Pain syndrome after laparoscopic myomectomy: pathogenesis and evolution of methods for combating pain

封面

如何引用文章

全文:

开放存取 开放存取
受限制的访问 ##reader.subscriptionAccessGranted##
受限制的访问 订阅或者付费存取

详细

Laparoscopic myomectomy is the main surgical option in the treatment of uterine fibroids and it currently has become the gold standard in the uterus-sparing approach. Despite its minimally invasive nature and proven clinical efficacy, postoperative pain remains a significant concern. According to published data, up to 80% of patients report moderate to severe pain during the first 24 hours after surgery. This can affect the early postoperative period, delay mobilization, prolong hospitalization, and increase the need for systemic analgesics, including opioids. Persistent pain may also reduce patient’s satisfaction with the treatment and limit the implementation of Enhanced Recovery After Surgery (ERAS) protocols aimed at improving perioperative outcomes.

This review provides a comprehensive analysis of the pathophysiological mechanisms underlying postoperative pain after laparoscopic myomectomy. It discusses the activation of somatic and visceral nociceptors, the development of peripheral and central sensitization, and the role of intracellular signaling and inflammatory mediators. Particular attention is given to the anatomical and physiological characteristics of uterine innervation, including the zones of overlapping somatic and visceral nociceptive input, and the superior hypogastric plexus in pain transmission. The characteristics of visceral pain, a challenging and less manageable aspect of postoperative pain, are discussed.

The analysis of published materials provides up-to-date information on modern approaches to pain management in patients after laparoscopic myomectomy. Special focus is placed on multimodal and preemptive analgesia techniques aimed at reducing both pain intensity and opioid consumption. Local interventions such as anterior abdominal wall infiltration and superior hypogastric plexus block are discussed as part of a pathophysiology-based approach to postoperative pain control. Data on the effect of pain severity on recovery parameters, patient satisfaction, and overall quality of medical care are presented.

Conclusion: The findings support the need for personalized analgesic strategies that account for neurophysiological pain mechanisms and surgical specifics. The use of pathogenetically-based and preemptive analgesic strategies can not only reduce the severity of pain, but can also improve the overall course of the postoperative period, increase patient compliance and the effectiveness of ERAS protocols.

全文:

受限制的访问

作者简介

Nikita Kharlov

Saint Petersburg State University

编辑信件的主要联系方式.
Email: nikita.kharlov@gmail.com
ORCID iD: 0000-0002-8318-5201

obstetrician-gynecologist, oncologist, Head of the Department of Gynecology, Hospital

俄罗斯联邦, St. Petersburg

Ekaterina Shapovalova

Saint Petersburg State University

Email: katerina_andmed@mail.ru
ORCID iD: 0000-0002-4574-2492

PhD, obstetrician-gynecologist, Head of the Department of Outpatient Gynecology, Hospital

俄罗斯联邦, St. Petersburg

Alexander Basos

Saint Petersburg State University

Email: asbasos@gmail.com
ORCID iD: 0000-0001-5020-9759

PhD, obstetrician-gynecologist, Head of Operative Gynecology Program, Hospital

俄罗斯联邦, St. Petersburg

Alexander Belousov

Saint Petersburg State University

Email: nikita.kharlov@gmail.com
ORCID iD: 0000-0002-2274-8170

Dr. Med. Sci., surgeon, oncologist, Deputy Chief Physician for Surgery and Oncology, Hospital

