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Reducing Postoperative Pain After Tubal Ligation With Rings or Clips: A Systematic Review and Meta-analysis

Harrison, Margo S. MD; DiNapoli, Marianne N. MD; Westhoff, Carolyn L. MD

doi: 10.1097/AOG.0000000000000342
Contents: Review
Journal Club

OBJECTIVE: To assess the effectiveness of using local anesthesia during interval laparoscopic tubal ligation to control postoperative pain.

DATA SOURCES: We searched MEDLINE, PubMed, and Cochrane databases and found additional articles from bibliographies of relevant studies.

METHODS OF STUDY SELECTION: We included only randomized, double-blind, placebo-controlled trials reporting postoperative pain after interval laparoscopic tubal ligation under general anesthesia (n=20). The trials compared the application of topical or injectable local anesthetic with placebo and used a visual analog scale (VAS) (scores 0–100) or the Modified McGill Pain Intensity Scale (subsequently converted to a VAS) to assess pain.

TABULATION, INTEGRATION, AND RESULTS: Pain scores were evaluated at the following times after extubation: 30 minutes, 1 hour, 2 hours, 4 hours, 8 hours, and 24 hours. The meta-analysis was based on random-effects methods for pooled data using RevMan. Postoperative pain decreased with the use of local anesthetic compared with placebo as follows (mean VAS decrease in millimeters, 95% confidence interval): 30 minutes 18.6 (11.7–25.5); 1 hour 16.6 (9.3–24.0); 2 hours 17.4 (9.6–25.2); 4 hours 12.5 (5.1–19.9); 8 hours 11.9 (6.7–17.1); and 24 hours 3.9 (−1.4 to 9.2). There was moderate heterogeneity in the data across studies (I2 statistic ranging from 55% to 75%). The effect size was similar for the following subgroups: pain scores reported as means or medians and use of McGill compared with VAS pain scales. A stratified analysis of trials including ring tubal ligation compared with clip tubal ligation showed the use of local anesthetic decreased pain substantially for both. No eligible studies assessed tubal ligation with cautery.

CONCLUSION: Use of local anesthetic during laparoscopic tubal ligation substantially reduces postoperative pain up to 8 hours after surgery.

Applying local anesthetic to the fallopian tubes significantly reduces pain after laparoscopic tubal ligation for at least 8 hours compared with placebo.

Department of Obstetrics & Gynecology, Columbia University Medical Center, and the Department of Epidemiology, Mailman School of Public Health, New York, New York.

Corresponding author: Carolyn L. Westhoff, 630 W 168th Street, New York, NY 10032; e-mail:

Financial Disclosure Dr. Westhoff has served on the scientific advisory board for Agile Therapeutics. She has also served on the data safety monitoring board for several U.S. Food and Drug Administration (FDA)/European Medicines Agency (EMA)-mandated, phase 4 safety studies of newly marketed Merck contraceptive products as well as the data safety monitoring board of several FDA/EMA-mandated, phase 4 safety studies of novel Bayer contraceptive products. The other authors did not report any potential conflicts of interest.

© 2014 by The American College of Obstetricians and Gynecologists.