Review

Morbid obesity, traditionally considered to be a contraindication to total laparoscopic hysterectomy, is now evolving into an indication. Innovations and advancements in minimally invasive surgical techniques have significantly improved patient morbidity and mortality rates, reduced operational costs, and provided patients with an overall safer surgical experience. Although the laparoscopic approach is associated with several physiologic and technical challenges in the morbidly obese, it is plausible that these patients stand to benefit the most from minimally invasive surgery. This report highlights the methods of preoperative optimization, intraoperative considerations, and postoperative management strategies employed to achieve a successful total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection in a patient with a BMI of 45kg/m², diagnosed with grade 1 endometrial adenocarcinoma and several obesity-related comorbidities.

Positive Association between Peri-Surgical Opioid Exposure and Post-Discharge Opioid-Related Outcomes

Background: Multiple studies have investigated the epidemic of persistent opioid use as a common postsurgical complication. However, there exists a knowledge gap in the association between the level of opioid exposure in the peri-surgical setting and post-discharge adverse outcomes to patients and healthcare settings. We analyzed the association between peri-surgical opioid exposure use and post-discharge outcomes, including persistent postsurgical opioid prescription, opioid-related symptoms (ORS), and healthcare resource utilization (HCRU). Methods: A retrospective cohort study included patients undergoing cesarean delivery, hysterectomy, spine surgery, total hip arthroplasty, or total knee arthroplasty in an academic healthcare system between January 2015 and June 2018. Peri-surgical opioid exposure was converted into morphine milligram equivalents (MME), then grouped into two categories: high (>median MME of each surgery cohort) or low (≤median MME of each surgery cohort) MME groups. The rates of persistent opioid use 30 and 90 days after discharge were compared using logistic regression. Secondary outcomes, including ORS and HCRU during the 180-day follow-up, were descriptively compared between the high and low MME groups. Results: The odds ratios (95% CI) of high vs. low MME for persistent opioid use after 30 and 90 days of discharge were 1.38 (1.24−1.54) and 1.41 (1.24−1.61), respectively. The proportion of patients with one or more ORS diagnoses was greater among the high-MME group than the low-MME group (27.2% vs. 21.2%, p < 0.01). High vs. low MME was positively associated with the rate of inpatient admission, emergency department admissions, and outpatient visits. Conclusions: Greater peri-surgical opioid exposure correlates with a statistically and clinically significant increase in post-discharge adverse opioid-related outcomes. The study findings warrant intensive monitoring for patients receiving greater peri-surgical opioid exposure.

A study of the analgesic efficacy of rectus sheath block in single-port total laparoscopic hysterectomy: a randomized controlled study

Objective

To investigate the postoperative analgesic effects of rectus sheath block (RSB) in combination with patient-controlled analgesia (PCA) compared with PCA alone after single-port total laparoscopic hysterectomy (TLH)

Methods

This randomized, single-blind study enrolled female patients that underwent single-port TLH. The patients were randomized to receive either fentanyl PCA (PCA group) or RSB with the same PCA. The primary outcomes were fentanyl consumption at 8 h postoperatively and visual analogue scale (VAS) pain scores, which represented the severity of postoperative pain.

Results

A total of 36 patients were enrolled in the study: 18 in the PCA group and 18 in the RSB group (two patients were excluded). The primary outcome of fentanyl consumption was significantly lower at 8 h postoperatively in the RSB group than in the PCA group (148 ± 61 µg versus 222 ± 107 µg, respectively). VAS scores were significantly lower at arrival in the post-anaesthesia care unit and at 30 min after arrival in the RSB group compared with the PCA group. There were no significant differences in the nausea/vomiting score and in additional analgesic consumption between the two groups.

Conclusions

RSB can be used as a multimodal approach for pain control in single-port TLH procedures.

Clinical Research Information Service (no. KCT0001461).

Effect of Low or High Pressure Alveolar Recruitment Maneuver on Postoperative Pain and Quality of Recovery in Patients with Obesity Undergoing Laparoscopic Sleeve Gastrectomy

Background: This study aimed to evaluate whether a low- or high-pressure alveolar recruitment maneuver (ARM) might reduce postoperative pain and improve the quality of recovery after laparoscopic bariatric surgery. Methods: 90 patients with a body mass index > 30 kg/m2 scheduled for laparoscopic sleeve gastrectomy were randomly assigned to control (n = 30), low ARM (n = 30), or high ARM groups (n = 30). For the low and high ARM groups, ARM was repeated five times to hold the peak airway pressure at 30 cmH2O and 60 cmH2O for 5 s, respectively, before removal of the trocar. Conventional methods to reduce post-laparoscopic pain, such as intraperitoneal saline irrigation, hemovac drainage, and gentle abdominal compression were performed in all patients, regardless of the assigned group. Results: Shoulder and surgical site pain scores 24 h postoperatively and rescue meperidine requirement were similar between the groups (p = 0.141, 0.101, and 0.82, respectively). The quality of recovery 40 (QoR40) score 24 h postoperatively was similar between the groups (p = 0.755). Postoperative pulmonary complications were similar between the groups (p = 0.124). Conclusion: Application of a low- or high-pressure ARM in addition to conventional methods to remove remnant peritoneal CO2 gas did not reduce postoperative shoulder or surgical site pain or improve the quality of recovery after laparoscopic sleeve gastrectomy.

The impact of low-pressure pneumoperitoneum on robotic-assisted radical cystectomy and intracorporeal ileal conduit urinary diversion: a case-control study

Purpose

To evaluate the role of low intra-abdominal pressure (IAP) in improving postoperative recovery in Robotic-assisted radical cystectomy (RARC) and intracorporeal ileal conduit urinary diversion (ICUD).

