Combined epidural-general anesthesia reduces opioid use and improves recovery after laparoscopic hysterectomy: a retrospective cohort study.

A total of 98 women were included: 42 in the GA group and 56 in the CEA + GA group. Baseline characteristics were comparable between the groups (Table  1 ). There were no significant differences in age (46.3 ± 7.1 vs 47.0 ± 7.8 years, P  = 0.64), BMI (22.0 ± 2.2 vs 22.4 ± 2.0 kg/m 2 , P  = 0.35), ASA class, indication for surgery, or prevalence of hypertension, diabetes, comorbidities, or previous abdominal/pelvic surgery (all P  > 0.05). Table 1 Baseline demographic and clinical characteristics of the study population Characteristics GA group ( n  = 42) CEA + GA group ( n  = 56) P value Age, years, mean ± SD 46.3 ± 7.1 47.0 ± 7.8 0.64 BMI, kg/m 2 , mean ± SD 22.0 ± 2.2 22.4 ± 2.0 0.35 ASA class, n (%)  I 27 (64.3) 35 (62.5) 0.86  II 15 (35.7) 21 (37.5) Indication for surgery, n (%)  Uterine fibroids 19 (45.2) 30 (53.6) 0.42  Adenomyosis 12 (28.6) 14 (25.0)  Functional uterine bleeding 8 (19.0) 9 (16.1)  Other benign 3 (7.1) 3 (5.4) Hypertension, n (%) 8 (19.0) 10 (17.9) 0.89 Diabetes mellitus, n (%) 4 (9.5) 5 (8.9) 0.92 ≥ 1 comorbidity, n (%) 11 (26.2) 14 (25.0) 0.9 Previous abdominal/pelvic surgery, n (%) 10 (23.8) 13 (23.2) 0.96 Data are presented as mean ± SD for continuous variables and as n (%) for categorical variables Abbreviations : ASA American Society of Anesthesiologists, BMI body mass index, CEA  +  GA combined epidural and general anesthesia, GA general anesthesia Baseline demographic and clinical characteristics of the study population Data are presented as mean ± SD for continuous variables and as n (%) for categorical variables Abbreviations : ASA American Society of Anesthesiologists, BMI body mass index, CEA  +  GA combined epidural and general anesthesia, GA general anesthesia Perioperative anesthetic and analgesic data are summarized in Table  2 . Surgical duration, anesthesia duration, and intraoperative blood loss were similar between groups ( P  > 0.05). In contrast, opioid and anesthetic requirements were lower in the CEA + GA group. Intraoperative fentanyl dose was significantly lower in the CEA + GA group (485 ± 72 vs 518 ± 78 μg, P  = 0.037), and 0–24 h postoperative opioid consumption was reduced (19.7 ± 5.3 vs 28.4 ± 6.1 mg morphine equivalents [ME], P  < 0.001). Total perioperative opioid dose was also significantly lower in the CEA + GA group (25.1 ± 6.4 vs 35.6 ± 7.9 mg ME, P  < 0.001). Additionally, the CEA + GA group received less intraoperative propofol (340 ± 77 vs 415 ± 73 mg, P  < 0.001) and had a shorter time to recovery from anesthesia (9.3 ± 2.5 vs 13.1 ± 4.2 min, P  < 0.001). Rescue analgesia within 24 h postoperatively was required less frequently in the CEA + GA group (7/56 [12.5%] vs 18/42 [42.9%], P  = 0.001), with fewer rescue doses per patient (0.3 ± 0.5 vs 1.2 ± 0.9, P  < 0.001). Table 2 Perioperative anesthetic and analgesic variables Variables GA group ( n  = 42) CEA + GA group ( n  = 56) P value Surgical duration, min, mean ± SD 64.8 ± 7.5 65.5 ± 7.0 0.65 Anesthesia duration, min, mean ± SD 95.0 ± 15.2 96.2 ± 14.8 0.71 Intraoperative blood loss, mL, mean ± SD 66 ± 17 65 ± 16 0.76 Intraoperative fentanyl dose, μg, mean ± SD 518 ± 78 485 ± 72 0.037 Postoperative opioid dose (0–24 h)*, mg ME 28.4 ± 6.1 19.7 ± 5.3 < 0.001 Total perioperative opioid dose, mg ME 35.6 ± 7.9 25.1 ± 6.4 < 0.001 Intraoperative propofol dose, mg, mean ± SD 415 ± 73 340 ± 77 < 0.001 Time to recovery from anesthesia, min 13.1 ± 4.2 9.3 ± 2.5 < 0.001 Rescue analgesia within 24 h, n (%) 18 (42.9) 7 (12.5) 0.001 No. of rescue doses, mean ± SD 1.2 ± 0.9 0.3 ± 0.5 < 0.001 Data are presented as mean ± SD for continuous variables and as n (%) for categorical