Risk factors of different types of acute pain after laparoscope-assisted vaginal hysterectomy

Purpose: Previous study has shown that acute pain after laparoscope-assisted vaginal hysterectomy (LAVH), which consists of several pain components, like somatic pain, visceral pain, shoulder pain, and low back pain (LBP). Potential risk factors of postoperative pain remain unclear. This study aimed to determine risk factors for different types of acute postoperative pain and provide guidance for personalized analgesic medication programs.

Patients and methods: This was a prospective, observational cohort study, in which 287 patients undergoing LAVH between January, 2017 and September, 2018 at the First Affiliated Hospital of Wenzhou Medical University, China were included. Univariate and multivariable logistic regression analyses were used to evaluate risk factors for the different types of acute pain after LAVH.

Results: In the total cohort, visceral pain and LBP were the most common complaints of patients, followed by somatic pain and shoulder pain. Multivariable analysis revealed that postoperative nausea and vomiting, BMI and main indication for surgery were associated with acute postoperative visceral pain. Preoperative chronic pain, BMI, preoperative anxiety and the number of trocars were associated with acute postoperative LBP, while occupation, pelvic adhesions, and history of abdominal surgery were risk factors for acute postoperative somatic pain.

Conclusion: Our study highlights that acute postoperative visceral pain and LBP are main components of pain after LAVH, and different types of acute pain after LAVH are correlated with preoperative, intraoperative and postoperative factors. Acute postoperative pain has unique risk factors according to the component type.

Risk factors; Visceral pain; Low back pain; Somatic pain; Laparoscope-assisted vaginal hysterectomy

[1] McLean SA, Ulirsch JC, Slade GD, Soward AC, Swor RA, Peak DA, et al. Incidence and predictors of neck and widespread pain after motor vehicle collision among us litigants and nonlitigants. Pain. 2014; 155: 309-321.

[2] Nielsen CS, Stubhaug A, Price DD, Vassend O, Czajkowski N, Harris JR. Individual differences in pain sensitivity: genetic and environmental contributions. Pain. 2008; 136: 21-29.

[3] Coghill R, Eisenach J. Individual differences in pain sensitivity: implications for treatment decisions. Anesthesiology. 2003; 98: 1312-1314.

[4] Wu M, Huang K, Long C, Tsai E, Tang C. Trends in various types of surgery for hysterectomy and distribution by patient age, surgeon age, and hospital accreditation: 10-year population-based study in Taiwan. Journal of Minimally Invasive Gynecology. 2010; 17: 612-619.

[5] Allam IS, Makled AK, Gomaa IA, El Bishry GM, Bayoumy HA, Ali DF. Total laparoscopic hysterectomy, vaginal hysterectomy and total abdominal hysterectomy using electrosurgical bipolar vessel sealing technique: a randomized controlled trial. Archives of Gynecology and Obstetrics. 2015; 291: 1341-1345.

[6] Ekstein P, Szold A, Sagie B, Werbin N, Klausner JM, Weinbroum AA. Laparoscopic surgery may be associated with severe pain and high analgesia requirements in the immediate postoperative period. Annals of Surgery. 2006; 243: 41-46.

[7] Eggemann H, Ignatov A, Frauchiger-Heuer H, Amse T, Costa SD. Laparoscopic-assisted vaginal hysterectomy versus vaginal hysterectomy for benign uterine diseases: a prospective, randomized, multicenter, double-blind trial (LAVA). Archives of Gynecology and Obstetrics. 2018; 297: 479-485.

[8] Pinto PR, McIntyre T, Nogueira-Silva C, Almeida A, Araújo-Soares V. Risk factors for persistent postsurgical pain in women undergoing hysterectomy due to benign causes: a prospective predictive study. Journal of Pain. 2012; 13: 1045-1057.

[9] Choi JB, Kang K, Song MK, Seok S, Kim YH, Kim JE. Pain charac-teristics after total laparoscopic hysterectomy. International Journal of Medical Sciences. 2016; 13: 562-568.

[10] Ruscheweyh R, Viehoff A, Tio J, Pogatzki-Zahn EM. Psychophysical and psychological predictors of acute pain after breast surgery differ in patients with and without pre-existing chronic pain. Pain. 2017; 158: 1030-1038.

[11] Schreiber KL, Zinboonyahgoon N, Xu X, Spivey T, King T, Dominici L, et al. Preoperative psychosocial and psychophysical phenotypes as predictors of acute pain outcomes after breast surgery. Journal of Pain. 2019; 20: 540-556.

[12] Pinto PR, Vieira A, Pereira D, Almeida A. Predictors of acute postsurgical pain after inguinal hernioplasty. Journal of Pain. 2017; 18: 947-955.

[13] Pinto PR, McIntyre T, Ferrero R, Almeida A, Araújo-Soares V. Predictors of acute postsurgical pain and anxiety following primary total hip and knee arthroplasty. Journal of Pain. 2013; 14: 502-515.

