Intra-Operative

Expand all

PROSPECT Recommendations

  • A recommendation of anaesthetic choice based on postoperative analgesic effect cannot be made for abdominal hysterectomy, because there is no evidence for the comparative benefits of different anaesthetic techniques in reducing postoperative pain. Moreover, anaesthetic choice should be based on factors other than the management of postoperative pain, including individual patient risk factors and local practice (Grade D)
  • General anaesthesia or single shot spinal anaesthesia with or without sedation is recommended for routine use in abdominal hysterectomy, but the continuous epidural catheter technique is not recommended for routine use, based on the relative risks and benefits of these techniques in this patient population (grade D)
  • Continuous epidural with or without a light general anaesthetic or combined epidural-spinal anaesthesia is recommended over general anaesthesia alone in high-risk patients, e.g. those at risk of organ dysfunction and some patients undergoing extensive surgery for malignancy. In these high-risk patients, the benefits of neuraxial anaesthesia (e.g. reduction in inhalation anaesthetics and opioid use as well as reduced paralytic ileus and improved pulmonary function) outweigh the risks. In these pa

Clinical Practice

  • The continuous epidural technique produces a less profound block than spinal anaesthesia and takes a longer time to perform as well as conveying a higher risk of rare complications such as epidural haematoma

Transferable Evidence from Other Procedures

  • Inhaled anaesthesia was similar to combined nitrous oxide/propofol anaesthesia for postoperative pain scores, supplementary analgesic consumption and time to recovery from anaesthetic in patients undergoing laparoscopic hysterectomy Nelskyla et al 1997 Click here for more information
  • Epidural and spinal anaesthesia are not significantly different for: the need for postoperative pain relief, anaesthetic failure rate, need for additional intra-operative analgesia, need for conversion to general anaesthesia, maternal satisfaction and the need for neonatal intervention as determined in a systematic review of caesarean section Ng et al 2004
  • Combined spinal-epidural anaesthesia has a higher postoperative analgesic efficacy than epidural anaesthesia alone Lew et al 2004 Click here for more information

Abdominal Hysterectomy-Specific Evidence - Study information

  • Combined general-epidural anaesthetic was superior to general anaesthetic alone for reducing postoperative pain scores in two studies, and one study showed greater postoperative benefits with an additional epidural bolus at closure Jorgensen et al 2001 Click here for more information
  • Combined general-epidural anaesthetic plus epidural at closure was superior to general anaesthetic alone and to combined general-epidural anaesthesia alone for reducing supplementary analgesic consumption Jorgensen et al 2001 Click here for more information
  • General plus epidural anaesthesia was superior to spinal plus epidural anaesthesia for reducing postoperative pain scores at rest (p=0.026) and on movement (p<0.001; n=40) within 0–72 h Callesen et al 1999
  • General plus epidural anaesthesia was superior to spinal plus epidural anaesthesia for reducing postoperative supplementary opioid consumption from PACU-72 h (p<0.05; n=40) Callesen et al 1999
  • Spinal plus epidural was associated with a significantly lower incidence of nausea (p<0.0001) and vomiting (p<0.002) than general plus epidural anaesthesia within 0–72 h (n=40) Callesen et al 1999

PROSPECT Recommendations

  • Intra-operative strong opioids are recommended for the treatment of postoperative pain in hysterectomy based on their analgesic efficacy in the early postoperative period (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

PROSPECT Recommendations

  • Intra-operative adenosine is not recommended based on limited evidence of its analgesic efficacy (grade A) and a lack of clinical experience with this agent (grade D)
  • Intra-operative NMDA-receptor antagonists are not recommended based on inconsistent evidence of their analgesic efficacy and effect on reducing PONV (grade A), as well as a lack of clinical understanding of these agents
  • Intra-operative benzodiazepines are not recommended based on limited evidence for their analgesic efficacy (grade A)
  • Intra-operative tryptophan is not recommended based on a lack of analgesic efficacy (grade A)

