Summary of key results from studies evaluating systemic analgesics, analgesics adjuncts, regional anesthesia, and surgical procedures in patients undergoing LH
| Study | Study design/adequate baseline analgesia | Pain scores | Cumulative opioid doses |
| Baseline analgesia (systemic non-opioids) | |||
| Jokela et al 15 | Acetaminophen 1 g/ondansetron every 6 hours (n=40), acetaminophen/placebo (n=40) and placebo/placebo (n=40). | NS | Rescue opioid oxycodone lower in acetaminophen group (0.34±0.15 vs 0.43±0.18 mg/kg). |
| Kim et al 16 | Ketorolac intramuscularly + bupivacaine infiltration (n=21), ketorolac intramuscularly/placebo (n=20), bupivacaine/placebo (n=21), placebo/placebo (n=21). | Lower in the ketorolac bupivacaine group by 1–1.7 NRS points. | Lower in ketorolac bupivacaine group vs placebo. |
| Kim et al 17 | Intravenous PCA remifentanil (n=20), intravenous PCA remifentanil + ketorolac (2 doses, n=19 and n=20), intravenous PCA fentanyl (n=20). | NS | Lower in patients with ketorolac. |
| Moon et al 18 | Fentanyl PCA with nefopam 2 or 4 mg (n=28 and 26) per PCA bolus or fentanyl only (n=27). | NS | Lower in both nefopam groups. |
| Analgesic adjuncts | |||
| Jokela et al 19 | 3 intravenous doses of dexamethasone 15 mg, 10 mg, and 5 mg, 30 patients in each group. Baseline analgesia: acetaminophen and ibuprofen from POD 1. | NS | Lower in dexamethasone 10 mg and 15 mg doses. |
| Thangaswamy et al 20 | Intravenous 4 mg (n=18) and 8 mg (n=19) dexamethasone vs placebo (n=18). Baseline analgesia: acetaminophen and ibuprofen after discharge to ward. | NS | Lower for the 8 mg dexamethasone dose vs placebo. |
| Nam et al 21 | Dexamethasone 10 mg + ondansetron (n=25) vs ondansetron (n=25). Baseline analgesia: not reported. | NS | NS |
| Jokela et al 22 | 2 doses of pregabalin (300 mg, n=31; 600 mg, n=30) vs diazepam (n=30). Baseline analgesia: acetaminophen and ibuprofen from POD 1. | NS | Oxycodone rescue lower for the 600 mg pregabalin dose (0.09±0.07 mg/kg) vs diazepam (0.15±0.13 mg/kg). |
| Asgari et al 23 | 3 doses of pregabalin (75, 150, or 300 mg, n=24 each). Baseline analgesia: diclofenac or pethidine on request. | Lower in the 150 and 300 mg groups by between 1.5 and 3 NRS points. | No patient in placebo or 300 mg group received rescue opioids. |
| Kim et al 24 | Bolus dexmedetomidine at end of surgery: placebo, 0.5, 0.75, or 1 μg/kg (n=30 each). Baseline analgesia: Not reported. | Less likely to require rescue analgesic (0.75 and 1 μg/kg groups). | |
| Jung et al 25 | Continuous intravenous infusion of dexmedetomidine (n=25) vs remifentanil (n=25). Baseline analgesia: ketorolac. | NS | |
| Choi et al 26 | Brief intravenous infusion of dexmedetomidine (n=30) vs remifentanil (n=25) vs fentanyl (n=30). Baseline analgesia: ketorolac. | NS | |
| Regional anesthesia | |||
| Hong and Lim33 | Epidural analgesia started before incision (n=25, pre-emptive) vs epidural started after surgery (n=25). Baseline analgesia: no. | Lower in pre-emptive epidural group by 2–3 NRS points between 3 and 12 hours postoperatively. | Lower in pre-emptive epidural group. |
| De Oliveira et al 34 | Preincisional 20 mL infiltration TAP block with ropivacaine (0.5%, n=22; and 0.25%, n=21) vs saline (n=23). Baseline analgesia: acetaminophen, ketorolac, ibuprofen. | Lower in ropivacaine groups by 1–3 NRS points on the first POD. | Lower in ropivacaine 5 mg/mL group. |
| Kane SM, 201235 | Postoperative 20 mL infiltration TAP block with 0.5% ropivacaine (n=28) vs no block (n=29). Baseline analgesia: ketorolac single shot at end of surgery. | NS | NS |
