Superior Hypogastric Plexus Nerve Block in Minimally Invasive Gynecology: A Randomized Controlled Trial

Impact on Anesthetic Agent Consumption After Autonomic Neural Blockade as Part of a Combined Anesthesia Protocol: A Randomized Clinical Trial

BACKGROUND

The intraoperative autonomic neural blockade (ANB) was found safe and effective in controlling pain and associated symptoms and reducing analgesic consumption after laparoscopic sleeve gastrectomy (LSG). This study evaluated whether ANB performed at the outset of LSG reduces anesthetic consumption and promotes hemodynamic stability.

METHODS

This prospective, double-blinded, randomized trial involved patients undergoing LSG in 2 high-volume institutions. Patients were randomized to receive ANB either at the onset or the end of the procedure. The primary outcome measure was the consumption of remifentanil and sevoflurane. Secondary outcomes included Aldrete scale score differences in the recovery room and hemodynamic stability during the surgery.

RESULTS

In total, 80 patients (40 in the ANB at the onset group and 40 in the control group) were included for analysis. The consumption of remifentanil was significantly lower in the onset group compared to the control group (mean difference -0.04 mcg/kg/min, 95% confidence interval [CI], -0.06 to -0.02; P < .0001). There were no differences in the Aldrete scale scores between the 2 groups. Mean heart rate (HR) and mean arterial pressure (MAP) were also significantly less during surgery in the ANB at the onset group. No complications related to the ANB occurred.

CONCLUSIONS

Performing ANB at the onset of LSG is a safe and effective approach that reduces remifentanil consumption and promotes hemodynamic stability during the procedure. This technique holds promise for optimizing anesthesia management in LSG and other minimally invasive surgeries.

A comparative retrospective analysis on robot-assisted laparoscopic surgery compared to conventional laparoscopy in case of myomectomy: experience in a third-level hospital of Southern Italy

Uterine myomas are the most common gynecological disease in reproductive-aged women, present several symptoms, and require effective medical and/or surgical strategies. This study aimed to compare robotic-assisted laparoscopic myomectomy (RALM) with laparoscopic myomectomy (LM) in terms of operative times, intraoperative estimated blood loss, pre- and post-hemoglobin levels drop, and length of hospital stay. Data from 50 clinical records (25 RALM in Group A and 25 LM in Group B) of patients with uterine fibroids were collected from December 2022 to December 2023 at Gynecological Unit of DAI Materno-Infantile Federico II in Naples, Italy. Patients aged 30-49 years with symptomatic fibroids were included. Data on peri-operative outcomes, including operative time for myomectomy (OTM), overall operative time (OOT), intraoperative estimated blood loss (EBL), pre- and post-operative hemoglobin levels, and length of hospital stay were analyzed. The OTM in the presence of > 5 myomas was 59 [52-65] vs 69 min [61-96] (p < 0.001) for RALM and LM groups, respectively. Moreover, also in presence of ≤ 5 myomas, a difference was observed in the RALM group 48[43-55] compared to the LM group 53[50-61] min (p = 0.07). The OOT was also statistically significant for Group A compared to Group B (83[65-93] vs 72[56-110] min, p < 0.001). There were no significant differences between the two groups in terms of pre- and post-operative hemoglobin levels and EBL (p = 0.178). Group A demonstrated a notably shorter hospital stay 1.2 [1-2] days compared to Group B 2.9[3-3.75] days (p = 0.007). Our study suggests potential advantages of RALM over LM in terms of reduced operative times and shorter hospital stays. The standardized approach and extensive surgical experience likely contributed to the favorable outcomes of RALM.

Safety and efficacy of ultrasound-guided superior hypogastric plexus block combined with conscious sedation in ambulatory patients undergoing percutaneous microwave ablation of uterine myomas: Study protocol for a single-center, double-blinded, randomized controlled trial

Background

Pain is a major challenge in performing ultrasound-guided percutaneous microwave ablation (PMWA) of uterine myomas. Inadequate analgesia by local anesthetics hinders the possibility of conducting PMWA of uterine myomas in the Ambulatory Surgery Center (ASC) of the Department of Ultrasound.

Objective

The superior hypogastric plexus (SHP) forms a suitable target for pain relief through the blockade, as it contains nociceptive afferent fibers from pelvic organs such as the uterus, rectum, and bladder. Superior hypogastric plexus block (SHPB) has demonstrated promise as an alternative treatment option for alleviating pelvic pain, reducing opioid consumption, and improving quality of life. This study aims to evaluate the efficacy of ultrasound-guided SHPB combined with conscious sedation as an alternative anesthesia option for ambulatory patients receiving ultrasound-guided PMWA of uterine myomas.

