Optimal Pain Management in Total Abdominal Hysterectomy

Analgesic efficacy and safety of duloxetine premedication in patients undergoing hysterectomy - A systematic review

Background and Aims

Patients undergoing hysterectomy by open or laparoscopic approach experience moderate to severe postoperative pain. A multimodal analgesic approach is recommended for these patients. This study reviews the analgesic efficacy of duloxetine, a selective serotonin and norepinephrine reuptake inhibitor used as an adjuvant for opioid-sparing postoperative analgesia.

Methods

After registering the protocol in the international prospective register of systematic reviews (PROSPERO), databases like PubMed, Ovid, Scopus, Cochrane Library and clinicaltrials.gov were searched for randomised controlled trials using relevant keywords to find studies in which duloxetine premedication was compared to a placebo in patients undergoing hysterectomy. The revised Cochrane risk-of-bias tool for randomised trials (RoB 2) was used to assess the quality of evidence.

Results

The qualitative systematic review included five of the 88 studies identified. The overall risk of bias in the included studies was very high. In all the studies, 60 mg oral duloxetine was used, and the control group was placebo. In two studies, duloxetine premedication was administered 2 h before and 24 h after surgery. In the other three studies, a single dose of 60 mg duloxetine was only administered 2 h before surgery. A pooled meta-analysis was not performed due to fewer studies that fulfilled the inclusion criteria and even fewer studies with consistent reporting of various outcomes.

Conclusion

The evidence is insufficient to advocate routine duloxetine premedication in patients undergoing hysterectomy.

The effect of erector spinae plane block on fentanyl consumption during open abdominal hysterectomy: a randomised controlled study

BACKGROUND

Perioperative analgesia is very important during an abdominal hysterectomy. Determining the impact of the erector spinae plane block (ESPB) on patients undergoing an open abdominal hysterectomy while under general anesthesia was our aim.

METHODS

In order to create equal groups, 100 patients who underwent elective open abdominal hysterectomies under general anesthesia were enlisted. The preoperative bilateral ESPB with 20 ml of bupivacaine 0.25% was administered to the ESPB group (n = 50). The same procedure was performed on the control group (n = 50), but they received a 20-ml saline injection instead. The primary outcome is the total amount of fentanyl consumed during surgery.

RESULTS

We found that the mean (SD) intraoperative fentanyl consumption was significantly lower in the ESPB group than in the control group (82.9 (27.4) g vs. 148.5 (44.8) g, with a 95% CI = -80.3 to -50.8; p 0.001). Likewise, mean (SD) postoperative fentanyl consumption was significantly lower in the ESPB group than in the control group (442.4 (17.8) g vs. 477.9 (10.4) g, with a 95% CI = -41.3 to -29.7; p 0.001). On the other hand, there is no statistically significant difference between the two study groups regarding sevoflurane consumption (89.2 (19.5) ml vs. 92.4 (15.3) ml, with a 95% CI = -10.1 to 3.8; p 0.4). We documented that during the post-operative period (0-24 h), VAS scores at rest were, on average, 1.03 units lower in the ESPB group (estimate = -1.03, 95% CI = -1.16-(-0.86), t = -14.9, p-value 0.001), and VAS scores during cough were, on average, 1.07 units lower in the ESPB group (estimate = -1.07, 95% CI = -1.21-(-0.93), t = -14.8, p-value 0.001).

CONCLUSION

Bilateral ESPB can be utilized as an adjuvant method to reduce intraoperative fentanyl consumption and enhance postoperative pain control in patients undergoing open total abdominal hysterectomy under general anesthesia. It is effective, secure, and little obtrusive.

TRIAL REGISTRATION

No protocol revisions or study amendments have been made since the trial's inception, according to the information on ClinicalTrials.gov (NCT05072184; principal investigator: Mohamed Ahmed Hamed; date of registration: October 28, 2021).

