Preoperative Acetazolamide for Improved Pain Control Following Laparoscopic Hysterectomy
Phase: PHASE4
Conditions: Post Operative Pain, Laparoscopic Hysterectomy, Referred Pain
Sponsor: Prisma Health-Upstate

 
 
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Preoperative Acetazolamide for Improved Pain Control Following Laparoscopic 
Hysterectomy 
Principal Investigator 
Paul B. Miller, MD 
Co-Investigator(s) 
Briana Rice, MD; Erica Robinson, MD; Savannah Micolucci, MD; John Van Deman III, MD 
Study Location(s) 
Prisma Health Greenville Memorial Hospital 
 
 
 

 
 
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TABLE OF CONTENTS 
 
I. 
ABSTRACT 
II. 
INTRODUCTION 
A. 
Background 
B. 
Importance / Justification for Study 
III. 
HYPOTHESIS & OBJECTIVES 
A. 
Hypothesis 
B. 
Objective(s) 
IV. 
DESIGN & METHODS 
A. 
Study Design 
B. 
Setting 
1. Resources Available 
2. Multi-Site Research 
C. 
Proposed Intervention 
1. Treatment 
2. Drug 
3. Device 
D. 
Population 
1. Inclusion Criteria 
2. Exclusion Criteria 
3. Sample size 
4. Local Number of Participants 
5. Study-Wide Number of Participants 
6. Recruitment Methods 
E. 
Specifics of Study Procedures 
1. Study Timelines 
2. Study Endpoints 
3. Outcome Measures/Data 
4. Data Collection Methods and Instruments Used 
5. Data Management 
6. Data and Specimen Banking 
7. Statistical Analysis 
V. 
ETHICAL CONSIDERATIONS 
A. 
Risks and Potential Benefits to Participants 
1. Risks to Participants 
2. Potential Benefits to Participants 
B. 
Participant Confidentiality and Privacy 
1. Participant Confidentiality 
2. Provisions to Protect the Privacy Interests of Participants 
C. 
Vulnerable Populations 
D. 
Consent Process 
E. 
Participant Economic Burden/Compensation & Other Study Details 
1. Economic Burden to Participants 
2. Compensation for Research-Related Injury 
3. Debriefing Participants 
4. Community-Based Participatory Research 
VI. 
BIBLIOGRAPHY 
VII. 
APPENDICES 
 
 

 
 
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I. ABSTRACT 
 
Provide a concise summary (a few sentences) that includes objectives, population, design, and outcome measures: 
This randomized controlled trial is designed to evaluate if a preoperative dose of acetazolamide will reduce pain 
overall and, specifically, right shoulder referred pain following total laparoscopic hysterectomy (TLH). This will be 
measured in patients undergoing TLH using a visual analog scale postoperatively, comparing patients who received 
acetazolamide and patients who received placebo. 
 
 
II. INTRODUCTION 
 
A. BACKGROUND 
Describe the rationale for the study, including the disease or condition being studied, citations, and synthesized earlier 
preclinical and clinical research on the topic of the study: 
Pain control following surgery is integral to surgical success, allowing faster recovery and return to function and 
increasing patient satisfaction. Minimally invasive surgery, such as laparoscopy, is becoming increasingly common as it 
involves smaller incisions and theoretically less discomfort. However, in order to perform laparoscopy, one must 
insufflate the abdomen with gas in order to create space in which to operate. The most commonly used gas today is 
carbon dioxide, as it is highly soluble and reduces the risk of air embolism compared to room air if absorbed. A 
consequence of using carbon dioxide is that it is converted to carbonic acid that can be irritating to the peritoneum 
and specifically the diaphragm, causing referred pain to the right subscapular (shoulder) region. Multiple strategies 
have been undertaken to help reduce this discomfort, one of which is using acetazolamide (a carbonic anhydrase 
inhibitor) to help reduce peritoneal acidification. Multiple studies have demonstrated an improvement in shoulder 
pain following preoperative administration in laparoscopic cholecystectomy, but studies evaluating use in pelvic 
surgery have had mixed results. The goal of this study is to add to this understanding and determine if acetazolamide 
is a useful adjunct to current pain control methods in laparoscopic gynecologic surgery. 
 