Methods

A retrospective case–control study of 49 bladder cancer patients offered RARC/ICUD with standard (12 mmHg, n = 24) or low IAP (8 mmHg, n = 25). Outcomes of interest included length of procedure (LoP), estimated blood loss (EBL), blood transfusion, margin positivity rates, time to first flatus (TtFF), time to first bowel movement (TtFBM), ileus and small bowel obstruction (SBO) rates, time to safe discharge (TtSD), postoperative hospital stay (PHS) and pain levels on a postoperative day (POD) 1 and 3. Perioperative complications were recorded using the Clavien-Dindo system.

Results

Demographic and baseline clinical characteristics, LoP, EBL and margin positivity rates were similar between groups. No transfusions were recorded. Median (IQR) TtFF, TtFBM and TtSD were significantly longer in Group 1 vs Group 2 (4 (1) vs 2 (1), 7 (3) vs 6 (2) and 8.5 (5.75) vs 5.0 (1), respectively). PHS and rates of postoperative ileus and SBO were lower in Group 2, however not statistically significant. Severe pain was uncommon in both groups but moderate/severe pain was significantly higher in Group 1 (95.8% vs 48% on POD1 and 62.5% vs 16% on POD3). No significant intraoperative complications were recorded and ≥ Grade 3 postoperative complications at 30 and 90 days were similar.

Conclusion

With limitations, Low-IAP RARC can be safely offered to RARC/ICUD patients and leads to faster bowel recovery, and shorter time to safe discharge compared to standard pneumoperitoneum.

Sodium Bicarbonate Sub-Diaphragmatic Irrigation Relieves Shoulder Pain After Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

Study Objective

To determine whether sub-diaphragmatic irrigation with sodium bicarbonate would relieve post-laparoscopic shoulder pain (PLSP) after total laparoscopic hysterectomy.

Design

Randomized double-blinded trial.

Setting

Teaching hospital.

Patients

Seventy patients undergoing total laparoscopic hysterectomy (TLH) for benign indications.

Intervention

We randomly allocated patients to intervention or control groups where sodium bicarbonate containing flushing liquid or normal saline was irrigated sub-diaphragm before sewing.

Measurement & Main Results

The primary outcome was PLSP following surgery measured by a numerical rating scale (NRS) (0 = no pain; 10 = worst pain imaginable). Secondary outcomes were abdominal incisional and visceral pain, analgesic use, and sodium bicarbonate related side effects. The incidence of PLSP in intervention group was significantly lower than that in control group (P < 0.05). Contrarily, incisional and visceral pain was similar in both groups (P = 0.1). The consumption of rescue analgesics in the intervention group was lower than that in the control group. Side effects were comparable in both study groups.

Conclusion

Sub-diaphragmatic irrigation with sodium bicarbonate could effectively reduce shoulder pain, but not abdominal incisional and visceral pain, in patients undergoing TLH without an increase in side effects.

Registration information

Clinical trial registry number: http://www.chictr.org.cn/ (ChiCTR2100041765).

Registration findings

http://www.chictr.org.cn/showproj.aspx?proj=66721 Link to clinical trial page and data repository: http://www.medresman.org.cn/pub/cn/proj/projectshshow.aspx?proj=2992.

Description and Comparison of Acute Pain Characteristics After Laparoscope-Assisted Vaginal Hysterectomy, Laparoscopic Myomectomy and Laparoscopic Adnexectomy

Purpose

To determine the characteristics of the acute pain after laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic myomectomy (LM), and laparoscopic adnexectomy (LA) and compare them with each other.

Patients and Methods

Patients undergoing LAVH, LM, and LA under general anaesthesia at the First Affiliated Hospital of Wenzhou Medical University between December 2017 and December 2019 were selected. Their data were collected before, during, and after the surgery. We evaluated the degrees of pain in each group of patients and compared them.

Results

There were differences in the baseline characteristics of the patients in the LAVH, LM, and LA groups. The severity and incidence of postoperative pain were higher in the LAVH group than in the LM and LA groups, followed by the LM and LA groups. Compared with the LA group, the postoperative pain in the LAVH and LM groups was more complicated. The LA group had the lowest incidence of two or more types of moderate to severe pain. The LAVH and LM groups mainly had visceral pain and low back pain, and the LA group mainly had incisional pain. Shoulder pain had the lowest incidence in the three groups.

Conclusion

There were different postoperative pain characteristics after the LAVH, LM, and LA, and we should clinically adjust analgesia programs for different gynaecological laparoscopic surgeries.

Transmuscular quadratus lumborum block versus oblique subcostal transversus abdominis plane block for analgesia in laparoscopic hysterectomy: a randomised single-blind trial

OBJECTIVE

The transmuscular quadratus lumborum (TQL) block and the oblique subcostal transversus abdominis plane (OSTAP) block both contribute to multimodal analgesia after laparoscopic surgery. The objective of this study was to compare the analgesic effects of the TQL block versus OSTAP block after laparoscopic hysterectomy.

DESIGN

Prospective single-centre randomised single-blind trial.

SETTING

University-affiliated hospital.

PARTICIPANTS

Patients aged between 18 and 65 years scheduled for laparoscopic hysterectomy.

INTERVENTIONS

Patients were randomised into two groups (1:1 ratio) and received bilateral TQL block or bilateral OSTAP block with 0.375% ropivacaine 20 mL on each side before surgery.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the cumulative morphine dose in the first 24 hours. The secondary outcome measures were the morphine consumption at each time interval after surgery, the time from the end of surgery to the first need for morphine, the Numerical Rating Scale (NRS) scores for visceral and incisional pain intensity, and the incidence of adverse events.

RESULTS

The cumulative morphine dose was significantly lower in the TQL group than in the OSTAP group (17.2 (12.5) vs 26.1 (13.3) mg, p=0.010). Compared with the OSTAP group, the morphine doses from 6 to 12, 12 to 18, and 18 to 24 hours were significantly lower, the time of first need for morphine was significantly longer and the NRS scores for visceral pain intensity were significantly lower in the TQL group.