The efficiency of ultrasound-guided erector spinae plane block in early cervical cancer patients undergoing laparotomic radical hysterectomy: A double-blind randomized controlled trial

Aims

We aim to compare the efficiency of erector spinae plane block (ESPB) with transversus abdominis plane block (TAPB) in patients undergoing laparotomic radical hysterectomy because only a few studies are reported exploring this matter.

Methods

In this randomized controlled trail, 154 eligible patients were randomly allocated into ESPB group [ESPB + patient-controlled intravenous analgesia (PCIA)] and TAPB group (TAPB + PCIA) at 1:1 ratio. The primary outcome was visual analog scale (VAS) score at rest state at 12 h.

Results

We found that ESPB group was associated with the lower VAS scores at rest and cough state than TAPB group at 2, 4, 6, 12, and 24 h postoperatively (P < 0.05). Less analgesic consumption and sufentanil consumption in PCIA pump were found in the ESPB group (P < 0.05). Moreover, ESPB group was followed by fewer rescue analgesia requirements, less rescue analgesic consumption, less adverse reactions, and higher analgesia satisfaction (P < 0.05).

Conclusions

Our study found that ESPB had advantages on analgesic effect and opioids consumption. In the future, more studies were needed to confirm our findings. Systematic Review Registration: https://www.chictr.org.cn/index.aspx, identifier: ChiCTR2100044240.

Efficacy and safety of co-crystal of tramadol-celecoxib (CTC) in acute moderate-to-severe pain after abdominal hysterectomy: A randomized, double-blind, phase 3 trial (STARDOM2)

BACKGROUND

STARDOM2 is a randomized, double-blind, phase 3 trial evaluating the efficacy and safety of co-crystal of tramadol-celecoxib (CTC)-a first-in-class analgesic co-crystal comprising racemic tramadol hydrochloride and celecoxib in a supramolecular network that modifies their pharmacokinetic properties-for the management of acute postoperative pain (NCT03062644; EudraCT:2016-000593-38).

METHODS

Patients with moderate-to-severe pain following abdominal hysterectomy were randomized 2:2:2:2:2:1 to oral CTC 100 mg (rac-tramadol hydrochloride 44 mg/celecoxib 56 mg) twice daily (BID); CTC 150 mg (66/84 mg) BID; CTC 200 mg (88/112 mg) BID; immediate-release tramadol 100 mg four times daily (QID); celecoxib 100 mg BID; or placebo, for 5 days. The primary endpoint was the sum of pain intensity differences over 0-4 h (SPID_0-4 ). Key secondary endpoints were rescue medication use within 4 h, 50% response rate at 4 h, and safety/tolerability.

RESULTS

Of 1355 patients enrolled, 1138 were randomized (full analysis set) and 1136 treated (safety analysis set). In the prespecified gatekeeping analysis of SPID_0-4 , CTC 200 mg was not superior to tramadol but showed non-inferior efficacy (p < 0.001) that was sustained throughout the 120-h period, despite a 5-day cumulative tramadol administration of 880 mg with CTC 200 mg BID versus 2000 mg with tramadol 100 mg QID. Treatment-emergent adverse events (TEAEs) and severe TEAEs were less common with CTC 200 mg versus tramadol. Treatment-related TEAEs were 14.4% with CTC 200 mg and 23.6% with tramadol.

CONCLUSIONS

Although the study did not meet its primary endpoint, CTC 200 mg showed a clinically relevant improvement in overall benefit/risk profile versus tramadol alone, with considerably lower cumulative opioid exposure.

SIGNIFICANCE

In the randomized, double-blind, phase 3 STARDOM2 trial-in acute moderate-to-severe pain after abdominal hysterectomy-the novel co-crystal of tramadol-celecoxib (CTC) 200 mg BID was superior to placebo and non-inferior to tramadol 100 mg QID. Although superiority to tramadol was not reached, CTC 200 mg BID exposed patients to lower cumulative opioid (tramadol) doses than tramadol (100 mg QID) alone, with fewer treatment-emergent adverse events. CTC 200 mg thus has a clinically relevant improved benefit/risk profile compared with tramadol alone.

