title: Non-opioid pain management in benign minimally invasive hysterectomy: A systematic review.
abstract: Less postoperative pain typically is associated with a minimally invasive hysterectomy compared with a laparotomy approach; however, poor pain control can still be an issue. Multiple guidelines exist for managing postoperative pain, yet most are not specialty-specific and are based on procedures that bear little relevance to a minimally invasive hysterectomy.
  
  
  
  The purpose of this study was to determine whether there is enough quality evidence within the benign gynecology literature to make non-opioid pain control recommendations for women who undergo a benign minimally invasive hysterectomy.
  
  
  
  We queried PubMed, ClinicalTrials.gov, and Cochrane databases using MeSH terms: "postoperative pain," "perioperative pain," "postoperative analgesia," "pain management," "pain control," "minimally invasive gynecologic surgery," and "hysterectomy." A manual examination of references from identified studies was also performed. All PubMed published studies that involved minimally invasive hysterectomies through November 9, 2016, were included. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were restricted to benign minimally invasive hysterectomies evaluating non-opioid pharmacologic therapies. Primary outcomes included amount of postoperative analgesics consumed and postoperative pain scores. Two reviewers independently completed an in-depth evaluation of each study for characteristics and results using an established database, according to inclusion/exclusion criteria. A risk assessment was performed, and a quality rating was assigned with the use of the Cochrane Collaboration's Grades of Recommendation, Assessment, Development and Evaluation approach.
  
  
  
  Initially 1155 studies were identified, and 24 studies met all inclusion criteria. Based on limited data of varying quality, intravenous acetaminophen, anticonvulsants and dexamethasone demonstrate opioid-sparing benefits; ketorolac shows mixed results in laparoscopic hysterectomies. Paracervical blocks provide pain-reducing benefits in vaginal hysterectomies.
  
  
  
  Convincing conclusions are difficult to draw because of the heterogeneous and contradictory nature of the literature. There is a clear need for more high-quality research that will evaluate each medication type for posthysterectomy pain control.
authors.affiliation: Department of Graduate Medical Education, Florida Hospital, Orlando, FL; Division of Surgery, Gynecology Section, Orlando Veterans Affairs Medical Center, Orlando, FL; Department of Obstetrics and Gynecology, University of Central Florida, Orlando, FL. Electronic address: Emily.Blanton@gmail.com.
authors.forename: Emily
authors.initials: E
authors.lastname: Blanton
authors.affiliation: Division of Surgery, Gynecology Section, Orlando Veterans Affairs Medical Center, Orlando, FL; Department of Obstetrics and Gynecology, University of Central Florida, Orlando, FL.
authors.forename: Georgine
authors.initials: G
authors.lastname: Lamvu
authors.affiliation: Department of Graduate Medical Education, Florida Hospital, Orlando, FL; Division of Surgery, Gynecology Section, Orlando Veterans Affairs Medical Center, Orlando, FL; Department of Obstetrics and Gynecology, University of Central Florida, Orlando, FL.
authors.forename: Insiyyah
authors.initials: I
authors.lastname: Patanwala
authors.affiliation: Division of Advanced and Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, VA.
authors.forename: Kenneth I
authors.initials: KI
authors.lastname: Barron
authors.affiliation: Department of Obstetrics and Gynecology, Denver Health Medical Center, Denver, CO.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Witzeman
authors.affiliation: Department of Obstetrics and Gynecology, Northshore University Health System, Highland Park, IL.
authors.forename: Frank F
authors.initials: FF
authors.lastname: Tu
authors.affiliation: Department of Obstetrics and Gynecology, University of Michigan Women's Hospital, Ann Arbor, MI.
authors.forename: Sawsan
authors.initials: S
authors.lastname: As-Sanie
mesh_terms: D000082:Acetaminophen / Q000008:administration & dosage; D000700:Analgesics / Q000627:therapeutic use*; D000701:Analgesics, Opioid; D000773:Anesthesia, Obstetrical; D000927:Anticonvulsants / Q000008:administration & dosage; D003907:Dexamethasone / Q000008:administration & dosage; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D020910:Ketorolac / Q000008:administration & dosage; D010535:Laparoscopy; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D059408:Pain Management / Q000379:methods*; D010149:Postoperative Pain / Q000188:drug therapy*; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
chemical_list: D000700:Analgesics; D000701:Analgesics, Opioid; D000927:Anticonvulsants; D000082:Acetaminophen; D003907:Dexamethasone; D020910:Ketorolac
keywords: gynecological surgery; hysterectomy; laparoscopy; minimally invasive; non-opioid; pain management