CONCLUSION

Compared with the OSTAP block, the TQL block reduced morphine consumption and provided better visceral pain relief with a longer duration of effect after laparoscopic hysterectomy.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR1800017995); pre-results.

Time Characteristics of Shoulder Pain after Laparoscopic Surgery

Objective:

To explore the time characteristics of shoulder pain after laparoscopic gynecological operation.

Methods:

We conducted prospective clinical observations and literature review. We studied 442 cases of laparoscopic gynecological surgery. We used a visual analogue scale to evaluate the pain of patients at different time points after operation. We searched the English literature of shoulder pain after gynecological laparoscopic surgery. The observation time points of these studies included 12–24 hours or the first day after surgery, and at least one time point before this time point.

Results:

The total incidence of shoulder pain was 68%. More than 90% of patients begin to feel shoulder pain on the first day after surgery, not on the day of surgery. 26 articles observed the severity of postlaparoscopic shoulder pain (PLSP) at different time points, of which 17 articles found that the intensity of the shoulder pain peaked at 12–24 hours or the first day after operation.

Discussion:

The occurrence of PLSP presents obvious time characteristics. The incidence and severity of PLSP peaked on the first day or 12–24 hours after operation. To prevent and treat PLSP better, clinicians should make a more in-depth study according to the time characteristics of PLSP.

Oxycodone versus morphine for analgesia after laparoscopic endometriosis resection

Background

The objective of this study was to compare the analgesic potency of oxycodone versus morphine after laparoscopic deep infiltrating endometriosis resection.

Methods

Fifty patients undergoing laparoscopic deep infiltrating endometriosis resection were randomized to receive oxycodone or morphine intravenous-PCA after surgery. The primary outcome was opioid consumption during the 24 h after surgery. Secondary outcomes included time to first request for analgesia, the number of bolus, pain, sedation, nausea, vomiting, respiratory depression, and bradycardia. The prominent pain that caused patients to press the analgesic device was also recorded.

Results

Oxycodone consumption (14.42 ± 2.83) was less than morphine consumption (20.14 ± 3.83). Compared with the morphine group, the total number of bolus (78 vs 123) was less and the average time to first request for analgesia (97.27 ± 59.79 vs 142.17 ± 51) was longer in the oxycodone group. The incidence of nausea was higher in the morphine group than in the oxycodone group at 0–2 h (45.45% vs 17.19%), 2–4 h (50% vs 17.19%),12–24 h (40.91% vs 13.04%) and 0–24 h (39.17% vs 19.13%). The overall incidence of vomiting was higher in the morphine group (27.27% vs 13.92%). There was no difference in visual analogue scale score, the incidence of respiratory depression, and bradycardia between groups. Of the three types of pain that prompted patients to request analgesia, the incidence of visceral pain was highest (59.9%, P < 0.01).

Conclusion

Oxycodone was more potent than morphine for analgesia after laparoscopic endometriosis resection, and oxycodone has fewer side effects than morphine.

Name of the registry: Chinese Clinical Trial Registry

Trial registration number: ChiCTR1900021870

URL of trial registry record:http://www.chictr.org.cn/edit.aspx?pid=35799&htm=4

Date of registration: 2019/3/13 0:00:00

Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery versus single-port laparoscopy: Comparison of early outcomes

AIM

The study objective was to compare intraoperative and early postoperative outcomes among patients who underwent hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (and single-port lararoscopy for presumed benign gynecologic disorders).

METHODS

We retrospectively reviewed 40 patients who underwent single-port laparoscopic hysterectomy and 20 patients who underwent hysterectomy via natural orifice transluminal endoscopic surgery. Patients' age, body mass index, history of previous delivery and surgery, total operation time (from skin incision to closure), intraoperative and postoperative complications conversion to another surgical procedure, drop of hemoglobin level, postoperative pain at 1 and 18 h, average hospital stay, and clinical outcomes were analyzed.

RESULTS

Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery was superior to single-port hysterectomy concerning the length of hospitalization (p < 0.001) and visual analog scale at 1 h (p = 0.024) and 18 h (p < 0.001). In transvaginal natural orifice transluminal endoscopic group, postoperative complications were lower than single-port laparoscopy group (p = 0.023). In transvaginal natural orifice transluminal endoscopy, group conversion to a standard vaginal hysterectomy occurred in two cases (10%). Four patients in the single-port laparoscopic hysterectomy group had umbilical herniation, three had port-site infections, and two patients had vaginal cuff hematoma. These patients required rehospitalization.

CONCLUSIONS

Despite hysterectomy via transvaginal natural orifice transluminal surgery has not yet found its place in routine practice in gynecology departments, it could be a prominent alternative approach to other minimally invasive surgical procedures in selected patients with many advantages including lesser pain and lower complication rates compared with single-port laparoscopic hysterectomy.

The risk of shoulder pain after laparoscopic surgery for infertility is higher in thin patients

Postlaparoscopic shoulder pain (PLSP) is a common clinical problem that needs to be addressed by medical professionals who are currently perform laparoscopic surgeries. The purpose of this study was to determine the perioperative clinical factors and demographic characteristics associated with PLSP. A prospective observational study was performed with 442 inpatients undergoing laparoscopic surgery for infertility. The pain visual analogue scale was used as the measuring instrument. To identify the predictors of PLSP, we performed multivariate conditional logistic regression. PLSP was correlated with body mass index (BMI, odds ratio = 0.815). The incidence of shoulder pain and more severe shoulder pain in patients with a lower BMI was significantly higher than it was in patients with a higher BMI, and BMI was significantly negatively correlated with PLSP. Most of the patients (95%) began to experience shoulder pain on the first postoperative day, and it rarely occurred on the day of surgery. Patients with lower BMI presented a higher risk of reporting shoulder pain on the first postoperative day. We should identify high-risk patients in advance and make specific treatment plans according to the characteristics of their symptoms.