Methods and analysis

This randomized controlled trial (RCT) will be carried out at the Department of Ultrasound, The First Affiliated Hospital of Xiamen University. Women scheduled for ultrasound-guided PMWA of uterine myomas will be eligible. 86 patients will be recruited and randomly assigned to either the intervention or control groups in a 1:1 ratio. The intervention group will undergo ultrasound-guided superior hypogastric plexus block (SHPB) combined with conscious sedation, while the control group will receive local anesthesia combined with conscious sedation. The primary outcome is the success rate of anesthesia, secondary outcomes include vasoactive drug consumption, acetaminophen consumption, sleep quality, sonographer satisfaction score, patient satisfaction score, the detained time in hospital, and adverse events.

Discussions

This RCT represents the inaugural effort to specifically evaluate the safety and efficacy of ultrasound-guided SHPB combined with conscious sedation in patients undergoing ultrasound-guided PMWA of uterine myomas and will provide valuable evidence and insight into the analgesic management of this ambulatory surgery.

Ethics and dissemination

This study has been approved by the Ethics Committee of the First Affiliated Hospital of Xiamen University (Scientific Research Ethics Review 2023, No. 139). The results will be submitted for publication in peer-reviewed journals.

Ultrasound-guided anterior quadratus lumborum block at the L2 level for postsurgical analgesia in patients undergoing laparoscopic gynaecological surgery: a single-centre, randomised, double-blinded trial at a university-affiliated hospital in China

OBJECTIVE

This study aimed to investigate the analgesic effect of an ultrasound-guided anterior quadratus lumborum block (QLB) at the L2 level on postoperative pain after laparoscopic gynaecological surgery.

DESIGN

Prospective single-centre randomised double-blind trial.

SETTING

University-affiliated hospital.

PARTICIPANTS

Sixty patients aged between 18 and 65 years scheduled for laparoscopic gynaecological surgery.

INTERVENTIONS

Before surgery, bilateral anterior QLB was performed with 20 mL of 0.375% ropivacaine injected on each side in the QLB group, whereas equal amount of saline was administered in the placebo group.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was the cumulative morphine dose in the first 24 hours, and the secondary endpoints were morphine consumption at each time interval, area under the curve (AUC) of the numeric rating scale (NRS) for pain, maximum pain intensity, incidence of moderate-to-severe pain (NRS>3), sedation score, adverse events, and time to home-readiness.

RESULTS

Cumulative morphine consumption in the first 24 hours after surgery was significantly lower in the QLB group than in the placebo group (mean difference, 14.2; 95% CI 6.3 to 22.1; p<0.001). The AUCs of NRS pain intensity scores, including visceral and incisional pain at rest and on movement, were significantly lower in the QLB group than in the placebo group (all p<0.001). The time to home-readiness was significantly shorter in the QLB group than in the placebo group (p<0.05).

CONCLUSION

Ultrasound-guided anterior QLB at the L2 level significantly reduced morphine consumption and relieved visceral and incision pain intensity after laparoscopic gynaecological surgery, which was beneficial for enhanced recovery.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR-IOR-17011960).

Efficacy and safety of robot-assisted laparoscopic myomectomy versus laparoscopic myomectomy: a systematic evaluation and meta-analysis

OBJECTIVE

Systematic evaluation of the efficacy and safety of robotic-assisted laparoscopic myomectomy (RALM) versus laparoscopic myomectomy (LM).

METHODS

PubMed, Embase, The Cochrane Library, and Web of Science database were searched by computer to seek relevant literature in order to compare the efficacy and safety of RALM with that of LM from the establishment of the databases to January 2023, and Review Manager 5.4 software was utilized to perform a meta-analysis on the literature.

RESULTS

A total of 15 retrospective clinical controlled studies were included. There exists a total of 45,702 patients, among 11,618 patients in the RALM group and the remaining 34,084 patients in the LM group. Meta-analysis results revealed that RALM was associated with lesser intraoperative bleeding (MD =  - 32.03, 95%CI - 57.24 to - 6.83, P = 0.01), lower incidence of blood transfusions (OR = 0.86, 95%CI 0.77 to 0.97, P = 0.01), shorter postoperative hospital stay (MD =  - 0.11, 95%CI - 0.21 to - 0.01, P = 0.03), fewer transitions to open stomach (OR = 0.82, 95%CI 0.73 to 0.92, P = 0.0006), and lower incidence of postoperative complications (OR = 0.58, 95%CI 0.40 to 0.86, P = 0.006) than LM, whereas LM is more advantageous in terms of operative time (MD = 38.61, 95%CI 19.36 to 57.86, P < 0.0001). There was no statistical difference between the two surgical methods in terms of maximum myoma diameter (MD = 0.26, 95%CI - 0.17 to 0.70, P = 0.24).

CONCLUSION

In the aspects of intraoperative bleeding, lower incidence of blood transfusions, postoperative hospital stay, transit open stomach rate, and postoperative complications, RALM has a unique advantage than that of LM, while LM has advantages over RALM in terms of operative time.

