Bilateral Ultrasound-Guided Erector-Spine Plane Block Versus General Anesthesia for Operative Hysteroscopic Polypectomy

Abstract

Objective:

Operative hysteroscopic polypectomy requires adequate intraoperative anesthesia and postoperative analgesia; both can cause complications. The ultrasound-guided erector spinae plane (ESP) block affects both visceral and somatic nerve fibers. When performed bilaterally, this block has similar effects as epidural analgesia, but with a low complication rate. This study assessed ESP blocking for hysteroscopic polypectomy and postoperative analgesia.

Materials and Methods:

For this randomized, controlled double-blinded study, 66 patients undergoing hysteroscopic polypectomy were randomized into 2 groups (33 subjects each). Group 1 received the ESP block plus a paracervical block (PCB) and group 2 received general anesthesia plus a PCB. The time to complete cervical dilation and total time of the procedure were recorded. Intraoperative monitoring of vital signs, behavioral observational pain score, and rescue dose of propofol were also recorded in addition to postoperative pain on a numeric rating scale (NRS) at 15 minutes; and 3, 6, 9, 12, and 24 hours postoperatively.

Results:

Compared to group 2, group 1's behavioral observational scale scores were decreased significantly; dilation time was significantly shorter; and NRS scores were lower, with lower analgesia needs 24 hours post-surgery. Total operative times were comparable in both groups.

Conclusions:

A bilateral ESP block was successful for hysteroscopic polypectomy as a method of anesthesia, with satisfactory intraoperative and postoperative analgesic effects.

Introduction

Operative hysteroscopy has become the standard treatment for endometrial polyps.^1,2 Cervical dilation and uterine intervention during hysteroscopic polypectomy require general anesthesia (GA) with or without local anesthetic injections, such as a paracervical block (PCB).^3–5 GA can cause major costs and some risks, such as hemodynamic instability, laryngospasm, bronchial asthma, and an allergic reaction to GA medications.^6,7 Women undergoing operative hysteroscopy with intrauterine procedures typically require additional pain control beyond that provided by a PCB.⁸ The postoperative pain can be severe enough to require the administration of high doses of opioids. Opioids can lead further to some adverse effects, such as drowsiness and respiratory impairment as well as nausea and vomiting.⁹

The erector spinae comprises a set of muscles and tendons that extend through the lumbar, thoracic, and cervical areas.¹⁰ It is in the lateral sulcus of the spine and includes the iliocostalis, longissimus, and spinalis muscles. As the erector spinae extends throughout the lumbar region, an erector spinae plane (ESP) block can produce abdominal analgesia.¹¹ The ultrasound (US)–guided ESP block is a novel truncal interfacial block technique providing analgesia of the thoracic or abdominal segmental innervation, depending on the level of administration.¹² Local anesthetic penetrates anteriorly, presumably through the costotransverse foramina to the paravertebral space. An ESP block is a good alternative to other invasive techniques, because the blockade can be performed easily and has a low complication rate.¹³ Also, the ESP block can be used in postoperative pain treatment, because the ESP block produces a central blocklike analgesia.^11–14

The aim of the current study was to assess ESP + PCB as a reliable method of anesthesia and postoperative analgesia for operative hysteroscopic polypectomy, compared to GA + PBC in terms of intraoperative anesthetic effects, procedure time, and patients' postoperative pain perception and analgesic drug requirements.

Materials and Methods

This study was conducted between April 2016 and June 2018. The study was designed as a randomized, double-blinded comparative study. The participants were married women ages 20–40 who had abnormal uterine bleeding and transvaginal sonographic reports of intracavity uterine polyps. These patients were selected to undergo operative hysteroscopy for endometrial polypectomy and had American Society of Anesthesiologists (ASA) physical statuses of I, II, and III. Official approval by the local ethics committee was obtained. After proper counseling and discussion, written, informed consents were also obtained from the patients during preanesthetic clinic visits before any study-related tests were performed.

The selected patients were randomized into 2 groups: (1) ESP block + PCB and (2) GA +PCB. All of the hysteroscopic interventions and PCBs were performed by the same surgeon, and the anesthesia procedures (GA and ESP block) were all performed by the same anesthesiologist.

Upon ward admission, a random ID was assigned to each patient. Simple randomization in the operating room was performed, using the closed-envelope method to determine each patient's group. The random ID was used when collecting all patient data in the ward postoperatively. These data were therefore collected blindly. The anesthesiologist performing the simple randomization also performed the block but did not play any role in the collection of postoperative data or in their analysis.

