|Year : 2016 | Volume
| Issue : 3 | Page : 270-273
Vaginal hysterectomy using local anesthesia and analgesics
O Onafowokan1, O Asemota2
1 Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, FCT, Gwagwalada, Abuja, Nigeria
2 Department of Family Medicine, Rhema Foundation Hospital, Kwali, Abuja, Nigeria
|Date of Web Publication||8-Feb-2017|
Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Gwagwalada, Abuja
Source of Support: None, Conflict of Interest: None
Context: Vaginal hysterectomy for pelvic organ prolapse is often performed under general or regional anesthesia. However, the performance of this operative procedure under local anesthetic has potential benefits, especially in resource-poor settings.
Aims: The aim of this study was to review the outcome of vaginal hysterectomy and pelvic floor repair using local anesthesia and supplementary analgesia.
Settings and Design: The study was retrospective and the setting was a cottage hospital in the northern Nigeria.
Subjects and Methods: A review of the case records of women who underwent a vaginal hysterectomy and pelvic floor repair for uncomplicated 4th degree (Stage III) uterovaginal prolapse, using local lidocaine infiltration and supplemental pentazocine injection.
Statistical Analysis Used: Descriptive statistics and frequencies were used to describe the population and outcomes of surgery.
Results: Eighteen women successfully had vaginal hysterectomy and pelvic floor repair using local anesthesia with supplemental pentazocine intramuscular injection. Four (22.2%) of the women required supplemental pentazocine injection. The mean duration of surgery was 101.67 (± 14.14) min and the average hospital stay was 36.22 (± 17.16) h. Thirteen (72.2%) women were satisfied with the surgery, anesthesia, and early ambulation while the others desired a totally painless surgery in addition to the early ambulation and short hospitalization.
Conclusions: The use of local anesthesia for vaginal hysterectomy and pelvic floor repair was successful in patients with severe uterovaginal prolapse. A larger, randomized controlled study is recommended.
Keywords: Anesthesia; hysterectomy; local; prolapse; vaginal.
|How to cite this article:|
Onafowokan O, Asemota O. Vaginal hysterectomy using local anesthesia and analgesics. Trop J Obstet Gynaecol 2016;33:270-3
| Introduction|| |
Pelvic organ prolapse (POP) is prevalent in parous women. Advanced POP is a common indication for vaginal hysterectomy.,,, Such hysterectomies are usually performed under general or regional anesthesia which may be a challenge in resource-poor settings., The option of local anesthesia offers several benefits including less anesthetic risks and intraoperative blood loss and shorter hospitalization.,,,,, However, local anesthesia is not popular with such procedures in our clime. This study was designed to review the outcome of vaginal hysterectomy using local anesthesia and analgesia in women with advanced POP.
| Subjects and Methods|| |
This was a retrospective cohort study involving case records review of 18 women who underwent vaginal hysterectomy and pelvic floor repair using local anesthesia with supplemental intramuscular analgesia. The surgeries were performed during a medical mission at a cottage hospital - Christian Mission hospital, Adoka, Benue state of Nigeria. The patients reviewed had vaginal hysterectomy and pelvic floor repair for Stage III (4th degree) uterovaginal prolapse using local anesthesia. The general anesthesia available was limited to Ketamine, which served as a backup, especially if there was need for conversion to abdominal hysterectomy. Women with medical conditions such as hypertension and diabetes were not selected for surgery.
Anesthesia was provided using local infiltration of 1% lidocaine with adrenaline (1:200,000). It was applied by infiltration at the site of the incision just before each stage of the procedure was initiated. The first stage was hysterectomy and incision sites on the cervix and vagina were infiltrated. At the second stage before the anterior repair, the anterior vaginal wall was infiltrated along the incision sites while the third stage was infiltration of the posterior vaginal wall and perineum before the colpoperineorrhaphy. Supplemental analgesia was provided with intramuscular pentazocine injection, 30 mg stat. A pain scale was not used, but the patients were asked to indicate whenever they felt pain that would need additional analgesia.
All the patients reviewed underwent vaginal hysterectomy, anterior colporrhaphy, and posterior colpoperineorrhaphy, with one patient undergoing additional bilateral salpingo-oophorectomy. All the operations were performed by the same surgical team, using standard procedures as would have been the case under general or regional anesthesia.
