NEW YORK – While some evidence in the surgical literature suggests that intraperitoneal bupivacaine reduces postoperative pain scores and narcotic use, a new randomized controlled trial shows no significant improvement in patients undergoing robot-assisted total laparoscopic hysterectomy.
“Despite evidence of benefit in laparoscopic surgery, there does not appear to be a benefit for using intraperitoneal bupivacaine. We need a larger sample size to study this,” Dr. Allan Klapper said at the annual Minimally Invasive Surgery Week.
Dr. Allan Klapper
The uptake of robot-assisted total laparoscopic hysterectomy increased by 9.5% in the United States, and hospitals with robotic capabilities perform 22.4% of hysterectomies with this technique, according to Dr. Klapper, an ob.gyn. at West Pennsylvania Allegheny Health System in Pittsburgh. Minimally invasive surgery, however, does not completely eliminate postoperative pain, and between one-third and two-thirds of patients report pain following such surgery.
Intraperitoneal bupivacaine (IB) was selected for the study because of positive reports in small studies of patients undergoing laparoscopic cholecystectomy and gynecologic procedures, Dr. Klapper explained. He noted that the positive studies were of poor quality, but other studies – also of poor quality – had negative results.
To investigate the role of IB in reducing postoperative pain and narcotic requirements in patients undergoing robot-assisted total laparoscopic hysterectomy, Dr. Klapper and his colleagues launched a prospective, double-blind, randomized, placebo-controlled trial comparing IB to normal saline in 41 patients managed with a standardized postoperative analgesic regimen.
Baseline characteristics showed no differences between the two groups in surgical indications, body mass index, operating room time, number of previous surgeries, and the percentage of patients undergoing lymph node dissection. Patients were excluded from the analysis if they converted to laparotomy, were allergic to IB, or were currently on treatment for chronic pain.
Complete data on pain response, as assessed by the visual analog scale, was available for 29 of the 41 patients. No significant differences in postoperative pain scores were observed between the two groups at 1, 16, 18, and 24 hours. Further, there was no significant difference in morphine dose between the IB and normal saline groups.
“One finding was the opposite of what I would have expected. Patients who underwent lymph node dissection used significantly less narcotic analgesic [P = .03],” Dr. Klapper told the audience.
Study strengths were the prospective, randomized design, and its being adequately powered to detect a significant difference between the two groups. But the study was conducted at a single institution and did not include data beyond 24 hours. Also, Dr. Klapper said that perhaps results should have been stratified according to indications for surgery.
“There is more and more pressure on us to achieve higher patient satisfaction scores. Soon down the line, patient satisfaction will become a metric for compensation. We need to focus on what we can do to improve patient satisfaction scores and experience,” Dr. Klapper said. “A larger sample of gynecologic oncology patients is needed to further support these conclusions, and we need to fine tune to avoid the problems in this study.”
The meeting was presented by the Society of Laparoendoscopic Surgeons and affiliated societies. Dr. Klapper reported that he is on the speakers bureau for Astellas.