Vaginal Vault Infiltration With Bupivacaine for Postoperative Pain Control After Total Laparoscopic Hysterectomy: A Randomized Control Trial
Authors: Kumar Roy Kallol , Kalyani Kanikaram Poojitha , Singh Nilanchali , Riwari Vimi , Zangmo Rinchen , Meena Jyoti , Das Anamika , Kashyap Deepika , Minz Archana 
Published: September 2023

A viable alternative to total abdominal hysterectomy is total laparoscopic hysterectomy (TLH), which offers abdominal route advantages for women in need of total hysterectomy for benign diseases. Fewer complications, faster recovery, and less pain are ensured by laparoscopy, although this method is not entirely devoid of pain. Reports from various authors indicate that up to 80% of laparoscopic surgery patients require opioid analgesia, which could increase hospital-stay duration and delay mobilization/recovery. Because of these statistics, opioid analgesic usages ought to be minimized, for the aforementioned reasons and also to prevent additional adverse effects. This study was performed to evaluate efficacy of reducing postoperative pain by infiltration of bupivacaine, a long-acting anesthetic agent, into the vaginal vault after TLH.

This study was a randomized control trial designed as a 2-arm double-blinded study conducted at a North-Indian Apical Center in the Department of Obstetrics and Gynecology. After written informed consent from all patients, computer-generated randomization software placed them in 1 of 2 groups: group 1, the intervention group (received the infiltration of bupivacaine in the vaginal vault following TLH), or group 2 (the control group).

The inclusion criteria were a uterine size of ≤12 weeks' pregnancy and patients requiring TLH with or without bilateral salpingo-oophorectomy for uterine size and benign conditions. Exclusion criteria were contraindication to any medication used by the study, presence of malignancy, history of multiple surgeries, and history of inflammatory disease. Postoperative pain outcome measured in both groups at 1, 3, 6, 12, and 24 hours via a visual analog score was the primary outcome. The secondary outcome was the need for rescue analgesia.

A complete profile of each patient was created, using eligibility criteria, body mass index, and demographic profile, and a complete gynecological and physical examination was performed, along with preoperative investigations for fitness to general anesthesia. Per standard protocol, general anesthesia was administered for all surgeries. After vault closure, a fine-tipped aspiration needle was used to administer 10 mL of bupivacaine, which was infiltrated laparoscopically at 2 different locations, approximately 2–4 cm apart. The control group omitted this step.

In the first 24 hours after operation, pain was treated using 1 g intravenous paracetamol every 6 hours. For the next 5 days, patients were given nonsteroidal anti-inflammatory drugs (diclofenac) 3 times daily for 5 days. Participants scaled their pain using the visual analog scale (VAS) score at the 1, 2, 6, 12, and 24 hours intervals postsurgery. Scores greater than 4 initiated the distribution of tramadol 50 mg intramuscular. Also recorded were the uterine weight, the operative time, complications, and the amount of operative bleeding.

Group 1 patients exhibited VAS scores of less than 4 at 1 hour postsurgery (100%), 3 hours postsurgery (100%), 6 hours postsurgery (97%), 12 hours postsurgery (96.7%), and 24 hours postsurgery (36.7%). The control group VAS scores of less than 4 for the respective times were as follows: 1 hour (93%), 3 hours (86.6%), 6 hours (30%), 12 hours (10%), and 24 hours (3.3%). From these data, it is clear that the infiltration with a local analgesia was effective in reducing postoperative pain.

Overall, a feasible and safe option for postoperative pain relief is vaginal cuff infiltration with local anesthetic. A significant increase in the number of women experiencing minimal postoperative pain for 24 hours after laparoscopic hysterectomy took place due to infiltration of the vaginal vault with 10 mL of 0.25% bupivacaine (with no complications). Furthermore, this method reduces requirements of additional opioid/analgesia usage. The beneficial use of local vault infiltration with bupivacaine after TLH within the first 24 postoperative hours is highlighted by this study.