Laparoscopic administration of
bupivacaine
at the uterosacral ligaments
during benign laparoscopic and
robotic hysterectomy:
a randomized controlled trial
DR. ARUNISHA JAISWAL
Journal
American Journal of
Obstetrics &
Gynecology NOVEMBER
2023
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AUTHORS
Frost AS, Kohn JR, Le
Neveu M, et al.
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PLACE OF
STUDY
Division of Minimally Invasive
Gynecological Surgery
&
Department of Gynecology and
Obstetrics
Johns Hopkins University School of
Medicine.
between March 15, 2021, and April 8,
2022.
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Agenda
 Background
 Objective
 Study Design
 Results
 Conclusion
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Background
Postoperative pain continues to be an undermanaged part of the
surgical experience. Multimodal analgesia has been adopted in
response to the opioid epidemic, but opioid prescribing practices
remain high after minimally invasive hysterectomy.Novel adjuvant
opioid-sparing analgesia to optimize acute postoperative pain control
is crucial in preventing chronic pain and minimizing opioid usage.
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Objective
This study aimed to determine the effect of direct laparoscopic uterosacral
bupivacaine administration on opioid usage and postoperative pain in patients
undergoing benign minimally invasive(laparoscopic and robotic) hysterectomy.
STUDY DESIGN
STUDY TYPE
Single-blinded triple arm
randomized controlled
trial
INCLUSION CRITERIA
EXCLUSION CRITERIA
RANDOMIZATION
Patients aged >18 years
undergoing benign
laparoscopic or robotic
hysterectomy.
•non-English-speaking
patients,patients with an allergy
to bupivacaine or actively using
opioid medications,patients
undergoing transversus
abdominis plane block and
patients undergoing
supracervical hysterectomy or
combination cases with other
surgical services.
Patients were randomized in a
1:1:1 fashion to the following uterosacral administration before
colpotomy: 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.
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OUTCOMES
PRIMARY OUTCOME
• 24-hour oral morphine equivalent
usage (postoperative day 0 and
postoperative day 1).
SECONDARY OUTCOMES
• Total oral morphine equivalent usage
in 7 days
• Last day of oral morphine equivalent
usage
• Numeric pain scores from the
universal pain assessment tool
• Return of bowel function.
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Patients reported postoperative pain scores,
total opioid consumption, and return of bowel
function via Qualtrics surveys.
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STATISTICAL ANALYSIS
Patient and surgical characteristics and primary and secondary outcomes were compared
using chi-square analysis and 1-way analysis of variance. Multiple linear regression was used
to identify predictors of opioid use in the first 24 hours after surgery and total opioid use in the
7 days after surgery.
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RESULTS
Of 518 hysterectomies screened, 410 (79%) were eligible, 215 (52%)
agreed to participate, and 180 were ultimately included in the final
analysis after ac-counting for dropout. Most hysterectomies (70%) were
performed laparoscopically, and the remainder were performed
robotically. Most hysterectomies (94%) were outpatient. Patients
randomized to bupivacaine had higher rates of former and current
tobacco use, and patients randomized to the no administration group had
higher rates of previous surgery.
• There was no difference in first 24-hour oral Morphine
equivalent use among the group (P=.10).
• Moreover, there was no difference in numeric pain scores
(although trend toward significance in discharge pain
scores in the bupivacaine group), total 7-day oral
morphine equivalent use, day of last opioid use, or return
of bowel function among the group (P>.05 for all).
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The predictors of increased 24-hour opioid usage among
all patients included only increased postanesthesia care unit
oral morphine equivalent usage.
The predictors of 7 day opioid usage among all patients
included: concurrent tobacco use and mood disorder, history
of previous laparoscopy, estimated blood loss of >200 ml,
and increased oral morphine equivalent usage in the
postanesthesia care unit.
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Conclusion
Laparoscopic uterosacral administration of bupivacaine
at the time of minimal invasive hysterectomy did not
result in decreased opioid usage or change in numeric
pain scores
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Thank you