Intraperitoneal lidocaine instillation during abdominal hysterectomy: A systematic review and meta-analysis of randomized placebo-controlled trials

AIM

To perform a systematic review and meta-analysis of all randomized placebo-controlled trials (RCTs) that inspected the analgesic benefits of intraperitoneal lidocaine instillation among patients undergoing abdominal hysterectomy.

METHODS

Five electronic databases were inspected from till August 5, 2021. The eligible RCTs were evaluated for risk of bias. The pooled endpoints were summarized as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI).

RESULTS

Five RCTs met the inclusion criteria comprising 263 patients (119 and 117 patients were allocated to lidocaine and control group, respectively). The included RCTs demonstrated a low risk of bias. The postoperative pain score at rest was significantly lower in favor of the lidocaine group (MD=-1.01, 95% CI [-1.20, -0.81], p<0.001), and subgroup analysis demonstrated the same at 2, 4, 8, 12, 24, and 48 h postoperatively. Moreover, the postoperative pain score at moving was significantly lower in favor of the lidocaine group (MD=-0.67, 95% CI [-1.01, -0.33], p<0.001), and subgroup analysis demonstrated the same at 2 and 48 h postoperatively. The postoperative morphine consumption during 0-24 h was significantly lower in favor of the lidocaine group (n = 5 RCTs, MD=-7.29 mg, 95% CI [-13.22, -1.37], p = 0.02). The rate of postoperative vomiting was significantly lower in favor of the lidocaine group (n = 4 RCTs, RR=0.54, 95% CI [0.31, 0.95], p = 0.03).

CONCLUSION

Among patients undergoing abdominal hysterectomy, intraperitoneal lidocaine instillation is feasible, cheap, safe, and associates with effective analgesia in terms of reduced postoperative pain score and morphine consumption.

Post-operative pain management modalities employed in clinical trials for adult patients in LMIC; a systematic review

BACKGROUND

Unrelieved postoperative pain afflicts millions each year in low and middle income countries (LMIC). Despite substantial advances in the study of pain, this area remains neglected. Current systematic review was designed to ascertain the types of clinical trials conducted in LMIC on postoperative pain management modalities over the last decade.

METHODS

A comprehensive search was performed in June 2019 on PubMed, Cochrane Library, CINAHL Plus, and Web of Science databases to identify relevant trials on the management of postoperative pain in LMIC. Out of 1450 RCTs, 108 studies were reviewed for quality evidence using structured form of critical appraisal skill program. Total of 51 clinical trials were included after applying inclusion/exclusion criteria.

RESULTS

Results are charted according to the type of surgery. Eleven trials on laparoscopic cholecystectomy used multimodal analgesia including some form of regional analgesia. Different analgesic modalities were studied in 4 trials on thoracotomy, but none used multimodal approach. In 11 trials on laparotomy, multimodal analgesia was employed along with the studied modalities. In 2 trials on hysterectomy, preemptive pregabalin or gabapentin were used for reduction in rescue analgesia. In 13 trials on breast surgical procedures and 10 on orthopaedic surgery, multimodal analgesia was used with some form of regional analgesia.

CONCLUSION

We found that over the past 10 years, clinical trials for postoperative pain modalities have evolved in LMIC according to the current postoperative pain management guidelines i.e. multi-modal approach with some form of regional analgesia. The current review shows that clinical trials were conducted using multimodal analgesia including but not limited to some form of regional analgesia for postoperative pain in LMIC however this research snapshot (of only three countries) may not exactly reflect the clinical practices in all 47 countries. Post Operative Pain Management Modalities Employed in Clinical Trials for Adult Patients in LMIC; A Systematic Review.

Effect of transcutaneous electrical nerve stimulation on quality of recovery and pain after abdominal hysterectomy

Background and Aims:

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive complementary therapy for postoperative pain management. The effect of TENS on quality of recovery (QoR) and pain treatment in the early postoperative period is not well documented. The aim of this study was to evaluate the effect of TENS on postoperative QoR and pain in patients who had undergone a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO).