variables. Postoperative opioid use is expressed as intravenous morphine equivalents (ME) Perioperative anesthetic and analgesic variables Data are presented as mean ± SD for continuous variables and as n (%) for categorical variables. Postoperative opioid use is expressed as intravenous morphine equivalents (ME) Postoperative recovery and ERAS outcomes are shown in Table  3 . VAS pain scores were consistently lower in the CEA + GA group during the first 24 h after surgery. At 6, 12, and 24 h postoperatively, mean VAS scores were lower in the CEA + GA group ( P  < 0.001). By 48 h, pain scores converged, with no significant difference between groups ( P  = 0.08). Recovery milestones favored the CEA + GA group, with significantly shorter times to first ambulation (17.1 ± 3.9 vs 22.4 ± 4.6 h, P  < 0.001), first flatus (23.5 ± 4.7 vs 28.8 ± 5.3 h, P  < 0.001), and first defecation (40.0 ± 7.5 vs 46.2 ± 8.1 h, P  = 0.001). A greater proportion of CEA + GA patients achieved early ambulation within 24 h (42/56 [75.0%] vs 16/42 [38.1%], P  < 0.001). Length of hospital stay was also significantly shorter in the CEA + GA group (2.9 ± 0.6 vs 3.4 ± 0.7 days, P  = 0.001). Table 3 Postoperative recovery and ERAS outcomes Outcomes GA group ( n  = 42) CEA + GA group ( n  = 56) P value VAS pain score 6 h 4.8 ± 1.3 3.4 ± 1.0 < 0.001 VAS pain score 12 h 5.7 ± 1.2 4.1 ± 1.1 < 0.001 VAS pain score 24 h 4.9 ± 1.1 3.6 ± 1.0 < 0.001 VAS pain score 48 h 3.1 ± 0.8 2.8 ± 0.7 0.08 Time to first ambulation, h 22.4 ± 4.6 17.1 ± 3.9 < 0.001 Time to first flatus, h 28.8 ± 5.3 23.5 ± 4.7 < 0.001 Time to first defecation, h 46.2 ± 8.1 40.0 ± 7.5 0.001 Length of hospital stay, days 3.4 ± 0.7 2.9 ± 0.6 0.001 Early ambulation within 24 h, n (%) 16 (38.1) 42 (75.0) < 0.001 Data are presented as mean ± SD for continuous variables and as n (%) for categorical variables Postoperative recovery and ERAS outcomes Data are presented as mean ± SD for continuous variables and as n (%) for categorical variables Changes in pain-related biochemical mediators and pain burden (AUC 0–24 h) are presented in Table  4 , with time-course data illustrated in Fig.  1 . At baseline (T0), VAS scores and serum levels of PGE₂, 5-HT, and SP were similar between groups. Over the first 24 h, the GA group exhibited higher exposure to pain-related mediators, with significantly higher AUC values for PGE₂, 5-HT, and SP (all P  < 0.001). Consistent with these findings, the VAS AUC was significantly greater in the GA group (110 ± 22 vs 78 ± 18 score·h, P  < 0.001). Table 4 Perioperative changes in pain-related biochemical mediators and VAS scores over 0–24 h Variables GA group ( n  = 42) CEA + GA group ( n  = 56) P value PGE₂ AUC, pg·h/mL 5220 ± 810 4050 ± 690 < 0.001 5-HT AUC, ng·h/L 5110 ± 740 3980 ± 630 < 0.001 SP AUC, μg·h/mL 490 ± 85 370 ± 70 < 0.001 VAS AUC, score·h 110 ± 22 78 ± 18 < 0.001 Data are presented as mean ± SD. AUC values (0–24 h) were calculated from serial measurements using the trapezoidal method, and between-group comparisons were performed using the independent-samples Student’s t test Fig. 1 Postoperative pain and pain-related biochemical mediators over time in the GA and CEA + GA groups. A  Visual Analog Scale (VAS) pain scores at T0–T4. B  Serum prostaglandin E2 (PGE2) concentrations at T0–T4. C  Serum 5-hydroxytryptamine (5-HT) levels at T0–T4. D  Serum substance P (SP) levels at T0–T4. Data are presented as mean ± SD. T0 indicates pre-induction, and T1–T4 correspond to 6, 12, 24, and 48 h postoperatively Perioperative changes in pain-related biochemical mediators and VAS scores over 0–24 h Data are presented as mean ± SD. AUC values (0–24 h) were calculated from serial measurements using the trapezoidal method, and between-group comparisons were performed using the independent-samples