The analgesic efficacy of ultrasound-guided transversus abdominis plane block with mid-axillary approach after gynecologic laparoscopic surgery: A randomized controlled trial.

BACKGROUND AND AIMS: The transversus abdominis plane (TAP) block is widely used in clinical practice as a part of the multimodal analgesic regimen after abdominal surgery. The analgesic efficacy of ultrasound (US)-guided TAP block with the mid-axillary approach was investigated in patients undergoing laparoscopic gynecologic surgery in a randomized controlled clinical trial. MATERIALS AND METHODS: Adult patients (n = 119) undergoing laparoscopic gynecologic surgery were randomized to undergo either TAP block with ropivacaine (Group A, n = 60) or that with saline (Group B, n = 59), in a blinded manner. Following general anesthesia, TAP block was performed bilaterally by infusion of either 20-mL 0.375% ropivacaine/one side in Group A or 20-mL saline/one side in Group B, under US guidance with a mid-axillary approach. Patient-controlled analgesia (PCA) was performed postoperatively with tramadol. The analgesic effect was postoperatively evaluated using a four-grade pain score and the prince Henry pain scale (PHS) at 0, 6, 12, and 24 h. Postoperative tramadol PCA consumption and vomiting/nausea were recorded. Statistical analyses were performed using the Mann-Whitney U-test or Fisher's exact probability test. A P < 0.05 was considered significant. RESULTS: There was no statistically significant difference in background characteristics. The dose of remifentanil was significantly higher in Group B (P = 0.01). The pain score (P = 0.02) and PHS (P = 0.01) were significantly lower in Group A at 0 h. Tramadol PCA consumption in the period of 0-6 h (P = 0.01) and postoperative nausea (P = 0.04) were significantly less in Group A. CONCLUSION: Postoperative pain/nausea and PCA consumption were significantly lower in patients with TAP block in the early postoperative stage. TAP block with a mid-axillary approach holds considerable promise as a part of a balanced postoperative analgesic regimen following laparoscopic gynecologic surgery.

Efficacy of dienogest in thinning the endometrium before hysteroscopic surgery.

STUDY OBJECTIVE: To investigate the efficacy of administration of dienogest to thin the endometrium before hysteroscopic surgery and to evaluate the surgical outcome. DESIGN: Retrospective clinical study (Canadian Task Force classification III). SETTING: Community hospital. PATIENTS: Twenty-six patients who underwent hysteroscopic surgery for treatment of endometrial polyps or submucous myomas <25 mm. INTERVENTIONS: Before hysteroscopic surgery, 13 patients (dienogest group) received 2 mg dienogest orally for 2 weeks, and 13 patients (GnRH group) received a gonadotropin-releasing hormone agonist subcutaneously 1 to 3 times every 4 weeks, and 4 of those received hormone therapy after surgery. Endometrial thickness, serum estradiol and progesterone concentrations, duration of surgery, weight of tissue removed, surgical field visualization, and time to resumption of spontaneous menstruation were recorded. MEASUREMENTS AND MAIN RESULTS: Endometrial thickness decreased from approximately 7.0 mm to 3.9 mm in the dienogest group. Duration of surgery and weight of tissue removed were similar between groups. The surgical field was clearly visualized in 12 patients in each group. Spontaneous menstruation resumed at approximately 22.0 days after hysteroscopic surgery in the dienogest group; in contrast, no resumption of spontaneous menstruation was observed within the first postoperative month in the GnRH group. No patients had perioperative complications, and none exhibited any residual tumor. CONCLUSION: Administration of dienogest for 2 weeks thinned the endometrium and yielded favorable surgical outcomes, similar to those with GnRH agonists. Administration of dienogest may be an effective and convenient treatment before hysteroscopy.

Total laparoscopic hysterectomy in patients with previous abdominal surgery.

