A Randomized Trial of Wound Infiltration with Extended-Release versus Short-Acting Bupivacaine Before Laparoscopic or Robotic-Assisted Hysterectomy

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Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252

additional area of suspicion in 11 patients, of which six (54%) of these additional samples were positive for endometriosis. Conclusion: NBI not only made neovascularization of superficial endometriosis more prominent but the depth of field of the laparoscopy was significantly shortened. This forced the operator to make a very close inspection of the peritoneal surfaces. Therefore NBI is a simple and non-invasive tool that can aid in the diagnosis of superficial endometriosis that may otherwise be missed at standard white light laparoscopy. 3

Plenary 1 - Laparoscopic Surgeries (11:00 AM - 12:00 PM) 11:20 AM – GROUP A

A Randomized Trial of Wound Infiltration with Extended-Release versus Short-Acting Bupivacaine Before Laparoscopic or Robotic-Assisted Hysterectomy Barron KI,1 Lamvu G,2 Schmidt RC,1 Fisk M,1 Blanton E,1 Patanwala I,1 Hoover F.1 1Advanced and Minimally Invasive Gynecology, Department of Obstetrics and Gynecology, Florida Hospital Orlando, Orlando, Florida; 2 Gynecologic Surgery, Department of Surgery, Orlando Veteran’s Affairs Medical Center, Orlando, Florida Study Objective: To evaluate if pre-incision infiltration with extendedrelease liposomal bupivacaine provides improved pain relief after laparoscopic or robotic-assisted total hysterectomy compared to 0.25% bupivacaine. Design: Triple-masked randomized controlled trial; patients followed for 14 days postoperatively. Setting: Tertiary-care community hospital. Patients: Patients recruited from July 2015 through January 2016. Sixtyfour patients were randomized and 60 were analyzed for the primary outcome. Intervention: Women scheduled to undergo multiport laparoscopic or robotic-assisted total hysterectomy for benign indications were randomized to receive pre-incision infiltration with either undiluted liposomal bupivacaine or 0.25% bupivacaine. Measurements and Main Results: The primary outcome was pain intensity by a numeric rating scale (0-10) using the Brief Pain Inventory (BPI) via telephone survey on postoperative days (POD) 1, 2, 3 and 14. A sample size of 28 per group (N=56) was planned to detect a 30% change in pain scores. Secondary outcomes were numeric pain scores while inpatient, pain interference as measured by the BPI, total opioid use, and adverse effects. There were no demographic differences between the two groups. For our primary outcome, there were no differences in composite pain scores on POD1, POD2, or POD14 (Table 1). We found lower average, worst, and composite pain scores on POD3 in the liposomal bupivacaine compared to the 0.25% bupivacaine group (average pain score 2.79
2.26 vs. 4.07
1.98, p=.025; worst pain score 3.72
2.81 vs 5.56
2.36, p=.007). There Table 1. Postoperative composite pain scores, numeric rating scale Variable POD1 composite Liposomal bupivacaine 0.25% Bupivacaine POD2 composite Liposomal bupivacaine 0.25% Bupivacaine POD3 composite Liposomal bupivacaine 0.25% Bupivacaine POD14 composite Liposomal bupivacaine 0.25% Bupivacaine

n

Pain score

P value

30 30

5.07
2.29 5.63
2.63

.377

29 30

3.74
2.24 4.87
2.28

.058

29 30

3.26
2.48 4.83
2.11

.009

28 28

2.00
2.78 2.39
2.81

.470

POD, Postoperative day. Composite, mean of average and worse pain scores. Data are mean
standard deviation.

were no differences in pain scores while inpatient (Figure 1), BPI pain interference scores, opioid use (Table 2), or reported adverse effects. Conclusion: For laparoscopic and robotic-assisted multiport hysterectomy there were decreased post-operative pain scores with pre-incisional liposomal bupivacaine compared to 0.25% bupivacaine on POD3 only, and no difference in opioid use, pain interference scores, or reported adverse effects. These findings indicate limited effectiveness of liposomal bupivacaine for laparoscopic hysterectomy. Table 2. Opioid medication use (acute oral morphine equivalents) Variable

Liposomal bupivacaine

0.25% Bupivacaine

P value

Inpatient opioid use* POD3 total opioid usey POD14 total opioid usez

216 (75-810) 320 (115-766) 360 (115-1086)

266 (54-634) 344 (84-784) 443 (84-1234)

.398 .892 .631

*n=32 in both groups. yn=29 in liposomal bupivacaine and 30 in 0.25% bupivacaine groups. zn=27 in liposomal bupivacaine and 28 in 0.25% bupivacaine groups. Data are median (range).

Fig. 1. Postoperative pain scores during the first 24 hours from surgery, numeric rating scale
standard deviation.

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Plenary 1 - Laparoscopic Surgeries (11:00 AM - 12:00 PM) 11:30 AM – GROUP B

Does Ulipristal Acetate Objectively Affect Surgical Experience at Laparoscopic Myomectomy? Luketic L,1 Shirreff L,1 Kives S,2 Liu G,3 El Sugy R,4 Leyland N,5 Solnik J,1 Murji A.1 1Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada; 2Department of Obstetrics and Gynecology, St. Michael’s Hospital, Toronto, Ontario, Canada; 3 Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; 4Department of Obstetrics and Gynecology, William Osler Health System, Brampton, Ontario, Canada; 5 Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada Study Objective: 1. Develop a grading tool to objectively assess various components of the laparoscopic myomectomy procedure. 2. Determine if pre-treatment with Ulipristal Acetate (UPA) affects surgical experience at laparoscopic myomectomy. Design: Retrospective review of laparoscopic myomectomy videos. Setting: Multiple fully-affiliated academic hospitals. Patients: Patients that had a laparoscopic or robotic myomectomy over a three-year period (2012-2015) for which a video of the myomectomy was made were included. Intervention: Two gynecologists independently reviewed laparoscopic/ robotic myomectomy surgical videos. Reviewers were blinded to whether or not patients had received pre-treatment with UPA. Each procedure was scored using a new 22-point surgical experience grading tool. The tool contained 6 subscales that evaluated: depth of myometrial incision, ease