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Back to Journal »Journal of Pain Research» Volume 14

Description and comparison of acute pain characteristics after laparoscopic-assisted vaginal hysterectomy, laparoscopic myomectomy and laparoscopic accessory resection

Authors: Chen Si, Du Wei, Zhuang X, Dai Qiang, Zhu Jie, Fu Hong, Wang Jie, Huang Li

Published on October 19, 2021 2021 Volume: 14 pages 3279-3288

DOI https://doi.org/10.2147/JPR.S335089

Single anonymous peer review

Editor who approved for publication: Dr. Li Jinlei

Chen Sijia,1,*Du Wenwen,1,*Zhuang Xiuxiu,1,*Dai Qinxue,1 Zhu Jingwen,2 Fu Haifeng,1 Wang Junlu,1 Huang Luping1 1 Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China; 2Wenzhou Medical University, Wenzhou, People’s Republic of China *These authors contributed equally to this work 577-55578999-689854 Email [email protected] Purpose: To determine laparoscopic assisted vaginal hysterectomy (LAVH), laparoscopic myomectomy (LM) ) And the characteristics of acute pain after laparoscopic accessory resection (LA) and compare with each other. Patients and methods: Select patients who received LAVH, LM and LA under general anesthesia in the First Affiliated Hospital of Wenzhou Medical University from December 2017 to December 2019. Their data was collected before, during and after the operation. We assessed the pain levels of each group of patients and compared them. Results: There were differences in the baseline characteristics of patients in the LAVH, LM, and LA groups. The severity and incidence of postoperative pain in the LAVH group were higher than those in the LM and LA groups, followed by the LM and LA groups. Compared with LA group, LAVH group and LM group had more complicated postoperative pain. The LA group had the lowest incidence of two or more types of moderate to severe pain. The LAVH and LM groups mainly had visceral pain and low back pain, and the LA group mainly had incision pain. The incidence of shoulder pain was the lowest among the three groups. Conclusion: The postoperative pain characteristics of LAVH, LM, and LA are different, and the analgesic plan should be adjusted according to different gynecological laparoscopic surgery. Keywords: postoperative pain, laparoscopic assisted vaginal hysterectomy, laparoscopic myomectomy, laparoscopic accessory resection

Acute postoperative pain is one of the most common problems after surgery. It delays the healing process, increases postoperative complications and mortality, and increases hospitalization time and nursing costs. 1 Although gynecological laparoscopic surgery is considered to be less traumatic, there are also some postoperative problems.2,3

Previous studies have shown that female patients are more prone to acute postoperative pain. 4,5 The postoperative pain of gynecological laparoscopic surgery is mild, but the incidence of postoperative pain is relatively high. One possibility for this difference is that the population includes only female patients who are sensitive to pain. 6-8 At the same time, some studies have shown that pain control after gynecological laparoscopic surgery is poor. 9 In addition, different treatment methods have produced 10 previous studies that investigated the characteristics of acute pain after laparoscopic total hysterectomy (TLH) and laparoscopic assisted vaginal hysterectomy (LAVH). 11,12 Today, gynecological laparoscopic surgery also involves laparoscopic myomectomy (LM) and laparoscopic accessory resection. (Los Angeles).

To solve the problem of unsatisfactory postoperative analgesia, we must first understand the nature, location, intensity, and duration of postoperative pain. LA also uses them to compare the pain characteristics associated with different laparoscopic gynecological procedures.

This study selected patients who received general anesthesia LAVH, LM, and LA at the First Affiliated Hospital of Wenzhou Medical University from December 2017 to December 2019. The written informed consent of each participant was obtained through preoperative interviews. Finally, the data of 669 patients were analyzed, including 249 in the LAVH group, 210 in the LM group, and 210 in the LA group. This prospective observational cohort study was approved by the Clinical Research Ethics Committee (2019-030) of the First Affiliated Hospital of Wenzhou Medical University and was conducted in accordance with the Declaration of Helsinki. The study is registered with the Chinese Clinical Trial Registry: ChiCTR-ROC-17013036. The exclusion criteria were: ASA≥3, age <19 years, malignant lesions, previous severe cardiopulmonary disease, liver and kidney dysfunction, history of mental illness, pregnant or lactating women, language and self-expression disorders.

In this study, the Numerical Rating Scale (NRS) was used to assess the intensity of pain. The pain score ranges from 0 to 10. According to the pain score, pain intensity is divided into four types: painless (NRS is 0), mild pain (NRS is 1 to 3), moderate pain (NRS is 4 to 6), and severe pain (NRS is 7 to 10) . 13

Previous studies have reported that the components of various forms of postoperative pain are as follows: Incision pain: pain on the wound surface or ventral surface that people can "touch"; visceral pain: pain may be deep and difficult to locate, mainly in the lower abdomen; low back pain: Pain between the 12th rib and the inferior gluteus muscles, with or without leg pain; shoulder pain: shoulder pain.