Student’s t test Postoperative pain and pain-related biochemical mediators over time in the GA and CEA + GA groups. A  Visual Analog Scale (VAS) pain scores at T0–T4. B  Serum prostaglandin E2 (PGE2) concentrations at T0–T4. C  Serum 5-hydroxytryptamine (5-HT) levels at T0–T4. D  Serum substance P (SP) levels at T0–T4. Data are presented as mean ± SD. T0 indicates pre-induction, and T1–T4 correspond to 6, 12, 24, and 48 h postoperatively Hemodynamic parameters are summarized in Fig.  2 . Baseline HR, MAP, and SpO₂ were similar between groups. The GA group showed significant increases in HR and MAP at 6 and 12 h postoperatively, while the CEA + GA group maintained stable HR and MAP. SpO₂ remained comparable between groups. These results suggest greater hemodynamic stability in the CEA + GA group during the early postoperative period. Fig. 2 Hemodynamic variables over time in the GA and CEA + GA groups. A  Heart rate (HR) at T0–T4. B  Mean arterial pressure (MAP) at T0–T4. C  Peripheral oxygen saturation (SpO2) at T0–T4. Data are presented as mean ± SD. T0 indicates pre-induction, and T1–T4 correspond to 6, 12, 24, and 48 h postoperatively Hemodynamic variables over time in the GA and CEA + GA groups. A  Heart rate (HR) at T0–T4. B  Mean arterial pressure (MAP) at T0–T4. C  Peripheral oxygen saturation (SpO2) at T0–T4. Data are presented as mean ± SD. T0 indicates pre-induction, and T1–T4 correspond to 6, 12, 24, and 48 h postoperatively Intraoperative and postoperative anesthesia-related adverse events are shown in Table  5 . The incidence of intraoperative adverse events was significantly lower in the CEA + GA group ( P  = 0.004). Within 24 h postoperatively, the CEA + GA group had significantly fewer PONV events (4/56 [7.1%] vs 12/42 [28.6%], P  = 0.005), and the need for anti-emetic medication was significantly lower ( P  = 0.01). Overall, any postoperative adverse event occurred in 12.5% of CEA + GA patients vs 42.9% of GA patients ( P  = 0.001). Table 5 Intraoperative and early postoperative anesthesia-related adverse events Events GA group ( n  = 42) CEA + GA group ( n  = 56) P value Intraoperative, n (%)  Movement response 3 (7.1) 2 (3.6) 0.42  Bradycardia 2 (4.8) 0 (0) 0.09  Hypotension needing vasopressor 3 (7.1) 1 (1.8) 0.16  Any intraoperative event 11 (26.2) 3 (5.4) 0.004 Postoperative within 24 h, n (%)  PONV (total) 12 (28.6) 4 (7.1) 0.005 Nausea only 8 (19.0) 3 (5.4) 0.04 Vomiting 4 (9.5) 1 (1.8) 0.09  Antiemetic use 10 (23.8) 3 (5.4) 0.01  Dizziness 4 (9.5) 3 (5.4) 0.42  Injection-site pain 2 (4.8) 0 (0) 0.09  Any postoperative event 18 (42.9) 7 (12.5) 0.001 Data are presented as n (%). The PONV category includes nausea and/or vomiting, as well as the need for antiemetic treatment Intraoperative and early postoperative anesthesia-related adverse events Data are presented as n (%). The PONV category includes nausea and/or vomiting, as well as the need for antiemetic treatment In the multivariable linear regression model for opioid consumption, CEA + GA was independently associated with significantly lower opioid use (β = –10.3 mg ME, P  < 0.001), while longer surgical duration was associated with higher opioid consumption (β = 0.6 mg ME per 10 min, P  = 0.03) (Table  6 ). In the multivariable logistic regression model for PONV, CEA + GA was associated with significantly reduced odds of PONV (adjusted OR 0.25, P  = 0.008), while higher opioid consumption was independently associated with increased PONV risk (adjusted OR 1.18 per 5 mg ME, P  = 0.005) (Table  7 ). Table 6 Multivariable linear regression analysis of factors associated with total perioperative opioid consumption Predictor β (95% CI) P value CEA + GA vs GA –10.3 (–13.2 to –7.4) < 0.001 Age (per year) 0.05 (–0.08 to 0.18) 0.45 BMI (per kg/m 2 ) 0.12 (–0.10 to 0.34) 0.28 ASA II vs I 1.1 (–0.9 to 3.1) 0.28 ≥ 1 comorbidity 0.8 (–1.4 to 3.0) 0.47 Surgical duration (per 10 min) 0.6 (0.1 to 1.1) 0.03 The dependent variable was total perioperative opioid dose (mg morphine equivalents, ME). Values are regression coefficients (β) with 95% confidence intervals. Surgical duration was modeled per 10-min increase. A positive β indicates higher opioid consumption. Statistical significance was set at P  < 0.05 Table 7 Multivariable logistic regression analysis of predictors of postoperative nausea and vomiting (PONV) Predictor Adjusted OR (95% CI) P value CEA + GA vs GA 0.25 (0.09–0.70) 0.008 Total opioid (per 5 mg ME) 1.18 (1.05–1.32) 0.005 Age (per year) 0.98 (0.93–1.04) 0.48 ASA II vs I 1.30 (0.50–3.37) 0.59 The outcome was PONV within 24 h after surgery (yes/no). Results are presented as adjusted odds ratios (OR) with 95% confidence intervals. Total opioid dose was modeled per 5 mg increase in intravenous morphine equivalents (ME) Multivariable linear regression analysis of factors associated with total perioperative opioid consumption The dependent variable was total perioperative opioid dose (mg morphine equivalents, ME). Values are regression coefficients (β) with 95% confidence intervals. Surgical duration was modeled per 10-min increase. A positive β indicates higher opioid consumption. Statistical significance was set at P  < 0.05 Multivariable logistic regression analysis of predictors of postoperative nausea and vomiting (PONV) The outcome was PONV within 24 h after surgery (yes/no). Results are presented as adjusted odds ratios (OR) with 95% confidence intervals. Total opioid dose was modeled per 5 mg increase in intravenous morphine equivalents (ME)

This single-center retrospective cohort study was conducted in the Department of Gynecology at Panan County People’s Hospital. Consecutive women who underwent laparoscopic hysterectomy between April 2021 and September 2023 were identified from the institution’s electronic medical records and anesthesia information systems. The study protocol was reviewed and approved by the institutional Ethics Committee, which waived the requirement for written informed consent due to the retrospective nature of the analysis. Eligible patients were adult women scheduled for elective laparoscopic hysterectomy for benign uterine conditions, including uterine fibroids, adenomyosis, functional uterine bleeding, and other benign indications. All patients were classified as American Society of Anesthesiologists (ASA) physical status I or II and received either general anesthesia alone or combined epidural-general anesthesia, based on the attending anesthesiologist and surgeon’s usual practice. Patients were excluded if they had severe organ dysfunction (heart, liver, kidneys, or lungs), required intraoperative conversion from laparoscopy to laparotomy, had known coagulation disorders, allergies to anesthetic/analgesic drugs, were unable to communicate or assess pain, had acute or chronic infections, or if key data on opioid use or other key variables were missing. Emergency surgery patients were also excluded. Group assignment was based on standard clinical practice, rather than randomization. All patients fasted for 8–12 h before surgery and were monitored with non-invasive blood pressure, electrocardiography, pulse oximetry, and capnography throughout the procedure. In the GA group, anesthesia was induced with intravenous propofol (1.5–2.0 mg/kg), fentanyl (2–3 μg/kg), and vecuronium bromide (0.1 mg/kg), followed by endotracheal intubation. Maintenance anesthesia included sevoflurane (1–2% in oxygen/air) with boluses of fentanyl and vecuronium as needed. In the CEA + GA group, a lumbar epidural block was administered in addition to