Material and Methods:

Fifty-two patients were randomized into two groups: control (sham TENS treatment) and TENS (TENS treatment). QoR, dynamic pain, and static pain were evaluated after surgery.

Results:

The QoR score was significantly higher in the TENS group as compared with that in the control group (P = 0.029). Pain scores during coughing (dynamic pain) were significantly less in TENS group compared to control group (P <0.001). However, there was no between-group difference in pain scores at rest (static pain) or total analgesic consumption (P = 0.63 or P = 0.83, respectively).

Conclusion:

TENS may be a valuable tool to improve patients' QoR and dynamic pain scores after TAH + BSO.

The Efficacy of Acetominophen for Total Laparoscopic Hysterectomy

OBJECTIVE

Despite limited data, acetaminophen, along with other agents, is commonly included in enhanced recovery after surgery (ERAS) protocols following laparoscopic hysterectomy. We aimed to systematically review the efficacy of acetaminophen on the management of postoperative pain after laparoscopic hysterectomy.

METHODS

We searched PubMed, SCOPUS, Web of Science, and Cochrane Library databases for relevant clinical trials investigating the role of acetaminophen in the management of pain after laparoscopic hysterectomy. We performed the risk of bias according to Cochrane's risk of bias tool. We performed the analysis of homogeneous data under the fixed-effects model during the analysis of heterogeneous data under the random-effects model. The primary outcome was the assessment of pain score after 2, 6, 12, and 24 h.

RESULTS

A total of 495 patients in 13 trials were included in our meta-analysis. Acetaminophen was not superior at reducing postoperative pain scores. Further analysis at progressive temporal points revealed no further significance; effect size at after 2 h (SMD = -0.020, 95% CI (-0.216; 0.176)), 6 h (SMD = -0.115, 95% CI (-0.312; 0.083)), 12 h (SMD = -0.126, 95% CI (-0.277; 0.025)), or 24 h (SMD = 0.063, 95% CI (-0.065; 0.191)). Pooled analysis was heterogeneous (P < 0.1); therefore, we conducted a sensitivity analysis yielding homogeneous results. The drug did not reduce opioid need (MD = -0.16, 95% CI (-2.39, 2.06), P = 0.89).

CONCLUSION

We conclude that acetaminophen is not beneficial for reducing pain after laparoscopic hysterectomy. Other alternatives have better results. Caution should be given to the inclusion of acetaminophen in ERAS protocols designed for laparoscopic hysterectomy, especially as a single agent or to reduce opioid consumption.

Intravenous magnesium sulfate for postoperative analgesia after abdominal hysterectomy under spinal anesthesia: a randomized, double-blind trial

Background and objectives

Abdominal Hysterectomy (AH) is associated with significant inflammatory response and can result in moderate to severe postoperative pain. This study aimed to evaluate the efficacy of magnesium infusion in reducing postoperative pain and analgesic consumption after AH under spinal anesthesia with Intrathecal Morphine (ITM).

Method

Eighty-six patients were included in this clinical, controlled, randomized, double-blind study. Patients received in Group Mg, MgSO₄ 50 mg kg⁻¹ for 15 minutes followed by 15 mg kg⁻¹ h⁻¹ until the end of the surgery; and in Group C, (control) the same volume of isotonic saline. Both groups received 100 μg of ITM. All patients received dipyrone + ketoprofen intraoperatively and postoperatively, and dexamethasone intraoperatively only. We evaluated the intensity of pain, tramadol consumption, and adverse events 24 hours postoperatively.

Results

Serum magnesium concentrations were higher in Group Mg at the end, and one hour after the operation (p = 0.000). Postoperative pain scores were reduced in Group Mg at 6 hours at rest and on movement (p < 0.05). Tramadol consumption did not show a statistically significant difference between Group Mg and Group C (15.5 ± 36.6 mg and 29.2 ± 67.8 mg respectively, p = 0.53). Hemodynamic variables, the incidence of pruritus, nausea, and vomiting were similar in the two groups.