B. IMPORTANCE / JUSTIFICATION FOR STUDY 
Describe the research question you intend to answer with findings from this study: 
Does use of acetazolamide preoperatively help reduce pain following total laparoscopic hysterectomy (TLH)? 
Explain why the current research question is pertinent, important, interesting, or novel: 
Reducing pain following surgery shortens hospital stays, reduces postoperative analgesic use, allows for faster return 
to activity, and improves patient satisfaction. Acetazolamide is a cheap and easy intervention which has been studied 
in general surgery literature but has not been specifically evaluated for gynecologic procedures. 
 
 
III. HYPOTHESIS & OBJECTIVES 
 
A. HYPOTHESIS 

 
 
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Describe the hypothesis/hypotheses that your study is intended to demonstrate, and your objectives are based: 
Preoperative acetazolamide will decrease postoperative pain scores on a visual analog scale following laparoscopic 
hysterectomy. 
 
B. OBJECTIVES 
Describe the details of each objective that will lead to the achievement of the study goal including a summary of the 
outcome measures: 
1. Abdominal/pelvic pain scores as determined on a visual analog scale (VAS; see Appendix 1) evaluated at five 
points: preoperatively, when first responsive in the post-anesthesia care unit (PACU), two hours 
postoperatively, four hours postoperatively, and 24 hours postoperatively. 
2. Right shoulder pain as determined on a VAS evaluated at five points preoperatively, when first responsive in 
the post-anesthesia care unit (PACU), two hours postoperatively, four hours postoperatively, and 24 hours 
postoperatively. 
3. Cumulative analgesia use during the first 24 hours postoperatively. 
 
 
IV. DESIGN & METHODS 
 
A. STUDY DESIGN 
Briefly describe the study design (systematic review, randomized controlled trial, other controlled clinical trial, 
observational [cohort, case-control, cross-sectional], or case study): 
This study is a randomized, double-blinded, controlled trial comparing levels of postoperative pain in patients 
undergoing TLH with and without pretreatment with oral acetazolamide. Patients scheduled to undergo TLH for 
benign indications (e.g., pelvic pain, endometriosis, uterine fibroids) will be identified by their surgeon as potential 
study candidates.  On the day of their preoperative appointment, they will have an opportunity to discuss the study 
with their provider and to sign consent forms for participation.  Demographic data will be recorded at that time (see 
Appendix 1).  The study coordinator will alert the Research Pharmacy when a patient is scheduled. The Research 
Pharmacy will randomize the patient and have the study drug available for the research coordinator to pick up at the 
satellite pharmacy on the 2nd floor of Greenville Memorial Hospital on the day of surgery. Subjects will be met in the 
preoperative area by a research study coordinator who will provide the study drug to the participant.  Preoperative 
assessment of pain using a VAS and administration of either study drug or placebo will be performed by the study 
nurse coordinator.  Members of both the anesthesia team and the surgeons will be unaware of the study group.  All 
patients will receive perioperative medications according to our institutional Enhanced Recovery After Surgery (ERAS) 
protocol (Appendix 2).  Surgery will be performed via whatever method is deemed appropriate by the surgeon with 
recording of surgical indication, pre- and intraoperative medications, length of surgery, intraoperative complications 
including transfusion, and blood loss.   
 
Upon first alert response in the PACU, subjects will be asked to provide pain scores for abdominal/pelvic pain and 
right subscapular pain using a VAS.  Pain scoring will then be repeated in the PACU or postoperative holding area at 
hours 2 and 4, with a final pain scoring at home via phone call on postoperative day 1.   Postoperative analgesics used 

 
 
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in the PACU and at home per patient report will be recorded along with length of PACU stay and length of hospital 
stay until discharge. 
 
