Review ArticleManaging Postoperative Pain After Minimally Invasive Gynecologic Surgery in the Era of the Opioid Epidemic
Section snippets
Nonopioid Analgesics
The traditional reliance on opioid-based pain management may not be ideal in the ambulatory setting because many of the side effects may delay discharge. Using nonopioid techniques with different mechanisms of action, such as acetaminophen, nonsteroidal anti-inflammatories (NSAIDs), local anesthetics, nerve blocks, tissue infiltration, wound instillation, or topical anesthetics (Table 1), may provide improved pain management with fewer side effects [14].
Regional Anesthesia
Epidural and spinal analgesia act as neuraxial regional blocks and are used extensively in thoracic, abdominal, and pelvic surgery. In epidural analgesia, a catheter is inserted into the epidural space in the thoracic or lumbar spine, and continuous infusion of a local anesthetic agent along with opioids results in postoperative analgesia [55]. Spinal analgesia requires intrathecal administration of anesthetics and/or opioids. Regional anesthesia has been most studied in the field of obstetrics
Surgical Techniques
Surgeons play an important role in selecting intraoperative techniques that reduce postoperative pain. Here, we will review the evidence behind intraoperative maneuvers that have been proposed to reduce postoperative pain after MIGS (Table 2).
Decreasing Postoperative Pain Through Enhanced Recovery After Surgery Pathways
Enhanced Recovery After Surgery (ERAS) programs are perioperative pathways that aim to optimize postoperative recovery through a multimodal and multidisciplinary approach (Figure). ERAS programs have become common in different surgical specialties because they have successfully reduced costs, decreased hospital stays, and decreased complications [153]. Despite robust data on ERAS outcomes in some specialties, such as colorectal surgery 154, 155, ERAS has been less widely adopted in gynecology.
Conclusion
It is important for MIGS surgeons to minimize and effectively manage their patients' postoperative pain. In this review, we considered the data supporting medication, surgical, and other options to reduce postoperative pain.
There is reasonable evidence to suggest the use of preemptive and postoperative NSAIDs and acetaminophen. The literature also supports the use of antiepileptics gabapentin and pregabalin and the glucocorticoid dexamethasone as preemptive analgesics. Alpha-2 agonists and NMDA
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Impact of pneumoperitoneum pressure during laparoscopic hysterectomy: A randomized controlled trial
2023, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :To establish pneumoperitoneum for laparoscopic surgery, the abdomen is insufflated with carbon dioxide (CO2) to a set pressure, typically 15 mmHg, which is maintained throughout the surgery. Abdominal distention due to pneumoperitoneum is proposed to contribute to postoperative pain [3]. Current studies investigating lower pneumoperitoneum pressure in gynecologic surgery suggest a minimal decrease in postoperative pain without a significant impact on opioid use, and potentially longer operative times and greater blood loss [6–8].
Authors’ Reply
2022, Journal of Minimally Invasive GynecologyPatterns of narcotic utilization in women undergoing hysterectomy for benign indications
2021, Journal of Gynecology Obstetrics and Human ReproductionPerioperative Opioid and Nonopioid Prescribing Patterns in AVF/AVG Creation
2021, Annals of Vascular SurgeryA prospective randomized controlled study of combined spinal-general anesthesia vs. general anesthesia for laparoscopic gynecological surgery: Opioid sparing properties
2020, Journal of Clinical AnesthesiaCitation Excerpt :One of the approaches to importantly reduce peri-operative opioid consumption is the use of a combination of spinal and general anesthesia, which has also been included in some enhanced recovery after surgery protocols [14], although this combination is scarcely reported for laparoscopic gynecological surgery [5,15,16]. There are very limited data on perioperative opioid consumption as related to combined spinal–general anesthesia in gynecological surgery [17]. The only randomized controlled trial of pain management effects of combined spinal–general anesthesia for laparoscopic gynecological surgery enrolled a small number of patients (18 to 20 per group), who underwent a single procedure (robotic sacrocervicopexy) [18].
The authors declare that they have no conflict of interest.