Laparoscopic Hysterectomy 2018

Laparoscopic Hysterectomy-Specific Evidence

Arguments for…

• Paracetamol was associated with a lower cumulative 24-hour dose of rescue oxycodone in a 3-arm study comparing paracetamol/ondansetron, paracetamol/placebo or placebo/placebo. Ondansetron did not influence the cumulative 24-hour dose of rescue oxycodone. Pain scores and opioid side effects were not different between groups (n=120) (Jokela 2010; LoE 1)
• The combination of bupivacaine port site infiltration and ketorolac resulted in lower pain scores during the first six hours following surgery than placebo or either technique alone in one small 4-arm study (n=83) (Kim 2005; LoE 1)
• Ketorolac had a sparing effect on remifentanil consumption, and decreased sedation score by, on average, approximately 0.5 points, in a study comparing IV-PCA using remifentanil, two combinations of remifentanil and ketorolac, and fentanyl combined with ketorolac (n=79) (Kim 2011; LoE 1)
• Fentanyl PCA with nefopam reduced cumulative on-demand fentanyl consumption during the first 48 postoperative hours (107 ± 105 mcg [2 mg nefopam per PCA bolus] and 120.7 ± 91.1 mcg [4 mg nefopam per PCA bolus]) compared with fentanyl PCA only (236 ± 128 mcg). Pain scores, side effects and patient satisfaction were not different between groups (n=81) (Moon 2016; LoE 1)

PROSPECT Recommendations

• A combination of paracetamol and NSAID/COX-2-selective inhibitor is recommended unless there are contraindications (Grade A), based on the origin and the type and duration of pain after laparoscopic hysterectomy as well as the available evidence of an opioid-sparing effect from procedure-specific RCTs (LoE 1)

Laparoscopic Hysterectomy-Specific Evidence

Arguments for…

• Dexamethasone was shown to reduce opioid consumption in two studies which were of higher quality (Jokela 2009, LoE 1; Thangaswamy 2010, LoE 1), while one study of lower quality (Nam 2009; LoE 2) found no effect:
  • Cumulative oxycodone dose was lower with dexamethasone than with placebo (during the first 24 hours postoperatively with 15 mg dexamethasone, and during the first 2 hours postoperatively with 10 mg dexamethasone). Resting and dynamic VAS scores as well as side effects (including sedation) were comparable. The 4-arm study compared three doses of dexamethasone (15 mg, 10 mg, and 5 mg, IV) versus placebo, administered before induction of anaesthesia (n=90) (Jokela 2009; LoE 1)
  • Dexamethasone 8 mg was associated with less cumulative postoperative fentanyl demand during the first 24 hours compared with placebo or dexamethasone 4 mg, although pain scores were not different. PONV were significantly less frequent in the dexamethasone 8 mg group. No adverse effects related to dexamethasone were observed. Dexamethasone 4 mg or 8 mg or placebo was administered 2 hours before induction of anaesthesia; all patients received paracetamol and ibuprofen as baseline analgesics (n=55) (Thangaswamy 2010; LoE 1)
  • Dexamethasone 10 mg plus ondansetron was compared with ondansetron only, with no differences between the two groups in the mean VAS scores and mean opioid consumption, but the rate of PONV was lower in the group receiving both drugs (n=50) (Nam 2009; LoE 2)

PROSPECT Recommendations

• A pre-operative, single dose of dexamethasone, administered intravenously, is recommended (Grade A) for its ability to decrease analgesic use and act as an antiemetic (LoE 1)
  • Effective doses seemed to be in the range of 8–10 mg (LoE 1)
  • Even though the timing of dexamethasone administration has not been specifically investigated in the setting of laparoscopic hysterectomy, evidence from visceral abdominal surgery suggests that early administration after anaesthetic induction may offer the best anti-emetic (Wang 2000), anti-inflammatory, and analgesic effects (Zargar-Shoshtari 2009)

