Abdominal hysterectomy is one of the most commonly performed gynecological procedures worldwide, second only to cesarean section in frequency. It involves surgical removal of the uterus, with or without the adnexa, depending on the underlying pathology [1]. The procedure is indicated for a variety of conditions including uterine fibroids, endometriosis, malignancy, chronic pelvic pain, abnormal uterine bleeding, and uterine prolapse, all of which significantly impact the quality of life of affected women .

Despite its therapeutic benefits, total abdominal hysterectomy (TAH) is associated with considerable postoperative pain, which can lead to delayed recovery, prolonged hospital stay, increased healthcare costs, and higher opioid consumption. Effective postoperative pain management is therefore essential to improve patient outcomes, enhance recovery, and reduce opioid-related adverse effects [2].

Postoperative pain is a complex physiological phenomenon that can be broadly classified into nociceptive and neuropathic types. Nociceptive pain, the most common form following surgery, arises from tissue injury and inflammation, whereas neuropathic pain results from nerve damage and is often more difficult to treat [3]. Furthermore, postoperative pain can be categorized based on duration into acute and chronic pain. Acute pain typically occurs immediately after surgery and is most intense within the first 24–48 hours, while chronic postoperative pain may persist beyond the healing period and significantly impair quality of life [4,5].

The management of postoperative pain is often challenging due to variability in individual pain perception, influenced by genetic, psychological, and sociocultural factors. In addition, concerns related to opioid use, including dependence, tolerance, and adverse effects such as nausea, vomiting, and respiratory depression, further complicate pain management strategies [4,6]. These limitations have led to increasing emphasis on alternative approaches that provide effective analgesia while minimizing opioid consumption.

Multimodal analgesia has emerged as a cornerstone in postoperative pain management. This approach involves the use of multiple analgesic agents and techniques targeting different pain pathways, thereby enhancing analgesic efficacy and reducing opioid requirements and associated side effects [7,8]. Among these strategies, local anesthetic techniques play a crucial role.

Local and regional anesthesia techniques are widely used for perioperative pain control. Local anesthesia provides targeted analgesia at the surgical site without affecting consciousness, whereas regional anesthesia blocks sensation over a larger area by targeting specific nerve pathways [9,10]. Techniques such as spinal anesthesia, epidural anesthesia, and peripheral nerve blocks have been shown to provide effective postoperative analgesia and reduce opioid consumption [11,12].

Local wound infiltration (LWI) with long-acting local anesthetics has gained popularity as a simple and effective method for postoperative pain control in abdominal surgeries. It involves the direct administration of local anesthetic into the surgical wound, providing site-specific analgesia with minimal systemic effects. Ropivacaine, a long-acting amide local anesthetic, is commonly used due to its favorable safety profile and lower cardiotoxicity compared to bupivacaine [13].

The mechanism of action of local anesthetics involves reversible blockade of voltage-gated sodium channels, thereby inhibiting nerve impulse conduction and preventing transmission of pain signals to the central nervous system [14,15]. However, the duration of analgesia provided by local anesthetics alone may be limited, necessitating the use of adjuvants to prolong their effect.

In recent years, the addition of adjuvants to local anesthetics has gained significant attention as a means to enhance the quality and duration of analgesia. Among these, dexmedetomidine, a highly selective α2-adrenergic agonist, has shown promising results due to its analgesic, sedative, and opioid-sparing properties. When used as an adjuvant, dexmedetomidine prolongs the duration of analgesia, improves pain control, and reduces postoperative analgesic requirements.

Given these advantages, the present study was undertaken to evaluate the efficacy of dexmedetomidine as an adjuvant to ropivacaine for local wound infiltration in patients undergoing total abdominal hysterectomy, with a focus on postoperative analgesia, analgesic consumption, hemodynamic stability, and side effects.

