Postoperative Schmerztherapie nach minimalinvasiver Hysterektomie

Angesichts der Entwicklung immer neuer, gewebeschonender Operationsverfahren sollte das Schmerzmanagement prozedurenspezifisch, d. h. in Abhängigkeit von der Invasivität des jeweiligen operativen Eingriffs, durchgeführt werden. In der vorliegenden Arbeit wurde am Beispiel der minimalinvasiven Hysterektomie ein Vergleich zwischen der thorakalen Periduralanalgesie (PDA) und der intravenösen patientengesteuerten Opioidgabe (i.v.-PCA) angestellt.

Im Rahmen dieser prospektiven Beobachtungsstudie wurden Frauen mit einer benignen uterinen Erkrankung, die sich einer vaginalen Hysterektomie (VH) oder einer laparoskopisch-assistierten vaginalen Hysterektomie (LAVH) unterzogen haben, 2 Gruppen mit jeweils 30 Patientinnen zugeordnet (PDA- vs. i.v.-PCA-Gruppe).

Im Unterschied zur i.v.-PCA-Gruppe hatten die Patientinnen der PDA-Gruppe in der frühen postoperativen Phase weniger Schmerzen, PONV, Muskelzittern, Müdigkeitsgefühl und einen niedrigeren Schmerzmittelbedarf (p < 0,01). Die Aufenthaltsdauer im Aufwachraum war ebenfalls reduziert. Die Patientenbefragung zur Lebensqualität ergab 6 Wochen nach der Operation für beide Gruppen im Vergleich zum präoperativen Ausgangswert signifikante Verbesserungen hinsichtlich des allgemeinen Gesundheitszustands und im Hinblick auf die Gefühlslage (p < 0,01). Dieser Effekt war in der PDA-Gruppe ausgeprägter als in der i.v.-PCA-Gruppe (p < 0,05).

Bei minimalinvasiven Verfahren zur Entfernung der Gebärmutter hat die PDA Vorteile gegenüber der i.v.-PCA. Insbesondere die Effektivität der Analgesie, der verminderte Analgetikabedarf und die reduzierte PONV-Rate tragen zum höheren Patientenkomfort bei. Dem stehen jedoch bei einigen Patienten Nachteile, wie Blasenfunktionsstörungen und Einschränkungen der Mobilität, gegenüber.

In view of the development of innovative and non-traumatic surgical techniques, postoperative pain management should be carried out depending on the invasiveness of the intervention. In the present study two analgesic strategies were compared in patients undergoing minimally invasive hysterectomy: epidural analgesia (EDA) and intravenous patient-controlled analgesia (iv-PCA).

For this prospective case controlled study 60 women with benign uterine diseases undergoing vaginal hysterectomy (VH) or laparoscopically assisted vaginal hysterectomy (LAVH) were enrolled. Patients were divided for analysis into two groups (n = 30 each) according to the postoperative analgesic strategy (EDA group versus iv-PCA group). A matched-pair analysis was applied (matching criteria: risk assessment, surgeon and age of patient) to minimize the differences between both groups. Patients were evaluated with respect to the extent of pain determined by a numeric rating scale (NRS 0–10 scale), analgesic consumption, rate of postoperative nausea and vomiting (PONV), mobilization from bed, oral intake of nutrition, complications, duration of stay in the recovery room as well as hospital stay and health-related quality of life (SF-36 Health Survey; collected before and 6 weeks after surgery).

Laparoscopically assisted removal of the uterus was carried out in 22 women and by vaginal hysterectomy in 38 women. No significant differences between the study groups were seen in the duration of surgery (iv-PCA 58 ± 25 min versus EDA 60 ± 26 min). Demographic data of both groups as well as intraoperative hemodynamic and respiratory parameters were comparable to a great extent. Compared to the iv-PCA group, women in the EDA group showed lower NRS values (p < 0.01): recovery room admission 4.7 ± 2.5 iv-PCA vs. 0.9 ± 1.3 EDA, recovery room discharge 3.8 ± 1.8 iv-PCA vs. 1.0 ± 1.2 EDA, day of surgery at 8 p.m. 5.0 ± 2.1 iv-PCA vs. 1.8 ± 2.3 EDA and first postoperative day at 8 a.m. 3.5 ± 1.7 iv-PCA vs. 1.9 ± 2.2 EDA. In addition, less PONV (iv-PCA 9/30 vs. EDA 1/30, p < 0.01), less shivering (iv-PCA 8/30 vs. EDA 2/30, p < 0.05), reduced fatigue (iv-PCA 26/30 vs. EDA 9/30, p < 0.05) and a lower consumption of analgesics were found. Average postoperative requirement for piritramide in the iv-PCA group was 7 mg (range 0–24 mg) on the day of surgery and 5 mg (0–39 mg) on the first postoperative day. In the EDA group no opiate medication was given postoperatively (p < 0.01). Duration of stay in the recovery room was shorter in the EDA group (71 ± 32 min vs. 50 ± 13 min, p < 0.05). Hospital stay was 5 days on average in both groups. There were no surgical complications or epidural catheter-related complications. Because of urinary retention catheterization of the bladder had to be made in 3 patients of the iv-PCA group and 13 patients of the EDA group (p < 0.05). Furthermore, the possibility to take a shower postoperatively was restricted in the EDA group because the epidural catheter was in place and thereby hygiene concerns. Regarding the early oral nutritional intake as well as postoperative mobilization, no significant differences between groups were found. In comparison with the preoperative status, the results regarding health-related quality of life were significantly better for both groups after a follow-up of 6 weeks (p < 0.01); however, this effect was especially pronounced in the EDA group (p < 0.05).

To reduce the number of patients suffering from postoperative pain a procedure-specific pain management should be developed. The results of this study have shown that even in minimally invasive surgery, such as vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy there are some advantages for epidural analgesia compared to intravenous patient-controlled analgesia. In particular reduced pain intensity, lower need for analgesics and reduced occurrence of PONV can lead to excellent patient comfort, fast recovery as well as positive effects on health-related quality of life. However, there are also some disadvantages such as an increased rate of urinary retention and restriction of mobility.