B. SETTING 
List the locations, with descriptions, of where procedures will be performed: 
Prisma Health Greenville Memorial Hospital, in the OR and the PACU. 
1. Resources Available 
List all research team members including contact details (e-mail addresses and telephone numbers): 
Paul Miller, MD: Paul.Miller@prismahealth.org; 864-455-5890 
Briana Rice, MD: Briana.Rice@prismahealth.org; 864-455-1607 
Erica Robinson, MD: Erica.Robinson@prismahealth.org; 864-455-1607 
Savannah Micolucci, MD: Savannah.Micolucci@prismahealth.org; 864-455-1607 
John Van Deman, MD: John.VanDeman@prismahealth.org; 864-483-5732 
Briefly describe the qualifications (include approximate years of research experience) of the PI and co-investigators as 
well as their specific roles in the study: 
Dr. Miller: Current Vice Chair of Academics and Research for the Prisma Department of OBGYN; Professor, University 
of SC School of Medicine-Greenville; 30 years of research experience; will oversee recruitment, any adverse events, 
IRB submission, funding approval, eventual data analysis and publication. 
Dr. Rice: Current fellow in Minimally Invasive Gynecologic Surgery (MIGS); will assist Dr. Miller with the above and be a 
participating surgeon. 
Dr. Robinson: Current Vice Chair of Operations for the Prisma Department of OBGYN; Associate Professor, University 
of SC School of Medicine-Greenville; MIGS division member; 15 years of research experience; participating surgeon  
Dr. Micolucci: Assistant Professor, University of SC School of Medicine-Greenville; 4 years of research experience; 
participating surgeon 
Dr. Van Deman: Assistant Professor, University of SC School of Medicine-Greenville; MIGS division member; 17 years 
of research experience; participating surgeon 
 
Describe availability/access to needed equipment and resources including access to the population of interest: 
Patients will be recruited from the respective clinics of the participating surgeons noted above. The Greenville 
Memorial Hospital Central Pharmacy will assist with randomization and dispensing of study drug/placebo.   Placebo 
capsules will be purchased from Compounding Solutions Pharmacy (1607 Laurens Road, Suite 110, Greenville, SC 
29607: point of contact: Pam Bramlett, RPH; ph: 864-558-0507).  Funding for study medications and personnel will be 
obtained from intradepartmental research funding sources.   Funding budget will be uploaded into the IRB 
documents. 
2. Multi-Site Research 
If applicable, list sites involved in this study outside of Prisma Health and indicate the primary and satellite site(s): 
N/A 
 
C. PROPOSED INTERVENTION 
1. Treatment 

 
 
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List the experimental treatment of interest and comparative treatment as applicable: 
Patients will be randomized to receive preoperative acetazolamide 500 mg ER capsule or a matching placebo within 
one hour of scheduled incision time. There will be no other deviation from standard of care treatment.  
2. Drugs 
List the primary drug intervention of interest and any additional drugs used: 
Acetazolamide ER 500 mg capsule 
3. Devices 
List the primary device intervention of interest: 
None 
 
D. POPULATION 
Briefly describe the population of interest: 
Patients scheduled to undergo TLH for benign indications (e.g., pelvic pain, endometriosis, uterine fibroids) 
1. Inclusion Criteria 
Describe the inclusion criteria for the population of interest: 
NOTE – inclusion criteria should, at a minimum: identify the disease or condition people must have to participate, 
define the acceptable age range, and delineate all other factors required to be in the study. 
Women (aged 21-65) undergoing TLH for benign indications with or without bilateral salpingoophorectomy, with or 
without cystoscopy, who are not undergoing concurrent reconstructive procedures.  
2. Exclusion Criteria 
Describe the exclusion criteria: 
NOTE – exclusion criteria should focus primarily on the protection of participants, with careful consideration of criteria 
needed to exclude those for whom participation would be unsafe. 
Allergy to acetazolamide or sulfonamides 
Known electrolyte disturbances 
Pregnancy 
Kidney failure or creatinine >1.5 
Diuretic or lithium use 
Chronic obstructive pulmonary disease (COPD) or other lung disease 
Central nervous system disorders 
Liver disease 
Glaucoma 
Preoperative or chronic opioid use 
Diagnosis of fibromyalgia 
Preoperative shoulder pain 
Conversion to laparotomy 
Intraoperative bladder or bowel injury 
Inability to understand or utilize visual analog scale 
3. Sample Size 

 
 
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If applicable, show the power calculation for the estimated sample size: 
Based on previous literature (Pourladian et al., 2016), we conducted several power calculations for various means and 
respective standard deviations for VAS scores at first response, postoperative day 11, and overall average VAS score. 
We expect similar responses at our institution. N per group is presented here for power of 0.8-0.9 and an alpha of 
0.05.  
 
