Effectiveness of local anesthetic on postoperative pain in different levels of laparoscopic gynecological surgery

Percutaneous-assisted laparoscopy for ovarian tissue cryopreservation: a single-center experience

PURPOSE

To compare surgical and post-operative outcomes of patients submitted to traditional laparoscopy and percutaneous-assisted laparoscopy for ovarian tissue explant for cryopreservation.

METHODS

This is a single-center retrospective comparative study conducted in IRCCS "Regina Elena" National Cancer Institute of Rome. Patients submitted to laparoscopic excision of ovarian tissue, before starting chemotherapy were enrolled. We compared the classic laparoscopic approach vs percutaneous-assisted laparoscopy, using the Percuvance grasping forceps.

RESULTS

Fifty-nine young oncologic women were enrolled; 38 underwent a conventional laparoscopy (LAP), 21 received a percutaneous laparoscopy (PERC). The baseline characteristics were similar in both groups, furthermore no differences were found in terms of peri-operative complications, median estimated blood loss (p = 0.4), operative time (p = 0.2), recovery times (p = 0.1), median time to chemotherapy (p = 0.7), median area of collected samples (p = 0.9). The postoperative pain evaluated by VAS-score, was significantly lower in the PERC group vs LAP group, both the day of surgery (range 0-4 vs 0-2; p = 0.02) and after 1 (range 0-3 vs 0-2; p = 0.002) and 2 days (range 0-3 vs 0-1; p = 0.0001). Moreover, better aesthetic results were detected in the PERC group, 2 months after surgery (median 9 vs 10, range 7-10 vs 9-10; p = 0.0001).

CONCLUSIONS

Percutaneous-assisted laparoscopy has proven to be an effective and safe procedure for the excision of ovarian tissue for cryopreservation, in young oncologic patients that want to preserve their fertility. The percutaneous procedure appears superior to conventional laparoscopy in terms of aesthetic outcomes and post-operative pain reduction.

CLINICAL TRIAL ID

NCT05134090, 24^th Nov 2021, retrospectively registered.

Regional Anesthesia Techniques for Pain Management for Laparoscopic Surgery: a Review of the Current Literature

Purpose of Review

The field of regional anesthesia has evolved tremendously in the last 15 years. New anesthesia protocols for ambulatory surgery and enhanced recovery after surgery have been developed as well. The focus of these techniques and protocols has centered on patient satisfaction and pain control while minimizing the use of opioids. The field of ambulatory surgery and anesthesia continues to evolve, and regional anesthesia and its plane techniques are at the center of these changes.

Recent Findings

Recent research has shown that regional techniques contribute to better pain control and patient experience and may decrease patient readmission rates. The safety of these techniques has been validated when performed by experienced practitioners. New techniques such as the erector spinae block (ESP) have been studied in the setting of laparoscopic surgery with promising results.

Summary

Regional anesthesia techniques for patients presenting for laparoscopic surgery are safe and seem to provide benefits. Those are related to patient experience, pain control, and readmission rates. Different techniques can be applied to a specific type of intervention. Application of these techniques depend on the clinical picture and patient. Future research may help us clarify how these techniques may improve patient satisfaction and operating room efficiency. New regional blocks may also develop based on what we know today.

Analgesic efficacy of ultrasound-guided transversus abdominis plane block for laparoscopic gynecological surgery: a randomized controlled trial

Background

This study aimed to determine whether ultrasound-guided transversus abdominis plane (TAP) block is more effective in reducing postoperative pain and analgesic consumption than local anesthetic infiltration (LAI) at the port site for elective laparoscopic gynecological surgeries.

Methods

Eighty patients with the American Society of Anesthesiologists status I/II undergoing laparoscopic gynecology surgery were enrolled for this randomized control trial. After general anesthesia was administered, patients in group C received LAI at each port site, and patients in group T received bilateral ultrasound-guided TAP block. Postoperative pain was assessed at time intervals of 1/2, 2, 4, 6, 8, and 24 h using the numeric rating scale (NRS). Clinical metrics such as postoperative analgesic diclofenac consumption, need for rescue fentanyl, nausea-vomiting scores, and antiemetic requirements were also recorded.

Results

Seventy-four patients were included in the final analysis. Postoperatively, patients in group T had significantly lower NRS than those in group C (P < 0.05). The highest difference in the postoperative NRS was observed at 2 h (median [1Q, 3Q]; group C = 3 [2, 4]; group T = 1 [0, 2]; P < 0.001). A statistically significant difference was observed in the frequency of diclofenac (75 mg intravenous) requirement between the groups (P = 0.010). No significant difference was observed between the groups in need of rescue fentanyl or antiemetic and the nausea-vomiting scores.