Conclusion

Infusion of MgSO₄ during AH undergoing spinal anesthesia with ITM reduced at 6 hours at rest and on movement. More studies should be performed to evaluate the potential antinociceptive effect of MgSO₄ in scenarios where a multimodal analgesia approach was employed.

Erector spinae plane block for postoperative analgesia in patients undergoing total abdominal hysterectomy: a randomized controlled study original study

Background: Abdominal hysterectomy is associated with marked postoperative pain and morbidity, but effective postoperative analgesia provides early recovery and ambulation.

Aim: We intended to assess the efficacy of bilateral erector spinae plane block (ESPB) on postoperative analgesia in females undergoing abdominal hysterectomy under general anesthesia.

Settings and Design: The design was a prospective, randomized, controlled, single-blind clinical study.

Patients and Methods: Sixty patients with American Society of Anesthesiologists (ASA) physical status classes Ι to ΙΙΙ were scheduled for elective abdominal hysterectomy under general anesthesia, patients were randomly allocated into two equal groups. ESPB patients received ultrasound-guided ESPB at T9 vertebrae level with 20 ml bupivacaine 0.5%. Control group patients did not receive a block. Total fentanyl consumption in the first 24 h and visual analogue scale (VAS) score for pain were evaluated postoperatively. Unpaired Student’s t-tests, chi-square tests, and Z tests were used to compare groups.

Results: No significant differences were recorded between the groups regarding age, weight, ASA physical status, or surgery duration, Total fentanyl consumption in the first 24 h was significantly higher in the control group than the ESPB group (P=0.003; 485±20.39 mcg vs 445±67.49 mcg, respectively), VAS for pain was significantly higher in the control group for the first 12 h postoperatively.

Conclusions: Bilateral ESPB provided effective postoperative analgesia and markedly decreased postoperative fentanyl consumption in patients undergoing an abdominal hysterectomy.

Reduced length of stay and hospitalization costs among inpatient hysterectomy patients with postoperative pain management including IV versus oral acetaminophen

OBJECTIVE

To compare the outcomes of hysterectomy patients who received standard pain management including IV acetaminophen (IV APAP) versus oral APAP.

METHODS

We performed a retrospective analysis of the Premier Database (January 2012 to September 2015) comparing hysterectomy patients who received postoperative pain management including IV APAP to those who received oral APAP starting on the day of surgery and continuing up to the third post-operative day, with no exclusions based on additional pain management. We compared the groups on length of stay (LOS), hospitalization costs, and average daily morphine equivalent dose (MED). The quarterly rate of IV APAP use for all hospitalizations by hospital was used as an instrumental variable in two-stage least squares regressions also adjusting for patient demographics, clinical risk factors, and hospital characteristics.

RESULTS

We identified 22,828 hysterectomy patients including 14,811 (65%) who had received IV APAP. Study subjects averaged 50 and 52 years of age, respectively in the IV APAP and oral APAP cohorts and were predominantly non-Hispanic Caucasians (≥60% in both cohorts). Instrumental variable models found IV APAP associated with 0.8 days shorter hospitalization (95% CI: -0.92 to -0.68, p<0.0001) and $2,449 lower hospitalization costs (95% CI: -$2,902 to -$1,996, p<0.0001). Average daily MED trended lower without statistical significance (-1.41 mg, 95% CI: -3.43 mg to 0.61 mg, p = 0.17).

CONCLUSIONS

Compared to oral APAP, managing post-hysterectomy pain with IV APAP is associated with shorter LOS and lower total hospitalization costs.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Comparison of Single-Shot Intrathecal Morphine Injection and Continuous Epidural Bupivacaine for Post-Operative Analgaesia after Elective Abdominal Hysterectomy

Background

Abdominal hysterectomy (AH) is painful. The aim of this study was to compare intrathecal morphine (ITM) and epidural bupivacaine (EB) for their analgaesia effectiveness after this surgery.

