Effect of Pre-Incision Skin Infiltration on Post-Hysterectomy Pain—A Double-Blind Randomized Controlled Trial

Abstract

In this double-blind placebo-controlled randomized trial, we compared the analgesic effect of preoperative 0.25% bupivacaine (n=21) skin infiltration with normal saline (n=19) in patients undergoing abdominal hysterectomy through a lower midline incision. All patients received postoperative patient-controlled analgesia with morphine and were followed for 72 hours. The main outcome measures were morphine consumption and pain score at rest, and the contribution of different components of pain was also assessed prospectively. No statistically significant differences were found. All except one patient (n=39) could distinguish the different characteristics of somatic and visceral pain. Visceral pain predominated in the first 48 hours. We concluded that local anaesthetic infiltration is not effective in reducing pain after abdominal hysterectomy. Effective postoperative analgesia should aim to eliminate the visceral pain component.

Influence of uterine exteriorization versus in situ repair on post-cesarean maternal pain: a randomized trial

“…They explained this surprising result by the fact that pain at various stages of the puerperium has been attributed to different factors. In one study of pain after abdominal hysterectomy by Leung et al, 5 the authors found that visceral pain dominated during the first 48 h after hysterectomy. The association between peritoneal stretch and uterine exteriorization can also be explained by this finding.…”

“…Finally, this study did not control the technique of removal of the placenta (manual or spontaneous) as it was depended on the preference of the surgeon, although there was a general agreement that the placenta not be removed manually. 5,6 To decrease the need for postoperative analgesics, considering their potential adverse effects, 8,9 especially if the woman is breast-feeding, 9 a surgical technique with less post-cesarean maternal pain is preferable. In conclusion, routine exteriorization of the uterus is associated with higher pain scores in early puerperium and it is recommended to perform in situ repair of the uterus during cesarean delivery.…”

Parietal peritoneal closure and persistent postcesarean pain

“…These visceral postoperative pain scores (epigastric and global abdominal pains) were the highest in our study, while the wound pain scores were the lowest in both groups. Leung et al [17] reported that visceral pain dominated during the first 48 hours after hysterectomy. Another explanation would be a better effect of the postoperative analgesia we used to relieve the somatic pain element.…”

Ropivacaine produces sensory blockade in the lumbar sacral region more frequently than mepivacaine in lower thoracic epidural anesthesia

“…Peripheral sensitization of visceral afferents may occur due to the release of proinflammatory molecules such as bradykinin, tachykinin, and prostaglandins at the site of injury [18]. Leung et al [19] have reported that pre-incision skin infiltration of local anesthetics during hysterectomy did not contribute to postoperative analgesia, because the pain had a visceral or somatic origin. Mihic and Abram [20] reported that the optimal regional anesthesia for hysterectomy was combined spinal and epidural anesthesia, for the reason noted by Leung et al [19].…”

“…Leung et al [19] have reported that pre-incision skin infiltration of local anesthetics during hysterectomy did not contribute to postoperative analgesia, because the pain had a visceral or somatic origin. Mihic and Abram [20] reported that the optimal regional anesthesia for hysterectomy was combined spinal and epidural anesthesia, for the reason noted by Leung et al [19]. These studies suggest that the blockade of visceral pain during and after surgery may contribute to the level of postoperative pain.…”