MATERIALS AND METHODS

Study Design and Setting

This prospective observational study was conducted in the Department of Anesthesiology and Critical Care at Government Medical College, Srinagar, over a period of three years (2022–2025), after obtaining institutional ethical committee approval.

Study Population

A total of 160 female patients scheduled for elective total abdominal hysterectomy (TAH) under general anesthesia were included in the study.

Inclusion Criteria

• Patients aged between 40–60 years
• American Society of Anesthesiologists (ASA) physical status I and II
• Patients undergoing elective total abdominal hysterectomy under general anesthesia
• Patients providing informed written consent

Exclusion Criteria

• Known hypersensitivity to study drugs (ropivacaine or dexmedetomidine)
• Patients with significant cardiovascular, hepatic, renal, or neurological disease
• Coagulation disorders
• Chronic opioid use or history of substance abuse
• Infection at the surgical site
• Patients unwilling to participate

Study Groups

Patients were divided into two groups (n = 80 each):

Group RD (Ropivacaine + Dexmedetomidine): Received local wound infiltration with ropivacaine combined with dexmedetomidine.

Group R (Ropivacaine): Received local wound infiltration with ropivacaine alone

Anesthetic Technique

All patients were premedicated as per institutional protocol. Standard monitoring including electrocardiography (ECG), non-invasive blood pressure (NIBP), heart rate (HR), and oxygen saturation (SpO2) was instituted.

General anesthesia was administered using a standardized technique. Following induction and endotracheal intubation, anesthesia was maintained with appropriate inhalational agents and muscle relaxants.

Intervention (Local Wound Infiltration)

At the end of surgery, prior to skin closure, local wound infiltration was performed:

Group RD: Ropivacaine with dexmedetomidine

Group R: Ropivacaine alone

The study drug was infiltrated along the surgical wound in a standardized manner.

Outcome Measures

Postoperative pain assessed using the Visual Analogue Scale (VAS) at 0, 6, 12, and 24 hours post operatively. 

Postoperative Analgesia Protocol

Rescue analgesia was administered when patients reported significant pain (VAS ≥ 4 as per institutional protocol). The timing and total dose of analgesics required within 24 hours were recorded.

Statistical Analysis

Data were entered and analyzed using appropriate statistical software. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were expressed as frequency and percentage. Chi-square test was used for categorical variables. Independent t-test was used for continuous variables. A p-value < 0.05 was considered statistically significant

RESULTS

The two groups were comparable at baseline. The distribution of ASA physical status did not differ significantly between groups (p = 0.526), and the overall burden of comorbidities was also similar (p = 0.869). Age distribution was comparable as well, with the largest proportion of patients belonging to the 41–50 years age group [Table 1].

Table 1. Baseline demographic and clinical characteristics

Postoperative pain scores were consistently lower in the dexmedetomidine group across all time points. At 0 hour, analgesia was markedly better in the dexmedetomidine group, where 90% of patients had a pain score of 0, compared with only 1.3% in the ropivacaine-only group (p < 0.001). At 6 hours, the dexmedetomidine group still showed better pain control, with the most frequent score being 2, whereas the ropivacaine group most commonly recorded a score of 3 (p = 0.010). By 12 hours and 24 hours, pain scores remained significantly lower in the dexmedetomidine group, although pain gradually increased in both groups over time.

Table 2. Postoperative pain scores by study group

The requirement for rescue analgesia was significantly reduced in the dexmedetomidine group. In this group, 21.3% of patients did not require rescue analgesia, compared with 2.5% in the ropivacaine-only group. Most patients in the ropivacaine group required rescue analgesia at the higher time point category, indicating greater analgesic need after plain ropivacaine infiltration (p < 0.001). Total analgesic consumption showed the same pattern, with a much larger proportion of patients in the control group requiring 100 mg or 150 mg of analgesic.