general anesthesia, using a mixture of 1.5% lidocaine and 0.4% ropivacaine. Epidural catheter placement was at the L1-L2 interspace with sensory block aimed between the T6 and L3 dermatomes. Perioperative care followed the institution’s ERAS pathway, emphasizing early mobilization, oral intake, and standardized postoperative care. Baseline demographic and clinical data were extracted from medical records. Intraoperative data included surgical duration, anesthesia duration, estimated blood loss, intraoperative opioid (fentanyl) and anesthetic (propofol) doses, and time to recovery from anesthesia. Pain intensity was assessed using a 10-cm Visual Analog Scale (VAS) at 6, 12, 24, and 48 h post-surgery, and opioid use was recorded for the first 24 h postoperatively. Recovery milestones, including time to first ambulation, first passage of flatus, first defecation, and length of hospital stay, were recorded. Postoperative adverse events, including PONV, dizziness, and injection site pain, were documented. Intraoperative events, such as movement responses, bradycardia, hypotension, and oxygen desaturation, were also recorded. Rescue analgesia use was documented within 24 h. Venous blood samples (3 mL) were collected at five time points: before anesthesia induction (T0) and at 6, 12, 24, and 48 h post-surgery (T1-T4). Concentrations of prostaglandin E₂ (PGE₂), 5-hydroxytryptamine (5-HT), and substance P (SP) were measured using enzyme-linked immunosorbent assay (ELISA) kits. Hemodynamic data, including heart rate (HR), mean arterial pressure (MAP), and peripheral oxygen saturation (SpO₂), were recorded at the same time points. Data were analyzed using SPSS software (version 22.0). Continuous variables were assessed for normality using the Kolmogorov–Smirnov test and reported as mean ± standard deviation for normally distributed data. Between-group comparisons were performed using independent-samples Student’s t-test for continuous variables and chi-square or Fisher’s exact test for categorical variables. Time-course data for VAS scores, biochemical mediators, and hemodynamic variables were summarized at each time point, with group differences in 0–24-h exposure assessed using AUC values. To assess the independent association between anesthesia type and opioid consumption, a multivariable linear regression model was used with total perioperative opioid dose (mg ME) as the dependent variable. Covariates included anesthesia group (CEA + GA vs GA), age, BMI, ASA class (II vs I), comorbidity presence, and surgical duration (per 10-min increment). A multivariable logistic regression model was used to evaluate factors related to PONV within 24 h, with PONV (yes/no) as the outcome and anesthesia group, age, ASA class, and total perioperative opioid dose (per 5 mg ME) as predictors. Regression coefficients (β) with 95% CI were reported for the linear model, and adjusted odds ratios (OR) with 95% CI for the logistic model. Model assumptions were checked using standard diagnostic procedures. All statistical tests were two-sided, with P  < 0.05 considered significant. Analyses were performed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA).

In women undergoing laparoscopic hysterectomy within an ERAS pathway, combined epidural and general anesthesia was associated with lower opioid exposure, improved early pain control, fewer anesthesia related adverse events including postoperative nausea and vomiting, and greater hemodynamic stability. Prospective randomized studies comparing general anesthesia, combined epidural and general anesthesia, and other regional techniques within standardized ERAS pathways, with longer follow up and patient reported outcomes, are warranted to confirm these findings and identify patients most likely to benefit.

