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the small details that influence postoperative pain

Ituk, Unyime; Habib, Ashraf S.

European Journal of Anaesthesiology (EJA): February 2017 - Volume 34 - Issue 2 - p 111–112
doi: 10.1097/EJA.0000000000000570

From the Department of Anesthesia, University of Iowa, Iowa City, Iowa (UI) and Duke University Medical Center, Durham, North Carolina, USA (ASH)

Correspondence to Ashraf S. Habib, Department of Anesthesia, Duke University Medical Center, Box 3094, Durham, NC 27710, USA. Tel: +1 9196682024; fax: +1 9196814698; e-mail:


We appreciate Stark and colleagues’ interest in our article1 and their comments regarding the potential impact of the surgical technique used on pain following caesarean delivery.2 We agree that there are data suggesting improved postoperative pain outcomes with the Misgav Ladach approach, which was confirmed in a recent meta-analysis.3

There were indeed some differences in surgical techniques across the studies included in our meta-analysis. However, the surgical technique was reported as being standardised in 16 of the 21 individual studies, with 14 studies reporting using a Pfannenstiel incision and two using the Misgav Ladach method. Although the other five studies did not report the surgical technique used, it is likely to be standardised as all included studies were single-centre studies. As there was expected clinical heterogeneity among the included studies, we used a random effects model in our analysis. A random effects meta-analysis model involves an assumption that the effects being estimated in the different studies are not identical, but follow some distribution. The summary effect in this model therefore represents our estimate of the mean of all relevant true effects. Study weights in the random effects model are assigned with the goal of minimising sampling errors both within study and across studies. This model therefore provides a better representation of the different effect sizes of the studies included in our meta-analysis.4 A subgroup analysis including only studies that used a Pfannenstiel incision or the Misgav Ladach method revealed a statistically significant reduction in 24-h opioid consumption with both techniques, with no difference in effect sizes between the two subgroups (Fig. 1). The effect on pain scores was minimal, and not clinically or statistically significant in those two subgroups. Those results are comparable with the pooled results that included all studies that were presented in our meta-analysis.

Fig. 1

Fig. 1

Postoperative pain after caesarean delivery is complex and is affected by a number of patient, surgical and anaesthetic factors. We agree that the surgical technique should be described and its standardisation considered in future studies assessing postoperative pain following caesarean delivery, including studies on the efficacy of local anaesthetic wound infiltration.

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1. Adesope O, Ituk U, Habib AS. Local anaesthetic wound infiltration for postcaesarean section analgesia: a systematic review and meta-analysis. Eur J Anaesthesiol 2016; 33:731–742.
2. Stark M, Mynbaev O, Tinelli A, Malvasi A. The small details that influence postoperative pain. Eur J Anaesthesiol 2017; 34:110–111.
3. Gizzo S, Andrisani A, Noventa M, et al. Caesarean section: could different transverse abdominal incision techniques influence postpartum pain and subsequent quality of life? A systematic review. PLoS One 2015; 10:e0114190.
4. Berkey CS, Hoaglin DC, Antczak-Bouckoms A, et al. Meta-analysis of multiple outcomes by regression with random effects. Stat Med 1998; 17:2537–2550.
© 2017 European Society of Anaesthesiology