俄罗斯联邦, St. Petersburg

参考

  1. Stewart E.A., Cookson C.L., Gandolfo R.A., Schulze-Rath R. Epidemiology of uterine fibroids: a systematic review. BJOG. 2017. 124(10): 1501-12. https://dx.doi.org/10.1111/1471-0528.14640
  2. Аганезова Н.В., Аганезов С.С., Шило М.М. Миома матки: современные практические аспекты заболевания. Проблемы репродукции. 2022; 28(4): 97-105. [Aganezova N.V., Aganezov S.S., Shilo M.M. Uterine fibroids: modern practical aspects of the disease. Russian Journal of Human Reproduction. 2022; 28(4): 97-105 (in Russian)]. https://dx.doi.org/10.17116/repro20222804197
  3. Rodriguez-Triana V.M., Kwan L., Kelly M., Olson T.H., Parker W.H. Quality of life after laparoscopic and open abdominal myomectomy. J. Minim. Invasive. Gynecol. 2021; 28(4): 817-23. https://dx.doi.org/10.1016/j.jmig.2020.07.023
  4. Don E.E., Mijatovic V., van Eekelen R., Hehenkamp W.J.K., Huirne J.A.F. The effect of a myomectomy on myoma-related symptoms and quality of life: a retrospective cohort study. J. Minim. Invasive. Gynecol. 2023; 30(11): 897-904. https://dx.doi.org/10.1016/j.jmig.2023.07.001
  5. Don E.E., Mijatovic V., Huirne J.A.F. Infertility in patients with uterine fibroids: a debate about the hypothetical mechanisms. Hum. Reprod. 2023; 38(11): 2045-54. https://dx.doi.org/10.1093/humrep/dead194
  6. Тюрина Н.А., Вирясова А.А., Оточина Н.А., Кузнецова А.А., Чепой М.О., Топоркова В.Р. Беременность и роды у женщин с множественной миомой матки. Акушерство и гинекология. 2025; 4: 158-63. [Tyurina N.A., Viryasova A.A., Otochina N.A., Kuznetsova A.A., Chepoy M.O., Toporkova V.R. Pregnancy and childbirth in women with multiple uterine fibroids. Obstetrics and Gynecology. 2025; (4): 158-63 (in Russian)]. https://dx.doi.org/10.18565/aig.2024.312
  7. Han Y., Yao R., Zhang Y., Yang Z., Luo H., Wang X.Y. et al. Hysteroscopic resection of type 3 fibroids could improve the pregnancy outcomes in infertile women: a case–control study. BMC Pregnancy and Childbirth. 2022; 22: 522. https://doi.org/10.1186/s12884-022-04828-3
  8. Cezar C., Becker S., di Spiezio Sardo A., Herrmann A., Larbig A., Tanos V. et al. Laparoscopy or laparotomy as the way of entrance in myoma enucleation. Arch. Gynecol. Obstet. 2017; 296(4): 709-20. https://dx.doi.org/10.1007/s00404-017-4490-x
  9. Bisch S.P., Jago C.A., Kalogera E., Ganshorn H., Meyer L.A., Ramirez P.T. et al. Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology – a systematic review and meta-analysis. Gynecol. Oncol. 2021; 161(1): 46-55. https://dx.doi.org/10.1016/j.ygyno.2020.12.035
  10. Nelson G., Fotopoulou C., Taylor J., Glaser G., Bakkum-Gamez J., Meyer L.A. et al. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: addressing implementation challenges - 2023 update. Gynecol. Oncol. 2023; 173: 58-67. https://dx.doi.org/10.1016/j.ygyno.2023.04.009
  11. Овечкин A.M. Послеоперационная боль: состояние проблемы и современные тенденции послеоперационного обезболивания. Регионарная анестезия и лечение острой боли. 2015; 9(2): 29-39. [Ovechkin A.M. Postoperative pain: the state of problem and current trends in postoperative analgesia. Regionarnaya anesteziya i lechenie ostroy boli. 2015; 9(2): 29-39 (in Russian)].
  12. Joo J., Moon H.K., Moon Y.E. Identification of predictors for acute postoperative pain after gynecological laparoscopy (STROBE-compliant article). Medicine (Baltimore). 2019; 98(42): e17621. https://dx.doi.org/10.1097/MD.0000000000017621