Computed N per Group – Postoperative day 1 
Index Nominal Power Actual Alpha Actual Power N per Group 
1 
0.800 
0.0502 
0.808 
16 
2 
0.825 
0.0502 
0.833 
17 
3 
0.850 
0.0502 
0.856 
18 
4 
0.875 
0.0502 
0.875 
19 
5 
0.900 
0.0501 
0.907 
21 
 
Computed N per Group – Overall VAS Scores 
Index Nominal Power Actual Alpha Actual Power N per Group 
1 
0.800 
0.05 
0.807 
48 
2 
0.825 
0.05 
0.831 
51 
3 
0.850 
0.05 
0.852 
54 
4 
0.875 
0.05 
0.876 
58 
5 
0.900 
0.05 
0.901 
63 
 
Given previous literature, current power calculations, and expectations for response rate (phone call) on 
postoperative day 1, we propose an of n=120 with n=60 in each study arm.  
4. Local Number of Participants 
List the number of expected participants within Prisma Health: 
100 
5. Study-Wide Number of Participants 
For multi-site studies, list the number of expected participants in total (study-wide): 
100 
6. Recruitment Methods 
Describe the recruitment process, including the source of participants: 

 
 
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NOTE – if the screening procedures are done as part of the study, they must be incorporated into this protocol with a 
description of the methods and their risks or discomforts. If participants are screened separately from the protocol, the 
method should be briefly acknowledged. 
Subjects will be recruited from the clinic populations of each of the participating surgeons.  After initial identification, 
their charts will be reviewed for inclusion and exclusion criteria by an assigned study coordinator.  If they meet 
criteria, they will be informed of the study by their surgeon at their preoperative visit and will be asked to sign an 
informed consent document if they choose to participate. 
If applicable, list and describe recruitment materials: 
NOTE – recruitment materials should inform potential participants about the availability and nature of the study. 
NA 
 
E. SPECIFICS OF STUDY PROCEDURES 
Describe all participant research procedures, preferably in chronological order and from the participant’s viewpoint. 
State where procedures will be done and if inpatient admission is required. Identify the required and optional study 
procedures. Identify the risks discomforts, and inconveniences of each procedure and intervention: 
• 
Patient is consented at preoperative appointment 
• 
Patient is randomized per study protocol 
• 
In preoperative area, patient reports a baseline pain score and a right shoulder pain score to the research 
nurse 
• 
Patient receives intervention or placebo in the preoperative area within one hour of proposed start of surgery 
• 
Patient undergoes surgery 
• 
When first awake and responsive in postoperative care, patient reports an abdominal/pelvic pain score and a 
right shoulder pain score 
• 
Pain scores are repeated at two and four hours postoperatively 
• 
Patient is given a copy of a visual analog scale to take home with them from the PACU or short-stay unit  
• 
Patient receives a phone call from a research coordinator at 24 hours postoperatively for report of pain scores 
and analgesics used 
• 
Patient’s chart will be abstracted and analgesic use in the perioperative period will be calculated in morphine 
equivalents 
Describe all standard care procedures related to this study, preferably in chronological order and from the 
participant’s viewpoint: 
Except for administration of study drug or placebo preoperatively, the patient will receive standard of care. 
If applicable, differentiate the procedures or combinations or schedules of the same procedures between study 
cohorts: 
None 
If applicable, describe the plans for the participants’ end of participation, including transfer of care back to their own 
physicians: 
None 

 
 
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1. Study Timelines 
List the duration of individual procedures and cumulative time commitment, including number and timing of visits and 
total duration of participation in the study: 
NOTE – the duration of the study should reflect the disease or condition and intervention being studied. Define the 
frequency of study measurements needed to capture the primary outcome measure. 
All prospective collection of data will be completed by 24 hours after surgery 
2. Study Endpoints 
For clinical trials, list the study endpoints: 
Study endpoints will be a phone call for pain scoring 24 hours postoperatively, breach of study protocol, or voluntary 
withdrawal. 
3. Outcome Measures/Data 
List all outcome measures/data that will be collected including explanations/definitions of measures as necessary: 
• 
Abdominal/pelvic pain and right subscapular pain rated on a VAS at five perioperative points  
• 
Total analgesic use perioperatively 
• 
Demographic data, medications, surgical data, length of stay – per Data Sheet  
4. Data Collection Methods and Instruments Used 
Describe how data will be collected including a copy of the data collection instrument/data collection form: 
Data will be collected from the electronic medical record and from direct patient interview by the surgeon, research 
coordinator, and PACU nurses.  All data will be entered into a secure REDCAP file within the Research Division of the 
Department of OBGYN. Participants will be deidentified and will be given an alpha-numeric identifier.  
 
