Pain management strategies in pelvic exenteration: insights from a developing unit

Pelvic exenteration (PEx) is a major surgical procedure associated with significant postoperative pain due to its radical dissection and reconstruction. Effective pain management is essential to improve recovery, minimize complications, and enhance patient outcomes. This study aims to evaluate perioperative pain control strategies in pelvic exenteration surgeries and to assess their effectiveness.

We conducted a retrospective review of patients who underwent PEx between October 2023 and January 2025 for management of advanced rectal cancer. Data were collected on demographics, surgical details, perioperative analgesic techniques (e.g.epidural, PCA, intrathecal opioids, analgesic adjuncts), surgical duration, time to mobilization, and length of stay.

A total of nineteen patients underwent PEx surgeries (eleven open, six robotic-assisted, and two laparoscopic). For postoperative pain, epidural analgesia with PCA was used in twelve cases (63.1%), Epidural analgesia with oxycodone in one patient, and PCA alone in six surgeries (31.5%). Time to switch from PCA to oral analgesia was earlier in robotic and laparoscopic as compared to open exnetaertions. Chronic Post-Surgical Pain occurred in five patients (26.3%), of whom four had identifiable risk factors, including sacrectomy and opioid tolerance. Robotic and laparoscopic approaches were associated with earlier mobilization and reduced ICU, and length of hospital stay.

Effective pain management in PEx remains challenging. Standardizing pain protocols could further enhance outcomes and recovery for this high-risk group. Surgical approach also affects analgesic choices and may impact pain and hospital results. We have created an institutional perioperative analgesic algorithm to guide clinical practice in PEx pain management.