Exclusion criteria included severe cardiovascular diseases, severe coagulopathies, mental diseases, allergy to local anesthetics, clinical conditions with abdominopelvic pain that could confuse the perception of pain (endometriosis, fibroid uterus, or chronic pelvic pain), being unable to comprehend a numeric rating scale (NRS), and disagreement with the study protocol.

The primary outcome was intraoperative anesthetic efficiency measured by a behavioral observational pain score. The secondary outcomes were operative time, vital signs, postoperative analgesia, and postoperative back pain and shoulder pain.

When each patient arrived in the operating room (OR), she had a 20-G cannula needle inserted and was premedicated intravenously (IV) with midazolam (0.02 mg/kg).

Anesthesia application

ESP block + PCB (group1)

Following routine monitoring recording (i.e., blood pressure [BP], heart rate [HR], and arterial oxygen saturation [using pulse oximetry]), each patient was placed in a sitting position. The ESP block was performed under ultrasonographic (USG) guidance using a linear 6–10-MHz US probe (Mindray DP 9900 plus, Mindray Bio-Medical Electronics, Shenzhen, China). According to the technique described by Forero et al.¹⁵ The linear US transducer was placed on a longitudinal parasagittal plane 3 cm lateral to the L-2 spinous process. In the current study, the injection was done at the level of L-2 to address pain arising from the pelvic structure.

The erector spinae muscles were identified superficial to the tip of the L-2 transverse process. The patient's skin was anesthetized with 3 mL of 2% lidocaine. A 21-gauge, 10-cm needle (Stimuplex,^® A–B Braun, Melsungen, Germany) was inserted, using an in-plane superior-to-inferior approach. The tip of the needle was placed into the fascial plane on the deep (anterior) aspect of the erector spinae muscles. The location of the needle tip was confirmed by a visible fluid spread lifting the erector spinae muscles off the bony shadow of the transverse process, shown on USG imaging. A total of 20 cc of 0.025% bupivacaine was injected. The same procedure was repeated for the opposite side. Then the patient was positioned in a lithotomy position.¹⁵

GA + PCB group (group 2)

Each patient was taken to the OR and placed in a supine position. Standard monitoring devices (electrocardiogram, oximeter, BP, etc.) were applied, and all parameters were assessed before the procedure (i.e., BP, HR, and arterial oxygen saturation, using pulse oximetry). All patients received general anesthesia with propofol (2–3 mg/kg) and fentanyl (0.3–0.6 μg/kg), both IV. A laryngeal mask airway was inserted, and anesthesia was maintained with sevoflurane and nitrous oxide in oxygen, and with spontaneous breathing. A rescue dose of propofol (50 mg) was given according to the patient's behavioral observational pain score.^16,17

PCB

The PCB was performed in both groups by a gynecologic surgeon, with each patient in a lithotomy position. A 22-G atraumatic spinal needle (DURA JECT^® I, Sterylab, Milan, Italy) was connected with a 20-mL syringe containing 10 mL of 2% buffered lidocaine that was injected (Laboratorio Farmacologico Cenate Sotto, Bergamo, Italy). The cervicovaginal fornix was located using the examining finger, and the injections were performed at the 3 o'clock and 9 o'clock positions. Intermittent aspiration was performed before and during the injection to ensure that the paracervical blood vessels were not punctured.⁴

Operative hysteroscopic polypectomy technique

The hysteroscopic procedures were performed in each patient's follicular phase of her menstrual cycle. The hysteroscopy was performed with a standard, 9-mm, continuous-flow gynecologic resectoscope, with a 9.0-mm straightforward (0°) telescope (Hopkins^® II telescope; Karl Storz, Tuttlingen, Germany) fitted with a 24F cutting loop (Karl Storz). Uterine distention and irrigation were performed with a solution of 1.5% glycine and 1.5% mannitol, and a suction-irrigating unit (Hysteromat, Karl Storz) was used to provide positive pressure (80 mm Hg) and continuous-outflow suction control (0.5 bars) to avoid fluid overload.

To evaluate the time-consuming aspect, an outside observer, who was blind to the anesthetic technique, recorded the operative time. All of the patients were shielded by a green towel, so the observer was completely blind to the type of anesthesia used. Two specific checkpoints were fixed: time 1, dilation of the cervix from the insertion of the tenaculum on the cervix to the end of the Hegar dilatator (no 9½); and time 2, time to perform the procedure from the insertion of the resectoscope (Karl Storz) in the uterine cavity to the complete removal of the hysteroscopy.

