ANALGESIC EFFICACY OF PRESURGICAL UTEROSACRAL LIGAMENTS INFILTRATION WITH 20 ML BUPIVACAINE 0.5% IN VAGINAL HYSTERECTOMY PERFORMED UNDER GENERAL ANESTHESIA: A RANDOMIZED TRIPLE BLIND PLACEBO-CONTROLLED CLINICAL TRIAL.
Mohamed Anwar Elnory1, Mohamed Hamed Abd al Rahman2
Department of Obstetrics and Gynecology1 & Anesthesia and Surgical Intensive care2, Benha Faculty Of Medicine, Benha University, Egypt.
Aim: To evaluate the analgesic efficacy of presurgical uterosacral ligaments (USLs) infiltration with local anesthetic in context of vaginal hysterectomy (VH) performed under general anesthesia. Patients and Methods: This prospective randomized, parallel group, placebo-controlled, triple-blinded, superiority trial, conducted at Benha University hospital and El-Hayat Specialized center, Benha, Egypt, from February 2013 to March 2015. 80 women included in this trial, 28 women had pelvic organ prolapse (POP) undergoing VH while the remaining 52 women were had either dysfunctional uterine bleeding (DUB) or uterine fibroids (UF) undergoing non-descent vaginal hysterectomy (NDVH), each group were randomized separately into presurgical local anesthesia (PLA) (20 ml bupivacaine 0.5%, in USLs) injection group (no= 40, 14 with POP, 26 with DUB or UF) or group in whom 20 ml normal saline injected in same fashion at ratio of 1 :1. The main outcomes measure were average total Nalbuphine consumption and postoperative pain evaluated by visual analogue scale (VAS) score as well as percentage of women with pain free in immediate and early postoperative period while the subsidiary outcomes were incidence of postoperative nausea, vomiting, narcotic side effects as well as hospital stay, time to first ambulation and time to first flatus. Results: The average total Nalbuphine consumption were 46% lower in PLA group compared to placebo (P< 0.0001) and the mean pain VAS at recovery room, 2 hours, 6 hours, was 32.5% (p= 0.003), 30% (P= 0.003), 32.5% (P= 0.0001) lower respectively in PLA group in comparison to placebo. Also the incidence of nausea and vomiting (P = 0.03, P = 0.03) were lower in PLA group and the time to first ambulation and time to first flatus were shorter in PLA group (P< 0.0001, P < 0.0001). Conclusion: Presurgical local anesthetic uterosacral ligaments infiltration with 20ml bupivacaine 0.5% in context with vaginal hysterectomy is effective in reducing postoperative pain scores as well as reduce the average total nalbuphine consumption.