Prophylactic antibiotics were provided with perioperative of Augmentin 1.5 g iv and 500 mg infusion of metronidazole. Postoperative analgesia was provided with 30-60 mg of pentazocine 6 hourly for the first 12 h and naproxen sodium (Cataflam) 50 mg twice daily for 5 days. Oral Augmentin and metronidazole were administered for 5 days postoperatively.
The patients were ambulated and commenced on oral intake early on the 1st postoperative day. They were discharged home when they were clinically stable and felt fit enough but after removal of the urethral catheter. Postoperative review was after 1 week.
Relevant data were extracted, including age, parity, marital status, educational status, duration of surgery, intra- and post-operative morbidity and mortality, length of hospitalization, and patient's satisfaction from the case files. The data were anonymized and entered into a Microsoft Excel spreadsheet file. Data analysis was done with the Statistical Package for Social Sciences (SPSS) software (SPSS V20.0, IBM, Chicago, Il, USA). Frequencies and descriptive statistics were used to describe the population and outcomes of surgery.
| Results|| |
Eighteen women reviewed had their surgery successfully without conversion to general anesthesia. The age range was 50-74 years with a mean of 61.72 ± 7.14 years. Most of them (16/18 or 89%) were postmenopausal. They were all women of high parity with a mean parity of 6.33 ± 1.63 (range of 4–10); 15 (83%) of them were grand multiparous. Eleven (61%) were married women, 6 (33%) were widowed, and 1 (6%) was separated. Six (33%) of them were uneducated while all others had some level of formal education. The women were predominantly (14/18 or 78%) farmers and traders [Table 1].
Of the 18 women reviewed, 11 (61%) of them tolerated the surgery without supplemental pentazocine injection while 4 (22%) had pentazocine injection on request. The other three women (17%) required a repeat dose of local anesthesia at some point during the surgery, in addition to the supplemental pentazocine injection but they declined general anesthesia. All the women indicated satisfaction with the surgery and early ambulation. Thirteen women (72%) indicated that they were satisfied with the anesthesia while the remainder wished it was totally pain-free.
The duration of surgery ranged from 90 to 140 min with a mean of 101.67 (±14.14) min.
The mean estimated blood loss range was 200–400 ml with an average of 314.29 (±49.98) ml and no requirement for blood transfusion. The average duration of hospital stay was 36.22 (±17.16) h with a range 16–96 h [Table 2]. Five women (28%) who had surgery later in the afternoon had a shorter length of hospital stay as they were discharged the next morning, <24 h after the surgery. One patient had rectal injury intraoperatively, and it was repaired primarily. She remained on admission until the 4th postoperative day. Ten patients had postoperative complications. These included eight women with watery vaginal discharge that did not require additional antibiotic treatment. One patient had vaginal vault sepsis and another complained of dysuria. There were no complaints about changes in their postoperative urine continence patterns.
| Discussion|| |
This retrospective study was undertaken to review the outcome vaginal hysterectomy and pelvic floor repair using local anesthesia supplemented with pentazocine intramuscular injections.
The mean age of 61.7 years, a large proportion of grand multiparous women (83.3%) and farmers in this study is consistent with reports from other local studies., Women in this age group are predisposed to medical disorders which may pose serious risks to other forms of anesthesia. However, only women without medical complications were selected for this surgery. The high proportion of educated women may have been due to the presence of the mission-built educational facility in the community. In this review, the success rate was high, mean operation time and blood loss were 102 min and 314 ml, respectively. The mean duration of hospital stay was 36 h.
The main finding is that vaginal hysterectomy and pelvic floor repair under local anesthesia are feasible in low-resource settings. The successful use of local anesthesia without conversion to general anesthesia was in concordance with similar reports in literature.,,,,, The high rate of satisfaction with the anesthesia, ambulation, and length of hospital stay is comparable to the finding of Buchsbaum and Duecy  and the Cochrane review by Nieboer et al. However, unlike the women studied by Miklos et al. and Axelsen and Bek, supplemental analgesia was given only on demand in the patients reviewed. Lidocaine is a commonly used local anesthetic for vaginal procedures and when combined with adrenaline, its speed of onset and duration of action are increased. However, the parietal peritoneum which is mainly supplied by the obturator nerve is not easily infiltrated. Consequently, most of the women in this study did not complain of pain until the parietal peritoneum was opened, at which stage some of the patients requested supplemental analgesia. The use of a pain scale would have been more objective at this stage.