Clinical Practice

  • Adenosine and tryptophan are not used routinely because of a lack of clinical experience with these agents
  • NMDA-receptor antagonists are not used routinely because of the current lack of understanding of their optimum dose, rate and route of administration as well as their cost-benefit relationship; in addition, they are associated with adverse side-effects, e.g. ketamine is known for its toxicity and for causing dysphoria

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence

PROSPECT Recommendations

  • Intra-operative administration of single dose epidural analgesia, in addition to anaesthesia, is not recommended for the treatment of postoperative pain based on evidence of a limited duration of effect in reducing postoperative pain and a lack of benefit in reducing supplementary analgesic consumption (grade A)
  • A recommendation cannot be made for epidural anaesthesia based on its postoperative analgesic effects because there is no evidence for its relative postoperative analgesic benefits compared with other methods of anaesthesia. Moreover, the choice of anaesthetic regimen should be based on anaesthetic requirement and the relative risks and benefits of the anaesthetic related to the patient and the surgical procedure (grade D) (See Anaesthetic techniques section)

Clinical Practice

  • Epidural analgesia is associated with a relatively high degree of patient monitoring and rare major complications
  • Epidural clonidine is not used routinely because it is associated with an increased risk of hypotension, sedation and bradycardia

Transferable Evidence from Other Procedures

  • Epidural and spinal anaesthesia were not significantly different for: the need for postoperative pain relief, anaesthetic failure rate, need for additional intra-operative analgesia, need for conversion to general anaesthesia, and maternal satisfaction in a systematic review of caesarean section Ng et al 2004

Abdominal Hysterectomy-Specific Evidence - Study information

  • Intra-operative epidural morphine, with or without postoperative epidural boluses, provided a significant benefit over epidural saline placebo in reducing postoperative pain scores at 6 h, but the results at 12 and 24 h were not significant Jorgensen et al 1982 Click here for more information
  • Intra-operative epidural morphine extended the time to first analgesic request in one study (p<0.05; n=14) Jorgensen et al 1982
  • Intra-operative epidural clonidine provided a significant benefit over placebo in reducing postoperative pain scores on cough and mobilisation at 4–12 h (p<0.05 for all times; n=22) Mogensen et al 1992a
  • Intra-operative epidural ketamine conferred a significant benefit over placebo for reducing the supplementary analgesic consumption within 0–4 (p<0.05), 0–8, 0–12 and 0–24 h (p<0.001), but at 0–1 and 0–2 h the results were not significant (n=40) Abdel-Ghaffar et al 1998
  • Intra-operative ketamine conferred a significant benefit over placebo for extending the time to first analgesic request (p<0.01; n=40) Abdel-Ghaffar et al 1998
  • Combined general-epidural anaesthetic plus epidural at closure was superior to general anaesthetic alone and to combined general-epidural anaesthetic alone for reducing postoperative pain Jorgensen et al 2001 Click here for more information
  • Combined general-epidural anaesthetic plus epidural at closure was superior to general anaesthetic alone and to combined general-epidural anaesthetic alone for reducing supplementary analgesic consumption Jorgensen et al 2001 Click here for more information
  • Intra-operative epidural morphine plus postoperative IV morphine was associated with a similar incidence of PONV as placebo plus IV morphine in one study (n=14) Jorgensen et al 1982
  • Intra-operative epidural morphine provided no significant benefit over placebo for reducing supplementary analgesic consumption within 0–24 h Jorgensen et al 1982 Click here for more information
  • Intra-operative epidural bupivacaine plus fentanyl conferred no significant benefit over placebo for reducing postoperative pain scores within 0–48 h in one study (n=50) Richards et al 1998
  • Intra-operative epidural bupivacaine plus fentanyl conferred no significant benefit over placebo for reducing supplementary analgesic consumption within 0–48 h in one study (n=50) Richards et al 1998
  • Intra-operative epidural clonidine provided no significant benefit over placebo in reducing postoperative pain scores at rest (n=22; n=40) Mogensen et al 1992a
  • Intra-operative epidural clonidine was associated with a significant decrease in arterial blood pressure compared with placebo in two studies (p<0.05 for both; n=40; n=22) Mogensen et al 1992a
  • Intra-operative epidural ketamine conferred no significant benefit over placebo for reducing postoperative pain scores within 0–24 h (n=40) Abdel-Ghaffar et al 1998
  • Intra-operative epidural neostigmine conferred no significant benefit for reducing postoperative pain scores or supplementary analgesic consumption within 0–24 h (n=45) Nakayama et al 2001a