Conclusions

In patients undergoing laparoscopic gynecological surgery, ultrasound-guided TAP block provided greater postoperative analgesic benefits in terms of lower NRS and reduced analgesic requirements than port site LAI.

Effect of Local Anesthetics on Postoperative Pain in Patients Undergoing Gynecologic Laparoscopy: A Systematic Review and Meta-analysis of Randomized Trials

OBJECTIVE

Pain remains a common complication after gynecologic laparoscopy. Use of local anesthesia may be beneficial in reducing postoperative pain. We performed a systematic review and meta-analysis to assess whether local anesthetic decreases postoperative pain after laparoscopic gynecologic procedures.

DATA SOURCES

We searched Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline from inception to November 2020 using Medical Subject Headings and free text combinations.

METHODS OF TRIAL SELECTION

We included randomized controlled trials of patients undergoing gynecologic laparoscopy receiving port site subcutaneous, subfascial, or intraperitoneal local anesthetic compared with placebo or no intervention. We included 20 trials (1861 participants) with size varying between 28 and 164 participants.

TABULATIONS, INTEGRATION, AND RESULTS

Meta-analysis was performed with RevMan 5.3 (Cochrane Collaboration, London, United Kingdom), with standard mean differences (SMDs) and random-effects model. Port site infiltration reduces postoperative pain at 4 hours (SMD -0.25; 95% confidence interval [CI], -0.44 to -0.06; 4 trials; 545 participants) and 6 hours (SMD -0.44; 95% CI, -0.82 to -0.06; 4 trials; 455 participants) after surgery. The administration of intraperitoneal local anesthetics reduces pain at 6 hours (-1.42; 95% CI, -3.22 to -0.30; 4 trials; 277 participants) after surgery.

CONCLUSIONS

The use of port site and intraperitoneal local anesthetic decreases immediate postoperative pain in patients undergoing gynecologic laparoscopy, although its impact on analgesia requirements is unclear. Routine usage of local anesthetics should be considered for people undergoing gynecologic laparoscopy.

Laparoscopic single port radical prostatectomy in the 2020: Why not? Our experience

OBJECTIVES

To analyze the feasibility, safety and advantages of Laparo-Endoscopic Single-site Surgery radical prostatectomy (LESS-RP) based on our personal experience.

PATIENTS AND METHODS

Details of 520 patients were retrospectively analyzed, from 2009 to 2019. Extraperitoneal approach, with only two accesses (2.5 cm and 5 mm respectively) was used to perform radical prostatectomy. Perioperative characteristics and postoperative oncologic and functional outcomes are reported.

RESULTS

The mean age was 66.6 ± 5.6 years. Mean PSA level was 9 ± 3.5 ng/ml. According to D'Amico classification, the percentage of patients with low-, intermediate-, and high-risk disease cases were 116 (22.4%), 275 (52.8%), and 129 (24.8%) respectively. Mean operative time was 156 ± 43 min. Mean estimated blood loss was 214 ± 93 ml. Positive surgical margins (PSMs) were detected in 110 (21.2%) patients. PSM rates in pT2 and pT3 stages were 20.1% and 22.9%, respectively. The overall complication rate was 9.2%, based on the modified Clavien classification. The 12 months continence and potency rates were 90.9% and 49.1%, respectively. The biochemical recurrence rate was 6.8%, at the median follow-up time of 26.7 months (IQR 12-32).

CONCLUSIONS

Our analyses show that LESS-RP is a safe procedure, if performed by surgeons with adequate experience and skills. Unlike the classic laparoscopic prostatectomy, this technique allows better aesthetic and psychological results, reduced postoperative pain, and a faster return to normal daily activity with the same functional and oncological results.