Intraoperative monitoring of vital signs of each patient's BP, HR, respiratory rate, arterial oxygen saturation, and behavioral observational pain score (facial expiration, restlessness movement, vocalization, muscle tone) were all recorded. The given rescue dose of propofol was also recorded. Postoperative evaluation of the patient's pain was performed with an 11-point NRS, with 0 representing one pain extreme (“no pain”) to 10 representing the other pain extreme (“pain as bad as you can imagine” or “worst pain imaginable”).^18,19 Recordings were made at 15 minutes post-operation in the recovery room, and at 3, 6, 9, 12, and 24 hours postoperation in the ward with a nurse totally blind to the technique of anesthesia. The number of patients who experienced back pain and shoulder pain was recorded in each group. The signs and symptoms of any intra- or postoperative complications related to anesthetic procedure or surgical techniques for 24 hours were documented. The first time to an analgesic requirement was recorded in minutes in both groups, and the total analgesic requirements in 24 hours were also recorded. A dose of IV meperidine (0.5 mg/kg) was administered if a patient's NRS score was ≥4.

Complications of surgical procedures or anesthetic techniques were observed and investigated during the operations and postoperative timeperiods.

Statistical analysis

Statistical analysis was performed, using SPSS Statistical Package, programmed version 19 (IBM Corp., Armonk, NY). A Student's t-test, χ² test, and Mann–Whitney-U test were used for statistical analysis, as appropriate. Data were presented as a mean ± standard deviation (SD), numbers, and frequencies, as appropriate. Statistical significance was determined at p < 0.05. The sample size was calculated with a 95% confidence interval, 80% power, and assuming Q1 = Q2 = 0.6 in terms of the behavioral observational pain score, to find a 0.5-unit difference between the 2 groups. Each group required 30 samples, and 33 samples were included in each group to raise the test power and compensate for patient dropouts.

Results

Sixty-six patients were enrolled in the study, with 33 patients in group 1 (ESP + PCB) and 33 patients in group 2 (GA + PCB). Demographic characteristics of these participants are shown in Table 1. The groups were homogeneous without significant differences in age, weight, height, body mass index, and ASA staging. The preoperative baseline vital signs of the enrolled participants, as shown in Table 2, were not significantly different in HR, mean arterial BPS, respiratory rates, and arterial oxygen saturation percentages.

Table 1.

Demographic Characteristics of Participants

	Group 1 (ESP block + PCB)	Group 2 (GA + PCB)
Variables	n = 33	n = 33
Age (yr)	36.2 ± 8.1	35.7 ± 6.9
Weight (kg)	74.3 ± 16.1	75.1 ± 18.2
Height (cm)	168.3 ± 11.9	166.9 ± 12.7
BMI (kg/m²)	26.32 ± 2.72	26.90 ± 2.52
Endometrial polyp size (cm²)	2.201 ± 0.611	2.195 ± 0.550
ASA I (stage)	22/27	23/27
ASA II (stage)	4/27 (14.8%)	3/27 (11.1%)
ASA III (stage)	1/27 (3.7%)	1/27 (3.7%)

Data are presented as mean ± standard deviation, and numbers and percentages and were analyzed using Student's t-test or χ² test as appropriate.

All analysis showed nonsignificant differences between the 2 groups; p > 0.05

ESP, erector spinae plane; PCB, paracervical block; GA, general anesthesia; yr, years; BMI, body mass index; ASA, American Society of Anesthesiologists,

Table 2.

Mean Values of Baseline Vital Signs

	Group 1 (ESP block + PCB)	Group 2 (GA + PCB)
Vital signs	n = 33	n = 33
HR (bpm)	77.8 ± 7.2	78.6 ± 6.3
Mean BP (mm Hg)	85.4 ± 5.6	87.4 ± 4.9
Respiratory rate (breaths/min)	17.92 ± 2.7	17.4 ± 4.1
Arterial oxygen saturation (%)	99.31 ± 0.72	99.25 ± 0.77

Data are presented as mean ± standard deviation, and were analyzed using Student's t-test.

All analyses showed nonsignificant differences between the 2 groups; p > 0.05

ESP, erector spinae plane; PCB, paracervical block; GA, general anesthesia; HR, heart rate; bpm, beats per minute; BP blood pressure; min, minute.