Preoperative variables include age, body mass index (BMI), education level, occupation, exercise habits, personal medical history, obstetric medical history, previous surgery history, preoperative chronic pain history, medical insurance type, main indications for surgery, and anxiety level. These data were obtained and entered the day before the operation. Pelvic adhesions are a preoperative factor found during surgery; we classify it as a preoperative factor because it exists before surgery. Intraoperative variables include the number of trocars, intraoperative diagnosis, operation duration, blood loss, and intraoperative complications. Postoperative variables included postoperative nausea and vomiting, pelvic drainage time, catheter indwelling time, and 24-hour pelvic drainage; they were collected and input after surgery.

In this study, two anesthesiologists performed anesthesia analgesia on LAVH, LM and LA with reference to the 2017 version of the expert consensus and previous perioperative analgesia records. No preoperative analgesics were used before the three types of laparoscopic surgery.

After the patient enters the ward, the anesthesiologist checks the name and information, and conducts routine assessment and monitoring, such as electrocardiogram (ECG), non-invasive blood pressure (NIBP), non-invasive pulse oxygen saturation (SpO2), etc. The bispectral index (BIS) is used to monitor the depth of anesthesia of the patient. Sufentanil (0.4μg/kg), propofol (2-3mg/kg) and rocuronium (0.6-0.8mg/kg) are used to induce anesthesia as intravenous injections. The tracheal intubation was performed 90 s after the rocuronium bolus injection. After intubation, the IPAP ventilation mode, tidal volume (6–8 mL/kg), RR (12 beats/min), inhalation-exhalation ratio (I/E=1/2) and oxygen/air ratio are 1: Two were used. After intubation, 3mg/kg/h propofol, 0.1-0.3μg/kg/min remifentanil and 1.0-2.5% sevoflurane were used to maintain the depth of anesthesia, and the BIS value was maintained between 40-60. All operations are performed by experienced personnel or supervised by gynecologists in accordance with the standardized LAVH protocol, which involves the use of one 10 mm and two or three 5 mm laparoscopic trocars to remove the uterus through the vagina. During the operation, the intra-abdominal pressure was maintained at 12-13 mmHg. After laparoscopic surgery, press the abdomen with your hand and open the laparoscopic trocar to drain CO2. Morphine (0.1 mg/kg iv) is used to prevent postoperative pain, and Palonosetron (0.25 mg iv) is used to prevent nausea and vomiting. Stop using inhaled anesthetics. After the skin was sutured, the surgeon used 10 mL of ropivacaine at a concentration of 0.75% to perform local infiltration anesthesia on the incision site. After the operation, the infusion of remifentanil and propofol was stopped. In the PACU, the anesthesiologist gives the patient intravenous morphine, asks about the intensity of pain every 5 minutes, and gives a dose of 1-2 mg of morphine (NRS ≥ 4 points) until sufficient analgesia is achieved (NRS <4 points). After 1 hour, the patient left the PACU and was taken to the ward. In the ward, when the patient's postoperative pain NRS≥4, indomethacin suppository 50mg was given. If postoperative pain persists and NRS≥4, pethidine is injected intramuscularly to relieve pain.

Researchers who were unaware of the patients undergoing surgery performed postoperative pain assessments. Follow-up to the ward at 17:00 on the first and second days after surgery, retrospectively assess and record the patient's pain. 14 The NRS score is used to assess postoperative acute pain and its components. According to previous studies, the first day after surgery was the day when the highest pain intensity score was recorded. 11 Therefore, this study used the maximum pain score within 2 days as the postoperative severity pain score. 15

All operations are performed or supervised by experienced gynecologists according to the LM standardized plan, which involves the use of one 10 mm and two or three 5 mm laparoscopic trocars to remove uterine fibroids through laparoscopic surgery. The rest of the process is the same as LAVH.

All operations are performed or supervised by experienced gynecologists in accordance with the LA standardized protocol, which involves laparoscopic removal of the ovaries using one 10 mm and two or three 5 mm laparoscopic trocars. After the operation, the patient did not receive conventional morphine analgesia, but was given non-steroidal anti-inflammatory drugs (NSAIDs) for analgesia. The rest of the process is the same as LAVH.

