Pain With Differing Insufflation Pressures During Robotic Sacrocolpopexy: A Randomized Controlled Trial

Abstract

ABSTRACT Pain after surgery may have different origins, such as incisions, affected viscera, surgical positioning, or peritoneal irritation from insufflation. Shoulder pain after gynecological laparoscopic surgery is a common concern thought to be associated with peritoneal irritation. Decreasing this pain is therefore a target for improvement of analgesic requirements and overall postoperative pain. This study aimed to determine changes in postoperative pain, surgical safety, and analgesic use via decreased insufflation pressures. The study was designed as a single-blinded, randomized clinical trial at a singular medical center within the United States where surgical treatment took place for pelvic organ prolapse via robotic-assisted sacrocolpopexy. Included were women 18 years or older who were able to complete the visual analog scale without assistance and who underwent scheduled robotic-assisted sacrocolpopexy. After inclusion, participants were randomized in a 1:1 ratio to undergo robotic-assisted sacrocolpopexy with peritoneal insufflation pressure at either 12 mm Hg (experimental) or 15 mm Hg (standard). Surgeries were performed by a single board-certified urogynecologist and resident assistant using a standard technique, the DaVinci Xi system, and an 8-mm AirSeal assist port. Surgeons and assisting OR professionals were not blinded to insufflation pressure. On the first postoperative day, all participants were asked to rate pain via a visual analog scale, as well as at 2 weeks postoperatively (with the addition of a PGI-I questionnaire). The 2-week surveys were collected by the principal investigator or primary surgeon (unblinded). A Likert scale of 0 to 10 was used to rate the highest preoperative and postoperative pain in the postanesthesia care unit. At the time of surgery, preoperative analgesia and opioid use were verified with active prescription records. After surgery, data were recorded for operative time, analgesic doses, conversion to laparotomy or increased insufflation pressure, additionally performed procedures, estimated blood loss, and length of stay. Enrollment occurred from April 27, 2021, to May 17, 2022, with final follow-up being completed on June 1, 2022. A total of 80 participants were enrolled, with 41 in the experimental insufflation group, and 39 in the standard insufflation group. Baseline differences did not exist between groups for prior abdominal surgeries, medical comorbidities, leading edge of prolapse, age, or body mass index. Although median preoperative pain was recorded as zero for both groups, the standard insufflation group did report a statistically higher pain level in the postoperative period. Furthermore, women in the experimental/lower insufflation group used statistically fewer morphine milliequivalents immediately after surgery as well as after discharge. There were no apparent operative problems significantly associated with lower insufflation pressures, as operative time, estimated blood loss, and length of stay in the hospital were not significantly different between groups. The analysis found that the use of 12 mm Hg insufflation pressure did lower opioid use and pain levels in comparison with 15 mm Hg in the immediate postoperative period. The use of this method proved both feasible and safe in all cases, without blood loss, operating time changes, or changes in completing cases through minimal invasive mess. These encouraging findings provide a zero-cost, surgeon-driven intervention method for the postoperative period of robotic gynecological surgeries with the potential lower patient pain levels and opioid use.