 
5. Data Management 
Describe the data monitoring procedures to assist in determining trends that affect the integrity of the study or 
participant safety. Include details on who will monitor, what they review, and how frequently data is reviewed. Also 
include any policies and procedures if a problem is identified, and the study needs to be suspended or stopped: 
Investigators will monitor participants for any adverse events during participation to identify any trend that may 
indicate a risk to subjects. If such a risk is identified, the study will be halted until evaluation can be completed.  
Interim analyses will occur after 30 and 50 subjects have been enrolled to assess for any adverse effects. 
6. Data and Specimen Banking 
Describe the storage and management plan of research samples and/or data to assure their integrity and availability 
for analyses to fulfill the objectives of the study: 
NOTE – clearly articulate if samples and data will be retained after the study is complete, whether data and/or 
samples may be shared with others, the purposes for which they may be used, and any restrictions on use. The 
protocol management plan must reflect information in the consent form on the additional use of data and samples. If 
participants are offered options, the participants’ choices as to further use should be outlined. 
Randomization scheme will be maintained and available to unblinded team members by the Research Pharmacy. Data 
will be kept in REDCAP in an encrypted format for 5 years after study completion. 
7. Statistical Analysis 
Describe how the data and samples will be analyzed to achieve all study objectives: 

 
 
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Sociodemographic characteristics will be assessed using Chi-square test or Fishers Exact test where appropriate. 
Data distribution will be assessed for normality using Kolmogorov–Smirnov test. A multivariable linear regression will 
be used to analyze the association between treatment and VAS pain scores over time. This will allow us to account for 
the treatment effect (between-subject factor) and the within-subject effect of VAS overtime. Accounting for the 
within-subject effect is critical because of the subjective nature of pain scores. Significance is defined as p<0.05. 
V. ETHICAL CONSIDERATIONS 
A. RISKS AND POTENTIAL BENEFITS TO PARTICIPANTS 
1. Risks to Participants 
Define the study as “minimal risk” or “more than minimal risk” considering all risks and burdens of participation: 
NOTE – If there are multiple study populations and the overall risk and benefit is different for individual populations, 
then define the risk for each population separately. 
Minor increase over minimal risk as the treatment includes an FDA approved medication 
Describe in detail all risks to participants (consider the physical, social, and psychological implications of the research): 
The study drug is already FDA approved and has a low side effect profile.  The placebo is an inactive  
2. Potential Benefits to Participants 
Describe any benefits to participants: 
NOTE – the classification of benefit should be weighed based on reasonable expectation of benefit for the individual 
participant. The possibility of indirect benefit, such as gaining generalizable knowledge may be sufficient depending on 
the nature and risks of the study. 
Subjects may have improved postoperative pain. 
 
B. PARTICIPANT CONFIDENTIALITY AND PRIVACY 
1. Participant Confidentiality 
Describe the plan to protect participant confidentiality including controls on storage, handling, and sharing of data. 
If applicable, include a schedule for destruction of identifiers associated with the data: 
NOTE – confidentiality is the researcher’s agreement with participants about how their identifiable private information 
(data) will be handled, managed, and disseminated. It protects the participants’ personally identifying data and 
records.  Confidentiality can be maintained by assigning records, data, and samples a code that does not embed 
personal identifiers and keeping the key to the code separately and securely. Further protections may include limiting 
access to identifiable data and the key to the code, and keeping records secured in double-locked storage and on 
secure, protected servers and computers. 
Research staff will be trained in protection of patient confidentially.  Captured data will be maintained on password 
protected electronic files, accessed through password protected computers that are housed behind locked office 
doors. 
2. Provisions to Protect the Privacy Interests of Participants 
Describe the plan to protect participant privacy, including how the investigator(s) will access information from or 
about participants: 
NOTE – privacy refers to a person’s desire to control the access of others to themselves (concerns people). Consider the 
methods used to identify and contact potential participants, the settings in which an individual will be interacting with 

