MMed, Faculty of Health Sciences, University of the Witwatersrand / Postoperative pain is prevalent and not optimally managed in most patients. Pain can lead to adverse emotional and systemic consequences. Numerous device orientated studies have been done in other countries looking at the effect of infusions of local anaesthetic at the wound site postoperatively via an elastomeric pump. There have however been no similar studies done in South Africa. The aims of this study was to assess whether the use of an incisional wound catheter and 0.39% bupivacaine infusion in patients post total abdominal hysterectomy for a 30 hour period will decrease opioid requirements compared to a control group having only systemic analgesia. Pain intensities were also documented at set observation periods. The opioid requirements between the 2 groups were comparable however the participants who had the bupivacaine infusion in their incisional site had less pain intensity scores until 6 hours post operation and had less pain intensity on movement at 30 hours post operation. A bupivacaine infusion in the incisional site decreases pain intensity in the above mentioned parameters but does not reduce opioid requirements.

Hysterectomy is the second highest frequency of gynecologic surgery. With limited medical resources, understanding of qualities and expenses of different types of surgery can be used as a reference for patients and hospital administrators in making related decisions. Therefore, the purpose of this study is to compare the outcomes between ¡§Total Abdominal Hysterectomy¡¨ and ¡§Laparoscopic Hysterectomy¡¨. Data sources are the health insurance report data files and charts of a regional teaching hospital. There were 114 cases between January 2006 and June 2010 at the sample hospital. Operating time, length of stay, and intra-operative blood loss between both types of hysterectomy are analyzed and compared by using t-test. Linear regression analysis is then used to examine the predictive factors that impact the outcomes of both types of surgery. The results indicate that, in terms of clinical results, laparoscopic hysterectomy takes 120.45 minutes on average, and total abdominal hysterectomy 104.35 minutes; laparoscopic hysterectomy requires an average of 4.73 days of hospital stay, and total abdominal hysterectomy 5.54 days; and finally, laparoscopic hysterectomy causes an average of intra-operative blood loss of 249.70cc, and total abdominal hysterectomy 290.21cc, laparoscopic hysterectomy costs an average of NT$69,268.85, and total abdominal hysterectomy NT$46,634.88. In regard to hospitalization costs, laparoscopic hysterectomy costs an average of NT$49,732.50, and total abdominal hysterectomy costs NT$42,066.27. Based on findings of this study, the following suggestions are proposed: (1) Laparoscopic hysterectomy can be safely and effectively used for patients with large uterine myoma or multiple myoma. (2)Hospitals should develop standardized medical treatment procedures; therefore, cost control would not be at the expense of the quality of care. Furthermore, standardization of medical treatment can be used to pinpoint whether there is any waste in the medical treatment process. Keywords: uterine myoma, hysterectomy, total abdominal hysterectomy, laparoscopic hysterectomy, outcome.

Introduction: Hysterectomy is the most common major gynecological operation in the Western World and approximately 5000 benign hysterectomies are performed in Sweden every year. Consequently it is a surgical procedure that affects many women. The procedure comprises challenges concerning perioperative health care, perceived postoperative symptoms, quality of life aspects and health economics. The concept of fast track is a multimodal strategy to reduce hormonal surgical stress response and achieve an enhanced postoperative recovery and is today considered to be evidence based in relation to colorectal surgery. Spinal anesthesia, as an important part of fast track, provides benefits of extended effect on analgesia and reduced postoperative morbidity. It is reasonable to believe that employing the strategies of fast track including spinal anesthesia could also provide substantial benefits for women requiring surgical removal of the uterus. Aims: To determine whether duration of hospital stay, presence and intensity of postoperative symptoms, duration of sick leave and cost-effectiveness differ between women undergoing benign fast track abdominal hysterectomy in spinal anesthesia with intrathecal morphine (SA) and in standard general anesthesia (GA). Material & Methods: 180 women participated in this open randomized multicenter study with five participating hospitals in the southeast region of Sweden. One hundred and sixty two completed the study; 82 women were randomized to SA and 80 to GA. A fast track model comprising premedication without sedatives, intravenous fluid regulation, analgesics based on non-opioids, pre-emptive antiemetic therapy, early enteral nutrition and mobilization and standard criteria for discharge were used. End points were duration of hospital stay, use of analgesics, perceived postoperative symptoms, occurrence of postoperative complications, duration of sick leave and health economic evaluations. Results: Duration of hospital stay did not differ between the two modes of anesthesia. Vomiting and pruritus occurred significantly more often after SA. Complication rates did not differ between groups. Women with SA experienced less overall discomfort and had a reduced need for opioids postoperatively. Abdominal pain, drowsiness and fatigue occurred less often and with lower intensity among the women in the SA group. Health related quality of life improved faster and the duration of sick leave was shorter in women after SA. Total costs (hospital costs plus costs for productivity loss) were lower for the SA group. Within the first 29 days after hysterectomy the women in the SA group gained more QALYs than women in the GA group. Conclusions: The duration of hospitalisation after fast track abdominal hysterectomy was less than 50 hours and mode of anesthesia did not influence this. SA displayed considerable advantages regarding postoperative symptoms and recovery. SA was considered cost-effective in comparison with GA due to lower total costs and more QALYs gained. Our study indicates that SA should be recommended as the first choice of anesthesia in benign abdominal hysterectomy.