Spinal Anesthesia Prior to Laparoscopic Hysterectomy Resulted in Decreased Postoperative Pain and Opioid Use.

Study Objective: To determine if a pre-operative morphine/bupivacaine spinal injection prior to laparoscopic hysterectomy reduced postoperative pain and resulted in less opioid consumption during the hospital stay. Methods: A retrospective cohort study (Canadian Task Force Classification II-2) was conducted at a single institution regional referral center (community hospital) in North Carolina. Three hundred nineteen patients met criteria for inclusion: 192 received spinal anesthesia and 127 did not. Baseline demographics were similar between the two groups. Median pain scores were significantly lower in the treatment than the control group on day of surgery (DOS) (2 vs. 6; P < 0.001) and postoperative day 1 (POD1) (2 vs. 4; P < 0.001). Results: Primary outcomes were pain scores on DOS and POD1 and inpatient opioid use. Pain scores were obtained using the 0 to 10 Numerical Rating Scale. Opioids were converted to oral morphine milliequivalents (OME). Median opioid use was also significantly lower in the treatment than the control group on DOS (0 vs. 15.00 OME; P < 0.001) and POD1 (0 vs. 7.5 OME; P < 0.001). Median length of stay between the groups was not significantly different. Conclusion: Pre-operative morphine spinal injection for laparoscopic hysterectomy led to significantly lower pain scores and inpatient opioid consumption. Pre-operative spinal anesthesia for benign laparoscopic hysterectomy appears helpful for enhancing the postoperative experience.

Does route of hysterectomy affect outcome in obese and nonobese women?

OBJECTIVE: Our objective was to compare the surgical outcomes of obese women having hysterectomy according to the route (abdominal, vaginal, or laparoscopic) of the procedure. METHODS: A chart review of 293 hysterectomy procedures was performed. Data were collected including operative and anesthesia time, estimated blood loss, change in hematocrit, hospital stay, complications, conversion to laparotomy, transfusion, and body mass index. An analysis of variance and a Newman-Keuls Multiple Comparison test were performed. RESULTS: Obese women experienced a significant decrease in hospital days (2.5 versus 4.2) and reported blood loss (204 mL versus 455 mL) in the laparoscopic hysterectomy and vaginal hysterectomy groups compared with the abdominal hysterectomy group. No significant difference was found in obese women between laparoscopic and abdominal hysterectomy for time spent in surgery and under anesthesia. For obese and normal weight women, vaginal hysterectomy offered the shortest surgery, anesthesia times, and hospital stays. CONCLUSIONS: For normal and obese women, vaginal hysterectomy offered the shortest hospital stay and surgery time. In obese patients for whom vaginal hysterectomy is not possible, laparoscopic hysterectomy should be considered before abdominal hysterectomy, because the laparoscopic route reduced hospital time and blood loss.

Humidified compared with dry, heated carbon dioxide at laparoscopy to reduce pain.

OBJECTIVE: To study whether using 95% humidified, heated carbon dioxide (CO(2)) at laparoscopy reduces pain compared with dry, heated CO(2). METHODS: Patients were randomly assigned to either heated, 95% humidified CO(2) (study group) or heated, dry CO(2) (control group) during laparoscopy. Pain control was achieved per standard protocols. Pain scales were administered the first 4 hours and 24 and 48 hours postoperatively. RESULTS: The 89 patients available in the intent-to-treat model revealed a decrease in total morphine equivalents and a decrease in pain scores at 1, 2, and 24 hours in the study group (directional P values < .05). Subgroup analysis in patients without chronic pelvic pain revealed lower mean pain scores at 1, 2, 24, and 48 hours and decreases in postoperative and total morphine equivalents (directional P values < .05) in the study group. CONCLUSION: At laparoscopy, heated, 95% humidified CO(2) effectively decreases postoperative pain and narcotics usage compared with heated, dry CO(2). LEVEL OF EVIDENCE: II-2.

Total laparoscopic hysterectomy utilizing a robotic surgical system.

OBJECTIVES: To describe the use of a robotic surgical system for total laparoscopic hysterectomy. METHODS: We report a series of laparoscopic hysterectomies performed using the da Vinci Robotic Surgical System. Participants were women eligible for hysterectomy by standard laparoscopy. Operative times and complications are reported. RESULTS: We completed 10 total laparoscopic hysterectomies between November 2001 and December 2002 with the use of the da Vinci Robotic Surgical System. Operative results were similar to those of standard laparoscopic hysterectomy. Operative time varied from 2 hours 28 minutes to 4 hours 37 minutes. Blood loss varied from 25 mL to 350 mL. Uterine weights varied from 49 g to 227 g. A cystotomy occurred in a patient with a history of a prior cystotomy unrelated to the robotic system. CONCLUSION: Total laparoscopic hysterectomy is a complex surgical procedure requiring advanced laparoscopic skills. Tasks like lysis of adhesions, suturing, and knot tying were enhanced with the robotic surgical system, thus providing unique advantages over existing standard laparoscopy. Total laparoscopic hysterectomy can be performed using robotic surgical systems.

Making the transition from standard gynecologic laparoscopy to robotic laparoscopy.

OBJECTIVES: To determine the feasibility of using a simple procedure, a bilateral tubal ligation, as a transition procedure when adopting robotic laparoscopy for gynecologic surgery. METHOD: To obtain robotic credentialing and gain experience with the robotic system, the surgeons first went through robotic training, then 4 women desiring permanent sterilization had robotically assisted laparoscopic bilateral tubal ligations performed, using the Parkland method. RESULTS: Total operating room time varied from 1 hour 25 minutes to 2 hours 31 minutes. Improvement in operating time for each surgeon was noted with each successive case. Best times in robotic cases were similar to those of standard laparoscopy. CONCLUSION: Robotically assisted laparoscopic tubal ligation using the Parkland method is a satisfactory procedure to provide transition for gynecologic surgeons and operating room personnel to gynecologic robotic surgery.

A randomized, controlled trial to compare ketorolac tromethamine versus placebo after cesarean section to reduce pain and narcotic usage.

OBJECTIVE: The purpose of this study was to determine whether postcesarean section administration of ketorolac tromethamine reduces pain and narcotic usage. STUDY DESIGN: A double-blinded randomized, placebo-controlled trial of ketorolac tromethamine was performed. Patients were randomly assigned to receive either ketorolac tromethamine or placebo. Patient-controlled analgesia (PCA) was used for pain control. Visual analog scales (VAS) were administered postoperatively to assess pain levels. Morphine equivalents and attempts were recorded. RESULTS: There were 22 patients in each arm of the study. There was no significant difference between patient demographics, blood loss, and type of anesthesia. Pain scores were significantly different at 2, 3, 4, 6, 12, and 24 hours by analysis of variance (ANOVA) (P=.033). There was a significant decrease in pain medication usage (P=.008) in the study group. CONCLUSION: Ketorolac tromethamine is efficacious in reducing postoperative pain and narcotics usage after cesarean section.