 
 
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an investigator, and the appropriateness of having all personnel present for research activities. Consider the methods 
used to obtain information about participants, the nature of the requested information, and how to access the 
minimum amount of information necessary to complete the study. 
Individual patient data collected as part of this investigation will remain confidential.  Composite results from this 
investigation, however, will be disseminated to the scientific community.  The data sheet will contain the patient’s 
name and medical record number for later chart review.  Actual data collection will only be performed by the 
investigators for their study or their designated research personnel.  Once the data are collected, each patient will be 
assigned an alpha-numeric identifier which will allow entry of de-identified data in a computer database. The original 
data sheets will be stored in a secure location in the Department of Obstetrics and Gynecology. 
 
 
C. VULNERABLE POPULATIONS 
Describe any vulnerable populations required to complete the study objectives as well as the plan to offer extra 
protection of confidentiality and privacy: 
NOTE – for studies enrolling minors, it should also be determined if a “more than minimal risk” study is no more than a 
minor increment over minimal risk. For minors, the risk level of the study, along with consideration of whether there is 
direct individual benefit, determines whether the study fits into a category of approvable research. 
None 
 
D. CONSENT PROCESS 
Describe the procedures to provide informed consent to potential participants: 
NOTE – be sure to include any therapeutic alternatives (may include standard care). It should be acknowledged if the 
drug, device, or intervention under study can be obtained outside of the study, such as through a prescription for off 
label use. Clearly describe risks and potential benefits including confidentiality and privacy risks. Clearly delineate who 
will have access to the participant’s information and under what circumstances data may be shared (i.e., with 
government agencies, sponsors, etc.). 
When obtaining consent, required federal regulations will be incorporated into the consent process. Participants will 
be given information in a language they understand. This study will have both English and Spanish consent versions 
available. Participants will be allowed ample time to review consent form. Any questions will be answered by study 
investigator. Subject will voluntarily sign and date the IRB approved ICF prior to any study activity. The participant 
may withdraw consent at any time. If the participant chooses not to participate in the study, they will receive usual 
care.  
 
 
E. PARTICIPANT ECONOMIC BURDEN/COMPENSATION & OTHER STUDY DETAILS 
1. Economic Burden to Participants 
If applicable, describe any potential economic burdens to participants: 
None 
2. Compensation for Research-Related Injury 
If applicable, provide details on the amount, method, and timing of compensation: 

 
 
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NOTE – if there are more than one study cohort, include descriptions if they will be compensated differently. 
None 
3. Debriefing Participants 
If applicable, describe the procedures to debrief participants including what data and information will be released: 
Patients may request to see a copy of any publication that results from this study. 
4. Community-Based Participatory Research 
If applicable, describe the details on Community-Based Participatory involvement with this study: 
Note – “Community-based Participatory Research (CBPR)” is a collaborative approach to research that equitably 
involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a 
research topic of importance to the community, has the aim of combining knowledge with action and achieving social 
change to improve health outcomes and eliminate health disparities. 
 
 
 
 

 
 
