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Original article
Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations
  1. Philipp Lirk1,
  2. Juliette Thiry2,
  3. Marie-Pierre Bonnet3,
  4. Girish P Joshi4 and
  5. Francis Bonnet2
  6. for the PROSPECT Working Group
    1. 1 Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
    2. 2 Department of Anesthesiology and Intensive Care Hôpital Tenon, Groupe Hospitalier Universitaire Est Parisien, Assistance Publique Hôpitaux de Paris, Université Pierre & Marie, Paris, France
    3. 3 Department of Anesthesiology and Intensive Care Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Université René Descartes, Paris, France
    4. 4 Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
    1. Correspondence to Dr Philipp Lirk, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; plirk{at}bwh.harvard.edu

    Abstract

    Background and objectives Laparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review was to evaluate the available literature regarding the management of pain after laparoscopic hysterectomy.

    Strategy and selection criteria Randomized controlled trials evaluating postoperative pain after laparoscopic hysterectomy published between January 1996 and May 2018 were retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the EMBASE and MEDLINE databases and the Cochrane Register of Controlled Trials. Efficacy and adverse effects of analgesic techniques were assessed.

    Results Of the 281 studies initially identified, 56 were included. Of these, 31 assessed analgesic or anesthetic interventions and 25 assessed surgical interventions. Acetaminophen, non-steroidal anti-inflammatory drugs, and dexamethasone reduced opioid consumption. Limited evidence hindered recommendations on alpha-2-agonists. Inconsistent evidence was found in the studies investigating pregabalin and transversus abdominis plane block, and no evidence was found for intraperitoneal local anesthetics, port site infiltration, or single-port laparoscopy. Measures to lower peritoneal insufflation pressure or humidify or heat insufflated gas seem to reduce the incidence of shoulder pain, but not abdominal pain.

    Conclusions The baseline analgesic regimen for laparoscopic hysterectomy should include acetaminophen, a non-steroidal anti-inflammatory drug, dexamethasone, and opioids as rescue analgesics.

    • laparoscopic hysterectomy
    • pain
    • analgesia
    • systematic review
    • evidence-based medicine

    This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, an indication of whether changes were made, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

    https://doi.org/10.1136/rapm-2018-100024

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      Footnotes

      • Presented at Interim data from this analysis were presented at the 36th Annual Meeting of the European Society of Regional Anaesthesia and Pain Therapy (ESRA), Lugano, Switzerland, September 2017.

      • Collaborators H Beloeil, A Hill, H Kehlet, P Lavand’homme, E Pogatzki-Zahn, N Rawal, J Raeder, S Schug, M van de Veldex

      • Contributors JT, PL, and M-PB conducted the literature search and analyzed the retrieved articles with FB. JT, PL, FB, and GPJ wrote the manuscript, which was reviewed and edited by all the other authors, who have also participated in the PROSPECT Working Group meetings using the Delphi method, and in defining the methodology of the PROSPECT group.

      • Funding PROSPECT is supported by an unrestricted grant from the European Society of Regional Anaesthesia and Pain Therapy (ESRA). In the past, PROSPECT had received unrestricted grants from Pfizer (New York, New York, USA) and Grunenthal (Aachen, Germany).

      • Competing interests GPJ has received honoraria from Baxter, Mallinckrodt, Pacira, and Merck Pharmaceuticals. FB has received honoraria from Pfizer, The Medicines Company, Abbott France, and Nordic Pharma France. Henrik Kehlet has received honoraria from Pfizer and Grunenthal. The Anesthesiology Unit of the University of Western Australia, but not Stephan Schug privately, has received research and travel funding and speaking and consulting honoraria from bioCSL, Eli Lilly, Indivior, iX Biopharma, and Pfizer within the last 2 years. Narinder Rawal has received honoraria from Baxter and Sintetica.

      • Patient consent for publication Not required.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Data sharing statement All data will be available on the website: www.postoppain.org.