Methods

Thirty-two patients undergoing elective AH were randomised into Group ITM (ITM 0.2 mg + 2.5 mL 0.5% bupivacaine) (n = 16) and Group EB (0.25% bupivacaine bolus + continuous infusion of 0.1% bupivacaine-fentanyl 2 μg/mL) (n = 16).The procedure was performed before induction, and all patients subsequently received standard general anaesthesia. Both groups were provided patient-controlled analgaesia morphine (PCAM) as a backup. Visual analogue scale (VAS) scores, total morphine consumption, hospital stay duration, early mobilisation time and first PCAM demand time were recorded.

Results

The median VAS score was lower for ITM than for EB after the 1st hour [1.0 (IqR 1.0) versus 3.0 (IqR 3.0), P < 0.001], 8th hour [1.0 (IqR 1.0) versus 2.0 (IqR 1.0), P = 0.018] and 16th hour [1.0 (IqR1.0) versus (1.0 (IqR 1.0), P = 0.006]. The mean VAS score at the 4th hour was also lower for ITM [1.8 (SD 1.2) versus 2.9 (SD 1.4), P = 0.027]. Total morphine consumption [11.3 (SD 6.6) versus 16.5 (SD 4.8) mg, P = 0.016] and early mobilisation time [2.1 (SD 0.3) versus 2.6 (SD 0.9) days, P = 0.025] were also less for ITM. No significant differences were noted for other assessments.

Conclusions

The VAS score was better for ITM than for EB at earlier hours after surgery. However, in terms of acceptable analgaesia (VAS ≤ 3), both techniques were comparable over 24 hours.

Continuous wound infiltration system for postoperative pain management in gynecologic oncology patients

PURPOSE

Major open surgery for gynecologic cancer usually involves a long midline skin incision and induces severe postoperative surgical site pain (POSP) that may not be effectively controlled with the conventional management. We investigated whether combining a continuous wound infiltration system (CWIS, ON-Q PainBuster^®) and intravenous patient-controlled analgesia (IV PCA) effectively decreases POSP, compared with IV PCA alone, in gynecologic oncology patients.

METHODS

This retrospective study included 62 Korean patients who received a long midline skin incision during gynecologic cancer surgery. The combined therapy group (n = 31), which received CWIS (0.5% ropivacaine infused over 72 h) and IV PCA (fentanyl citrate), and the IV PCA only group (n = 31) were determined using 1:1 matching. POSP was assessed using resting numeric rating scale (NRS) scores measured for 96 h after surgery, which were analyzed using a linear mixed model.

RESULTS

The slopes of the predicted NRS values from the linear mixed model were significantly different between the groups. Compared with the control group, the combined therapy group had lower predicted NRS scores for the first 72 h, but higher predicted scores between 72 and 96 h. Moreover, the mean NRS scores over the first 48 h postoperation were significantly lower in the combined therapy group than in the control group; the scores were similar in both groups during the remaining period. With the exception of a higher body mass index in the CWIS group, the other variables, such as the dosage and usage time of fentanyl citrate, use of additional painkillers, and side effects, including wound complications, did not differ between groups.

CONCLUSIONS

Combined therapy using CWIS and IV PCA may be a useful strategy for POSP management in gynecologic oncology patients.

Comparison of fentanyl iontophoretic transdermal system and routine care with morphine intravenous patient-controlled analgesia in the management of early postoperative mobilisation: results from a randomised study

INTRODUCTION

Fentanyl iontophoretic transdermal system (ITS) (IONSYS^®, The Medicines Company, Parsippany, NJ, USA) and morphine intravenous (IV) patient-controlled analgesia (PCA) have demonstrated equivalent pain control in several published studies. The primary objective of the current study was to compare fentanyl ITS with morphine IV PCA with regard to the patient's ability to mobilise with acute postoperative pain.

METHODS

In this multicentre, open-label, randomised, active-controlled, prospective phase IV study, postoperative patients initially received IV morphine and were titrated to pain score ⩽ 4out of 10 on a Numeric Rating Scale (NRS) and then received fentanyl ITS (up to 240 µg (6 doses)/hour; up to a maximum of 3.2 mg (80 doses)/24 hours) or morphine IV PCA (doses up to 20 mg morphine/2 hours, up to 240 mg/24 hours). The primary efficacy measure was ability to mobilise, assessed using patient responses to three validated questions regarding mobility on a 6-point Likert scale (0 = no difficulty to mobilise to 5 = a very great deal of difficulty to mobilise). The study was originally planned to include ~200 patients. However, following the early suspension and termination of the study, a total of 108 patients were randomised to study treatment.