Laparoscopic Hysterectomy-Specific Evidence

Arguments for…

• Pregabalin was found to be opioid sparing or to decrease pain scores in two well-designed trials (Jokela 2008, LoE 1; Asgari 2017, LoE 1):
  • VAS pain scores at rest, on movement and on coughing were comparable between two doses of pregabalin (300 mg and 600 mg) or diazepam (10 mg). However, the cumulative dose of oxycodone (0–24 h after surgery) was lower in the pregabalin 600 mg group compared with the diazepam group. In the 3-arm study (n=91), pregabalin or diazepam were given as premedication and after 12h. Opioids were administered on the day of surgery (Jokela 2008, LoE 1)
  • 150 mg and 300 mg (but not 75 mg) of pregabalin decreased pain scores compared with placebo. Pregabalin or placebo was administered in two pre-operative doses and one postoperative dose. Curiously, not a single patient in the pregabalin 300 mg and the placebo group required any rescue opioids despite the fact that no standardised multimodal regimen was used (n=96) (Asgari 2017, LoE 1)

Arguments against…

• Pregabalin was associated with an increased incidence of side-effects in two studies (Jokela 2008, LoE 1; Asgari 2017, LoE 1). It should be noted, however, that the doses used were rather high (up to 600 mg)
  • Patients receiving pregabalin (300 mg and 600 mg) suffered from side effects such as dizziness, blurred vision and headaches more frequently than those receiving diazepam (n=91) (Jokela 2008, LoE 1)
  • In the 300 mg pregabalin group, the sedation score was significantly higher than in the placebo and the lower dosed (75 or 150 mg) pregabalin groups (n=96) (Asgari 2017, LoE 1)

PROSPECT Recommendations

• Pregabalin is not recommended (Grade A) as although pregabalin has potential opioid-sparing effects, it may be associated with side effects precluding its widespread use, especially at higher doses (LoE 1)

Laparoscopic Hysterectomy-Specific Evidence

Arguments for…

• In patients receiving 1 mcg/kg body weight of dexmedetomidine, time to rescue analgesic was prolonged by, on average, 11 minutes compared with placebo, and the number of patients requiring rescue analgesics in the PACU (93% of control patients) was reduced to 50% and 43% in patients receiving 0.75 and 1 mcg/kg body weight dexmedetomidine, respectively. Dexmedetomidine was administered as a bolus at the end of surgery: placebo, 0.5, 0.75 or 1 mcg/kg (n=120) (Kim 2013; LoE 1)

Arguments against…

• Early VAS scores (until 30 minutes after arrival in PACU) were not significantly different when intravenous infusions of dexmedetomidine/ketorolac were compared with remifentanil/ketorolac, administered from the end of surgery to the arrival in PACU (n=50) (Jung 2011; LoE 1)
• There were no differences in pain scores or analgesic side effects between remifentanil, fentanyl and dexmedetomidine, each administered as brief analgesic infusions at the end of surgery (n=85) (Choi 2016; LoE 1)

PROSPECT Recommendations

• Dexmedetomidine is not recommended (Grade D, LoE 4) due to limited and inconsistent procedure-specific evidence of analgesic benefit

Laparoscopic Hysterectomy-Specific Evidence

• No procedure-specific evidence was identified in this review

PROSPECT Recommendations

• Ketamine is not recommended (Grade D, LoE 4) because of a lack of procedure-specific evidence

Laparoscopic Hysterectomy-Specific Evidence

• No procedure-specific evidence was identified in this review

PROSPECT Recommendations

• IV lidocaine is not recommended (Grade D, LoE 4) because of a lack of procedure-specific evidence