In this retrospective cohort of women undergoing laparoscopic hysterectomy within an ERAS pathway, combined epidural and general anesthesia was associated with lower perioperative opioid consumption, better early postoperative pain control, faster recovery milestones, greater hemodynamic stability, and fewer anesthesia-related adverse events than general anesthesia alone. These findings are consistent with, and add to, the growing evidence supporting multimodal opioid sparing perioperative strategies in minimally invasive gynecologic surgery. Randomized and observational studies of ERAS programs in laparoscopic hysterectomy and benign gynecologic surgery have similarly reported shorter length of stay, earlier mobilization and bowel recovery, and fewer complications, largely attributable to standardized multimodal analgesia and early ambulation (Erkan et al. 2024 ; Ortiz Vazquez et al. 2025 ; Helou et al. 2020 ; Sinha et al. 2023 ). The observed reductions in total perioperative opioid use and rescue analgesia align with ERAS oriented multimodal analgesia studies in laparoscopic gynecologic surgery (Bisch et al. 2021 ). For example, Geng et al. reported improved quality of recovery with an opioid sparing ERAS protocol without an increase in adverse events (Geng et al. 2021 ). Other contemporary reports suggest that multimodal largely non opioid regimens can achieve comparable or improved analgesia while reducing opioid related side effects relative to traditional opioid based strategies (Ahmed and Amjad 2025 ). Population based analyses of hysterectomy further support that greater use of non opioid modalities including neuraxial techniques is associated with lower opioid exposure and improved postoperative outcomes (Lasanta Gorbea et al. 2025 ). Collectively, our results suggest that adding an epidural component to general anesthesia may be a practical method to incorporate neuraxial based multimodal analgesia into routine laparoscopic hysterectomy, particularly in settings where peripheral nerve blocks are not routinely implemented. A clinically important finding was the lower incidence of postoperative nausea and vomiting and other opioid related adverse events in the combined epidural and general group. Postoperative nausea and vomiting remains a common and distressing complication after gynecologic laparoscopy, especially among relatively young and otherwise healthy women who often receive substantial perioperative opioids (Nam et al. 2024 ; Cho et al. 2025 ). Randomized trials and meta analyses in gynecologic and other laparoscopic populations indicate that opioid sparing or opioid free approaches reduce postoperative nausea and vomiting while maintaining acceptable analgesia and recovery quality (Nam et al. 2024 ; Shen et al. 2025 ; Choi et al. 2022 ; Hu et al. 2024 ). Our multivariable findings showing that combined epidural and general anesthesia was independently associated with reduced postoperative nausea and vomiting, while higher opioid exposure increased risk, are consistent with this literature and underscore the role of opioid minimization in prevention. Beyond analgesia and postoperative nausea and vomiting, combined epidural and general anesthesia was associated with greater perioperative hemodynamic stability and fewer cardiorespiratory events. This is biologically plausible because neuraxial blockade can attenuate sympathetic activation and blunt the neuroendocrine stress response to surgical stimuli, thereby reducing fluctuations in heart rate and blood pressure (Hewson et al. 2024 ; Pirie et al. 2022 ). Prior studies in hysterectomy and gynecologic laparoscopy have similarly reported improved recovery profiles and reduced hemodynamic variability with neuraxial approaches compared with general anesthesia based strategies (Taflan et al. 2025 ; Hwang and Kim 2022 ). Together with broader perioperative evidence on neuraxial anesthesia, our findings suggest that an epidural component may help limit hemodynamic lability during the early postoperative period as anesthetic depth lightens (Hewson et al. 2024 ). This study also provides mechanistic support, with lower postoperative levels of prostaglandin E2, 5 hydroxytryptamine, and substance P in the combined epidural and general group, paralleling improved pain scores during the first 24 h. Although biochemical mediator profiling is uncommon in gynecologic ERAS studies, neuraxial and multimodal approaches may attenuate inflammatory and neurohumoral responses after surgery, which may contribute to both analgesia and physiologic stability (Ortiz Vazquez et al. 2025 ; Helou et al. 2020 ; Bisch et al. 2021 ; Pirie et al. 2022 ). Taken together, these findings are consistent with current ERAS principles for minimally invasive gynecologic surgery, which emphasize multimodal non opioid analgesia, neuraxial or regional techniques when appropriate, and structured postoperative nausea and vomiting prophylaxis (Lirk et al. 2019 ; Geng et al. 2021 ; Hessami et al. 2023 ). Clinically, combined epidural and general anesthesia may represent a feasible opioid sparing option for selected ASA I to II patients undergoing laparoscopic hysterectomy, with potential benefits in early recovery and perioperative safety (Ortiz Vazquez et al. 2025 ; Helou et al. 2020 ; Bisch et al. 2021 ; Pirie et al. 2022 ). Several limitations merit consideration. Several limitations merit consideration. First, the retrospective single center design and modest sample size limit causal inference and may leave residual confounding despite multivariable adjustment, including provider preference, subtle differences in ERAS adherence, or clinician experience. Second, intraoperative opioid titration and antiemetic prophylaxis were not fully protocolized, introducing potential practice variability. Third, pain assessment and mediator measurements were confined to the early postoperative period, and longer term outcomes such as chronic postsurgical pain, post discharge functional recovery, and patient reported satisfaction were not evaluated. Fourth, sensory block level was not systematically recorded, which could have helped contextualize epidural effects. Finally, the epidural regimen reflects local practice and may not generalize to other neuraxial techniques or higher risk populations (Taflan et al. 2025 ; Hwang and Kim 2022 ; Liu et al. 2021 ).

