Elsevier

Journal of Minimally Invasive Gynecology

Volume 25, Issue 7, November–December 2018, Pages 1165-1178
Journal of Minimally Invasive Gynecology

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

https://doi.org/10.1016/j.jmig.2017.09.016Get rights and content

Abstract

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.

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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    The authors declare that they have no conflict of interest.

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