Percutaneous-assisted vs mini-laparoscopic hysterectomy: comparison of ultra-minimally invasive approaches

To assess the feasibility and the safety of the ultra-minimally invasive (U-MIS) approaches in gynecology, we compared our experience in percutaneous assisted hysterectomy (PSS-H) with a series of 3 mm mini-laparoscopy hysterectomy (m-LPS-H). 126 patients affected by benign and malignant gynecological conditions were considered eligible for minimally invasive hysterectomy: 80 patients received PSS approach and 46 m-LPS approach. For both groups, we evaluated intra and perioperative outcomes, post-operative pain and cosmetic outcomes. The baseline characteristics were comparable between the two study groups. As well, no differences were reported in the clinical indications for hysterectomy, principally fibroids/adenomyosis, endometrial hyperplasia and early stage endometrial cancer. The median operative time was 88.5 (40-190) minutes for PSS-H group and 95.0 (42-231) minutes in m-LPS-H group (p = 0.131). No differences were detected in median estimated blood loss (p = 0.104) as well, in the uterine manipulator usage (p = 0.127) between the two different surgical approaches. Only 1 (2.2%) conversion to standard laparoscopy occurred in m-LPS-H group (p = 0.691). One intra-operative complication was recorded 1 (1.3%) in the PSS-H group (p = 0.367). The post-operative early complication was recorded in five cases of PSS-H group (p = 0.158), none for m-LPS-H procedures. The results in post-operative pain detection was statistically significant after 4 h in favor of m-LPS-H group (p = 0.001). After 30 days no differences in cosmetic satisfaction were detected between the two groups (p = 0.206). PSS-H and m-LPS-H are two valid U-MIS alternatives for benign gynecological conditions and low/intermediate risk endometrial cancer.

Laparoscopic-guided transversus abdominis plane block versus trocar site local anesthetic infiltration in gynecologic laparoscopy

Background

Relieving postoperative pain and prompt resumption of physical activity are of the utmost importance for the patients and surgeons. Infiltration of local anesthetic is frequently used methods of pain control postoperatively. Laparoscopically delivered transversus abdominis plane block is a new modification of ultrasound-guided transversus abdominis plane block.

This study was conducted to compare the efficacy of laparoscopic-guided transversus abdominis plane block with trocar site local anesthetic infiltration for pain control after gynecologic laparoscopy.

Results

No statistically significant difference between the two groups in mean visual analogue scale at 1, 18, and 24 h (P = 0.34, P = 0.41, and P = 0.61, respectively), while the mean visual analogue scale was significantly lower in the laparoscopic-guided transversus abdominis plane block group than in the trocar site local anesthetic infiltration group at 3, 6, and 12 h (P = 0.049, P = 0.011, and P = 0.042, respectively). No statistically significant difference was observed in the cumulative narcotics consumed at 3 h (P = 0.52); however, women with transversus abdominis plane block have consumed significantly less amount of narcotics than women with trocar site infiltration at 6, 12, and 24 h (P = 0.04, P = 0.038, and P = 0.031 respectively). Patient satisfaction was significantly higher in the laparoscopic-guided transversus abdominis plane block group (P = 0.035).

Conclusion

Laparoscopic-guided transversus abdominis plane block is more effective in reduction of both pain scores in the early postoperative period and the cumulative narcotics consumption than trocar site local anesthetic infiltration in gynecologic laparoscopy.

Trial registration

Clinical Trials.gov NCT02973451

Preemptive Local Anesthesia in Ankle Arthroscopy

BACKGROUND

Complex anesthesia is increasingly used in order to reduce postoperative pain and accelerate rehabilitation. The aim of this study was to evaluate the efficacy and safety of preemptive local anesthesia combined with general or spinal anesthesia in ankle arthroscopy.

METHODS

From January 2014 to February 2016, 80 ankle anterior arthroscopies were performed. Patients were randomly assigned to one of 4 groups, depending on the type of anesthesia: A, general and local preemptive; B, spinal and local preemptive; C, general and placebo; D, spinal and placebo. After general or spinal anesthesia, each patient randomly received an injection of 7 mL of a mixture of local anesthetics or the same amount of normal saline. After 2, 4, 8, 12, 16, 24, 48, and 72 hours following the release of the tourniquet, the pain intensity level was measured with a visual analog scale (VAS). The use of additional analgesics and any adverse effects were also noted.

RESULTS

Preemptive local anesthesia (groups A and B) resulted in a significantly lower level of pain intensity during the first 24 hours after surgery. Until 8 hours after the release of the tourniquet, the pain intensity level was statistically lower in the groups A, B, and D in comparison to C. During hospitalization, none of the patients from groups A and B received on-demand ketoprofen intravenously. No side effects of local anesthetic agents were observed. Two patients had transient numbness and paresthesia in the field of sensory nerve innervation of the dorsal intermediate cutaneous nerve of the foot.

CONCLUSION

Preemptive operative site infiltration with a mixture of local anesthetics performed in ankle arthroscopy was a safe procedure. It reduced the level of intensity of postoperative pain and the amount of analgesics used.

LEVEL OF EVIDENCE

Level I, prospective randomized study.