Table 3. Rescue analgesia timing and total analgesic consumption

Hemodynamic parameters remained stable in both groups. Mean arterial pressure (MAP) and heart rate (HR) showed no significant intergroup difference at 0, 6, 12, or 24 hours. Oxygen saturation also remained well preserved in both groups throughout the postoperative period. A statistically significant difference in SpO2 at 12 hours was reported, but the overall values remained within a clinically acceptable range, with most patients maintaining saturations between 96% and 99%.

FIGURE 1. Mean arterial pressure

FIGURE 2. Mean heart rate among the study population

Fig 3. Post operative side effects

DISCUSSION

This study was conducted to evaluate the effect of dexmedetomidine as an adjuvant to ropivacaine for local wound infiltration in patients undergoing total abdominal hysterectomy. The findings demonstrated that the addition of dexmedetomidine significantly improved postoperative analgesia, reduced analgesic requirements, and decreased the incidence of postoperative side effects, without causing clinically significant hemodynamic instability.

The demographic characteristics in our study were comparable between the two groups. The majority of patients belonged to the 41–50 years age group, followed by 51–60 years, which is consistent with the typical age distribution for gynecological conditions requiring hysterectomy. Similar findings were reported by Swati Singh et al. [16], who observed a mean age of 48.4 years, and Reddy et al. [17], who also reported maximum distribution in the 40–50 years age group. This similarity supports the representativeness of our study population.

The ASA physical status distribution was also comparable between groups, with a predominance of ASA I patients. This is in agreement with findings reported by Swati Singh et al. [16] and Reddy et al. [17], who also demonstrated similar baseline characteristics. Such comparability strengthens the internal validity of the study and ensures that observed differences in outcomes are attributable to the intervention.

A key finding of the present study was the significantly lower postoperative pain scores in the dexmedetomidine group at all time intervals (0, 6, 12, and 24 hours). At 0 hour, 90% of patients in the dexmedetomidine group reported a pain score of 0, compared to only 1.3% in the ropivacaine group, indicating superior immediate analgesia. Even at 24 hours, pain scores remained lower in the dexmedetomidine group, suggesting prolonged analgesic effect.

These findings are consistent with Almarakbi et al. [18], who demonstrated prolonged time to first analgesic request and reduced opioid consumption with dexmedetomidine in TAP blocks. Similarly, Luan et al. [19] reported reduced sufentanil consumption and PCA use in patients receiving dexmedetomidine, especially in the early postoperative period. Although their study showed comparable pain scores, the reduced analgesic requirement aligns with our findings of superior analgesia.

The results of Swati Singh et al. [16], who evaluated wound infiltration, are particularly comparable to our study. They reported significantly lower pain scores and reduced morphine requirement in the dexmedetomidine group, closely mirroring our observations. Likewise, Hengfei Luan et al. [19] demonstrated that dexmedetomidine potentiated the analgesic effect of ropivacaine and reduced opioid consumption without affecting wound healing.

Further support is provided by Shaman Bhardwaj et al. [20], who reported improved VAS scores and reduced rescue analgesia in cesarean section patients receiving dexmedetomidine. Similarly, S A Mohamed et al. [21] observed delayed analgesic requirement and improved pain control with dexmedetomidine infiltration, reinforcing its analgesia-prolonging effect.

In the present study, the requirement and timing of rescue analgesia differed significantly between the two groups. A notable proportion (21.3%) of patients in the dexmedetomidine group required no rescue analgesia, compared to only 2.5% in the control group. Additionally, the need for analgesia was delayed in the dexmedetomidine group, indicating prolonged duration of action.

These findings are in agreement with Almarakbi et al. [18], who reported prolonged time to first analgesic request, and Luan et al. [19], who observed reduced early postoperative analgesic demand. Similar observations were made by Swati Singh et al. [16], Hengfei Luan et al. [19], and Shaman Bhardwaj et al. [20], all of whom demonstrated reduced and delayed analgesic requirement with dexmedetomidine.