According to the results shown in Table 3, cervical dilation time was significantly shorter in group 1, with a mean ± SD of 2.1 ± 3.5 minutes (range: 1–11 minutes), compared to group 2 with a mean ± SD of 5.3 ± 6.9 minutes (range: 1–20 minutes); P < 0.05. Yet, the total operative times and infusion volumes needed for uterine distension were nonsignificantly different in both studied groups. No surgical complications (cervical lacerations or uterine ruptures) were observed, and all patients were discharged to go home in good general condition. The ESP block was performed successfully for all patients in group 1; complications (bleeding and subcutaneous emphysema) were not observed in any patient during intervention or at 24 hours postoperatively.

Table 3.

Intraoperative Findings Related to Hysteroscopy Procedure

	Group 1 (ESP block+ PCB)	Group 2 (GA + PCB)
Variables	n = 33	n = 33	p
Cervical dilation time (min)^a	4.6 (1–11)	6.9 (1–20)	0.0363^*
Total procedure time (min)^a	13.6 (8–27)	15.0 (7–29)	0.3229
Volume infused of distention media (mL)^b	1560 ± 430	1630 ± 390	0.5337

Significant, p < 0.05.

Cervical dilation time and total procedure time are presented as median (range) were analyzed using a Mann–Whitney–U test.

Distention media volumes, presented as mean ± standard deviation (range), were analyzed using Student's t-test.

p > 0.05 = (nonsignificant difference between groups).

ESP, erector spinae plane; PCB, paracervical block; GA, general anesthesia; min, minutes.

The intraoperative HR and systolic BP (SBP) changes during different steps of the procedures (before PCB, then with the starts of 15 and 30 minutes of the cervical-dilation procedure) were recorded and compared between both groups (Table 4). There was a significant increase in HR and SBP from the start of the cervical dilation, at 30 minutes after cervical dilation, and at the end of the procedure in group 2, compared to group 1; p < 0.05.

Table 4.

Intraoperative Changes in Vital Signs

	Group 1 (ESP + PCB)	Group 2 (GA + PCB)
Vital signs	n = 33	n = 33	p
HR
• Before PCB	73.3 ± 4.7	74.0 ± 3.8	0.5499
• At start of cervical dilation	74.0 ± 6.8	80.3 ± 6.6	0.0011^*
• After 15 min of start of cervical dilation	72.1 ± 8.2	78.7 ± 9.3	0.0078^*
• After 30 min of start of cervical dilation	71.8 ± 8.1	77.4 ± 11.0	0.0379^*
Mean BP (mm Hg)
• Before PCB	91.53 ± 12.20	90.54 ± 12.80	0.7723
• At start of cervical dilation	101.33 ± 11.67	126.57 ± 13.39	<0.0001^*
• After 15 min of start of cervical dilation	93.82 ± 13.80	118.60 ± 13.16	<0.0001^*
• After 30 min of start of cervical dilation	90.42 ± 14.63	119.60 ± 13.19	<0.0001^*

Significant, p < 0.05.

Data are presented as mean ± standard deviation and were analyzed using Student's t-test.

ESP, erector spinae plane; PCB, paracervical block; GA, general anesthesia; HR, heart rate; min, minutes; BP, blood pressure.

Table 5 shows that group 1 had a lower statistically significant number of patients with high behavioral observational pain scores (facial expiration, restlessness movement, vocalization, consonability, muscle tone), compared with group 2 (p < 0.05) and in the number of patients whom received rescue doses of propofol. Propofol was needed in only 3/33 cases in group 1, compared to 16/33 cases in group 2; p < 0.05.

Table 5.

Intraoperative Behavioral Observational Pain Scores Related to Anesthesia Techniques

	Group 1 (ESP + PCB)	Group 2 (GA + PCB)
Variables	n = 33	n = 33
Facial expiration (n)	3/33 (7.4%)	6/33 (18.5%)^*
Restlessness movement (n)	5/33 (14.8%)	9/33 (29.6%)^*
Vocalization (n)	3/33 (7.4%)	5/33 (14.8%)^*
Consolability (n)	3/33 (7.4%)	19/33 (66.6%)^*
Muscle tone (n)	4/33 (11.1%)	16/33 (55.5%)^*
# of patients who received rescue dose of propofol	3/33 (7.4%)	16/33 (55.5%)^*

Significant, p < 0.05.