Efficacy of transmuscular quadratus lumborum block in the multimodal regimen for postoperative analgesia after total laparoscopic hysterectomy: A prospective randomised double-blinded study

Background and Aims

Transmuscular Quadratus Lumborum Block (TQLB) is a novel regional anaesthesia technique, however, its analgesic efficacy as a component of multimodal analgesia (MMA) in Total Laparoscopic Hysterectomy (TLH) is not well studied. The aim of the study was to evaluate the analgesic efficacy of TQLB as a component of MMA for postoperative pain in TLH.

Methods

A prospective double-blind randomised controlled study was done after approval from the ethical committee and informed patient consent. After randomisation, 37 patients in Group-Q received 20 ml 0.375% ropivacaine and in Group-C, 37 patients received saline in TQLB bilaterally after TLH surgery. All patients received intravenous patient controlled analgesia (IV-PCA) with fentanyl along with diclofenac 75 mg every 12 h. All the patients were assessed at 2, 4, 6, 8, 12, 18, and 24 hours. The primary outcome was the time to first analgesic request. The secondary outcome measures were total fentanyl consumption in 24 hrs, pain scores during rest and movement, postoperative nausea-vomiting, sedation and complications related to local anaesthetic and TQLB procedure.

Results

The mean [standard deviation (SD)] time to first analgesic request was 7.8 (1.5) hours in Group-Q and 3.2 (1.0) hours in Group-C (P < 0.0001). The mean (SD) dose of fentanyl used in 24 hours was 167.3 (44) μg in Group-Q and 226.5 (41.9) μg in Group-C (P < 0.0001).

Conclusion

The ultrasound-guided TQLB provides effective postoperative analgesia after TLH surgery in a multimodal analgesia approach. It reduces the fentanyl consumption and improves the visual analogue scale (VAS) score.

Role of paracervical block in reducing postoperative pain after laparoscopic hysterectomy: A systematic reivew and meta-analysis of randomized controlled trials

OBJECTIVE

We aimed to perform a systematic review and meta-analysis in order to evaluate the effect of paracervical anesthetic block among women undergoing laparoscopic hysterectomy.

METHODS

A systematic search was done in Cochrane Library, PubMed, ISI web of science, and Scopus during January 2021. We selected randomized clinical trials (RCTs) compared paracervical anesthetic block versus normal saline (control group) among women undergoing laparoscopic hysterectomy. We pooled the continuous data as mean difference (MD) and dichotomous data as risk ratio (RR) with the corresponding 95% confidence intervals using Revman software. Our primary outcome was pain scores evaluated by visual analog scale (VAS) at 30 min and 1 hour. Our secondary outcomes were postoperative additional opioids requirement and length of hospital stay.

RESULTS

Three RCTs met our inclusion criteria with a total number of 233 patients. We found that paracervical anesthetic block was linked to a significant reduction in VAS pain score at 30 min and 1 hour post-hysterectomy (MD= -2.13, 95% CI [-3.09, -1.16], p>0.001 & MD= -1.87, 95% CI [-3.22, -0.52], p = 0.006). There was a significant decrease in additional opioids requirement postoperatively among paracervical anesthetic block group in comparison with control group (p = 0.002). No significant difference was found between both groups regarding the length of hospital stay.

CONCLUSION

Paracervical anesthetic block is effective in reducing postoperative pain after laparoscopic hysterectomy with decrease in opioids administration postoperatively.

Systematic review and meta-analysis of ropivacaine use in laparoscopic hysterectomy

To assess the efficacy of all forms of ropivacaine administration for the management of pain and opioid use, specifically in patients undergoing laparoscopic hysterectomy. We searched PubMed, Cochrane CENTRAL, Web of Science, and SCOPUS for relevant clinical trials matching our eligibility criteria. Outcomes of interest included: Pain intensity (measured either by visual analog scale score or by numerical rating scale score), QoR-40 score (Overall quality of recovery tool, designed to measure physical comfort, physical independence, pain, emotional status, and need for support), and the need for opioid rescue. We performed the analysis under the fixed-effects model for homogeneous data and random-effects model for heterogeneous data. Most heterogeneous data were solved by the leave-one-out method, in cases where this was not successful, we then proceeded to conduct at least one subgroup meta-analysis in an attempt to solve heterogeneity. We assessed the risk of bias using Cochrane's risk of bias tool. A total of five clinical trials were included. Regarding the pain score, there was no significant difference between either group [standardized mean difference=-0.17, 95% confidence interval (CI): (-0.56, 0.23); p=0.41]. The analysis of the overall RoQ40 scores favored the ropivacaine group over the control group significantly [mean difference (MD)=17.68, 95% CI: (1.48, 33.87); p<0.001]. Regarding the use of opioids, the analysis revealed no significant difference between either group [MD=-2.57, 95% CI: (-6.62, 1.49); p=0.21]. Ropivacaine administration by any method does not seem to be effective in reducing pain or reducing the need for opioid use after laparoscopic hysterectomy procedures; however, the administration did show a significant improvement in the patient's "overall quality of recovery," as measured using the QoR-40 tool.