Analgesic Efficacy of Intraoperative Superior Hypogastric Plexus (SHP) Block during Abdominal Hysterectomy: A Systematic Review and Meta-Analysis of Controlled Trials

Background and Objectives: Abdominal hysterectomy is a major surgery that is often associated with pronounced postsurgical pain. The objective of this research is to conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) and nonrandomized comparative trials (NCTs) that have surveyed the analgesic benefits and morbidity of intraoperative superior hypogastric plexus (SHP) block (intervention) compared with no SHP block (control) during abdominal hysterectomy. Materials and Methods: The Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, Web of Science, PubMed, Scopus, and Embase were searched from inception until 8 May 2022. The Cochrane Collaboration tool and Newcastle-Ottawa Scale were used to evaluate the risk of bias of RCTs and NCTs, respectively. In a random effects mode, the data were pooled as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Results: Five studies (four RCTs and one NCT) comprising 210 patients (SHP block = 107 and control = 103) were analyzed. The overall postsurgical pain score (n = 5 studies, MD = -1.08, 95% CI [-1.41, -0.75], p < 0.001), postsurgical opioid consumption (n = 4 studies, MD = -18.90 morphine milligram equivalent, 95% CI, [-22.19, -15.61], p < 0.001), and mean time to mobilization (n = 2 studies, MD = -1.33 h, 95% CI [-1.98, -0.68], p < 0.001) were significantly decreased in the SHP block group contrasted with the control arm. Nevertheless, there was no significant variance between both arms regarding operation time, intraoperative blood loss, postsurgical NSAID consumption, and hospital stay. There were no major side effects or sympathetic block-related aftermaths in both groups. Conclusions: During abdominal hysterectomy and receiving perioperative multimodal analgesia, the administration of intraoperative SHP block is largely safe and exhibits better analgesic effects compared to cases without administration of SHP block.

Superior Hypogastric Plexus Block for Pain Management Post-Hysterectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

We aimed to evaluate the efficacy of superior hypogastric plexus (SHP) block in pain relief among women undergoing hysterectomy. Cochrane Library, PubMed, ISI web of science, and Scopus were searched from inception to May 2021 for the available randomized clinical trials (RCTs). We included RCTs that compared SHP block (intervention group) to saline (control group) in hysterectomy. Our primary outcomes were pain scores at different time intervals using the Visual Analog Scale (VAS). Our secondary outcomes were postoperative opioid consumption within 24 hours and postoperative nausea and vomiting incidence. We extracted the available data from included studies and pooled them in a meta-analysis model using RevMan software. Four RCTs with a total number of 289 patients met our inclusion criteria. The VAS pain scores were significantly declined at post-anesthesia care unit (PACU), 2, 6, and 12 hours postoperatively among SHP block group (p < 0.05). However, no significant difference was reported in VAS pain score 1 day postoperatively between intervention and control groups. Moreover, SHP block significantly reduced the postoperative opioid consumption and incidence of nausea and vomiting (p = 0.03 & p = 0.003). In conclusion, superior hypogastric plexus block effectively reduces postoperative pain, opioid consumption, and incidence of nausea and vomiting post-hysterectomy.

Paragastric Autonomic Neural Blockade to Prevent Early Visceral Pain and Associated Symptoms After Laparoscopic Sleeve Gastrectomy: a Randomized Clinical Trial

Background

Visceral pain (VP) following laparoscopic sleeve gastrectomy remains a substantial problem. VP is associated with autonomic symptoms, especially nausea and vomiting, and is unresponsive to traditional pain management algorithms aimed at alleviating somatic (incisional) pain. The present study was performed to evaluate the safety and effectiveness of laparoscopic paragastric autonomic neural blockade (PG-ANB) in managing the symptoms associated with VP following sleeve gastrectomy.

Study Design

This prospective, double-blinded, randomized clinical trial involved patients undergoing laparoscopic sleeve gastrectomy at two high-volume institutions. The patients were randomized to laparoscopic transversus abdominis plane block with or without PG-ANB. The primary outcome was patient-reported pain scores assessed at 1, 8, and 24 h postoperatively. The secondary outcome measures were analgesic requirements, nausea, vomiting, hiccups, and hemodynamic changes immediately after PG-ANB and postoperatively.

Results

In total, 145 patients (block group, n = 72; control group, n = 73) were included in the study. The heart rate and mean arterial pressure significantly decreased 10 min after PG-ANB. The visual analog scale score for pain was significantly lower in the PG-ANB than in the control group at 1 h postoperatively (p < 0.001) and 8 h postoperatively (p < 0.001). Vomiting, nausea, sialorrhea, and hiccups were significantly less prevalent in the PG-ANB group. Patients in the PG-ANB group received fewer cumulative doses of analgesics at 1 h postoperatively (p = 0.003) and 8 h postoperatively (p < 0.001). No differences between the groups were detected at 24 h (p = 0.298). No complications related to PG-ANB occurred.

Conclusion

PG-ANB safely and effectively reduces early VP, associated autonomic symptoms, and analgesic requirements after laparoscopic sleeve gastrectomy.

Graphical abstract