Laparoscopic Hysterectomy-Specific Evidence

Arguments for…

• Pre-emptive epidural analgesia (PCEA) was associated with lower pain scores and rescue PCEA opioid consumption, and reduced side effects (nausea, vomiting and pruritus) compared with epidural analgesia initiated after the end of surgery. PCEA with lidocaine and morphine was continued for 72 hours (Hong 2008; LoE 1)
  • Patients in the pre-emptive epidural group had median pain scores <4 after surgery, and <3 at three hours postoperatively, whereas the control group reached similar pain control only between 12–24 hours after surgery
  • The overall recovery effect of this 72-hour regimen compared to other simple multimodal opioid-sparing techniques was not determined

PROSPECT Recommendations

• Epidural analgesia provides pain relief for patients undergoing laparoscopic hysterectomy (LoE 1), but it should be considered a reserve intervention (Grade D) because surgery is now often performed on an ambulatory basis and less invasive modalities are adequate for managing pain in most patients

Laparoscopic Hysterectomy-Specific Evidence

Arguments for…

• Pre-incisional TAP block with ropivacaine (5 mg/ml or 2.5 mg/ml) was associated with lower NRS pain scores than saline in the PACU and at 24 hours. 5 mg/mL ropivacaine was associated with lower opioid consumption than saline. All patients (n=66) received standard multimodal analgesia (opioid, paracetamol, ibuprofen) (De Oliveira 2011; LoE 1)
• Liposomal bupivacaine compared with plain bupivacaine for subcostal TAP block led to no clinically significant difference in median maximal pain scores in the immediate postoperative period, but the liposomal bupivacaine group had decreased maximum pain scores, decreased opioid use and a lower incidence of PONV for the first 24 h. Patients were undergoing robotic-assisted laparoscopic hysterectomy and received baseline analgesia of paracetamol and ibuprofen (n=58) (Hutchins 2015; LoE 1)

Arguments against…

• One study found no differences in pain scores or opioid requirements with postoperative TAP block compared with no block. Intra- and postoperative titration of analgesics was at the discretion of the treating doctors, and all patients (n=57) received NSAID (Kane 2012; LoE 1)
• A study comparing postoperative TAP block with placebo in the setting of ambulatory laparoscopic hysterectomy found a lower VAS score at discharge in the TAP group (<1 point on the NRS scale; statistically, but not clinically relevant), and no difference at 12 or 24 h. All patients (n=197) received a standard baseline analgesic regimen including ibuprofen and paracetamol. TAP block was performed using the loss-of-resistance technique without ultrasound, under laparoscopic vision (Calle 2014; LoE 1)
• One study found no benefit concerning pain scores or opioid use, and no difference in adverse events, with TAP block versus placebo added to multimodal analgesia (two non-opioids, morphine PCA) (n=65) (Torup 2015; LoE 1)
• Ultrasound-guided TAP block was not associated with a benefit in VAS scores, opioid consumption, postoperative mobilization, or adverse events compared with systemic opioid analgesia (n=44) (Ghisi 2016; LoE 1)
• When TAP blocks were added to a systemic analgesia regimen including opioid PCA there was no benefit in terms of opioid consumption during the first 24 hours, and no difference in pain scores (n=40) (Guardabassi 2017; LoE 1)
• Postoperative single-shot ultrasound-guided TAP block did not decrease pain scores compared with trocar site infiltration (n=88, each patient as own control) (El Hachem 2015; LoE 1)

PROSPECT Recommendations

• TAP blocks are not recommended (Grade D, LoE 4) as procedure-specific evidence is inconsistent

Laparoscopic Hysterectomy-Specific Evidence

Arguments against…

• Two studies investigating different regimens of local anaesthetics used for intraperitoneal instillation demonstrated no clinically relevant benefit versus placebo (Arden 2013; LoE 1; Andrews 2014; LoE 1)
  • Instillation of local anaesthetic in the pelvic region, but not the trocar insertion sites, led to no difference in VAS scores or adverse events compared with saline placebo (n=140; all patients received NSAID and paracetamol) (Arden 2013; LoE 1)
  • Continuous intraperitoneal infusion of 5 mg/mL levobupivacaine at 2 mL/hour for 48 hours was of no benefit compared with saline placebo in terms of pain scores or analgesic requests (n=60; baseline analgesia was NSAID, paracetamol and opioids) (Andrews 2014; LoE 1)