The average blood loss of 314 ml in this study was higher than 149.8 ml and 153 ml and reported by Buchsbaum and Duecy  and Miklos et al., respectively. This may be attributable to the multiple procedures performed in the 18 women reviewed. The use of Lidocaine with Adrenaline also facilitates separation of tissue planes and reduces blood loss; hence, the blood loss at such operative procedures should be less when compared with the same procedures when performed under other forms of anesthesia. Adrenaline even in low doses may affect cardiac function particularly in elderly women. Fortunately, those with hypertensive and cardiac conditions were not included in the study.
The mean duration of surgery in this study was higher than those reported by Akmel and Segni  and Nieboer et al. probably because multiple operative procedures were performed for these selected women. Besides, most of the other reports described patients with different types of vaginal wall repair. The average duration of hospital stay was consistent with the 1–2 days reported in other studies.,, The rectal injury reported in this study was inadvertent most likely due to severe atrophy and fragility of the perineal tissues. The patient affected had an uneventful recovery.
Prophylactic antibiotics were administered perioperatively and extended to 5 days postoperatively. This was the routine practice in the center and may not have been evidence based.
The retrospective approach and the small size are limitations of this study. Follow-up was limited to 1 week, and the study did not have the opportunity to compare the outcome between local anesthesia and regional anesthesia which was more popular.
| Conclusions|| |
This review showed that local anesthesia with supplemental parenteral analgesia could be an effective anesthetic option for vaginal hysterectomy and pelvic floor repair in with severe uterovaginal prolapse. The affordability and availability of local anesthetic agents, early recovery from anesthesia, early ambulation, minor postoperative complications, and short length of hospital stay are attractive benefits shown in this study.
A larger, randomized controlled study is recommended.
We are indebted to Dr. James Abah and the management of the hospital who organized the cohort of patients for the surgical mission and Dr. Babatunde A. Gbolade for reviewing the manuscript and providing additional references.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta B, Vaid NB, Suneja A, Guleria K, Jain S. Anterior vaginal prolapse repair: A randomised trial of traditional anterior colporrhaphy and self-tailored mesh repair. SAJOG 2014;20:47-50.
Akmel M, Segni H. Pelvic organ prolapse in Jimma University specialized hospital, Southwest Ethiopia. Ethiop J Health Sci 2012;22:85-92.
Umeora OU, Onoh RC, Eze JN, Igberase GO. Abdominal versus vaginal hysterectomy: Appraisal of indications and complications in a Nigerian Federal Medical Centre. NJOG 2009;4:25-9.
Obiechina NJ, Ugboaja JO, Onyegbule OA, Eleje GU. Vaginal hysterectomy in a Nigerian tertiary health facility. Niger J Med 2010;19:324-5.
Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, et al.
Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009;3:CD003677.
Miklos JR, Sze EH, Karram MM. Vaginal correction of pelvic organ relaxation using local anesthesia. Obstet Gynecol 1995;86:922-4.
Axelsen SM, Bek KM. Anterior vaginal wall repair using local anaesthesia. Eur J Obstet Gynecol Reprod Biol 2004;112:214-6.
Flam F. Sedation and local anaesthesia for vaginal pelvic floor repair of genital prolapse using mesh. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:1471-5.
Buchsbaum GM, Duecy EE. Local anesthesia with sedation for transvaginal correction of advanced genital prolapse. Am J Obstet Gynecol 2005;193:2173-6.
Buchsbaum GM, Albushies DT, Schoenecker E, Duecy EE, Glantz JC. Local anesthesia with sedation for vaginal reconstructive surgery. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:211-4.
Narayansingh GV, Kissoon W, Ramsewak SS. Local anaesthesia for vaginal hysterectomy in a patient with second degree utero-vaginal prolapse. J Obstet Gynaecol 1993;13:73-4.
[Table 1], [Table 2]