  13. Харлов Н.С., Карамян Р.А., Басос А.С., Шаповалова Е.А., Ионова Т.И., Никитина Т.П., Белоусов А.М. Лапароскопическая миомэктомия: качество жизни пациенток при «fast-track»-хирургии. Вопросы гинекологии, акушерства и перинатологии. 2025; 24(2): 168-74. [Kharlov N.S., Karamyan R.A., Basos A.S., Shapovalova E.A., Ionova T.I., Nikitina T.P., Belousov A.M. Laparoscopic myomectomy: quality of life of patients in “fast-track” surgery. Gynecology, Obstetrics and Perinatology. 2025; 24(2): 168-74 (in Russian)]. https://dx.doi.org/10.20953/1726-1678-2025-2-168-174
  14. Sao C.H., Chan-Tiopianco M., Chung K.C., Chen Y.J., Horng H.C., Lee W.L. et al. Pain after laparoscopic surgery: focus on shoulder-tip pain after gynecological laparoscopic surgery. J. Chin. Med. Assoc. 2019; 82(11): 819-26. https:// dx.doi.org/10.1097/JCMA.0000000000000190
  15. Шаповалова Е.А., Басос А.С., Шкарупа И.А., Глущенко Ж.В., Терешин С.М., Бабина У.Ф., Савина А.А., Ширяева А.В. Болевой синдром в области плеча после лапароскопии: эпидемиология, патогенез, методы профилактики. Акушерство и гинекология. 2023; 9: 44-51. [Shapovalova E.A., Basos A.S., Shkarupa I.A., Glushchenko Zh.V., Тereshin S.M., Babina U.F., Savina A.A., Shiryaeva A.V. Shoulder pain syndrome after laparoscopy: epidemiology, pathogenesis, prevention methods. Obstetrics and Gynecology. 2023; (9): 44-51 (in Russian)]. https://dx.doi.org/10.18565/aig.2023.145
  16. Kehlet H., Jensen T.S., Woolf C.J. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006; 367(9522): 1618-25. https://dx.doi.org/10.1016/S0140-6736(06)68700-X
  17. Lunde S., Nguyen H.T., Petersen K.K., Arendt-Nielsen L., Krarup H.B., Søgaard-Andersen E. Chronic postoperative pain after hysterectomy for endometrial cancer: a metabolic profiling study. Mol. Pain. 2020; 16: 1744806920923885. https://dx.doi.org/10.1177/1744806920923885
  18. Gottschalk A., Smith D.S. New concepts in acute pain therapy: preemptive analgesia. Am. Fam. Physician. 2001; 63(10): 1979-84.
  19. Pinsard M., Mouchet N., Dion L., Bessede T., Bertrand M., Darai E. et al. Anatomic and functional mapping of human uterine innervation. Fertil. Steril. 2022; 117(6): 1279-88. https://dx.doi.org/10.1016/j.fertnstert.2022.02.013
  20. Euasobhon P., Atisook R., Bumrungchatudom K., Zinboonyahgoon N., Saisavoey N., Jensen M.P. Reliability and responsivity of pain intensity scales in individuals with chronic pain. Pain. 2022; 163(12): e1184-91. https://dx.doi.org/10.1097/j.pain.0000000000002692
  21. Boonstra A.M., Schiphorst Preuper H.R., Balk G.A., Stewart R.E. Cut-off points for mild, moderate, and severe pain on the visual analogue scale for pain in patients with chronic musculoskeletal pain. Pain. 2014; 155(12): 2545-50. https://dx.doi.org/10.1016/j.pain.2014.09.014
  22. Laughlin-Tommaso S.K., Lu D., Thomas L., Diamond M.P., Wallace K., Wegienka G. et al. Short-term quality of life after myomectomy for uterine fibroids from the COMPARE-UF Fibroid Registry. Am. J. Obstet. Gynecol. 2020; 222(4): 345.e1-22. https://dx.doi.org/10.1016/j.ajog.2019.09.052
  23. Tsuzuki Y., Tsuzuki S., Wada S., Fukushi Y., Fujino T. Recovery of quality of life after laparoscopic myomectomy. J. Obstet. Gynaecol. Res. 2019; 45(1): 176-81. https://dx.doi.org/10.1111/jog.13808
  24. Овечкин А.М., Баялиева А.Ж., Ежевская А.А., Еременко А.А., Заболотский Д.В., Заболотских И.Б., Карелов А.Е., Корячкин В.А., Спасова А.П., Хороненко В.Э., Уваров Д.Н., Ульрих Г.Э., Шадрин Р.В. Послеоперационное обезболивание. Клинические рекомендации. Вестник интенсивной терапии имени А.И. Салтанова. 2019; 4: 9-33. [Ovechkin A.M., Bayalieva A.Zh., Ezhevskaya A.A., Eremenko A.A., Zabolotskij D.V., Zabolotskikh I.B., Karelov A.E., Koryachkin V.A., Spasova A.P., Khoronenko V.E., Uvarov D.N., Ulrikh G.E., Shadrin R.V. Postoperative analgesia. Guidelines. Annals of Critical Care. 2019; 4: 9-33 (in Russian)]. https://dx.doi.org/10.21320/1818-474X-2019-4-9-33