PROSPECT Recommendations

• Intraperitoneal instillation of local anaesthetic is not recommended (Grade A) as procedure-specific evidence showed no clinically significant benefit (LoE 1)

Laparoscopic Hysterectomy-Specific Evidence

• A combination of bupivacaine port site infiltration and ketorolac was associated with lower pain scores and opioid consumption than placebo during the first six hours following surgery, in a 4-arm study comparing the two interventions alone or in combination with placebo (n=83) (Kim 2005; LoE 1)
• Trocar site infiltration was associated with the same (low) pain scores as single-shot ultrasound-guided TAP blocks, in a setting of multimodal analgesia (n=88, each patient as own control) (El Hachem 2015; LoE 1)
• Port-site infiltration with liposomal bupivacaine, when compared with plain bupivacaine, showed lower pain scores on postoperative days 2 and 3, with no difference in opioid consumption, psychometrics or analgesic side-effects (n=60) (Barron 2017; LoE 1)

PROSPECT Recommendations

• Port site infiltration is not recommended for laparoscopic hysterectomy (Grade D) as there is no supporting procedure-specific evidence, although significant benefit has been demonstrated for this intervention for laparoscopic cholecystectomy (Barazanchi 2018)

Laparoscopic Hysterectomy-Specific Evidence

• In a study comparing isoflurane and propofol for maintenance of general anaesthesia, pain scores and postoperative analgesic requirements were comparable in the two groups (n=60) (Nelskyla 1997; LoE 1)
• No difference was found when anaesthesia was maintained with sevoflurane versus propofol (n=148) (Pokkinen 2014; LoE 1)
• A single anti-emetic dose of propofol at the end of surgery did not influence pain scores or opioid requirements (n=107) (Kim 2014; LoE 1)

PROSPECT Recommendations

• General anaesthesia is the standard of care for laparoscopic hysterectomy, and from an acute pain standpoint, choice of maintenance anaesthetics has no detectable effect on postoperative pain (LoE 1). The main determinants for choosing the maintenance anaesthetic agents are patient-related, such as cardiovascular comorbidity and the risk of PONV (Grade D)

Laparoscopic Hysterectomy-Specific Evidence

LAVH vs minilaparotomy

Arguments for…

• LAVH was associated with less pain than minilaparotomy (n=81) (Muzii 2007; LoE 1)

LAVH vs TLH

Arguments against…

• There was minimal difference in pain scores between LAVH and laparoendoscopic single-site total laparoscopic hysterectomy (n=76) (Song 2015; LoE 1)
• In one study, there were no differences in postoperative pain and adverse events between total laparoscopic hysterectomy, LAVH, and non-descent vaginal hysterectomy (n=90) (Roy 2011; LoE 1)

LAVH vs vaginal hysterectomy

Arguments against…

• One study found only minor differences in pain (<1 point on the NRS scale) when LAVH was compared with vaginal hysterectomy (n=97) (Eggemann 2018; LoE 1)
• In one study, there were no differences in postoperative pain and adverse events between total laparoscopic hysterectomy, LAVH, and non-descent vaginal hysterectomy (n=90) (Roy 2011; LoE 1)

Single-port surgery vs minilaparotomy

Arguments for…

• One study comparing single-port surgery versus minilaparotomy reported less pain in the single-port group (n=102) (Chen 2011; LoE 1)

Arguments against…

• Two studies comparing single-port surgery versus minilaparotomy found no difference (Li 2012; n=108; LoE 1 and Jung 2011; n=64; LoE 1)