Stata 15 is used for statistical analysis. If the baseline data is normally distributed and the variances are consistent, the mean ± standard deviation is used to summarize; otherwise, the median (quartile) is used, and the count data is expressed as a component ratio or a ratio. The Kolmogorov-Smirnov test is used to determine normality. Box plots or scatter plots are used to prove outliers. Chi-square test is used to compare the measurement data of each group. Bonferroni's test is used for multiple comparisons. All statistical tests were two-sided tests, and statistical significance was set as P<0.05.

A total of 823 patients participated in this study. Finally, data from 669 patients were used for the final statistical analysis; these data included data from 249, 210, and 210 patients in the LAVH, LM, and LA groups, respectively (Figure 1). Figure 1 Recruitment flow chart, showing the number of patients recruited by type of surgery and the follow-up as of the first and second day. Abbreviations: LAVH, laparoscopic assisted vaginal hysterectomy; LM, laparoscopic hysterectomy; LA, laparoscopic accessory resection.

Figure 1 Recruitment flow chart, showing the number of patients recruited by type of surgery and the number of people lost to follow-up as of the first day and the second day of follow-up.

Abbreviations: LAVH, laparoscopic assisted vaginal hysterectomy; LM, laparoscopic hysterectomy; LA, laparoscopic accessory resection.

As shown in Table 1, there are significant differences in the preoperative baseline characteristics of patients in the LAVH, LM, and LA groups, such as age, BMI, anxiety, education, preoperative chronic pain, occupation, medical insurance type, and diabetes. Medical history, history of blood pressure, parity, history of dysmenorrhea, chief complaint, and pelvic adhesions. There are also significant differences in the number of trocars during the operation and the duration of the operation. There were significant differences in the duration of postoperative pelvic drainage, catheter indwelling time, and 24-hour pelvic drainage volume in the three groups (Table 1). Table 1 Demographics and patient characteristics of laparoscopic assisted vaginal hysterectomy, laparoscopic myomectomy, and laparoscopic accessory resection

Table 1 Demographics and patient characteristics of laparoscopic assisted vaginal hysterectomy, laparoscopic myomectomy, and laparoscopic accessory resection

The incidence of visceral pain was the highest and the most severe in the LAVH group (Tables 2 and 3), followed by low back pain; the LAVH group had moderate incision pain less than low back pain and shoulder pain the least. Up to 73.1% of patients in the LAVH group had one or more types of moderate to severe pain (Tables 2 and 3). Table 2 The incidence of different types of pain after laparoscopic-assisted vaginal hysterectomy Table 3 The incidence of moderate to severe pain after laparoscopic-assisted vaginal hysterectomy

Table 2 The incidence of different types of pain after laparoscopic assisted vaginal hysterectomy

Table 3 The incidence of moderate to severe pain after laparoscopic-assisted vaginal hysterectomy

The incidence of visceral pain in the LM group was the highest and the most severe (Tables 4 and 5), followed by low back pain; moderate to severe incision pain was milder than low back pain; shoulder pain in the LM group was the mildest. Among patients in the LM group, 61.0% had one or more forms of moderate to severe pain (Tables 4 and 5). Table 4 The incidence of different types of pain after laparoscopic myomectomy Table 5 The incidence of moderate to severe pain after laparoscopic myomectomy

Table 4 The incidence of different types of pain after laparoscopic myomectomy

Table 5 The incidence of moderate to severe pain after laparoscopic myomectomy

As shown in Table 6 and Table 7, the acute postoperative pain in the LA group was dominated by incision pain, followed by visceral pain and low back pain; shoulder pain was the mildest. In the LA group, as many as 39.0% of patients had one or more types of moderate to severe pain, but no one had four types of moderate to severe pain (Tables 6 and 7). Table 6 The incidence of different types of pain after laparoscopic accessory resection Table 7 The incidence of moderate to severe pain after laparoscopic accessory resection

Table 6 The incidence of different types of pain after laparoscopic accessory resection

Table 7 The incidence of moderate to severe pain after laparoscopic accessory resection

The LAVH group had the most severe pain, followed by the LM group and the LA group. The consumption of opioids in the operating room of the LAVH group was higher than that of the LA group, but there was no significant difference from the LM group; there was no significant difference between the LM group and the LA group. There was no significant difference in the number of opioid users in PACU between the three groups. In the ward, the LAVH group used indomethacin and meperidine the most, followed by the LA group; the LM group had the least number of users. The total consumption of opioids in the LAVH group was the highest, which was significantly different from the LA group, but not significantly different from the LM group, and there was no significant difference between LA and LM (Table 8). Table 8 Comparison of laparoscopic-assisted vaginal hysterectomy, laparoscopic myomectomy and laparoscopic accessory resection

Table 8 Comparison of laparoscopic-assisted vaginal hysterectomy, laparoscopic myomectomy and laparoscopic accessory resection

This study found significant differences in the baseline characteristics of patients in the LAVH, LM, and LA groups. Preoperative baseline characteristics such as age, obesity, anxiety, education, chronic pain, and occupation have an impact on postoperative pain. .16-20 Pelvic adhesions are also an important factor affecting postoperative pain. Patients with pelvic adhesions are prone to postoperative pain. 21 Similarly, there were significant differences in the number of trocars and operation time in the three groups. There were significant differences in variables such as postoperative pelvic drainage time, catheter indwelling time, and 24h pelvic drainage time among the three groups. The difference between these intraoperative and postoperative variables also affects the difference in postoperative pain.

