Post-operative caesarean section pain and analgesia following neuraxial anaesthesia

Introduction: Pain following caesarean section (CS) may hinder recovery and ability to care for the newborn. NICE [1] and PROSPECT [2] suggest analgesia be individualised. Regular paracetamol and NSAID should be co-prescribed. NICE advise adding regular dihydrocodeine where required. PROSPECT advise opioids for breakthrough where other techniques (e.g. regional) are contraindicated. Our protocol is PR diclofenac 100 mg in theatre, regular oral paracetamol 1 g + ibuprofen 400 mg, breakthrough dihydrocodeine 30 mg and oramorph 5 mg. The NHSL pain scale is a 0–4 numeric patientreported score, with >2 and <3 representing high and low scores. A CS audit in 2019–20 demonstrated 95% of patients being satisfied/very satisfied with pain relief, but 42% and 31% reported high pain scores on movement and rest, respectively. Only 28% received PR diclofenac, 85% paracetamol + ibuprofen, and 86% breakthrough dihydrocodeine. This re-audit assessed dynamic pain scores following introduction of regular dihydrocodeine 30 mg. Methods: After hospital clinical audit team approval, a prospective reaudit of postoperative CS pain and analgesia following neuraxial anaesthesiawas performed using a standardised patient questionnaire conducted on postoperative day 1 or 2 in Sep–Oct 2021. Participation was voluntary, occurring contemporaneously with routine postneuraxial anaesthesia follow-up. The NHSL pain scale was used. Elective and emergency patients were included. Cases under general anaesthetic were excluded. Results: The main outcomes are reported in the Table. (Table Presented) Discussion: Following introduction of regular dihydrocodeine, pain scores on movement did not improve. Use of breakthrough analgesia reduced. Time taken to receive breakthrough analgesia increased. The COVID-19 pandemic impacted staff absence rates. Telephone reviews post-discharge were not evaluated for the re-audit, which may skew results, with confounding factors contributing to pain. Future work will include midwife education, review opioid protocol prescribing and introduction of routine regional anaesthetic techniques (e.g. TAP block), followed by re-audit.

Effectiveness of Early Postpartum Rectus Abdominis versus Transversus Abdominis Training in Patients with Diastasis of the Rectus Abdominis Muscles: A Pilot Randomized Controlled Trial

Purpose: To determine feasibility of a randomized controlled trial (RCT) comparing postpartum rectus abdominis training with transversus abdominis training in reducing the inter-recti distance in patients with diastasis of the rectus abdominis muscles (DRAM). Method: A pilot, randomized controlled trial with longitudinal assessment following vaginal delivery at 6 and 12 weeks postpartum was completed. Forty-four women with DRAM (inter-recti distance of >= 30mm as measured by digital calipers) were recruited from a regional public hospital in Australia. The standard treatment group (n = 21) was provided with a 5-second transversus abdominis activation exercise in crook lying. The experimental group (n = 23) was provided with a 1-second rectus abdominis crunch exercise. Dosage was between 1-10 repetitions at baseline and between 1-20 at 6 weeks, twice a day, at least 5 days per week, prescribed depending on individual participant ability. The primary outcome measure was inter-recti distance. Feasibility measures were recruitment rate, loss to follow-up, adverse events, and exercise adherence. Results: The rectus abdominis group achieved greater reduction of the inter-recti distance at 6 weeks (at and below the umbilicus) and 12 weeks (above, below, and at the umbilicus). Recruitment rate was acceptable (45%) and there were no adverse events, but loss to follow-up was high due to COVID-19 impacts and participants did not return exercise adherence diaries. Conclusion: Prescription of rectus abdominis exercise during the early postpartum period following vaginal delivery resulted in a greater reduction of the inter-recti distance at 6 and 12 weeks when compared with transversus abdominis exercise. This pilot trial was impacted by high loss to follow up due to COVID-19 restrictions, but feasibility was otherwise acceptable. The findings of the study will inform future fully powered trials comparing these two exercise types in postpartum women with DRAM.

2021 Owen H Wangensteen Scientific Forum of the American College of Surgeons

The proceedings contain 629 papers. The topics discussed include: barriers to Covid-19 vaccination in underserved minorities: impact of health care access and sociodemographic perspectives;concomitant cholecystectomy during initial bariatric surgery does not increase risk of postoperative complications or bile duct injuries;identifying behavioral facilitators to weight loss after bariatric surgery: are there differences between Medicaid and non-Medicaid patients?;impact of post-discharge phone calls on nonurgent hospital returns;laparoscopic heller myotomy is associated with fewer postoperative complications compared to the thoracoscopic approach: a NSQIP study;population-wide analysis of the effect of bariatric surgery on idiopathic intracranial hypertension in obese patients;reducing operating room inefficiencies via a novel surgical app shortens the duration of laparoscopic Roux-en-y gastric bypass;subtotal gastrectomy vs gastroenterostomy in duodenal obstruction secondary to peptic ulcer disease: results of a retrospective nationwide study;and enhanced recovery after bariatric surgery: further reduction in opioid use with the introduction of dexmedetomidine and transverse abdominis plane block.

Prevalence and Potential Risk Factors for Occupational Low Back Pain Among Male Military Pilots: A Study Based on Questionnaire and Physical Function Assessment.

