Younger Patients Report More Pain After Single-Port Adnexal Laparoscopy, Retrospective Study Finds

Younger women undergoing single-port access laparoscopy for adnexal disease reported modestly higher postoperative pain than older patients, according to a retrospective cohort study conducted at two South Korean hospitals. After adjusting for analgesic regimen, surgery type, and body mass index, patients under 40 years of age had significantly higher numeric rating scale pain scores at 24 hours after surgery compared with patients over 55. The adjusted difference, however, was small — about 0.28 points on the 0–10 pain scale — and fell well below the minimal clinically important difference for postoperative pain, which the authors cite as roughly 1.0 to 2.0 points, and about 1.5 points after gynecologic surgery.

The study, published in Frontiers in Medicine, analyzed 470 female patients who underwent single-port access (SPA) laparoscopy for adnexal disease at Kangbuk Samsung Hospital and Uijeongbu Eulji Medical Center between January 2020 and September 2023. Patients were stratified into three age groups based on STRAW+10 menopause staging criteria and Korean menopause epidemiology: under 40 years (n = 257), 40 to 55 years (n = 138), and over 55 years (n = 75). All patients had complete pain scores at four postoperative time points — 6, 12, 24, and 48 hours — which formed the primary outcomes of the analysis.

SPA laparoscopy has been increasingly adopted in gynecologic surgery because it offers cosmetic advantages and surgical outcomes comparable to conventional multi-port laparoscopy. Yet the technique carries a particular pain problem: all instruments must pass through a single umbilical opening, requiring a substantially larger incision than conventional laparoscopy. Postoperative pain at the umbilical site therefore remains clinically significant despite the minimally invasive nature of the procedure, making analgesic strategy a central question for surgeons using this approach.

Patients in the cohort received one of three analgesic regimens: continuous wound infiltration (CWI) alone, using a system delivering 0.3% ropivacaine at 2 mL per hour for 48 hours; intravenous patient-controlled analgesia (IV PCA) alone, using fentanyl citrate at doses adjusted for age and body weight; or a combination of both modalities. Rescue nonsteroidal anti-inflammatory drugs were given when patients requested them at pain scores of 4 or higher, with pethidine reserved as a second-line agent. Notably, per-patient actual fentanyl consumption was not available in the retrospective dataset, a limitation the authors acknowledge could partly shape the observed age–pain relationship, since IV PCA dosing was itself adjusted for age.

In unadjusted comparisons, median NRS pain scores did not differ significantly among the three age groups at any time point. The picture changed, however, when the researchers applied multivariable linear regression adjusting for treatment modality, surgery type, and BMI in a complete-case analysis of 464 patients. In that model, patients under 40 had significantly higher pain scores at 24 hours (β = +0.276, p = 0.046), with a borderline trend at 6 hours (β = +0.259, p = 0.053). A repeated-measures analysis accounting for within-patient correlation across time points likewise found younger age independently associated with higher pain scores overall (β = +0.172, 95% CI +0.037 to +0.307, p = 0.012).

Rescue analgesic use told a consistent story. Patients under 40 required rescue NSAIDs significantly more often during the 0–6 hour (28.8% vs. 15.9% and 18.7% in the older groups, p = 0.009), 6–12 hour (16.0% vs. 5.1% and 12.0%, p = 0.007), and 24–48 hour (16.7% vs. 10.9% and 5.3%, p = 0.024) periods. In multivariable logistic regression of rescue NSAID use at 24–48 hours, younger age showed a trend toward higher demand (OR = 3.15, 95% CI 0.92–10.75, p = 0.067) that did not reach statistical significance. Interestingly, overall rescue NSAID use across the full postoperative period was actually highest in the oldest group, a pattern the adjusted analyses did not confirm as an independent age effect.

Across all age groups, the combined CWI plus IV PCA regimen was associated with the lowest pain scores. In the multivariable model it was the strongest predictor of lower NRS scores at every time point measured, including 6 hours (β = −0.923, p < 0.001), 24 hours (β = −0.422, p < 0.001), and 48 hours (β = −0.249, p = 0.029). Within the youngest group, the combined regimen produced significantly lower scores than either single modality at 6 and 12 hours (both p < 0.001), with borderline differences at 24 hours. In the 40–55-year group, its advantage extended through 24 hours, while in patients over 55 it outperformed CWI alone at 6, 12, and 48 hours but showed no significant advantage over IV PCA alone at most time points — a null finding the authors caution cannot be read as equivalence given the small subgroup of only 29 patients receiving IV PCA alone in that age band.

Crucially, the authors themselves flag the interpretive limits of these within-age-group patterns. Formal age-by-treatment interaction tests did not reach statistical significance at any time point (omnibus F-test p-values ranged from 0.107 to 0.658), meaning the data do not demonstrate that the effectiveness of the analgesic regimens actually differs by age. The authors describe these patterns as exploratory and hypothesis-generating rather than confirmatory, and they explicitly state that the findings do not establish that age should directly guide regimen selection. A three-way age-by-treatment-by-time interaction in the repeated-measures model was also not significant (p = 0.078).

The study addressed a potential confounder with a prespecified sensitivity analysis adjusting for endometriosis, the only diagnosis in the cohort with an established neuroinflammatory mechanism — involving peripheral sensitization and central dorsal horn hyperexcitability — that could lower pain thresholds independently of surgical trauma. Endometriosis was far more prevalent in younger patients (39.3% in the under-40 group versus 0% in the over-55 group), but it was not independently associated with higher pain scores or greater late rescue NSAID use. The age-related association was preserved and slightly strengthened after this adjustment (24-hour NRS β = +0.289, p = 0.037), suggesting differential endometriosis prevalence did not fully explain the finding.

The authors also detail the study’s other limitations. The retrospective, non-randomized design means treatment allocation reflected clinical practice rather than chance: CWI alone was used more often in older patients (36.0% in the over-55 group vs. 18.7% in the under-40 group), and adnexectomy dominated among older patients (98.7%) while cystectomy predominated in younger ones (84.4%), reflecting the natural age distribution of adnexal disease. Although regression adjusted for surgery type, differences in surgical extent remain a potential source of confounding. Patients who discontinued IV PCA early — predominantly because of opioid-related nausea, vomiting, dizziness, or hypotension — were excluded, which may bias side-effect and efficacy comparisons in favor of IV PCA-containing regimens. Pain was assessed only at rest, age served as a surrogate for menopausal status, and the over-55 subgroups were small. The cohort also overlaps with the authors’ previous reports comparing the same three regimens. Within those constraints, the authors conclude that younger age was independently, if modestly, associated with higher pain at 24 hours, and they call for prospective studies to confirm the finding and to test whether extended CWI duration or supplemental analgesics in the 24–48 hour window might benefit younger patients.

Subject of Research: Age-related differences in postoperative pain and analgesic requirements after single-port access laparoscopy for adnexal disease

Article Title: Article title age-related differences in postoperative pain after single-port access adnexal laparoscopy: a three-arm analgesic strategy comparison

Article References: Paik, E. S., Yu, M., Kang, J., & Kang, J.-H. (2026). Article title age-related differences in postoperative pain after single-port access adnexal laparoscopy: a three-arm analgesic strategy comparison. Frontiers in Medicine, 13, Article 1951712. https://doi.org/10.3389/fmed.2026.1951712

Image Credits: AI Generated

DOI: 10.3389/fmed.2026.1951712

Keywords: single-port laparoscopy, postoperative pain, adnexal disease, continuous wound infiltration, patient-controlled analgesia, retrospective cohort study, gynecologic surgery, endometriosis, rescue analgesics, pain assessment, multivariable regression, menopausal age groups