PURPOSE: To evaluate the effects of previous abdominal surgery on the feasibility and the safety of total laparoscopic hysterectomy (TLH). METHODS: One hundred seventy-four consecutive patients who underwent TLH in private hospital between February 2008 and December 2009 were retrospectively reviewed. Surgical history, operation time, blood loss, transfusion, conversion to an open surgery, complications and hospital stay were assessed in each patient. The patients were classified into two groups; patients with or without a history of abdominal surgery. RESULTS: Group 1 included patients with a history of abdominal surgery (n = 44) and Group 2 included patients without a history (n = 130). The complication rate was 6.8% in patients with (Group 1) and 5.4% in patients without (Group 2) a history of abdominal surgery, respectively. No bladder, bowel, ureteral, or vascular injuries occurred in either group. Transfusion was required in one patient without a history of abdominal surgery (Group 2; 0.8%). Three patients with (Group 1; 6.8%) and two patients without (Group 2; 1.5%) a history of abdominal surgery were converted to laparotomy. No statistically significant difference was noted between the groups with respect to the complication and conversion rates. CONCLUSIONS: In our study, TLH can be performed successfully in patients with a history of abdominal surgery.

Laparoscopic resection of an epidermal inclusion cyst at the vaginal cuff.

An epidermal inclusion cyst rarely occurs at the vaginal cuff, whereas it sometimes develops at the vulva and the site of episiotomy due to entrapment of the squamous epithelium. We present the case of a 58-year-old woman who developed an epidermal cyst at the vaginal cuff 6 years after laparoscopic hysterectomy. Although we could not make a precise diagnosis at imaging before the operation, the cyst was completely removed at laparoscopic surgery without any complications. To our knowledge, this is the first report of an epidermal inclusion cyst at the vaginal cuff that was successfully treated at laparoscopic surgery. Laparoscopic surgery was useful in magnifying the surgical field and in delicate manipulation of various devices to resect this pelvic floor tumor that required adhesiolysis of surrounding organs.

[Influence of general anesthesia in pregnant patients for gynecologic surgery].

BACKGROUND: Surgery during pregnancy is suspected to have various harmful influences to pregnant patients and fetuses. Although laparoscopic surgery has been recently reported to have some advantages over open surgery in this condition, it often requires general anesthesia. METHODS: The influence of general anesthesia was retrospectively investigated in 12 patients having undergone gynecologic surgery during pregnancy in comparison with 18 with surgery under lumbar and epidural anesthesia. RESULTS: Patients receiving general anesthesia required less pain relief compared with those receiving lumbar and epidural anesthesia. Pregnancy was adequately maintained after surgery in all patients. No abortions or preterm deliveries occurred. There was no significant difference in influence on mother and babies between these two patient groups. CONCLUSIONS: General anesthesia during pregnancy is not necessarily associated with harmful influences on mother and babies compared with lumbar and epidural anesthesia if selected appropriately.

[Effects of rikkunshito on the postoperative nausea and vomiting (PONV) after laparoscopic gynecological surgery].

BACKGROUND: Postoperative nausea and vomiting (PONV) is one of unignorable complications after general anesthesia. The aim of this study was to examine prophylactic effects of TSUMURA rikkunshito (TJ-43), a herbal medicine consisting of eight herbs, on PONV after laparoscopic surgery. METHODS: One hundred and forty-two female patients undergoing gynecological laparoscopic surgery (ASA-PS1-2) were randomly allocated to one of two groups receiving rikkunshito (n = 91) and control (n = 51). The oral administration of 2.5 g of TJ-43 was commenced the night before surgery and was continued for 3 days after surgery. The suppository form containing 1.5 g of TJ-43 was used during surgery. RESULTS: There were no significant differences of the incidence of PONV between the two groups. The patterns of change in the degree of PONV were similar between the two groups, although TJ-43 group showed slightly earlier reduction in symptom scores. The patients with TJ-43 showed earlier postoperative recovery of oral meal intake. CONCLUSIONS: Perioperative administration of TJ-43 showed a possible effectiveness to reduce the severity of PONV and to promote earlier recovery of oral meal intake after gynecological laparoscopic surgery.