[14] Montes A, Roca G, Sabate S, Lao JI, Navarro A, Cantillo J, et al. Genetic and clinical factors associated with chronic postsurgical pain after hernia repair, hysterectomy, and thoracotomy: a two-year multicenter cohort study. Anesthesiology. 2015; 122: 1123-1141.

[15] Choi JB, Kang K, Song MK, Seok S, Kim YH, Kim JE. Pain charac-teristics after total laparoscopic hysterectomy. International Journal of Medical Sciences. 2016; 13: 562-568.

[16] Tolver MA, Strandfelt P, Rosenberg J, Bisgaard T. Pain characteristics after laparoscopic inguinal hernia repair. Surgical Endoscopy. 2011; 25: 3859-3864.

[17] Tolver MA, Strandfelt P, Rosenberg J, Bisgaard T. Pain characteristics after laparoscopic inguinal hernia repair. Surgical Endoscopy. 2011; 25: 3859-3864.

[18] Krismer M, van Tulder M. Low back pain (non-specific). Best Practice & Research Clinical Rheumatology. 2007; 21: 77-91.

[19] Gopinath B, Jagnoor J, Kifley A, Nicholas M, Blyth F, Kenardy J, et al. Differential predictors of pain severity over 12 months following noncatastrophic injury sustained in a road traffic crash. Journal of Pain. 2019; 20: 676-684.

[20] Dobscha SK, Lovejoy TI, Morasco BJ, Kovas AE, Peters DM, Hart K, et al. Predictors of improvements in pain intensity in a national cohort of older veterans with chronic pain. Journal of Pain. 2016; 17: 824-835.

[21] Sipilä R, Estlander A, Tasmuth T, Kataja M, Kalso E. Development of a screening instrument for risk factors of persistent pain after breast cancer surgery. British Journal of Cancer. 2012; 107: 1459-1466.

[22] Tan K. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. The Lancet. 2004; 363: 157- 163.

[23] Ruscheweyh R, Viehoff A, Tio J, Pogatzki-Zahn EM. Psychophysical and psychological predictors of acute pain after breast surgery differ in patients with and without pre-existing chronic pain. Pain. 2017; 158: 1030-1038.

[24] , Jones RN, Kiely DK, Hausdorff JM, Shmerling RH, Guralnik JM, et al. Chronic musculoskeletal pain and the occurrence of falls in an older population. The Journal of the American Medical Association. 2009; 302: 2214.

[25] Chou R, Gordon DB, Leon-Casasola OAD, Rosenberg JM, Bickler S, Brennan T, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Commit. Journal of Pain. 2016; 17: 131-157.

[26] Gordon DB, Deleon-Casasola OA, Wu CL, Sluka K, Brennan T, Chou R. Research gaps on practice guidelines for acute postoperative pain management in adults: findings from a review of the evidence for an American Pain Society Clinical Practice Guideline. Journal of Pain. 2015; 17: 158-166.

[27] Persson AK, Pettersson FD, Dyrehag L, Åkeson J. Prediction of postop-erative pain from assessment of pain induced by venous cannulation and propofol infusion. Acta Anaesthesiologica Scandinavica. 2016; 60: 166-176.

[28] Bisgaard T, Klarskov B, Rosenberg J, Kehlet H. Characteristics and prediction of early pain after laparoscopic cholecystectomy. Pain. 2001; 90: 261-269.

[29] Miaskowski C, Cooper B, Paul SM, West C, Langford D, Levine JD, et al. Identification of patient subgroups and risk factors for persistent breast pain following breast cancer surgery. Journal of Pain. 2012; 13: 1172-1187.

[30] Moons KGM, Kengne AP, Woodward M, Royston P, Vergouwe Y, Altman DG, et al. Risk prediction models: i. development, internal validation, and assessing the incremental value of a new (bio)marker. Heart. 2012; 98: 683-690.

[31] Lee SY, Kim CH, Kim YJ, Kim HR. Laparoscopic surgery for colorectal cancer patients who underwent previous abdominal surgery. Surgical Endoscopy. 2016; 30: 5472-5480.

[32] Kim IY, Bo RK, Kim YW. Impact of prior abdominal surgery on rates of conversion to open surgery and short-term outcomes after laparoscopic surgery for colorectal cancer. PLoS ONE. 2015; 10: e0134058.

[33] Ghezzi F, Uccella S, Cromi A, Siesto G, Serati M, Bogani G, et al. Postoperative pain after laparoscopic and vaginal hysterectomy for benign gynecologic disease: a randomized trial. American Journal of Obstetrics and Gynecology. 2010; 203: 118.e1-118.e8.

