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Introduction: Transvaginal cholecystectomy (TVC) is the most common Natural Orifice Transluminal Surgery (NOTES) performed in women to date yet there is a paucity of data on intraoperative and immediate post operative pain management. Previous studies have demonstrated that NOTES procedures are associated with less post-operative pain and faster recovery times. We analyzed the intraoperative and postoperative opioid use for TVC compared to traditional 4-port laparoscopic cholecystectomies (LC) during the last 2 years in our facility.
Methods: We performed a retrospective analysis of the last 20 TVC to the last 20 LC patients at our facility. We compared demographics, intraoperative and postoperative opioid use and times in the operating room and in the Post Anesthesia Care Unit (PACU). The opioid use is described in the morphine equivalent (mg). We obtained data from electronically recorded anesthesia records of the perioperative period.
Results: There were no significant differences between the average age and BMI between the LC (41years, 30kg/m2) vs. TVC (40years, 30kg/m2) groups (p=0.9; p=0.88). The average time of patient in the operating room was significantly greater for the TVC (115.3 +/- 20.2 min) compared to LC (88.4 +/- 21.6 min, p=0.002). The OR preparation time (TV: 36.2 +/- 8.1min vs. LC: 22.5 +/- 5.1; p<0.001), operative time (TV: 115.3 +/- 21.6 min vs. LC: 82.4 +/- 19.8 min; p<0.001) and emergence time (TV: 17 min vs. LC: 10.5 min; p=0.04) were significantly greater for the TVC compared to LC. The OR opioid use was significantly greater for the TV group (TV: 31.8 +/- 10.7mg vs. LC: 25.6 +/- 6.9mg; p=0.04), however, after adjusting for OR time the difference in OR opioid between two groups becomes non-significant (p=0.09). Interestingly, while the average (PACU) time was significantly greater for the TVC group (195.7 +/- 88.9 min vs. 141.7 +/- 61.6 min, p=0.03), the average opioid use with significantly less for the TV group (0mg, range 0-2.5) compared to LC group (6.3mg, range 0-9.5), p=0.01. The overall opioid use (OR + PACU) was not significantly different between the groups (TV: 33.6 +/- 10.1mg vs. LC: 31.6 +/- 7.3mg; p=0.48). The average PACU pain Visual Analogue Pain Score was not statistically significantly different between the TVC and LC groups (p=0.51).
Conclusion: There was significantly less use of opioids in the PACU period for the TVC group despite no difference shown in Visual Analogue Pain scores. Additionally, significantly greater OR prep, operative, emergence and PACU time was required for patients undergoing the TVC approach. This retrospective analysis of transvaginal cholecystectomy patients suggests that there is indeed less postoperative pain measured by the reduced opioid use after transvaginal NOTES cholecystectomy.