Single-port vs standard three-port laparoscopic surgery

Arguments against…

• In one study, patients undergoing single-port surgery required more rescue analgesics than those undergoing standard three-port surgery (n=60) (Chung 2015; LoE 2)
• Other studies found no difference in pain scores or analgesics between single-port surgery and standard three-port surgery (Kim 2015; n=243; LoE 2 and Song 2013; n=41; LoE 2)

Single-port surgery vs minilaparoscopy

Arguments against…

• Compared to single-port hysterectomy, minilaparosopy led to lower pain scores in one study (n=68) (Fanfani 2013; LoE 2)

Robotic vs conventional laparoscopic hysterectomy

Arguments against…

• No differences in pain scores or analgesics were found when robotic and conventional laparoscopic hysterectomy were compared (Paraiso 2013; n=53; LoE 1 and Sarlos 2012;n=95; LoE 1)

Laparoscopic combined vs conventional LAVH

Arguments against…

• Laparoscopic combined hysterectomy was not different from conventional LAVH in terms of pain scores or analgesic consumption (n=26) (Tchartchian 2017; LoE 2)

Minilaparoscopy vs conventional (larger-bore) hysterectomy

Arguments against…

• Minilaparoscopy compared to conventional (larger-bore) hysterectomy led to no (n=76) (Ghezzi 2011; LoE 1) or only minimal (n=76) (Acton 2016; LoE 2) decreases in pain scores

PROSPECT Recommendations

• No recommendations are made regarding surgical techniques, which are chosen based on anatomical and patient-centred factors, with postoperative pain scores playing a lesser role

Laparoscopic Hysterectomy-Specific Evidence

Closed-suction drains vs no drains

Arguments for…

• Closed suction (Jackson–Pratt) drains reduced shoulder-tip pain at 24 h compared with no drains, and at 48 h, fewer women who received drains experienced abdominal pain (VAS scores were measured at 3 h, 24 h, and 48 h after surgery). There were no statistically significant differences in VAS scores for back pain at any time point. Demand for oral analgesics was higher in patients with no drain (n=164) (Shen 2003; LoE 1)

Low vs high pneumoperitoneum pressure

Arguments for…

• Low-pressure (8 mmHg) pneumoperitoneum was associated with a lower incidence of shoulder-tip pain in the early postoperative period than standard-pressure (12 mmHg) pneumoperitoneum (5% vs 36%), while abdominal pain was similar between groups (n=42) (Bogani 2014; LoE 1)
• Lower inflation pressure was associated with less shoulder tip pain than standard pressure (n=99) (Madsen 2016; LoE 1)

Carbon dioxide (CO₂): humidified and heated or eliminated

Arguments for…

• When CO₂ was humidified and heated, postoperative shoulder tip pain scores, but not abdominal pain scores, were lower than when using control gases (n=97) (Herrmann 2015; LoE 1)
• Elimination of CO₂ with an open umbilical trocar decreased postoperative pain scores compared with control, but additional trocar site infiltration did not decrease pain scores or opioid consumption further (n=289) (Radosa 2013; LoE 2)

Combined multifunctional instrument vs conventional laparoscopic cautery

Arguments against…

• A combined multifunctional instrument (Thunderbeat, Olympus, Tokyo, Japan) was associated with a shorter surgery time, but only a small reduction in postoperative pain, compared with conventional laparoscopic cautery (n=50) (Fagotti 2014; LoE 1)

EnSeal vs conventional bipolar coagulation

Arguments against…

• No difference in postoperative pain scores was found when an EnSeal (Ethicon, Norderstedt, Germany) was compared to conventional bipolar coagulation (n=160) (Rothmund 2013; LoE 2)

PROSPECT Recommendations

• No recommendations are made regarding surgical techniques, which are chosen based on anatomical and patient-centred factors, with postoperative pain scores playing a lesser role
• However, evidence suggests that low inflation pressure or humidified and heated CO₂ may decrease shoulder-tip pain, but not abdominal pain (LoE 1)