PROSPECT Recommendations

  • Intra-operative wound infiltration is recommended based on specific evidence that it reduces pain following hysterectomy at 8 h (grade A). Although this outcome did not reach clinical significance, this method of analgesia is convenient and has a favourable safety profile Gallagher et al 2001 Click here for more information

Clinical Practice

  • Intra-operative wound infiltration is a well-established method of analgesia with a favourable safety profile

Transferable Evidence from Other Procedures

  • Intra-operative wound infiltration with local anaesthetic was superior to pre-incisional administration, which in turn was superior to placebo for reducing pain scores (mean VAS = 51, 59 and 76 mm, respectively) and the proportion of patients requiring postoperative analgesics (28, 50 and 76%, respectively), in patients undergoing laparoscopic cholecystectomy (n=70) Sarac et al 1996
  • Intra-operative wound infiltration plus intraperitoneal administration of bupivacaine reduced postoperative overall pain for 0–2 h and incisional pain for 0–3 h (p<0.01, for both comparisons), as well as 3-h morphine consumption (p<0.05) and nausea (p<0.05) in patients undergoing laparoscopic cholecystectomy (n=58) Bisgaard et al 1999

Abdominal Hysterectomy-Specific Evidence - Study information

  • There is mixed evidence for a benefit of intra-operative wound infiltration for reducing postoperative pain scores, and the benefits are of marginal clinical significance Cobby et al 1997 Click here for more information
  • Intra-operative wound infiltration provides no significant benefit over placebo for reducing supplementary analgesic consumption Cobby et al 1997 Click here for more information
  • Wound infiltration with ketorolac provided no significant benefit over placebo for reducing postoperative pain scores or supplementary analgesic consumption in one study (n=20) Richman et al 1994
  • Wound infiltration with local anaesthetic provided no significant benefit over placebo for extending the time to first analgesic request in one study (n=41) Hannibal et al 1996
  • Wound infiltration with local anaesthetic was not significantly different from placebo for the incidence of PONV in the three studies reporting this parameter (all groups received postoperative strong opioids) Klein et al 2000

PROSPECT Recommendations

  • Intraperitoneal analgesia is not recommended based on its lack of benefit in reducing pain scores and supplementary analgesic consumption following abdominal hysterectomy (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Intraperitoneal analgesia is an effective method for controlling postoperative pain in gynaecological laparoscopy Narchi 1995
  • Intraperitoneal wound infiltration with local anaesthetic produced a clinically significant decrease in VAS score of 13 mm on a 100-mm scale at 1–4 h in patients undergoing laparoscopic cholecystectomy, from a meta-analysis of 13 studies (p<0.05) Møiniche et al 2000
  • Intraperitoneal plus wound infiltration with bupivacaine reduced postoperative overall pain for 0–2 h and incisional pain for 0–3 h (p<0.01, for both comparisons), as well as 3-h morphine consumption (p<0.05) and nausea (p<0.05) in patients undergoing laparoscopic cholecystectomy (n=58) Bisgaard et al 1999

Abdominal Hysterectomy-Specific Evidence - Study information

PROSPECT Recommendations

  • The type of surgical technique for hysterectomy should be based on factors other than the management of postoperative pain, such as the technical feasibility of the operation, the indication for hysterectomy and operative risk-factors of the patient (grade D)
  • If the surgical requirements (based on technical feasibility, patient indication for hysterectomy and risk factors) allow, LAVH or VH is recommended over open hysterectomy because it is associated with significantly lower postoperative pain, reduced supplementary analgesic consumption and a shorter recovery time compared with abdominal hysterectomy (grade A)

