The following is a summary of “Laparoscopic administration of bupivacaine at the uterosacral ligaments during benign laparoscopic and robotic hysterectomy: a randomized controlled trial,” published in the NOVEMBER 2023 issue of Obstetrics and Gynecology by Frost, et al.

Postoperative pain management remains challenging, contributing to the opioid epidemic despite the adoption of multimodal analgesia. Minimally invasive hysterectomy patients often experience high opioid prescribing rates. For a study, researchers sought to evaluate the impact of direct laparoscopic uterosacral bupivacaine administration on opioid usage and postoperative pain in patients undergoing benign minimally invasive hysterectomy. The primary objective was to assess the effect of uterosacral bupivacaine administration on 24-hour oral morphine equivalent usage. Secondary objectives included evaluating total opioid usage in 7 days, the last day of oral morphine equivalent usage, numeric pain scores, and the return of bowel function.

It was a single-blinded, triple-arm, randomized controlled trial conducted at an academic medical center from March 15, 2021, to April 8, 2022. The study focused on patients aged >18 years undergoing benign laparoscopic or robotic hysterectomy. Exclusion criteria comprised Non-English-speaking patients, individuals allergic to bupivacaine or actively using opioid medications, those experiencing transversus abdominis plane block, and patients with supracervical hysterectomy or combination cases with other surgical services. Participants were randomized in a 1:1:1 ratio to receive uterosacral administration before colpotomy, with options of no administration, 20 mL of normal saline, or 20 mL of 0.25% bupivacaine. All patients received incisional infiltration with 10 mL of 0.25% bupivacaine. The primary outcome measured was the 24-hour oral morphine equivalent usage (postoperative day 0 and postoperative day 1). Secondary outcomes included total oral morphine equivalent usage in 7 days, the last day of oral morphine equivalent usage, numeric pain scores using the universal pain assessment tool, and the return of bowel function. Patients provided feedback on postoperative pain scores, total opioid consumption, and return of bowel function through Qualtrics surveys. Comparative analyses of patient and surgical characteristics, primary and secondary outcomes, were conducted using chi-square analysis and 1-way analysis of variance. Multiple linear regression was employed to identify predictors of opioid use in the first 24 hours post-surgery and total opioid use in the 7 days following surgery. 

Out of 518 hysterectomies initially screened, 410 (79%) met the eligibility criteria, with 215 (52%) agreeing to participate. After accounting for dropout, the final analysis included 180 participants. Most hysterectomies (70%) were conducted laparoscopically, and the remaining procedures were performed robotically. Additionally, most (94%) of the hysterectomies were outpatient procedures. Patients randomized to receive bupivacaine demonstrated higher rates of former and current tobacco use, while those in the no-administration group had higher rates of previous surgery. No significant difference was observed in the first 24-hour oral morphine equivalent use among the groups (P = 0.10). Furthermore, there were no notable differences in numeric pain scores, though a trend toward significance was observed in discharge pain scores in the bupivacaine group. Additionally, there were no significant differences in total 7-day oral morphine equivalent use, day of the last opioid use, or return of bowel function among the groups (P > 0.05 for all). Predictors of increased 24-hour opioid usage included only elevated postanesthesia care unit oral morphine equivalent usage. Predictors of 7-day opioid usage encompassed concurrent tobacco use and mood disorder, a history of previous laparoscopy, estimated blood loss of >200 mL, and increased oral morphine equivalent usage in the postanesthesia care unit.

In conclusion, the laparoscopic uterosacral administration of bupivacaine during minimally invasive hysterectomy did not lead to reduced opioid usage or alterations in numeric pain scores.

Source: ajog.org/article/S0002-9378(23)00519-7/fulltext