A randomized clinical trial on the effect of a lidocaine patch on shoulder pain relief in laparoscopic cholecystectomy

The incidence of laparoscopy-related shoulder pain reaches 90% in women. We evaluated the effect of lidocaine patch 5% on the shoulder pain after laparoscopic cholecystectomy (LC) in female patients. Total 63 female patients were randomly allocated to patch group (n = 31) and control group (n = 32). Patch group received lidocaine patch 5% and dressing retention tape on both shoulder, and control group received only dressing retention tape. Abdominal and shoulder pains were evaluated with rating on numeric rating scale (0 = no pain and 10 = the worst pain) at baseline and at 30 min, 6 h, 24 h, and 48 h after surgery. There were no significant differences in patient characteristics and operation details. The overall incidence of shoulder pain was significantly lower in patch group than in control group (42% vs. 78%, P = 0.005). The severity of shoulder pain also was significantly reduced in patch group compared to control group at 24 h and 48 h after surgery (P = 0.01 and P = 0.015, respectively). Complications related to lidocaine patch were not found except nausea. Lidocaine patch 5% reduced the incidence and severity of postoperative shoulder pain in female patients undergoing LC without complications.

Role of para-cervical block in reducing immediate postoperative pain after total laparoscopic hysterectomy: a prospective randomized placebo-controlled trial

Objective

To study the efficacy and safety of 0.5% bupivacaine in paracervical block to reduce immediate postoperative pain after total laparoscopic hysterectomy.

Methods

A prospective, randomized, double-blind, placebo-controlled study was conducted at a tertiary referral center involving thirty women each in the treatment and placebo groups. Paracervical block with 10 mL of 0.5% bupivacaine (treatment group) or 0.9% saline (placebo group) was administered following general anesthesia and prior to proceeding with total laparoscopic hysterectomy. Visual analogue scale (VAS) scores at 30 and 60 minutes post extubation and mean VAS score (average VAS score at 30 and 60 minutes) were compared. Adequate pain control was defined as mean VAS score ≤5. Additional postoperative opioid requirement, hospital stay, and readmissions were also compared.

Results

Baseline variables such as age, previous history of cesarean section, operating time, and weight of the specimen were comparable in both groups. VAS scores at 30 (5.0±2.8 vs. 7.0±1.4) and 60 minutes (5.2±2.8 vs. 7.0±0.8) and the mean VAS score (5.1±2.7 vs. 6.8±0.9) were significantly lower in the treatment group. Adequate pain control (mean VAS score ≤5) was 57% higher and additional opioid consumption was 47% lower in the treatment group. No significant difference was found in the duration of hospital stay and readmission rate.

Conclusion

Paracervical block with bupivacaine was useful in reducing immediate postoperative pain with a 25% reduction in mean VAS score and a 47% reduction in opioid consumption in the first hour after total laparoscopic hysterectomy.

Bupivacaine local anesthetic to decrease opioid requirements after radical cystectomy: Does formulation matter?

INTRODUCTION

Reduction of opioids is an important goal in the care of patients undergoing radical cystectomy (RC). Liposomal bupivacaine (LB) has been shown to be a safe and effective pain reliever in the immediate postoperative period and has been reported to reduce postoperative opioid requirements. Since the liposomal formulation is predicated on slow systemic absorption, the amount of bupivacaine administered is notably higher than that typically used with standard bupivacaine (SB) formulations. In addition, LB is costly, not universally available, and studies comparing this formulation to SB are lacking. We sought to determine if there is a difference in postoperative opioid requirements in patients who receive LB vs. high dose SB at the time of RC.

METHODS

In May 2019 we transitioned to administration of high-volume SB injected intraoperatively at the time of RC. This prospective cohort was compared to a historical cohort of patients who received injection of LB at the time of surgery. Primary endpoints included postsurgical opioid use measured in morphine equivalent dose (MED) and patient-reported Numeric Rating Scale (NRS) pain scores and length of stay. All patients were managed using principles of enhanced recovery after surgery (ERAS).

RESULTS

From May 2019 through August 2019, 28 patients underwent RC and met eligibility criteria to receive SB at the time of surgery. They were compared to a historical cohort of 34 patients who received LB between November 2017 and July 2018. There was no difference in MED exposure either in the postanesthesia care unit (SB 9.0 ± 8.9 MED vs. LB 6.5 ± 9.4 MED, P= 0.29) or during the remainder of the hospital stay (SB 36.8 ± 56.9 MED vs. LB 42.1 ± 102.5 MED, P= 0.81), no difference in NRS pain scores on postoperative day 1 (SB 2.6 ± 1.6 vs. LB 2.1 ± 1.7, P= 0.23), day 2 (SB 2.4 ± 1.8 vs. LB 1.9 ± 1.6, P= 0.19), or day 3 (SB 1.9 ± 1.8 vs. LB 1.7 ± 1.7, P= 0.69) and no difference in length of stay (SB 5.0 ± 1.7 days, LB 4.9 ± 3.3 days, P= 0.93). Subgroup analysis of open RC and robotic-assisted RC showed no significant difference in MED or pain scores between LB and SB patients.

CONCLUSIONS

Among patients undergoing RC under ERAS protocol there was no significant difference in postoperative opioid consumption, NRS pain scores, or length of stay among patients receiving SB compared to LB.

The Median Effective Dose of One Intravenous Bolus of Oxycodone for Postoperative Analgesia After Myomectomy and Hysterectomy With Local Ropivacaine Wound Infiltration: An Up-Down Dose-Finding Study

BACKGROUND

Oxycodone has been shown to be an effective analgesic for early postoperative analgesia, especially for abdominal operations associated with severe visceral pain. However, the dose needed varies depending on the operation and application of multimodal analgesia, such as local ropivacaine wound infiltration. Therefore, we conducted this study to estimate the median effective dose (ED50) of oxycodone that provides analgesia for hysterectomy and myomectomy with local ropivacaine wound infiltration.