Clinical Practice

  • Abdominal rather than transvaginal hysterectomy is indicated in patients who have never been pregnant, who suffer from cancer of the uterus or patients having a uterus size that precludes the transvaginal approach

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

  • LAVH provided a significant benefit over abdominal hysterectomy for reducing postoperative pain scores over the first week following surgery, providing a reduction in 100-mm VAS scores of 16 mm at 24 h, 24 mm at 48 h and 18 mm at 1 week Hwang et al 2002 Click here for more information
  • LAVH was superior to abdominal hysterectomy for reducing total supplementary analgesic consumption Falcone et al 1999 Click here for more information
  • There is some evidence that LAVH may be associated with a lower incidence of nausea at 34 h, in one study (p<0.05; n=40) Ellstrom et al 1998
  • LAVH was associated with a significantly shorter hospital stay/convalescence time than abdominal hysterectomy Howard et al 1993
  • LAVH and total vaginal hysterectomy were similar for postoperative pain scores (n=60) Hwang et al 2002
  • LAVH was associated with a lower total number of complications (e.g. febrile morbidity, infections and major organ or vessel injury) than total vaginal hysterectomy (p<0.05; n=60) Hwang et al 2002
  • Vaginal hysterectomy was superior to abdominal hysterectomy for reducing postoperative pain scores at 24 h (p<0.001; n=60) Hwang et al 2002
  • Vaginal hysterectomy was associated with a lower total number of complications than abdominal hysterectomy (p<0.05; n=60) Hwang et al 2002
  • Vaginal hysterectomy was associated with a shorter hospital stay and faster return to work than abdominal hysterectomy (p<0.05; n=60) Hwang et al 2002
  • One study reported no significant difference between vaginal and laparoscopic hysterectomy for the complication rate (n=473) Garry et al 2004
  • Vaginal hysterectomy and laparoscopic hysterectomy produced no significant difference in postoperative pain scores over 24 h in one study (n=473) Garry et al 2004
  • LAVH was associated with significantly longer operating times than abdominal hysterectomy Ellstrom et al 1998
  • LAVH was associated with longer operative times and greater blood loss than total vaginal hysterectomy (p=0.01 for both comparisons; n=60) Hwang et al 2002
  • One study reported a significantly longer operative time for laparoscopic compared with vaginal hysterectomy (p<0.05; n=45) Richardson et al 1995

PROSPECT Recommendations

  • Active patient warming is recommended in high-risk patients because there is evidence that it reduces intra-operative bleeding (grade A) and improves outcome in high-risk patients (grade D); however, it has no analgesic benefit (grade A)
  • Leaving the peritoneum open is not recommended over the conventional technique of peritoneal closure because there is evidence that it has no significant analgesic benefit (grade A)
  • Routine use of drains is not recommended, despite some evidence for an analgesic benefit in laparoscopic hysterectomy, because there is a lack of specific evidence, and a risk of infection and patient dissatisfaction (grade D)
  • Wet dressings are not recommended over conventional dressings because there is not yet sufficient evidence to support their benefit in reducing postoperative pain (grade A)
  • It is recommended that the choice of surgical incision for hysterectomy is based on surgical requirements (dependent on the technical feasibility of the operation, the indication for hysterectomy and operative risk-factors of the patient) rather than postoperative pain outcome. If allowed by the surgical requirements, a transverse incision is recommended over a vertical incision because it is associated with lower postoperative pain and less pulmonary dysfunction, while it is has a similar morbi
  • Diathermy is recommended over the scalpel for hysterectomy incisions based on lower postoperative pain and opioid use as well as greater speed of incision and less blood loss, as shown in patients undergoing elective midline laparotomy (grade B)