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VI. BIBLIOGRAPHY 
 
Bala I, Bhatia N, Mishra P, Verma GR, Kaman L. Comparison of preoperative oral acetazolamide and intraperitoneal 
normal saline irrigation for reduction of postoperative pain after laparoscopic cholecystectomy. J Laparo Advanced Surg 
Tech 2015;25:285-90 
McGrail K, Chapple AG, Stone G, Sutton EF, Chappell NR. Systematic review and meta-analysis of perioperative 
administration of acetazolamide for management of postoperative pain after laparoscopy.  JSLS 2022;26(3):1-9 
Medairos R, Lankford J, Everett R, Berger G, Weierstahl K, Woehlck H, Jacobsohn K, Johnson S. Impact of acetazolamide 
on perioperative pain control in robotic assisted laparoscopic prostatectomy.   Urology 2023;172:126-30 
Movassaghi R, Peirovifar A, Aghamohammadi D, Mohammadipour Anvari H, Golzari SE, Kourehpaz Z.  Premedication 
with single dose of acetazolamide for the control of referral shoulder pain after laparoscopic cholecystectomy. Anesth 
Pain Med 2015;5(6):e29366 
Pourladian I, Lois AW, Frelich MJ, Woehlck HJ, Weber M, Kastenmeier AS, Gould JC, Goldblatt MI.  Acetazolamide 
reduces postoperative pain following laparoscopic inguinal herniorrhaphy.  Surg Endosc 2016;30:2685-9 
Rahimzadeh P, Hamid Reza Faiz S, Hoseini M, Hamzeh Mousavie S, Imani F, Reza Negahi A. Comparison of 
intraperitoneal bupivacaine, acetazolamide, and placebo on pain relief after laparoscopic cholecystectomy surgery: a 
clinical trial. Med J Islam Repub Iran 2018;32:112 
Singh R, Sen I, Wig J, Minz M, Sharma A, Bala I. An acetazolamide based multimodal analgesic approach versus 
conventional pain management in patients undergoing laparoscopic living donor nephrectomy. Ind J Anaesth 
2009;53(4): 434-42 
Woehlck HJ, Otterson M, Yun H, Connolly LA, Eastwood D, Colpaert K. Acetazolamide reduces referred postoperative 
pain after laparoscopic surgery with carbon dioxide insufflation. Anesthesiology 2003;99:924-8 
 
 
 
 

 
 
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VII. 
APPENDICES 
 
Appendix 1: Visual Analog Pain Scale 
 
 
 
 

 
 
I R B # 2 3 1 0 7 3 6, v er0 5 0 6 2 0 2 5  
 
1 5  
V ersi o n: 1 . 0 
V ersi o n d at e: 0 1 M a y 2 0 2 1  
A p p e n di x 2: E n h a nc e d R ec o v er y Aft er S ur g er y Pr ot oc ol  
 
MI G S t ot al l a p ar osc o pic 
h yst er ect o m y c as es  
P R E -O P  
 Cl e ar  li q ui ds u p u ntil 3 h o urs b ef or e 
s ur g er y 
 Ac et a mi n o p h e n 6 5 0 m g p o   
I N D U C TI O N 
 Mi d az ol a m pr n  
 Pr o p of ol  
 K et a mi n e b ol us 0. 5 m g/k g  
 A V OI D F E N T A N YL  
M AI N T E N A N C E  
 M uscl e r el ax a nt a n d v ol atil e  a n est h etic  
 K et a mi n e i nf usi o n at 4 mc g/ k g/ mi n. O n e 
h o u r pri or t o c as e fi nis h, r e d uc e t o 1 
mc g/k g/ mi n  
 Li d oc ai n e i nf usi o n at 2 m g/ mi n 
 If a d e q u at e a n est h esi a b ut t ac h yc ar dic, 
c o nsi d er b et a bl oc k er 
 If a d e q u ac y of a n est h esi a diffic ult t o 
ass ess, t h e n c o nsi d er BI S m o nit or  
 C R N A a n d a n est h esi ol o gist will c o nf er 
t o g et h er as t o t h e n e e d f or n arc otic.  If 
d e e m e d n ec ess ary, us e l o n g er acti n g 
s uc h as hy dr o m or p h o n e i n l o w est 
p ossi bl e d os e  
 K et or ol ac 3 0 m g I V  at e n d of c as e  
I V F M A N A G E M E N T 
 R ec eiv es a T O T AL of 1 lit er fr o m pr e -o p 
t o i n d ucti o n, t h e n I V F’s g o o n p u m p 
st arti n g wit h b a g # 2 at 3 ml/ k g/ hr f or 
cl os e d c as es 
 If fl ui d b ol us n e e d e d, c o nsi d er c oll oi d 
P A C U  
 A dj ust k et a mi n e i nf usi o n wit hi n 1 -5 
mc g/k g/ mi n t o ac hi e v e l o w est eff ectiv e 
d os e ( d ys p h ori a i ncr e as es at d os es > 4 
mc g/k g/ mi n)  
 Disc o nti n u e li d oc ai n e i nf usi o n i n P A C U  
 I V F’s at 3 ml/ k g/ hr 
 M a y us e I V ac et a mi n o p h e n or 
hy dr o m or p h o n e pr n