METHODS

In this dose-finding study, the ED50 of oxycodone for postoperative analgesia was estimated separately for laparoscopic hysterectomy, transabdominal hysterectomy, laparoscopic myomectomy, and transabdominal myomectomy. We used the sequential allocation designed by Dixon. Trials were conducted simultaneously in the 4 surgical type groups. A predefined dose of oxycodone was injected 30 minutes before the end of the operation with an initial dose of 0.1 mg/kg. A series of trials were performed following the rule of a relative 10% increase in dose after inadequate analgesia and a relative 10% decrease in dose after adequate analgesia. The study was conducted until the collection of 7 crossover points was achieved. Local ropivacaine wound infiltration was administered during abdominal stitching. The mean blood pressure (MBP) and heart rate (HR) were analyzed to assess the hemodynamic changes associated with oxycodone administration.

RESULTS

A total of 113 patients were included in the estimation of ED50: 28 each in the laparoscopic hysterectomy group and transabdominal myomectomy group, 27 in the transabdominal hysterectomy group, and 30 in the laparoscopic myomectomy group. The estimated oxycodone ED50 (95% confidence interval [CI]) after laparoscopic hysterectomy, transabdominal hysterectomy, laparoscopic myomectomy, and transabdominal myomectomy was 0.060 mg/kg (0.053-0.068), 0.079 mg/kg (0.072-0.086), 0.060 mg/kg (0.051-0.071), and 0.092 mg/kg (0.086-0.098), respectively, for postoperative analgesia with local ropivacaine wound infiltration. The ED50 of oxycodone was different between laparoscopic surgeries and transabdominal surgeries (P < .001). The MBP and HR before and after oxycodone injection were different, regardless of surgical type.

CONCLUSIONS

The oxycodone ED50 for postoperative analgesia was lower for laparoscopic hysterectomy (0.060 mg/kg) and laparoscopic myomectomy (0.060 mg/kg) than for transabdominal hysterectomy (0.079 mg/kg) and transabdominal myomectomy (0.092 mg/kg) when combined with local ropivacaine wound infiltration. A single intravenous injection of oxycodone is associated with an acceptable decrease in MBP and HR within a short time.

Ultrasound-guided anterior and posterior quadratus lumborum block for analgesia after laparoscopic hysterectomy

Aim: Laparoscopic procedures are now preferred over open surgeries, and total laparoscopic hysterectomy is becoming increasingly popular. Quadratus lumborum (QL) block is an evolving technique for abdominal surgeries that blocks T5-L1 nerve branches. Methods: We used a combination of anterior and posterior QL block given bilaterally in two patients and evaluated perioperative opioid consumption, postoperative pain score and patient satisfaction. Results: There was reduced perioperative opioid consumption along with postoperative visual analog scale for pain over the first 24 h. Both patients appreciated the level and standard of pain relief. Conclusion: QL block is promising as a part of multimodal analgesia for laparoscopic abdominal surgeries. Further studies are needed to determine the best possible combination of different approaches to QL block.

Comparison of Intraperitoneal Normal Saline Infusion with Pulmonary Recruitment Maneuver in Reducing Shoulder and Upper Abdomen Pain Following Gynecologic Laparoscopic Procedures: A Randomized, Controlled, Triple-Blind Trial

Objectives

The current study aimed at evaluating the effect of intraperitoneal infusion of normal saline (NS) and pulmonary recruitment maneuver (PRM) on the reduction of pain in shoulder, upper abdomen, and incision site after elective laparoscopic gynecologic surgery.

Methods

Totally, 280 patients (mean age: 30.5 years) that underwent laparoscopic gynecologic surgery from October 2013 to August 2015 were randomly and equally allocated into four groups. Group A received intraperitoneal infusion of NS 1.5 - 2 mL/kg of body weight; group B received PRM with five manual pulmonary inflations at a maximum pressure of 60 cm H₂O; group C simultaneously received two former interventions; and finally the control group D received routine method of gentle abdominal pressure. All patients were assessed in the first 24 hours after surgery.

Results

There was an unsteady pattern for pain in shoulder, upper abdomen, and incision site at different time points across the studied groups over the trial. Patients in group B showed significantly lower shoulder pain 24 hours after laparoscopic gynecologic surgery (P = 0.01), while patients in group D had significantly lower incision site pain (P < 0.001).

Conclusions

PRM was superior to intraperitoneal infusion of NS for reducing pain in the first 24 hours after laparoscopic gynecologic surgery.

Effect of posterior quadratus lumborum blockade on the quality of recovery after major gynaecological laparoscopic surgery: A randomized controlled trial

Bilateral quadratus lumborum blockade (QLB) using ultrasound guidance has been introduced as an abdominal truncal block to improve postoperative analgesia and quality of recovery (QoR) after abdominal surgery, but efficacy remains controversial. The primary aim of this study was to evaluate the efficacy of posterior QLB on the postoperative QoR, and secondarily to evaluate postoperative pain after gynaecological laparoscopic surgery (LS). This study was a single-centre randomized controlled trial. QLB group patients underwent bilateral posterior quadratus lumborum injections with 25–30 mL of 0.25% levobupivacaine after induction of general anaesthesia; the control group underwent no block. Both groups were administered fentanyl-based intravenous patient-controlled analgesia postoperatively. The postoperative QoR was measured using the Quality of Recovery 40 (QoR-40) questionnaire score; postoperative pain was evaluated using the visual analogue scale (VAS) and the cumulative postoperative fentanyl dose. Thirty-one and 29 patients were randomised to the QLB and control groups, respectively. The intraoperative remifentanil dosage was significantly less in the QLB group. The median (interquartile range) for the QoR-40 score was not different between the groups: 154 (133–168) in the QLB group and 158 (144–172) in the control group. There were no statistically significant differences in secondary outcome variables. Single-shot QLB did not improve the QoR or postoperative pain in patients managed by multimodal analgesia after gynaecological LS.

Influence of Gas Pain, Post-operative Resilience, and Body Temperature Discomfort in Laparoscopic Myomectomy Patients after Thermotherapy

PURPOSE

The purpose of this study was to investigate the effects of thermotherapy on gas pain, post-operative resilience, and body temperature discomfort among patients who received laparoscopic myomectomies.

