Preemptive Analgesia in Minimally Invasive Gynecologic Surgery.

Preemptive analgesia is an intervention provided before initiating painful stimuli that may reduce or prevent subsequent pain. This systematic review examines the evidence supporting the practice of preemptive analgesia in minimally invasive gynecologic surgery (MIGS). We searched PubMed, Cochrane Register for Controlled Trials, and Embase from inception through February 26, 2018. The search was limited to human and English language studies. A total of 324 studies were identified. The abstracts were screened for relevance for minimally invasive gynecologic surgery (MIGS) and preemptive analgesia. The final trials reviewed were restricted to randomized controlled trials of preemptive medications given before the completion of MIGS surgery. Preemptive blocks (including paracervical, triple antibiotic paste, and pudendal) appear to have the most consistently beneficial effect on postoperative pain in MIGS with an excellent cost-benefit ratio, with the exception of liposomal bupivacaine, which requires further evaluation to determine if its added cost delivers better outcomes. Preemptive anticonvulsants, ketamine, and dexmedetomidine have a positive effect on postoperative pain and opioid use but are limited by side effects. Preemptive dexamethasone, acetaminophen, and nonsteroidal anti-inflammatory drugs have a modest effect on postoperative pain control. Despite these findings, additional quality work is needed to find more definitive methods of preemptive pain control for MIGS.