Warm and humidified insufflation gas during gynecologic laparoscopic surgery reduces postoperative pain in predisposed patients-a randomized, controlled multi-arm trial

Markus Breuer, Julia Wittenborn, Rolf Rossaint, Julia Van Waesberghe, Ana Kowark, Deborah Mathei, András Keszei, Svetlana Tchaikovski, Magdalena Zeppernick, Felix Zeppernick, Elmar Stickeler, Norbert Zoremba, Ivo Meinhold-Heerlein, Christian Bruells, Markus Breuer, Julia Wittenborn, Rolf Rossaint, Julia Van Waesberghe, Ana Kowark, Deborah Mathei, András Keszei, Svetlana Tchaikovski, Magdalena Zeppernick, Felix Zeppernick, Elmar Stickeler, Norbert Zoremba, Ivo Meinhold-Heerlein, Christian Bruells

Abstract

Background: Postoperative pain remains a common problem in gynecologic laparoscopy, especially in head zone-related regions, triggered by intra-abdominal pressure during capnoperitoneum. Humidified and prewarmed insufflation gas may ameliorate pain and be beneficial.

Methods: This prospective randomized controlled parallel group multi-arm single-center study investigated the effects of temperature and humidity of insufflation gas on postoperative pain during gynecologic laparoscopy with a duration ≥ 60 min. Female participants (18-70 years) were blinded and randomly assigned-computer generated-to either insufflation with dry cold CO2 with forced air warming blanket ("AIR"), humidified warm gas without forced air warming blanket ("HUMI"), or humidified warm gas with forced air warming blanket ("HUMI +"). We hypothesized that using humidified warm gas resulted in lower pain scores and less analgesic consumption. The primary endpoint postoperative pain was assessed for different pain localizations every 12 h during 7 days after surgery. Secondary endpoints were demand for painkillers and epidural anesthetics, length of stay in recovery room, and hospital stay. (Registration: ClinicalTrials.gov NCT02781194-completed).

Results: 150 participants were randomized. Compared to group "AIR" (n = 48), there was significantly less pain in group "HUMI +" (n = 48) in the recovery room (- 1.068; 95% CI - 2.08 to - 0.061), as well as significantly less ibuprofen use at day two (- 0.5871 g ± 0.258; p-value = 0.0471). Other variables did not change significantly. Stratification for presence of endometriosis or non-previous abdominal surgery in patient history revealed significantly less pain in both groups "HUMI" (n = 50) and "HUMI +" versus group "AIR." Related side effects were not noted.

Conclusion: In the overall population, the use of warm, humidified insufflation gas did not yield clinically relevant effects; however, in predisposed patients with endometriosis and who could otherwise expect high pain levels, warm and humidified gas may be beneficial.

Keywords: Gynecology; Laparoscopy; Postoperative pain; Warm humidified insufflation gas.

Conflict of interest statement

Markus Breuer, Julia Wittenborn, Julia van Waesberghe, Ana Kowark, Deborah Mathei, András Keszei, Svetlana Tchaikovski, Magdalena Zeppernick, Felix Zeppernick, Elmar Stickeler, Rolf Rossaint, Norbert Zoremba, Ivo Meinhold-Heerlein, and Christian Bruells have no conflicts of interest or financial ties to disclose.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
CONSORT flow diagram. Numbers are given in brackets
Fig. 2
Fig. 2
A VAS pain score of the three intervention groups—abdominal pain. “AIR” = red. “HUMI” = green. “HUMI +” = blue. (Filled symbol: median; empty symbol: min and max). B VAS pain score of the three intervention groups—pain on coughing. “AIR” = red. “HUMI” = green. “HUMI +” = blue. (Filled symbol: median; empty symbol: min and max). C VAS pain score of the three intervention groups—pain on movement. “AIR” = red. “HUMI” = green. “HUMI +” = blue. (Filled symbol: median; empty symbol: min and max). D VAS pain score of the three intervention groups—shoulder pain. “AIR” = red. “HUMI” = green. “HUMI +” = blue. (Filled symbol: median; empty symbol: min and max)
Fig. 3
Fig. 3
A Maximum pain scores of the three intervention groups. “AIR” = dot. “HUMI” = triangle. “HUMI +” = square. B Estimated treatment effect on pain score with significant less pain score in group “HUMI +” vs control group at arrival in PACU (Asterisk). “HUMI” vs “AIR” = dot. “HUMI +” vs “AIR” = triangle
Fig. 4
Fig. 4
A Maximum pain scores of the three intervention groups with stratification by endometriosis. “AIR” = dot. “HUMI” = triangle. “HUMI +” = square. B Estimated treatment effect on pain score with stratification by endometriosis. Significant less pain score in subjects suffering from endometriosis (Asterisk). “HUMI” vs “AIR” = dot. “HUMI +” vs “AIR” = triangle
Fig. 5
Fig. 5
A Maximum pain scores of the three intervention groups with stratification by previous abdominal surgery. “AIR” = dot. “HUMI” = triangle. “HUMI +” = square. B Estimated treatment effect on pain score with stratification by previous abdominal surgery. Significant less pain score in subjects, without previous abdominal surgery (Asterisk). “HUMI” vs “AIR” = dot. “HUMI +” vs “AIR” = triangle

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