Hysterectomy, Pneumoperitoneum
Conditions
Brief summary
With the limited evidence that lower pneumoperitoneum pressures improve postoperative pain in laparoscopic or robotic hysterectomy for benign indications, we would like to determine if we can both further validate this idea but also show that it has minimal effect on physician satisfaction performing the surgery.
Detailed description
Minimally invasive hysterectomy, including conventional laparoscopic and robotic-assisted hysterectomy, is a commonly performed gynecologic surgery that universally results in postoperative pain for patients. Opioid medications are helpful to control postoperative pain and are routinely given to women who undergo minimally invasive hysterectomy. However, opioid abuse is on the rise in the United States, and there is increased awareness of misuse leading to abuse, overdose, and chronic opioid use. In addition to narcotic usage, postoperative pain also has negative effects on patient satisfaction and length of stay in the post-anesthesia care unit (PACU) leading to potential hospital admission. There is existing evidence that reducing the pressure used to create the pneumoperitoneum during laparoscopic surgery may affect pain scores that patients endorse in the PACU. Due to improved postoperative pain, patients may have decreased opioid use in the PACU and at home, shorter hospital stay, and improved overall patient satisfaction. If lower pneumoperitoneum pressures during laparoscopic surgery can be shown to reduce postoperative pain, then the ultimate question becomes whether there is ability to adapt this practice of using lower pressures to maintain pneumoperitoneum. It is unclear whether physician satisfaction will be affected. There are several publications investigating the effect of lower pneumoperitoneum pressures on postoperative pain. A systematic review in 2016 included 238 patients (three RCTs), showed pneumoperitoneum pressures of 8mmHg had a statistically significant although minimal decrease in postoperative pain compared to 12mmHg, although lower pressures were associated with worse visualization. The authors concluded that the systematic review was inconclusive and further studies were necessary. A randomized pilot study with 60 patients comparing low pressure (7mmHg) using the AirSeal System versus standard insufflation (15mmHg), showed lower postoperative shoulder pain in the group with lower pressure using the AirSeal system. Two abstracts in the Journal of Minimally Invasive Gynecology present retrospective studies showing decreased postoperative pain with lower pneumoperitoneum pressure. The first abstract is from 2015, included a sample size of 170 patients who underwent benign robotic gynecologic surgery, 85 patients in each arm (12mmHg and 15mmHg). They showed no difference in median recovery time in the PACU and significantly lower median first pain score (5 vs 6, p=.04). The second abstract is from 2018 and included a sample size of 598 patients who underwent benign robotic gynecologic surgery, 99 patients in 15mmHg arm, 100 patients in 12mmHg arm, 99 patients in 10mmHg arm, and 300 patients in 8mmHg arm. They showed lower initial pain scores with each degree of lower pressure (5.9 vs 5.4 vs 4.4 vs 3.8, p=\<.0001) and shorter hospital stays with lower pressures. They showed no difference in operative times or blood loss in the four arms. Similar studies have been done with cholecystectomy patients that have shown improved postoperative shoulder pain with lower pneumoperitoneum pressures. There is also an ongoing clinical trial that is still recruiting patients that is studying this similar comparison using 9mmHg vs 15mmHg with and without the AirSeal system. However, the literature summarized here has never included blinding the intervention of lower pneumoperitoneum pressure to the surgeon to determine awareness of pressure and its effect on visualization and physician satisfaction.
Interventions
OTHERPneumoperitoneum pressure = 15mmHg
Randomized pneumoperitoneum 1
OTHERPneumoperitoneum pressure = 12mm Hg
Randomized pneumoperitoneum 2
OTHERPneumoperitoneum pressure = 10mmHg
Randomized pneumoperitoneum 3
Sponsors
University of Arizona
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
OTHER
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Masking description
Research coordinator will have randomized the patient into one of the 3 arms. The randomized pneumoperitoneum pressure will be set for the surgical procedure and blinded to the surgeon and first assistant, either fellow or resident.
Intervention model description
Three arms including those with pneumoperitoneum pressure of 15mmgHg versus 12mmgHg vs 10 mmHg during laparoscopic or robotic hysterectomy for benign indications.
Eligibility
Sex/Gender
FEMALE
Age
18 Years to 99 Years
Healthy volunteers
Yes
Inclusion criteria
* female patients * greater than or equal to 18 years old * English-speaking * undergoing laparoscopic or robotic total hysterectomy for benign indications by one of the two minimally invasive gynecologic surgeons at Banner University Medical Center - Phoenix
Exclusion criteria
* patients with body max index \>35 * American Society of Anesthesiologists (ASA) score III or IV * preoperative uterine weight estimated to be greater than 500gm (measured by sonography and using the following formula: length x width x anteroposterior diameter x 0.52) * patients on chronic opioids for chronic pain (defined as \> 3 months regular opioid use) * patients who refuse participation in the study * patients who do not provide informed consent
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Physician Satisfaction Part 1 | From completion of surgery to one hour postoperative | Physician satisfaction questionnaire completed immediately postoperative, 3 questions in length and measured with VAS score (0-5) |
| Physician Satisfaction Part 2 | From completion of surgery to one hour postoperative | Included in the physician satisfaction questionnaire is presumed pneumoperitoneum pressure, measured as 10mmHg, 12mmHg, or 15mmHg (circle one - 10mmHg, 12mmHg, 15mmHg) |
| Physician Satisfaction Part 3 | From completion of surgery to one hour postoperative | Included in the physician satisfaction questionnaire are two yes/no questions on effect of pneumoperitoneum on visualization and operative time (circle one - yes, no) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Postoperative Pain | From completion of surgery to 24 hours postoperative | Self reported pain intensity in PACU (VAS 0-10) first reported and maximum pain score, pain score at 6 hours postoperative, and pain score at 24 hours postoperative |
| Postoperative Shoulder Pain | From completion of surgery to 24 hours postoperative | Self reported shoulder pain intensity (VAS 0-10) at 6 hours postoperative and pain score at 24 hours postoperative |
Other
| Measure | Time frame | Description |
|---|---|---|
| Length of hospital stay | From completion of surgery to hospital discharge time up to 7 days | Time in minutes of length of stay in hospital |
| Intraoperative Respiratory Parameters: End tidal CO2 | From start of surgery to end of surgery | End tidal CO2 |
| Narcotic usage | From completion of surgery to 24 hours postoperative | Morphine equivalent units in PACU and at 24 hours postoperative |
| Patient Satisfaction | From completion of surgery to 24 hours postoperative | Patient satisfaction questionnaire completed 24 hours postoperative over the phone, 2 questions in length, VAS score (0-5) on satisfaction with overall postoperative pain and shoulder postoperative pain |
| Intraoperative Respiratory Parameters: Peak inspiratory pressure | From start of surgery to end of surgery | Peak inspiratory pressure |
| Intraoperative Respiratory Parameters: Tidal volume | From start of surgery to end of surgery | Tidal volume |
Countries
United States
Outcome results
None listed