Clinical Practice

  • A transverse incision is the preferred method for hysterectomy for safety and cosmetic reasons. However, a vertical incision may be required where large fibroids need to be removed or where the upper abdomen must be explored. Pulmonary complications are also less likely with transverse incisions
  • Wound drains are invasive and can increase the risk of infection and, in addition, their extraction is associated with significant patient anxiety

Transferable Evidence from Other Procedures

  • Drains were superior to no drains for reducing postoperative shoulder-tip pain at 24 h (p=0.01) and 48 h (p=0.018) (non-significant at 3 h), and for reducing abdominal pain at 48 h (p=0.007) (non-significant at 3 and 24 h); but the results were not significant for back pain at any time, in LAVH Shen et al 2003 Click here for more information
  • Drains were superior to no drains for reducing postoperative paracetamol consumption, in LAVH (p<0.001; n=164) Shen et al 2003
  • The Pfannenstiel incision decreased the operating time and hospital stay without affecting morbidity and mortality compared with the vertical incision - as shown in two retrospective studies of surgery for uterine cancer, which did not assess postoperative pain (n=332; n=113) Horowitz et al 2003
  • Laparotomy incisions using diathermy were significantly faster (p<0.04) and were associated with significantly less blood loss (p=0.002), lower 48-h postoperative pain scores (p<0.05) and lower 5-day morphine consumption compared with scalpel incisions (p<0.04), in patients undergoing elective midline laparotomy (n=100) Kearns et al 2001
  • Active patient warming and prevention of intra-operative hypothermia decreases the risk of wound infection, hospitalisation time and the incidence of morbid cardiac events in high-risk patients, in a review Leslie et al 2003

Abdominal Hysterectomy-Specific Evidence - Study information

  • Operative time was significantly shorter for the unsutured compared with the conventional sutured peritoneum (n=66; n=144) Behtash et al 2001
  • Active intra-operative warming was associated with significantly less intra-operative bleeding than placebo (p<0.05; n=41) Persson et al 2001
  • Wet film dressing showed a marginally significant benefit over conventional dressing at day 3 for reducing postoperative pain scores (p=0.046; n=30), but this result was non-significant at all other times Briggs 1996
  • Unsutured and sutured peritoneum techniques were not significantly different for postoperative pain scores at rest or for supplementary analgesic consumption, for up to 5 days following the operation (n=66; n=144) Behtash et al 2001
  • There was no significant benefit of active intra-operative warming over placebo for reducing postoperative pain scores or supplementary analgesic consumption for the 48-h study period (n=41) Persson et al 2001
  • Wet film dressing was not significantly different from conventional dressing for supplementary analgesic consumption (n=30) Briggs 1996

PROSPECT Recommendations

  • Intra-operative music played to the patient during general anaesthesia is recommended based on its effects in reducing postoperative pain scores, supplementary analgesic consumption and rehabilitation time (grade A)
  • Therapeutic suggestions and electroacupuncture are not recommended based on their lack of analgesic efficacy (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

  • Intra-operative music was superior to placebo for reducing postoperative pain scores on the first postoperative day (p<0.001) (non-significant on the second and third day) (n=58) Nilsson et al 2001
  • Intra-operative music was superior to placebo for reducing supplementary analgesic consumption on the day of surgery (p=0.028), and there was a trend towards significance on the first postoperative day (p=0.057; n=89) Nilsson et al 2001
  • Intra-operative music was superior to placebo for time to sitting (p=0.008; n=89) Nilsson et al 2001
  • Of six studies, all showed no significant benefit of intra-operative therapeutic suggestions over placebo for reducing postoperative pain scores for up to 5 days Block et al 1991
  • Five out of six studies showed no significant benefit of intra-operative therapeutic suggestions over placebo for reducing supplementary analgesic consumption McLintock et al 1990 Click here for more information
  • Electroacupuncture provided no significant benefit over placebo for reducing postoperative pain scores at rest and on coughing, or for reducing supplementary analgesic consumption (n=50) Christensen et al 1993