Data are presented as ratios (percentages) and were analyzed using a χ² test.

ESP, erector spinae plane; PCB, paracervical block; GA, general anesthesia.

Statistical analysis of the mean values of postoperative NRS scores showed a significant decrease in group 1 at 15 minutes in the recovery room; then at 3, 6, 9, 12, and 24 hours in the postoperative follow-up timeperiod, compared to group 2 (Table 6). The time to first pethidine requirement as a narcotic medication was 23.5 ± 3.8 minutes in group 2 and 178.5 ± 45.6 minutes in group 1; p < 0.05). The mean 24-hour pethidine dose requirement was also higher in group 2, compared to group 1 (320.05 ± 10.6 mg for group 2 and 210.05 ± 20.5 for group 1) with a statistically significant difference between both groups; p < 0.05.

Table 6.

Postoperative Procedure

Variables	Group 1 (ESP + PCB)	Group 2 (GA + PCB)
Variables	n = 33	n = 33	p
NRS (n)
15 min in recovery	0.44 ± 0.35	0.96 ± 0.73	0.0016
3 hr	0.54 ± 0.5	6.0 ± 1.66	<0.0001^*
6 hr	0.77 ± 0.75	4.59 ± 1.09	<0.0001^*
9 hr	0.95 ± 0.84	3.45 ± 1.01	<0.0001^*
12 hr	2.8 ± 0.9	3.7 ± 0.7	<0.0001^*
24 hr	2.4 ± 0.79	3.2 ± 0.42	<0.0001^*
Postsurgery narcotic use
Time to first pethidine requirement (min)	178.5 ± 45.6	23.5 ± 3.8	<0.001^**
Mean 24-hr pethidine requirement (mg)	210.05 ± 20.5	320.05 ± 10.6	<0.01^*
Back pain (n)	5/33 (14.8%)	21/33 (74.0%)	<0.0001^*
Shoulder pain (n)	6/33 (18.5%)	19/33 (66.6%)	<0.0001^*

Significant: p < 0.05; ^** highly significant: p < 0.001.

Data are presented as mean ± standard deviation and ratio (percentages) and were analyzed using Student's t-test and χ² test as appropriate.

ESP, erector spinae plane; PCB, paracervical block; GA, general anesthesia; NRS, numeric rating scale; min, minutes; hr, hours; n, number.

Discussion

Pain during hysteroscopic polypectomy is mainly generated by cervical dilation and uterine distention; the cervix and uterus are insensitive to hot or fine touch stimuli but are sensitive to distension.²⁰ The pelvic autonomic system is comprised of the superior and inferior hypogastric plexuses. The inferior hypogastric plexus is formed by contributions from the hypogastric nerves, the pelvic splanchnic nerves, and the sacral sympathetic chain. Accordingly, the inferior hypogastric plexus is a mixed plexus that consists of both sympathetic and parasympathetic fibers that are distributed to all pelvic viscera and to the erectile structures in the perineum.^21–23

Most women are able to undergo diagnostic hysteroscopy without general anesthesia.²⁴ The benefits of not using anesthesia include no adverse medication reactions, reduced procedure time and cost, and avoidance of a pain-inducing paracervical block.^15,25–27 Not using anesthesia appears particularly appropriate for diagnostic procedures using a hysteroscope that is <4 mm in diameter.²⁰ Anesthetic management is necessary for surgical hysteroscopic procedures. To ensure complete anesthesia during hysteroscopy, a block of the sensory levels from T-8 to S-5 is required.²⁸ Options include IV medication (i.e., conscious sedation) and regional or general anesthesia, with or without PCB.

PCB consists of an injection of anesthetic around the cervix at a depth of ∼4 mm, reaching the second to fourth sacral nerve roots passing through Frankenhäuser's plexus.⁴ Paracervical anesthetics block transmission of pain through sympathetic, parasympathetic, and visceral sensory fibers before they enter the uterus at the level of the internal os.²⁵ The anatomical basis for the paracervical block is that the upper vagina, cervix, and lower uterus are innervated by the uterovaginal (or Frankenhäuser) plexus, which contains fibers derived from the inferior hypogastric (pelvic) plexus (T-10–L-1) and sacral nerve roots (S-1–S-4). Previous published studies proved the limitation of PCB for control of pain during intrauterine operative procedures in conscious women.^5,17