  25. Ong C.K.S., Seymour R.A., Lirk P., Merry A.F. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth. Analg. 2010; 110(4): 1170-9. https://dx.doi.org/10.1213/ANE.0b013e3181cf9281
  26. Kotagal M., Hakkarainen T.W., Simianu V.V., Beck S.J., Alfonso-Cristancho R., Flum D.R. Ketorolac use and postoperative complications in gastrointestinal surgery. An. Surg. 2016; 263(1): 71-5. https://dx.doi.org/10.1097/SLA.0000000000001260
  27. Matteson K.A., Schimpf M.O., Jeppson P.C., Thompson J.C., Gala R.B., Balgobin S. et al. Prescription opioid use for acute pain and persistent opioid use after gynecologic surgery: a systematic review. Obstet. Gynecol. 2023; 141(4): 681-96. https://dx.doi.org/10.1097/AOG.0000000000005104
  28. Yiu C.H., Gnjidic D., Patanwala A., Fong I., Begley D., Khor K.E., Rimington J., Bugeja B., Penm J. Opioid-related adverse drug events in surgical patients: risk factors and association with clinical outcomes. Expert Opin. Drug Saf. 2022; 21(9): 1211-23. https://dx.doi.org/10.1080/14740338.2022.2049230
  29. Lee M., Silverman S.M., Hansen H., Patel V.B., Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011; 14(2): 145-61.
  30. Gupta G.P., Massagué J. Cancer metastasis: building a framework. Cell. 2006; 127(4): 679-95. https://dx.doi.org/10.1016/j.cell.2006.11.001
  31. Hashemian A.M., Omraninava A., Kakhki A.D., Sharifi M.D., Ahmadi K., Masoumi B. et al. Effectiveness of local anesthesia with lidocaine in chronic opium abusers. J. Emerg. Trauma Shock. 2014; 7(4): 301-4. https:// dx.doi.org/10.4103/0974-2700.142765
  32. Nassif G.J., Miller T.E. Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review. Curr. Med. Res. Opin. 2019; 35(12): 2129-36. https://dx.doi.org/10.1080/03007995.2019.1646001
  33. Dahl J.B., Rosenberg J., Dirkes W.E., Mogensen T., Kehlet H. Prevention of postoperative pain by balanced analgesia. Br. J. Anaesth. 1990; 64(4): 518-20. https://dx.doi.org/10.1093/bja/64.4.518
  34. Steinberg A.C., Schimpf M.O., White A.B., Mathews C., Ellington D.R., Jeppson P. et al. Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines. Am. J. Obstet. Gynecol. 2017; 217(3): 303-13.e6. https://dx.doi.org/10.1016/j.ajog.2017.03.013
  35. Winnie L., Kao Y.H., Liao C.C., Tamura T., Chang M.L., Hsieh K.Y. Comparative analgesic efficacies of ropivacaine and bupivacaine for postoperative rectus sheath block in paediatric abdominal surgery: a meta-analysis of randomized controlled trial and retrospective cohort studies. Pain Res. Manag. 2021; 2021: 5535730. https://dx.doi.org/10.1155/2021/5535730
  36. Patil P., Dhulkhed P.V., Dhulkhed V.K. Isobaric forms of ropivacaine vs. bupivacaine in lower abdominal surgeries: a hospital-based, prospective, comparative study. Med. Gas Res. 2023; 13(3): 123-7. https://dx.doi.org/10.4103/2045-9912.359678
  37. Gluck O., Barber E., Feldstein O., Tal O., Kerner R., Keidar R. et al. The effect of subcutaneous and intraperitoneal anesthesia on post laparoscopic pain: a randomized controlled trial. Sci. Rep. 2021; 11(1): 81. https://dx.doi.org/10.1038/s41598-020-80130-6
  38. Jadon A., Ahmad A., Sahoo R.K., Sinha N., Chakraborty S., Bakshi A. Efficacy of transmuscular quadratus lumborum block in the multimodal regimen for postoperative analgesia after total laparoscopic hysterectomy: a prospective randomised double-blinded study. Indian J. Anaesth. 2021; 65(5): 362-8. https://dx.doi.org/10.4103/ija.IJA_1258_20