RESULTS

One hundred and eight patients were recruited prior to undergoing surgical procedures (orthopaedic surgical procedures (72%) or underwent major abdominal procedures (28%)). Postoperatively, 58 were randomised to receive fentanyl ITS, and 50 to morphine IV PCA. Fentanyl ITS patients had a greater ability to mobilise at the time of stopping study drug, with an adjusted mean ability to mobilise score (95% confidence interval (CI)) of 0.14 (-0.19, 0.47) for fentanyl ITS patients and 2.37 (1.98, 2.76) for morphine IV PCA patients (p < 0.001).

CONCLUSION

Patients treated with fentanyl ITS reported that they were better able to mobilise than patients treated with morphine IV PCA, at all time-points following surgery out to 24 hours.

Postoperative pain relief following hysterectomy: A randomized controlled trial

Background:

Women experience moderate to severe postoperative pain following total abdominal hysterectomy (TAH). The transversus abdominis plane (TAP) block is a new modality for providing postoperative pain relief in these patients.

Materials and Methods:

The present study was a single center, prospective randomized trial. After the Institutional Ethics Committee approval and informed consent, patients were randomized to either epidural group: Epidural block placement + general anesthesia (GA) or TAP group: Single shot TAP block + GA. Patients in both the groups received standard general anesthetic technique and intravenous tramadol patient-controlled analgesia in the postoperative period. Patients were monitored for tramadol consumption, visual analog scale (VAS) both at rest and on coughing, hemodynamics, and side effects at 0, 2, 4, 6, 8, 12, and 24 h postoperatively.

Results:

The total consumption of tramadol in 24 h was greater in TAP group as compared to epidural group (68.8 [25.5] vs. 5.3 [11.6] mg, P < 0.001). The VAS scores at rest and on coughing were higher in TAP group as compared to the epidural group at 6, 8, 12, and 24 h postoperatively (P < 0.05). None of the patients in either group had any adverse effects.

Conclusion:

Epidural analgesia provided greater tramadol-sparing effect with superior analgesia postoperatively as compared to TAP block in patients up to 24 h following TAH.

Effect of Preoperative Oral Amantadine on Acute and Chronic Postoperative Pain After Mandibular Fracture Surgery

BACKGROUND

Postoperative pain from open reduction and internal fixation of mandibular fracture is a serious issue. Amantadine is an N-methyl-D-aspartic acid or N-methyl-D-aspartate (NMDA) receptor antagonist that can be effective against postoperative pain.

OBJECTIVES

The present study examined the efficacy of amantadine in alleviating the postoperative pain of mandibular fracture surgery.

PATIENTS AND METHODS

In this double-blind study, 60 patients (ASA physical status I-II) were randomly divided into two groups. The mean ages of the participants were 31.2 ± 13.1 years and 32.3 ± 18.1 years, respectively. The male/female ratios were 24/6 and 26/4, respectively, in the case and control groups. Randomization was based on a single sequence of random assignments using computer-generated random numbers. Group I was given oral amantadine 100 mg 1 hour before surgery, and group II received a placebo at the identical time. Through PCA pumps, patients received a bolus dose of morphine at 0.02 mg/kg body weight, to a maximum of 1.5 mg. PCA pumps were set at 6 minutes lockout intervals and a maximum dose of 0.15 mg/kg/h, to a maximum of 10 mg/h. Pain was assessed using a visual analog scale (VAS) at 0, 2, 4, 6, 12, and 24 hours and 1, 2, 3, 4, 5, and 6 months after surgery. The amounts of analgesic consumed were recorded for the first 24 hours, and for 6 months after surgery.

