Multimodal pain management after robotic-assisted total laparoscopic hysterectomy reduces postoperative opioid use and pain scores (1180)

Document Type

Conference Proceeding

Publication Date

9-1-2023

Publication Title

Gynecologic Oncology

Abstract

Objectives: The standard of care for pain management after laparoscopic hysterectomy is non-specific; however, in light of the ongoing opioid epidemic, a transition to non-opioid pain medication regimens is desired by both physicians and patients. This study aimed to create a non-opioid multimodal pain regimen for women undergoing robotic hysterectomy to minimize postoperative opioid usage.

Methods: Forty-nine adult women undergoing robotic-assisted total laparoscopic hysterectomy (RATLH) with a single surgeon at an academic-affiliated community hospital were enrolled in this prospective pilot study with retrospective controls. Full institutional IRB approval was obtained, and this study was registered in National Clinical Trials. In the intervention arm ( n = 10, enrolled from November 2020 through May 2022), women received a multimodal pain medication regimen, including gabapentin, acetaminophen, celecoxib, ketorolac, a paracervical block with 0.5% ropivacaine, 0.5% ropivacaine at all robotic port sites and an opioid, such as oxycodone or hydrocodone, if needed. Control arm participants ( n = 39, underwent surgery from November 2018 through December 2019) received a postoperative regimen of acetaminophen, ketorolac, ibuprofen, and an opioid, such as oxycodone or hydrocodone. Primary outcomes included total opioid pain medications required between 0 and 3 h (h) and 3-24 h postoperatively in morphine milligram equivalents (MME). Secondary outcomes included pain scores (numerical rating score 1–10), length of stay (LOS) (hours), operative time (minutes), estimated blood loss (EBL), and return to the office or emergency department (ED) due to postoperative pain within two weeks of hospital discharge. Results were analyzed using χ 2 tests, t -tests, and Mann-Whitney U tests.

Results: Demographics were similar between the intervention and control groups, with no difference between age, body mass index, and prior surgeries. Intraoperative characteristics were similar when comparing resected uterine weight, concomitant oophorectomy, and the number of robotic ports utilized. A statistically significant decrease in opioid usage was noted in the intervention group. The intervention group used 62% less MMEs 0-3 h postoperatively (2.0 vs 5.3 mean MME, P < 0.05) and 98% less MMEs 3-24 h postoperatively (0.2 vs 12.3 mean MME, P < 0.05). Pain scores were similar between cases and controls at 0-3 h (3.8 vs 5.1, P = 0.26); however, the scores significantly decreased at 3-24 h (1.8 vs 5.4, P < 0.05) postoperatively. Mean LOS was decreased in the intervention group (12.0 h vs 35.8 h, P < 0.05). There was no difference in EBL, operative time, or return office and ED visits for postoperative pain between groups.

Conclusions: A multimodal pain protocol integrated through the perioperative period, using gabapentin, acetaminophen, celecoxib, ketorolac, and local anesthetic injection at port sites and paracervical block, results in decreased opioid use and pain scores throughout the postoperative course.

Volume

176

First Page

S123

Last Page

S124

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