The increase in the number of trocars is accompanied by an increase in injuries, which increases postoperative pain. However, the number of trocars used in laparoscopic surgery is small, the operation space is small, the requirements for doctors are higher, and the intraoperative time may be longer. It is more likely to cause injury, and the possibility of postoperative pain will increase. Therefore, the relationship between the number of trocars and postoperative pain remains controversial. A larger number of trocars is a protective factor for low back pain, which may be related to the reduction of operation time. 22-24

Comparing the characteristics and incidence of postoperative pain in the LAVH group, the LM group and the LA group, it was found that visceral pain and low back pain were the most common forms of postoperative pain in the LAVH group and the LM group; however, incision pain was the most common postoperative pain in the LA group , But the pain score is low. The LAVH group had the highest severity, followed by the LM and LA groups, indicating that the severity of postoperative pain was related to the size of the surgical trauma. 25 But at the same time, the severity and incidence of postoperative pain in the LM and LA groups were not the same as those in the LA group. be ignored. We cannot underestimate the postoperative analgesia of short surgery. 9 The relatively frequent use of analgesics in the three groups is related to the most severe postoperative pain in the LAVH group, but there is no significant difference between the use of LM and the LA group, indicating that the more severe postoperative pain in the LM group has not received enough attention. Due to the short half-life of remifentanil, the dose of remifentanil administered during surgery was not counted in this study; the results of this study indicate that the same gynecological laparoscopy in the LAVH, LM and LA groups can be associated with postoperative pain, but There are significant differences in its performance, incidence and severity.

According to previous studies, visceral pain may be related to insufficient doses of opioids or non-steroidal anti-inflammatory drugs. For these patients, it is necessary to increase the use of opioids and NSAIDs. 26 Due to the side effects of opioids, for patients with risk factors before surgery, opioid prescriptions can be personalized to help reduce excessive opioid intake. 27 And low-dose low-dose back pain combined with general anesthesia can also be considered for gynecological surgery Immediately reduce the amount of opioids in the perioperative period. 28 Previous studies have reported that low back pain may be related to preoperative anxiety, duration of surgery and longer time in bed after surgery. LAVH. For these patients, it is necessary to reduce the perioperative bedtime and consider anti-anxiety intervention. 29 For patients with incision pain as the main cause, the effect of local anesthesia may be poor. 30 It is necessary to increase the dose of regional block local anesthetics, improve regional block technology, and use NSAIDs in combination. The postoperative incision pain of these surgical patients may be effectively controlled. 31 At the same time, regional block has a therapeutic effect on visceral pain. 32 For patients with severe shoulder pain, shortening the duration is more beneficial. 33 Changes in surgical methods will also affect patients' postoperative pain. 23,24 In conclusion, the active use of low opioid drugs, multi-modality, preventive and individualized analgesia programs can achieve the greatest analgesia effect, the smallest adverse reactions, the best physical and mental function, the best quality of life, and patient satisfaction Spend.

The patients were interviewed at 17:00 on the first and second days. But in fact, the pain should be assessed at the same time after the operation. We only know the patient's maximum pain in 2 days, and we did not follow up and investigate the patient for a longer period of time. The study did not further discuss and analyze the mechanism of postoperative pain, which is also a shortcoming. This study only compares LAVH, LM, and LA as a form of gynecological laparoscopic surgery, and we can further study the postoperative pain of other operations.

The characteristics of acute pain after LAVH, LM and LA are different. The LAVH group had the highest incidence and the most severe postoperative pain, followed by the LM group and the LA group. The acute postoperative pain in the LAVH and LM groups was mainly visceral pain and low back pain, and the LA group was mainly incisional pain. The clinical analgesia plan should be adjusted according to different surgical conditions.

The clinical data used to support the results of this study can be obtained from the corresponding author upon reasonable request.

This work was supported by the National Natural Science Foundation of China (81803937, 81603685 and 81573742), Zhejiang Natural Science Foundation (CN) (LY15H290006, LY19H290008) and Wenzhou Science and Technology Bureau (CN) (2018ZY003).

The authors report no conflicts of interest in this work.

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