| Calle et al 36 | Postoperative 40 mL infiltration TAP block with 1.5 mg/kg body weight bupivacaine (n=100) vs placebo block (n=97). Baseline analgesia: acetaminophen, ketorolac. | Lower at discharge in TAP group (less than 1 NRS point). | NS |
| El Hachem et al 37 | Postoperative 30 mL ultrasound-guided or laparoscopically guided TAP block using 0.25% mg/mL bupivacaine vs trocar infiltration (n=88, each patient as own control). Baseline analgesia: acetaminophen, ketorolac. | NS | NS |
| Torup et al 38 | Preincisional 40 mL ultrasound-guided TAP block using ropivacaine 0.5% (n=34) vs placebo (n=31). Baseline analgesia: acetaminophen, ketorolac. | NS | NS |
| Hutchins et al 39 | Preincisional 30 mL bupivacaine 0.25% subcostal TAP block (n=30) vs 30 mL 1.3% liposomal bupivacaine (n=28). Baseline analgesia: acetaminophen, ibuprofen. | Worst pain score lower by 2.5 NRS points during the first 24 hours and 2 NRS points during 24–48 hours in liposomal group. | Lower during the first 24 hours and until 48 hours in the liposomal group. |
| Ghisi et al 40 | Preincisional 40 mL levobupivacaine 0.375% (n=22) vs no block (n=22), combined with systemic analgesia. Baseline analgesia: opioid only. | NS | NS |
| Guardabassi et al 41 | Postoperative opioid PCA plus TAP block (n=20) vs opioid PCA (n=20). | NS | NS |
| Intraperitoneal local anesthetics | |||
| Arden et al 42 | Intraperitoneal bupivacaine infiltration (n=67) vs placebo (n=73). Baseline analgesia: ketorolac, acetaminophen. | NS | NS |
| Andrews et al 43 | Continuous intraperitoneal bupivacaine infusion (n=30) vs placebo (n=30). Baseline analgesia: non-standardized mix of NSAID, acetaminophen, opioids. | NS | NS |
| Port site infiltration | |||
| Kim et al 16 | See above. | Lower in the ketorolac bupivacaine group by 1–1.7 NRS points. | Lower in ketorolac bupivacaine group vs placebo. |
| El Hachem et al 37 | See above. | NS | NS |
| Barron et al 44 | Bupivacaine 0.25% vs liposomal bupivacaine (n=30 each). No standardized multimodal baseline medication. | Worst pain improved in liposomal group on POD 2 and 3 by 1.5–2 NRS points. | NS |
| Anesthetic techniques | |||
| Nelskyla et al 45 | Maintenance with isoflurane (n=30) vs propofol (n=30). Baseline analgesia: ketoprofen. | NS | NS |
| Pokkinen et al 46 | Maintenance with sevoflurane (n=74) vs propofol (n=74). Baseline analgesia: acetaminophen. | NS | NS |
| Kim et al 47 | Single bolus propofol (0.5 or 1 mg/kg) or placebo (n=33, 34, and 40). Baseline analgesia: ketorolac in PCA. | NS | NS |
| Surgical techniques | |||
| Muzii et al 48 | LAVH (n=40) vs MLH (n=41). Baseline analgesia: not standardized. | Lower in LAVH group by 1.5–2 NRS points on POD 1 and 2. | |
| Song et al 49 | TLH (n=38) vs LAVH (n=38). Baseline analgesia: not standardized. | Lower in TLH by 1 NRS point 18 hours after surgery. | NS |
| Eggemann et al 50 | Vaginal hysterectomy vs LAVH, with or without peritoneal closure (n=47–50 each). | Lower in vaginal hysterectomy by less than 1 NRS point. | NS |
| Chen et al 51 | Single-port LAVH (n=50) vs the conventional multiport LAVH (n=52). Baseline analgesia: intramuscular pain medicine on request. | Lower in the single-port group by 1–1.5 NRS points at 24 and 48 hours. | Lower in the single-port group. |
| Li et al 52 | Single-port LAVH (n=52) vs conventional LAVH (n=56). Baseline analgesia: not reported. | NS | |
| Jung et al 53 | Single-port LAVH (n=30) vs 4-port LAVH (n=34). Baseline analgesia: tamiflumate, intramuscular ketorolac or meperidine on request. | NS | NS |