Laparoscopic hysterectomy is increasingly the preferred approach for benign uterine conditions due to its reduced surgical trauma, lower postoperative pain, and shorter hospital stay compared to open procedures (Nian et al. 2024 ; Kilpiö et al. 2020 ; Lirk et al. 2019 ). The incorporation of enhanced recovery after surgery (ERAS) pathways in gynecologic surgery further accelerates recovery, reduces opioid consumption, and decreases postoperative nausea and vomiting (PONV) without compromising safety (Nian et al. 2024 ; Kilpiö et al. 2020 ; Geng et al. 2021 ). However, despite the adoption of ERAS protocols, many women still experience moderate-to-severe pain during the first 24–48 h after laparoscopic hysterectomy, with optimal perioperative analgesia being crucial for successful recovery (Lirk et al. 2019 ; Geng et al. 2021 ). Inadequately controlled postoperative pain can delay mobilization, impair recovery quality, and increase the risk of cardiopulmonary and thromboembolic complications (Cozowicz et al. 2024 ). While opioids remain central to perioperative pain management, their use is limited by dose-dependent adverse effects, including PONV, ileus, sedation, and delayed bowel function, which can undermine the benefits of minimally invasive surgery and ERAS (Cozowicz et al. 2024 ; Hessami et al. 2023 ; Zhang et al. 2023 ). Recent studies in hysterectomy and other gynecologic procedures indicate that multimodal, opioid-sparing strategies can reduce opioid exposure, improve functional outcomes, and lower PONV rates. However, the effectiveness of these strategies varies, and the optimal combination of anesthetic and analgesic techniques remains debated (Geng et al. 2021 ; Cozowicz et al. 2024 ; Hessami et al. 2023 ; Zhang et al. 2023 ; Nam et al. 2024 ; Cho et al. 2025 ). Neuraxial and regional anesthesia techniques are essential components of multimodal analgesia, offering well-documented opioid-sparing and analgesic benefits when combined with general anesthesia in abdominal and pelvic surgeries (Cozowicz et al. 2024 ; Geng et al. 2023 ; Taflan et al. 2025 ). In gynecologic surgery, adding blocks such as transversus abdominis plane and quadratus lumborum blocks to standard regimens has been shown to reduce pain scores, decrease opioid requirements, and enhance recovery quality after both open and laparoscopic procedures (Geng et al. 2021 , 2023 ). A recent study comparing combined spinal–epidural anesthesia with general anesthesia plus an epidural catheter in abdominal hysterectomy demonstrated better early recovery in the neuraxial group (Taflan et al. 2025 ). These findings support the potential clinical benefits of combining neuraxial or regional anesthesia with general anesthesia in gynecologic surgery. However, most available evidence focuses on open or mixed-approach hysterectomy or peripheral nerve blocks, with few studies specifically examining combined epidural–general anesthesia in laparoscopic hysterectomy (Nian et al. 2024 ; Lirk et al. 2019 ; Geng et al. 2023 ; Taflan et al. 2025 ). Particularly, the impact of this technique on perioperative opioid use, PONV, hemodynamic stability, and ERAS-related recovery outcomes in a real-world laparoscopic setting remains underexplored. Furthermore, the relationship between anesthetic techniques, pain-related biochemical mediators (e.g., prostaglandin E₂, 5-hydroxytryptamine, substance P), and clinical pain outcomes has not been fully investigated. To address this gap, we conducted a retrospective cohort study comparing women undergoing laparoscopic hysterectomy with either general anesthesia alone or combined epidural–general anesthesia, focusing on perioperative opioid consumption, pain profiles, hemodynamic stability, anesthesia-related adverse events, and early recovery.