  39. Otake A., Sasamoto N., Sato N., Kumasaka R., Yamamoto Y., Adachi K. Comparative study of postoperative analgesic effects of intraoperative levobupivacaine local infiltration anesthesia and transversus abdominis plane block following gynecologic laparoscopy. Gynecol. Minim. Invasive Ther. 2022; 11(4): 231-7. https://dx.doi.org/10.4103/gmit.gmit_120_21
  40. Сюткина И.П., Хабаров Д.В., Смагин А.А., Инешина А.Д., Кочеткова М.В. О перспективах применения миофасциальных блоков в акушерско-гинекологической практике. Акушерство и гинекология. 2021; 3: 50-7. [Syutkina I.P., Khabarov D.V., Smagin A.A., Ineshina A.D., Kochetkova M.V. On the prospects of using myofascial blocks in obstetric and gynecological practice. Obstetrics and Gynecology. 2021; (3): 50-7 (in Russian)]. https://dx.doi.org/10.18565/aig.2021.3.50-57
  41. Rocha A., Plancarte R., Nataren R.G.R., Carrera I.H.S., De Los Reyes Pacheco V.A., Hernandez-Porras B.C. Effectiveness of superior hypogastric plexus neurolysis for pelvic cancer pain. Pain Physician. 2020; 23(2): 203-8.
  42. Khodaverdi S., Alebouyeh M.R., Sadegi K., Mehdizadehkashi A., Kaveh M., Entezari S.R. et al. Superior hypogastric plexus block as an effective treatment method for endometriosis-related chronic pelvic pain: an open-label pilot clinical trial. J. Obstet. Gynaecol. 2021; 41(6): 966-71. https://dx.doi.org/10.1080/01443615.2020.1820468
  43. Aurore V., Röthlisberger R., Boemke N., Hlushchuk R., Bangerter H., Bergmann M. et al. Anatomy of the female pelvic nerves: a macroscopic study of the hypogastric plexus and their relations and variations. J. Anat. 2020; 237(3): 487-94. https://dx.doi.org/10.1111/joa.13206
  44. Astepe B.S., Aytuluk H.G., Yavuz A., Türkay Ü., Terzi H., Kale A. Intraoperative superior hypogastric plexus block during cesarean section: a new technique for pain relief. J. Matern. Fetal Neonatal Med. 2020; 33(15): 2657-63. https://dx.doi.org/10.1080/14767058.2019.1676414
  45. Salem H., Bukhari I.A., Al Baalharith M., AlTahtam N., Alabdrabalamir S., Jamjoom M.Z. et al. Analgesic efficacy of intraoperative superior hypogastric plexus (SHP) block during abdominal hysterectomy: a systematic review and meta-analysis of controlled trials. Medicina (Kaunas). 2023; 59(5): 893. https://dx.doi.org/10.3390/medicina59050893
  46. Gundogdu E., Yılmaz T.G. The role of intraoperative superior hypogastric plexus blocks in pain management for total abdominal hysterectomy: a comparative study. Eur. Res. J. 2023; 9(5): 1201-6. https://dx.doi.org/10.18621/eurj.1340891
  47. Aytuluk H.G., Kale A., Basol G. Laparoscopic superior hypogastric blocks for postoperative pain management in hysterectomies: a new technique for superior hypogastric blocks. J. Minim. Invasive Gynecol. 2019; 26(4): 740-7. https://dx.doi.org/10.1016/j.jmig.2018.08.008
  48. Clark N.V., Moore K., Maghsoudlou P., North A., Ajao M.O., Einarsson J.I. et al. Superior hypogastric plexus block to reduce pain after laparoscopic hysterectomy: a randomized controlled trial. Obstet. Gynecol. 2021; 137(4): 648-56. https://dx.doi.org/10.1097/aog.0000000000004329
  49. De Silva P., Daniels S., Bukhari M.E., Choi S., Liew A., Rosen D.M.B. et al. Superior hypogastric plexus nerve block in minimally invasive gynecology: a randomized controlled trial. J. Minim. Invasive Gynecol. 2022; 29(1): 94-102. https://dx.doi.org/10.1016/j.jmig.2021.06.017

补充文件

附件文件
动作
1. JATS XML
下载
2. Figure: Flowchart of the stages of source search

下载 (285KB)
索引源数据

版权所有 © Bionika Media, 2025