RESULTS

There were no significant differences between the two groups with respect to age, gender, nausea and vomiting, sleep quality, blood pressure, and heart rate. No significant differences were observed between the two groups in pain scores (P = 0.39) and analgesic consumption (P = 0.78).

CONCLUSIONS

The results suggest that a single dose of preoperative oral amantadine did not reduce acute or chronic postoperative pain, nor analgesic consumption.

Multimodal pain control is associated with reduced hospital stay following open abdominal hysterectomy

OBJECTIVE

To study the association of a multimodal pain protocol (MMPC) and reduced hospital stay after open abdominal hysterectomy.

STUDY DESIGN

The study design was a comparison of a prospective cohort with a retrospective historical control. We enrolled endometrial cancer patients undergoing open abdominal hysterectomy with lymphadenectomy by the same surgeon. Control patients from 2008 to 2010 who received morphine PCA alone were compared with a similar demographic group of patients from 2011 to 2013 who received MMPC. MMPC consisted of gabapentin (900mg PO) and acetaminophen (1g IV) administered 45-60min preoperatively. The surgical site was injected with bupivacaine with 0.5% epinephrine prior to incision. The postoperative pain control regimen consisted of gabapentin (300mg PO every 6h), acetaminophen (1g IV every 8h for 24h postoperatively), ketorolac (15mg IV every 6h for 48h postoperatively), morphine PCA (2mg IV every 10min, no basal rate) and oxycodone/acetaminophen (10/325mg PO every 6h as needed).

RESULTS

Length of hospital stay (LOH) of the study cohort (N=105 with MMPC) was compared with the historical with postoperative morphine alone (N=113 without MMPC). There were no differences in demographic, uterine cancer stage, or comorbidities between the two arms. The LOH was 1.6 days for patients receiving MMPC and 3.3 days for patients who received morphine alone (P<0.001).

CONCLUSION

Multimodal pain control is associated with significantly reduced hospital stay after open abdominal hysterectomy.

Preemptive use of gabapentin in abdominal hysterectomy: a systematic review and meta-analysis

OBJECTIVE

To examine the evidence of preemptive use of gabapentin in abdominal hysterectomy.

DATA SOURCES

We conducted an electronic based search using the following databases: PubMed, EMBASE, Ovid MEDLINE, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials. The following medical subject heading terms, keywords, and their combinations were used: "postoperative pain, hysterectomy, gynecologic surgical procedures, gabapentin, preemptive analgesia, and preemptive anesthesia." We manually searched the reference lists of identified studies.

METHODS OF STUDY SELECTION

Randomized controlled trials of women who underwent a total abdominal hysterectomy, with or without bilateral salpingo-oophorectomy, under general anesthesia were examined. Only trials with preoperative dose of gabapentin were included.

TABULATION, INTEGRATION, AND RESULTS

The meta-analysis and systematic review were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Fourteen trials met the inclusion criteria. The pooled data consisted of 448 cases in the gabapentin group and 443 others in the control group. The 24-hour cumulative narcotic consumption and the visual analog scale scores at 24 hours postoperatively were used for postoperative pain assessment. There was a significant decrease in morphine consumption at 24 hours when gabapentin was administered before surgery (from 24.3-55.9 mg to 13.2-42.7 mg, standardized mean difference -0.69) as well before and after surgery (from 25.7-80 mg to 20.3-55 mg, standardized mean difference -1.45), respectively. Metaregression analysis showed that the effect of gabapentin in reducing morphine consumption (compared with placebo) at 24 hours was stronger in the preoperative only group than in the preoperative and postoperative groups. Preemptive gabapentin decreased visual analog scale from 9-42.7 to 2-25.3 (standardized mean difference -1.03, 95% confidence interval [CI] -1.36 to -0.71). Compared with the control group (16.1-96.7%), the rate of nausea was less in the gabapentin group (11.6-70%, relative risk 0.76, 95% CI 0.66-0.88).

CONCLUSION

Preemptive administration of gabapentin is effective in decreasing postoperative pain scores, narcotic consumption, and nausea, and vomiting.

LEVEL OF EVIDENCE

I.