Total analgesic consumption was significantly lower in the dexmedetomidine group, with a higher proportion of patients requiring minimal or no analgesics, while the ropivacaine group required higher doses. This highlights the opioid-sparing effect of dexmedetomidine.

Comparable findings were reported by Shaman Bhardwaj et al. [20], Almarakbi et al. [18], and Luan et al. [19], who all demonstrated reduced postoperative opioid consumption with dexmedetomidine. Similarly, Swati Singh et al. [16] and Hengfei Luan et al. [19] reported reduced analgesic requirements, further validating our results. Studies by Deshwal et al. [22], Bansal et al. [23], and Mohamed et al. [21] also support the analgesic-sparing role of dexmedetomidine across different surgical settings.

Hemodynamic parameters remained stable in both groups throughout the study period. There were no statistically significant differences in heart rate or mean arterial pressure at any time point. This suggests that local infiltration of dexmedetomidine does not result in significant systemic absorption or cardiovascular effects.

This observation is consistent with Swati Singh et al. [16], who reported no significant hemodynamic changes. Almarakbi et al. [18] noted a mild decrease in heart rate without clinical significance, while Reddy et al. [17] observed minor fluctuations that did not require intervention. Similarly, Madangopal et al. [24] reported some variability at higher doses, but without clinical consequences. These findings collectively confirm the hemodynamic safety of dexmedetomidine when used locally.

Regarding postoperative side effects, the incidence of nausea and vomiting was significantly lower in the dexmedetomidine group, likely due to reduced opioid consumption. Other side effects such as pruritus, urinary retention, and hypotension were comparable between groups and not statistically significant.

These findings are supported by Swati Singh et al. [16], who also reported fewer side effects in the dexmedetomidine group. Luan et al. [19] found no significant increase in adverse effects, while Bansal et al. [23] and Deshwal et al. [22] confirmed improved analgesia without increased complications. Additionally, Shelwatkar et al. [25] and Reddy et al. [17] reported similar safety profiles, further supporting the tolerability of dexmedetomidine.

Overall, the findings of the present study demonstrate that dexmedetomidine is an effective and safe adjuvant to ropivacaine for local wound infiltration. It provides superior postoperative analgesia, reduces analgesic consumption, delays the need for rescue analgesia, and minimizes opioid-related side effects, without causing significant hemodynamic disturbances.

CONCLUSION

The present study demonstrates that the addition of dexmedetomidine to ropivacaine for local wound infiltration in total abdominal hysterectomy significantly enhances postoperative analgesic outcomes. Patients receiving dexmedetomidine exhibited markedly superior pain control, with 90% reporting a VAS score of 0 at 0 hours, compared to only 1.3% in the ropivacaine-only group. This analgesic benefit persisted over time, with consistently lower pain scores observed at 6, 12, and 24 hours.

Importantly, the use of dexmedetomidine resulted in a substantial reduction in analgesic requirements. 21.3% of patients required no rescue analgesia, and a majority required only minimal doses, whereas most patients in the control group required higher analgesic consumption, with 68.8% needing 100 mg of rescue analgesia. These findings clearly highlight the analgesic-sparing and opioid-sparing effect of dexmedetomidine.

In addition, the dexmedetomidine group demonstrated a significantly lower incidence of postoperative nausea (8.8% vs 22.5%) and vomiting (2.5% vs 16.3%), reflecting improved overall patient comfort and recovery profile. Despite its pharmacological profile, dexmedetomidine did not produce any clinically significant hemodynamic instability, with mean arterial pressure and heart rate remaining comparable between the two groups throughout the study period.

In conclusion, dexmedetomidine, when used as an adjuvant to ropivacaine for local wound infiltration, provides prolonged and effective postoperative analgesia, reduces analgesic consumption, and improves patient outcomes without compromising safety. Its incorporation into multimodal analgesic protocols for abdominal hysterectomy can be considered a simple, safe, and highly effective strategy to optimize postoperative pain management.

Conflict of interest: Nil

Funding: Nil

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