| Chung et al 54 | Single-port (n=30) vs conventional laparoscopy (n=30). Baseline analgesia: PCA and tramadol. | NS | NS but higher incidence of rescue analgesics in the single-port group. |
| Kim et al 55 | Single-port (n=122) vs conventional laparoscopy (n=121). Baseline analgesia: not reported. | NS | NS |
| Song et al 56 | Single-port (n=20) vs conventional laparoscopy (n=21). Baseline analgesia: ketorolac in PCA, zaltoprofen orally. | NS | NS |
| Fanfani et al 57 | Single-port hysterectomy (n=34) vs miniport laparoscopy (n=34). Baseline analgesia: intravenous acetaminophen on demand. | Lower in miniport group by 1–1.5 NRS points until 8 hours postoperatively. | Opioids not reported but rescue analgesics not different. |
| Paraiso et al 58 | Conventional (n=27) vs robotic-assisted (n=26) laparoscopy. Baseline analgesia: not reported. | NS | NS |
| Sarlos et al 59 | Robotic vs conventional laparoscopic hysterectomy, (n=95). Baseline analgesia: not reported. | NS | NS |
| Tchartchian et al 60 | Laparoscopic-assisted combined (n=14) vs LAV hysterectomy (n=12). Baseline analgesia: detailed scheme including metamizole, opioid PCA. | NS | NS |
| Ghezzi et al 61 | MLH (n=38) vs LH (n=38). Baseline analgesia: ketorolac, acetaminophen. | NS | NS |
| Acton et al 62 | Laparoscopy using 5 mm (n=36) or 10 mm (n=40) laparoscope. Baseline analgesia: acetaminophen, celecoxib. | Less pain by approximately 1 NRS point in the 5 mm group. | |
| Shen et al 63 | Drain (n=80) vs no drain (n=84). Baseline analgesia: not reported. | Lower for shoulder tip pain. | Lower in the drain group. |
| Bogani et al 64 | Low-pressure (n=20) vs standard-pressure (n=22) laparoscopy. Baseline analgesia: acetaminophen, ketorolac on demand. | Abdominal pain similar, shoulder tip pain lower in low-pressure group. | Rescue analgesics NS. |
| Madsen et al 65 | Laparoscopy with deep neuromuscular blockade and low pressure (n=49) or standard pressure (n=50). Baseline: acetaminophen, etodolac. | Abdominal pain similar, incidence of shoulder tip pain lower in low-pressure group. | NS |
| Herrmann and De Wilde66 | Laparoscopy using humidified and heated CO2 (n=48) or controls (n=49). Baseline analgesia: metamizole. | NS | Higher in control group |
| Radosa et al 67 | Active CO2 elimination (n=98), CO2 elimination plus trocar site infiltration (n=95), or control (n=96). Baseline analgesia: metamizole. | Higher in the control group by 0.5–1.7 NRS points at 3, 24, and 48 hours. | Higher piritramide requirement in the control group during the first 24 hours. |
| Roy et al 68 | TLH (n=30) vs LAVH (n=30), vs non-descent vaginal hysterectomy (n=30). Baseline analgesia: not reported. | NS | |
| Fagotti et al 69 | Thunderbeat electrosurgery or conventional cautery (n=25 patient per group). Baseline analgesia: acetaminophen. | Lower pain scores by 1–1.5 NRS points mm in the Thunderbeat group. | More patients requiring rescue analgesics in the conventional group. |
| Rothmund et al 70 | Standard bipolar (n=80) vs EnSeal cautery (n=80). Baseline analgesia: not reported. | NS |
Empty fields denote variable not reported.
CO2, carbon dioxide; LAVH, laparoscopic-assisted vaginal hysterectomy; LH, laparoscopic hysterectomy; MLH, minilaparoscopic hysterectomy; NRS, Numerical Rating Scale; NS, no significant difference between groups; NSAID, non-steroidal anti-inflammatory drug; PCA, patient-controlled analgesia; POD, postoperative day; TAP, transversus abdominis plane; TLH, total laparoscopic hysterectomy.