METHODS

The experimental group consisted of 62 patients with thermotherapy and the control group consisted of 60 patients. Thermotherapy was applied individually to the experimental group four hours after surgery. The collected data was analyzed using descriptive statistics, t-tests, χ²-tests, and repeated measures of analysis of variance, using IBM SPSS Statistics version 18.

RESULTS

The results showed no significant interaction effect between the group and time of measurement in gas-related pain in the experimental group. For gas-related pain, there was significant difference in right shoulder pain at 24 hours (t=-4.222, p=.000), 48 hours (t=-3.688, p=.000), 72 hours (t=-2.250, p=.028), and left at 24 hours (t=-3.727, p=.000), 48 hours (t=-4.150, p=.000), and 72 hours (t=-2.482, p=.016) and both shoulders at 24 hours (t=-2.722, p=.009) and 48 hours (t=-2.525, p=.014). There was no significant difference in epigastric pain, excluding both epigastric pain at 48 hours (t=2.908, p=.005), 72 hours (t=3.010, p=.004), but there was a significant difference in objective body temperature discomfort (t=2.895, p=.008).

CONCLUSION

Thermotherapy relieved shoulder gas-related pain and objective body temperature discomfort. It needs to be developed and applied to improve post-operative discomfort in patients with laparoscopic hysterectomies.

Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations

Background and objectives

Laparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review was to evaluate the available literature regarding the management of pain after laparoscopic hysterectomy.

Strategy and selection criteria

Randomized controlled trials evaluating postoperative pain after laparoscopic hysterectomy published between January 1996 and May 2018 were retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the EMBASE and MEDLINE databases and the Cochrane Register of Controlled Trials. Efficacy and adverse effects of analgesic techniques were assessed.

Results

Of the 281 studies initially identified, 56 were included. Of these, 31 assessed analgesic or anesthetic interventions and 25 assessed surgical interventions. Acetaminophen, non-steroidal anti-inflammatory drugs, and dexamethasone reduced opioid consumption. Limited evidence hindered recommendations on alpha-2-agonists. Inconsistent evidence was found in the studies investigating pregabalin and transversus abdominis plane block, and no evidence was found for intraperitoneal local anesthetics, port site infiltration, or single-port laparoscopy. Measures to lower peritoneal insufflation pressure or humidify or heat insufflated gas seem to reduce the incidence of shoulder pain, but not abdominal pain.

Conclusions

The baseline analgesic regimen for laparoscopic hysterectomy should include acetaminophen, a non-steroidal anti-inflammatory drug, dexamethasone, and opioids as rescue analgesics.

Analgesic effect of trigger point injection and EMLA for shoulder pain in patients undergoing total laparoscopic hysterectomy: A randomized controlled study

BACKGROUD

The purpose of this study was to evaluate the effects of trigger point injection (TPI) and eutectic mixture local anesthetics (EMLA) cream on the postoperative shoulder pain in patients undergoing total laparoscopic hysterectomy.

METHODS

In this randomized, single-blinded, and controlled study, total 75 patients were randomly allocated to TPI group (n = 25), EMLA group (n = 25), and control group (n = 25). TPI group received TPIs with 2 mL of 0.2% ropivacaine, and EMLA group received an occlusive dressing with EMLA cream 2 g on both shoulders. Overall, abdominal, and shoulder pains were evaluated at rest and in motion on postoperative day 3.

RESULTS

The incidence of shoulder pain was significantly reduced in EMLA group (56%) compared to control (88%) or TPI (88%) groups (P = .025 in both); the severity of shoulder pain was mitigated in EMLA and TPI groups compared to control group (P < .001, each). Consequently, the overall pain decreased in EMLA group and TPI group (P = .023). The patients with exercise habit (n = 31) showed lower incidence of pain than patients without exercise habit (n = 26) (P = .002, P = .005, and P = .037 in overall, abdominal, and shoulder pain, respectively). TPI or EMLA treatments decreased shoulder pain irrespective of exercise habit (P = .001 and P < .001, respectively), but decreased overall pain only in patients without exercise habit (P = .019). Lastly, EMLA lowered overall pain score at the time of first analgesic request in ward compared to control group (P = .02).

CONCLUSIONS

TPI and EMLA with occlusive dressing effectively reduced the shoulder pain after total laparoscopic hysterectomy.

The analgesic efficacy of oblique subcostal transversus abdominis plane block after laparoscopic hysterectomy: A randomized, controlled, observer-blinded study

BACKGROUND

We aimed to assess whether an ultrasound (US)-guided oblique subcostal transversus abdominis plane (OSTAP) block would improve the postoperative pain scores and decrease the tramadol consumption after a laparoscopic hysterectomy.

METHODS

Sixty-six female patients with American Society of Anesthesiologists I, II, or III, aged 18 to 65 years who were scheduled for laparoscopic hysterectomy for benign gynecologic pathologies were recruited in this randomized, controlled, observer-blinded trial. Sixty patients completed the study. Patients were randomized into 2 groups. In the OSTAP group, the patients received a bilateral OSTAP block with 40 mL of 0.375% bupivacaine and in the Sham group received an US-guided bilateral OSTAP with 40 mL of 0.9% saline. All patients received tramadol patient-controlled analgesia for the first 24th hour. Patients in the Sham group received an US-guided bilateral OSTAP with 40 mL of 0.9% saline. The primary outcome was the 24th hour tramadol consumption. The secondary outcomes included visual analog scale (VAS) scores during movement, the tramadol consumption at the 1st, 4th, and 12th postoperative hours, and nausea scores at the 24th hour postoperatively.