Objectives: Low back pain (LBP) has negative implications for the military's combat effectiveness. This study was conducted to determine the prevalence and risk factors of LBP among pilots through a questionnaire and physical function assessments. Methods: Data on the demographic and occupational characteristics, health habits, physical activity, and musculoskeletal injuries of 217 male pilots (114 fighter, 48 helicopter, and 55 transport pilots) were collected using a self-reported questionnaire and physical function assessments. Results: LBP prevalence was 37.8% in the total cohort and 36.0, 45.8, and 34.5% among fighter, helicopter, and transport pilots, respectively. Multivariate regression analysis revealed that the risk factors significantly associated with LBP were neck pain [odds ratio (OR): 3.559, 95% confidence interval (CI): 1.827-6.934], transversus abdominis activation (OR: 0.346, 95% CI: 0.172-0.698), and hip external rotator strength (OR: 0.001, 95% CI: 0.000-0.563) in the total cohort; neck pain (OR: 3.586, 95% CI: 1.365-9.418), transversus abdominis activation (OR: 0.268, 95% CI: 0.094-0.765), hip external rotator strength (OR: 0.000, 95% CI: 0.000-0.949), and weekly flying hours (OR: 3.889, 95% CI: 1.490-10.149) in fighter pilots; irregular strength training (OR: 0.036, 95% CI: 0.003-0.507) and hip external rotator strength (OR: 0.000, 95% CI: 0.000-0.042) in helicopter pilots; and neck pain (OR: 6.417, 95% CI: 1.424-28.909) in transport pilots. Conclusions: High volume flight schedules and weak core muscle functions have significant negative effects on pilots' back health. LBP is commonly associated with high weekly flying hours, worsening neck pain, transversus abdominis insufficient activation, and reduced hip extensor/rotator strength. Risk factors vary among pilots of different aircraft. Thus, specific core muscle training would be especially important for military pilots.

Effects of transversus abdominis plane block on discharge timing after minimally invasive hysterectomy: A retrospective cohort study

Objectives: The primary aim of this study was to compare time to discharge for gynecologic oncology patients who received a postoperative transversus abdominis plane (TAP) block following minimally invasive hysterectomy and those who did not. Methods: We performed an Institutional Review Board-approved, retrospective, single institution study of all gynecologic oncology patients who underwent robotic-assisted total laparoscopic hysterectomy from January 2019 to May 2020. We compared a cohort of patients who received an immediate postoperative TAP block to a cohort of patients who did not. Primary outcomes included time to discharge and date of discharge. Secondary outcomes included postoperative pain scores, opioid use in morphine milligram equivalents (MME), postoperative complications, urgent care/emergency visits and readmissions. Linear regression models were performed to adjust for covariates. Statistical analysis was performed using R Version 3.6.3. Results: Of the 171 patients who underwent minimally invasive hysterectomy by the gynecologic oncology service during the study period, 73 (42.7%) received a postoperative TAP block and 98 (57.3%) did not. The two cohorts had similar demographics and characteristics. Patients who received a TAP block had a shorter time to discharge (1454 min vs 1634 min, P = 0.001), without increasing time spent in the operating room. Patients who received a TAP block were more likely to discharge on postoperative day 1 (POD1) compared to patients who did not (81% vs 65%, P = 0.01). Patients who received a TAP block had less opioid use in the recovery room (10 MME vs 25 MME, P = 0.002), however, no difference was seen in opioid use after discharge from the recovery room (16 MME vs 23 MME, P = 0.25). Highest recovery room pain score was lower in the TAP block group (4 vs 7, P = 0.002), however, pain scores were similar on POD1 (5 vs 5, P = 0.86). No differences were seen in postoperative complications, urgent care/emergency visits, or readmissions. Linear regression adjusted for potential confounders showed a significant decrease in median time to discharge of 26.9% in the TAP block cohort (ratio of median 0.731, 95% CI 0.594 to 0.899). Conclusions: Utilization of a postoperative TAP block shortened time to discharge after minimally invasive hysterectomy in our gynecologic oncology patients. Addition of this perioperative intervention may help mitigate hospital resources, which is especially advantageous during the COVID-19 pandemic when resources are limited.

Enhanced-view totally extraperitoneal (eTEP) approach for the treatment of abdominal wall hernias: mid-term results.

INTRODUCTION: Multiple minimally invasive techniques have been described for ventral hernia repair. The recently described enhanced view totally extraperitoneal (eTEP) ventral hernia repair seems an appealing option since it allows to address midline and lateral hernias, placing the mesh in the retromuscular position without the use of traumatic fixation. AIM: To report on the mid-term result of a series of patients with ventral hernias repaired by the eTEP approach. METHODS: A retrospective analysis of our case series between June 2017 and December 2019. Demographic and clinical data were gathered. Hernia characteristics, surgical details, hernia recurrences, and complications are reported. RESULTS: 66 patients were included in the study. Median follow-up was 22 months (interquartile range 12-26). 60% of patients were male. Mean age, BMI, % of Type-2 diabetes and % of smoking were 59 ± 12 years, 30 kg/m2, 24% and 23%, respectively. Mean hernia defect size was 5.5 ± 2.9 cm. Forty-three eTEP Rives-stoppa and 23 eTEP-Transversus abdominis release (14 unilateral, 9 bilateral) were performed. 22 inguinal hernias and 15 lateral defects were simultaneously repaired. We report 1 recurrence (1.5%) and 10 surgical site occurrences (15%; 6 seromas, 2 hematomas and 2 surgical site infections). Four patients required reinterventions (6%). CONCLUSION: eTEP is a promising approach to treat midline hernias and allows the simultaneous treatment of lateral and inguinal defects, keeping the mesh in the retromuscular position. However, comparative studies must be performed to know its real benefit in laparoscopic ventral hernia repair.