A US-guided ESP block is a regional anesthesia technique, described by Forero et al., in 2016.¹⁵ The ESP block is one of the pain-management procedures for patients of all age groups (children, adolescents, and adults) undergoing abdominal and thoracic surgeries.^11,12,23 The US-guided ESP block is a relatively simple procedure to perform, with sonographic, easily identified landmarks and endpoints for needle placement and local anesthetic drug injection.¹⁴ This block has been reported to produce an analgesic effect on somatic and visceral pain by affecting the ventral rami and rami communicants that include sympathetic nerve fibers, as local anesthetic drugs spread cranially and caudally through the paravertebral space.^12,27 The ESP block can induce effective postoperative analgesia when performed at a T-4–T-5 level for thoracic surgery, and a T-7 level for abdominal surgeries.^13,16

The current study hypothesized that ESP blockade could be used effectively as an analgesic method for an intrauterine procedure, especially if combined with a PCB. The ESP block has been effective as an analgesic method for laparoscopic inguinal hernia repair.²⁸ The ESP block requires injection of local anesthetic agents into the paraspinal tissues, which are far away from the pleura and neuraxial structures; thus, the risks of tissue damage and complications are minimal. Complications of ESP block have not been reported in 2016 and 2017; however a pneumothorax after an ESP block was reported in 2018.¹⁴

When performed bilaterally, ESP blockade has a similar effect as epidural analgesia.^13,29 The ESP block represents a simpler, possibly safer alternative to epidural or paravertebral thoracic blocks, because the transverse process—which represents the ultrasonic target—is easy to visualize and the point of injection is far from the neuroaxis, pleura, and large vascular structures.¹⁴ In addition, the extensive craniocaudal diffusion of the anesthetic allows wide coverage with a single injection, allowing the approach to occur at points relatively distant from the surgical zone.¹⁴ For abdominal surgery, the block has been performed at the level of T-7 and its effect showed extension from the T-6 to the T-12,^12,28 whereas injection of 20 mL of contrast material at T-7 in cadavers showed extensive craniocaudal spread between the levels of the C-5–T-2 and L2–L3 transverse processes.²⁸ Consequently, hysteroscopic polypectomy needs anesthesia coverage at T-8.

The US-guided ESP block is an easy-to-perform peripheral nerve block that provides long-lasting postoperative analgesia. It has been used successfully in laparoscopic procedures, such as cholecystectomy, and should be kept in mind as an option for multimodal analgesia for children.³⁰ In 2018, Tulgar et al. reported 3 cases of ESP block performed successfully in patients undergoing various laparoscopic abdominal surgical procedures (laparoscopic cholecystectomy or laparoscopic inguinal-hernia repair).²⁸ In 2018, a study by Luis-Navarro et al. used an intraoperative ESP block to reduce the need for IV analgesics during surgery and laparoscopic nephrectomy with a high success rate and no complications.²⁹

To the current authors' knowledge, the current study is the first on ESP blockade in an operative hysteroscopic procedure. Most studies of ESP have only been performed with a small number of patients and some of them were not randomized. However, much of the research up to now has not involved use of an ESP block for a pelvic procedure.

The current study showed better intraoperative satisfaction of the patients the ESP block was used as an alternative for GA; this was reflected by the time needed for cervical dilation and the total time needed for the procedure that were statistically significantly lower. In the postoperative period, the pain score and total consumption of analgesia were reduced significantly with the ESP block, compared to GA. The ESP block is an easy, reliable sonographic technique that benefits the neuraxial block with less risk of hemodynamic instability and postdural puncture headache in addition to inducing less back pain and shoulder pain, which usually follows gynecologic endoscopic procedures.

It appears that the cost of an ESP block is higher because of the need for US guidance. Yet, Bowling reported that enhanced recovery pathways have valuable economic benefits. These include reducing postoperative pain and opioid consumption, and shortening length of hospital stays by 30%–50%, with similar reductions in complications and readmissions.³⁰

One of the weak points of the current study was that assessment of back pain and shoulder pain in the postoperative timeperiod made use of a subjective pain-response sign; no objective tool was used for this assessment.

Conclusions

Although the number of randomized clinical studies about the ESP block is limited, promising results were reported in this current study, showing successful use of bilateral ESP blockade for hysteroscopic polypectomy with satisfactory intraoperative and postoperative analgesic effects. Further studies in this context are highly recommended.

Footnotes

Author Disclosure Statement

No financial conflicts of interest exist.

Funding Information

No funding was received for this article.

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