RESULTS

At all time points, tramadol consumption of the OSTAP group remained significantly lower when compared with Sham group. The OSTAP group showed a statistically significant reduction at the postoperative 24th hour tramadol consumption (mean difference 22 mg, 95% confidence interval -38.4 to -5.6 mL; P = .009). Compared with the Sham group, OSTAP block reduced the VAS scores at all time points during movement. Nausea scores at the 24th postoperative hour were significantly lower in the OSTAP group compared with the Sham group CONCLUSION:: We concluded that bilateral US-guided OSTAP blocks reduced 24th hour tramadol requirements and VAS scores after laparoscopic hysterectomy. The OSTAP block is a promising technique for producing effective and prolonged postoperative analgesia in patients undergoing laparoscopic hysterectomy surgeries.

Effects of Deep Versus Moderate Neuromuscular Blockade in Laparoscopic Gynecologic Surgery on Postoperative Pain and Surgical Conditions: Protocol for a Randomized Controlled Trial

Background

Postoperative pain, especially shoulder pain, is commonly reported after laparoscopic gynecologic procedures. Some studies suggest that a lower insufflation pressure may reduce the risk of postoperative pain; however, there is no agreement on the optimal pneumoperitoneum pressure during gynecologic laparoscopic surgery or whether lower pressure would lead to clinically significant improvements without increasing operative complications. Questions remain regarding the clinical significance of improvements, safety, and cost-effectiveness of deep neuromuscular blockade with low-pressure pneumoperitoneum.

Objective

The primary objective of this study was to assess the superiority of anesthesia with deep neuromuscular blockade with pneumoperitoneum 8 mm Hg over moderate blockade with pneumoperitoneum 12 mm Hg in terms of overall pain 24 hours after surgery in adult women undergoing pelvic surgery for hysterectomy or benign adnexal diseases. Effects on the intensity and timing of postoperative pain in specific locations, surgeon satisfaction, respiratory and hemodynamic stability, operating times, and direct and indirect costs will be assessed.

Methods

In this multicenter, randomized controlled trial with a superiority design, 300 patients will be randomly allocated in the ratio 1:1 to moderate neuromuscular blockade with a target insufflation pressure of 12 mm Hg or deep neuromuscular blockade with a target insufflation pressure of 8 mm Hg, with stratification by type of surgery and clinical center. The patient, the statistician, and the nurse who will assess the primary endpoint will be blinded to the allocation.

Results

Recruitment to this trial is expected to open in June 2018 and is expected to close in June 2019.

Conclusions

This study is designed to confirm the reported benefits of postoperative pain and provide additional data needed to address questions regarding the effects of this intervention on operating theater management and direct and indirect costs. Strengths of this protocol include the large sample size distributed among diverse institutions across the Italian territory and the collection and analysis of data on numerous secondary objectives. Limitations include the possible introduction of bias because the surgeon and anesthesiologist are not blinded to the intervention.

Registered Report Identifier

RR1-10.2196/9277

Effects of epidural anesthesia on postoperative nausea and vomiting in laparoscopic gynecological surgery: a randomized controlled trial

PURPOSE

Patients undergoing laparoscopic gynecological surgery are susceptible to postoperative nausea and vomiting (PONV). We hypothesized that a combination of epidural and general anesthesia to minimize intraoperative opioid administration would reduce the incidence of PONV following laparoscopic gynecological surgery.

METHODS

Women undergoing elective laparoscopic gynecological surgery were randomly assigned to receive general anesthesia alone (group G, n = 45) or general anesthesia with epidural anesthesia (group GE, n = 45). Patients in group G received fentanyl and remifentanil for intraoperative analgesia, and those in group GE received single-shot ropivacaine at the time of induction of anesthesia. The primary outcome was the incidence of PONV within 24 h of surgery. Secondary outcomes included the use of rescue metoclopramide within 24 h of surgery and the time to first incidence of PONV and first use of rescue metoclopramide.

RESULTS

The incidence of PONV within 24 h of surgery was 60.0% in group G and 44.4% in group GE [relative risk (RR): 0.53, 95% confidence interval (CI): 0.23-1.23, p = 0.14]. There were no intergroup differences in the use of rescue metoclopramide (40.0% in group G, 24.4% in group GE, RR: 0.49, 95% CI 0.20-1.20, p = 0.11) and the time to first incidence of PONV and first use of rescue metoclopramide (p = 0.20 and 0.12, respectively).

CONCLUSION

Minimizing intraoperative opioid administration by combining epidural and general anesthesia did not reduce the 24-h incidence of PONV or rescue metoclopramide use after laparoscopic gynecological surgery.

Managing Postoperative Pain After Minimally Invasive Gynecologic Surgery in the Era of the Opioid Epidemic

In this review, we examine the evidence behind nonopioid medication alternatives, peripheral nerve blocks, surgical techniques, and postoperative recovery protocols that can help minimize and effectively treat postoperative pain after minimally invasive gynecologic surgery (MIGS). Because of the depth and heterogeneity of the data, a narrative review was performed of reported interventions. A comprehensive review was performed of PubMed, Embase, and the Cochrane Database with a focus on randomized controlled trials. In the absence of literature specific to benign gynecology, similar specialty or procedural data were reviewed. A variety of nonopioid medications, surgical techniques, and postoperative recovery protocols have shown significant improvements in postoperative pain after gynecologic surgery. Nonopioid medication options that are beneficial include acetaminophen, nonsteroidal anti-inflammatories, and antiepileptics. Incision infiltration with local anesthesia also significantly reduces pain. Surgically, minimally invasive approaches, reducing the laparoscopic trocar size to <10 mm, and evacuating the pneumoperitoneum at the end of the case all have significant benefits. Lastly, enhanced recovery pathways show promise in reducing pain after MIGS. By using a multimodal approach, minimally invasive gynecologic surgeons can help to minimize and manage postoperative pain with less reliance on opioid pain medications.