[34] Brandsborg B, Nikolajsen L, Hansen C, Kehlet H, Jensen T. Risk factors for chronic pain after hysterectomy. Anesthesiology. 2007; 106: 1003-1012.

[35] Brandsborg B, Dueholm M, Nikolajsen L, Kehlet H, Jensen TS. A prospective study of risk factors for pain persisting 4 months after hysterectomy. Clinical Journal of Pain. 2009; 25: 263-268.

[36] Kim YS, Kwon SJ. High thoracic midline dorsal column myelotomy for severe visceral pain due to advanced stomach cancer. Neurosurgery. 2000; 46: 85-92.

[37] Bruce J, Thornton AJ, Scott NW, Marfizo S, Powell R, Johnston M, et al. Chronic preoperative pain and psychological robustness predict acute postoperative pain outcomes after surgery for breast cancer. British Journal of Cancer. 2012; 107: 937-946.

[38] Hetmann F, Schou-bredal I, Sandvik L, Kongsgaard UE. Does chronic pre-operative pain predict severe post-operative pain after thoracotomy?a prospective longitudinal study. Acta Anaesthesiologica Scandinavica. 2013; 57: 1065-1072.

[39] Gerbershagen HJ, Özgür E, Dagtekin O, Straub K, Hahn M, Heidenreich A, et al. Preoperative pain as a risk factor for chronic post-surgical pain - six month follow-up after radical prostatectomy. European Journal of Pain. 2009; 13: 1054-1061.

[40] Schreiber KL, Kehlet H, Belfer I, Edwards RR. Predicting, preventing and managing persistent pain after breast cancer surgery: the importance of psychosocial factors. Pain Management. 2014; 4: 445-459.

[41] Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011; 152: S2-S15.

[42] Leggett PL, Churchman-Winn R, Miller G. Minimizing ports to improve laparoscopic cholecystectomy. Surgical Endoscopy. 2000; 14: 32-36.

[43] Kaunisto MA, Jokela R, Tallgren M, Kambur O, Tikkanen E, Tasmuth T, et al. Pain in 1,000 women treated for breast cancer: a prospective study of pain sensitivity and postoperative pain. Anesthesiology. 2013; 119: 1410-1421.

[44] Pan PH, Tonidandel AM, Aschenbrenner CA, Houle TT, Harris LC, Eisenach JC. Predicting acute pain after cesarean delivery using three simple questions. Anesthesiology. 2013; 118: 1170-1179.

[45] Straatman J, Cuesta MA, de Lange-de Klerk ESM, van der Peet DL. Long-term survival after complications following major abdominal surgery. Journal of Gastrointestinal Surgery. 2016; 20: 1034-1041.

[46] Al-Chaer ED, Traub RJ. Biological basis of visceral pain: recent developments. Pain. 2002; 96: 221-225.

[47] van der Wal JBC, Iordens GIT, Vrijland WW, van Veen RN, Lange J, Jeekel J. Adhesion prevention during laparotomy: long-term follow-up of a randomized clinical trial. Annals of Surgery. 2011; 253: 1118-1121.

[48] Imudia A, Kumar S, Saed G, Diamond M. Pathogenesis of intra-abdominal and pelvic adhesion development. Seminars in Reproductive Medicine. 2008; 26: 289-297.

[49] Molegraaf MJ, Torensma B, Lange CP, Lange JF, Jeekel J, Swank DJ. Twelve-year outcomes of laparoscopic adhesiolysis in patients with chronic abdominal pain: a randomized clinical trial. Surgery. 2017; 161: 415- 421.

[50] Lis AM, Black KM, Korn H, Nordin M. Association between sitting and occupational LBP. European Spine Journal. 2007; 16: 283-298.

[51] Hartvigsen J, Leboeufyde C, Lings S, Corder EH. Is sitting-while-at-work associated with low back pain? A systematic, critical literature review. Scandinavian Journal of Public Health. 2000; 28: 230-239.

[52] Singh S, Kumar D, Kumar S. Risk factors in cervical spondylosis. Journal of Clinical Orthopaedics and Trauma. 2014; 5: 221-226.

[53] Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. Journal of Bone and Joint Surgery-American Volume. 2006; 88: 21-24.

[54] Bolser DC, Hobbs SF, Chandler MJ, Ammons WS, Brennan TJ, Foreman RD. Convergence of phrenic and cardiopulmonary spinal afferent information on cervical and thoracic spinothalamic tract neurons in the monkey: implications for referred pain from the diaphragm and heart. Journal of Neurophysiology. 1991; 65: 1042-1054.

[55] Zirak N, Soltani G, Hafizi L, Mashayekhi Z, Kashani I. Shoulder pain after caesarean section: comparison between general and spinal anaesthesia. Journal of Obstetrics and Gynaecology. 2012; 32: 347-349.

[56] Herron RAC. Post-operative brachial plexus paralysis. The British Medical Journal. 1952; 1: 1115-1116.