A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy

Randomized clinical trial comparing radially expanding trocars with conventional cutting trocars for the effects on pain after laparoscopic cholecystectomy

BACKGROUND

Trocar incisions are important sources of pain the first days after laparoscopic cholecystectomy. Radially expanding trocars may cause less pain than conventional cutting trocars.

METHODS

In a patient- and observer-blinded trial, 80 patients were randomized to undergo laparoscopic cholecystectomy using either radially expanding trocars (radial group) or conventional cutting trocars (cutting group). Two 10-mm and two 5-mm trocars were used in both treatment groups. All the patients received standardized anesthetic and analgesic treatment. The primary outcome was incisional pain. Pain was registered during mobilization using a visual analog scale (VAS) and a verbal rating scale (VRS) before and 6 h after the operation, and at postoperative days 1 and 2. The needs for a fascial incision to retract the gallbladder, active surgical hemostasis, and supplementary requirements of opioids during the hospital stay were registered. In addition, 2 days after the operation, the incidence and severity of suggilations at the trocar incisions were measured.

RESULTS

Data from 77 patients were available for statistical analysis. In the radial group, 23 patients needed fascial incision for gallbladder retraction compared with 11 patients in the cutting group (p = 0.006). No significant intergroup differences in VAS or VRS pain scores or any other variable were found.

CONCLUSIONS

The use of radially expanding trocars has no effect on incisional pain after laparoscopic cholecystectomy.

Randomized clinical trial of the influence of intraperitoneal local anaesthesia on pain after laparoscopic surgery

Background

There is controversy about the effectiveness of intraperitoneal local anaesthesia (LA) in laparoscopic surgery. The aim of the present randomized clinical trial was to compare the analgesic effect of pre-emptive (preoperative) versus postoperative intraperitoneal LA in two different types of laparoscopic surgery.

Methods

Between July 2004 and January 2005, 133 consecutive patients scheduled to undergo laparoscopic fundoplication or hernia repair were randomly assigned to one of three treatments: placebo solution (50 ml 0·9 per cent saline) or LA (50 ml 0·5 per cent lidocaine) administered immediately after creation of the pneumoperitoneum, or LA (50 ml 0·5 per cent lidocaine) at the end of the operation. Analgesic requirements were analysed, and pain was assessed using a visual analogue scale (VAS) from 0 to 100 at 6, 12, 24 and 48 h after surgery.

Results

The duration of pneumoperitoneum (median 66 versus 46 min respectively; P < 0·001) and overall pain intensity (median VAS score 46·7 versus 6·5; P < 0·001) were higher for laparoscopic fundoplication than for hernia repair. Preoperative application of LA reduced abdominal pain (median 28·6 versus 74·9; P < 0·005), shoulder pain (median 24·3 versus 43·8; P = 0·004) and analgesic consumption (mean(s.d.) 11·1(5·0) versus 18·5(5·4) mg piritramide per 48 h; P = 0·002) after fundoplication, but had no analgesic effects after hernia repair.

Conclusion

Pre-emptive application of LA reduced postoperative pain and analgesic requirements after laparoscopic fundoplication.

Post-operative recovery profile after laparoscopic cholecystectomy: a prospective, observational study of a multimodal anaesthetic regime

BACKGROUND

Laparoscopic cholecystectomy is now often an ambulatory procedure, but dependent on short-term post-operative complaints of pain and post-operative nausea and vomiting (PONV). The efficacy of post-anaesthesia care units (PACUs) is therefore important to facilitate return to normal functions. We investigated the feasibility and efficacy of a standardized, evidence-based anaesthesia/analgesic regime to identify residual problems in the early post-operative phase.

METHODS

One hundred and thirty-four consecutive patients admitted for elective laparoscopic cholecystectomy at Hvidovre University Hospital between 15 March and 30 September 2005 were included in the study. The standardized, evidence-based regime consisted of total intravenous (i.v.) anaesthesia (propofol-remifentanil), well-defined fluid therapy, dexamethasone, ketorolac, ondansetron, sufentanil and incisional bupivacaine intra-operatively, and in the PACU on demand (prn) administration of sufentanil, morphine, paracetamol, ondansetron, droperidol, oral fluids and oxygen (if SpO(2) < 93%) with PACU discharge using a modified Aldrete score.

RESULTS

Protocol violations were moderate and occurred unsystematically, 8% had medical violations and 10% did not receive the pre-planned fluid amount. Severe PONV was seen in 2%. Thirteen per cent experienced severe pain, and the presence of any pain and/or PONV were predictors of an extended PACU stay. Mean oxygen demand was 46 min (range, 0-300 min), which influenced time to discharge (mean, 88 min). There were on average 2.7 treatment interventions (range, 0-11) before discharge.

CONCLUSION

An evidence-based, multimodal approach to the anaesthetic/analgesic management in laparoscopic cholecystectomy is feasible and advantageous in the early post-operative phase. Pain and PONV are predictors of a complicated recovery profile and deserve further attention. Transient oxygen desaturations postpone discharge from the PACU, but the clinical significance of this fact is questionable.

PROSPECT: evidence-based, procedure-specific postoperative pain management

Existing general guidelines for perioperative pain management do not consider procedure-specific differences in analgesic efficacy or applicability of a given analgesic technique. For the clinician, an evidence-based, procedure-specific guideline for perioperative pain management is therefore desirable. This chapter reviews the methodology and results of

PROSPECT

a public web site (www.postoppain.org) which provides information and recommendations for evidence-based procedure-specific postoperative pain management.

PROSPECT: a practical method for formulating evidence-based expert recommendations for the management of postoperative pain

BACKGROUND

Many patients still suffer severe acute pain in the postoperative period. Although guidelines for treating acute pain are widely published and promoted, most do not consider procedure-specific differences in pain experienced or in techniques that may be most effective and appropriate for different surgical settings. The procedure-specific postoperative pain management (PROSPECT) Working Group provides procedure-specific recommendations for postoperative pain management together with supporting evidence from systematic literature reviews and related procedures at http://www.postoppain.org

METHODS

The methodology for PROSPECT reviews was developed and refined by discussion of the Working Group, and it adapts existing methods for formulation of consensus recommendations to the specific requirements of PROSPECT.

RESULTS

To formulate PROSPECT recommendations, we use a methodology that takes into account study quality and source and level of evidence, and we use recognized methods for achieving group consensus, thus reducing potential bias. The new methodology is first applied in full for the 2006 update of the PROSPECT review of postoperative pain management for laparoscopic cholecystectomy.

CONCLUSIONS

Transparency in PROSPECT processes allows the users to be fully aware of any limitations of the evidence and recommendations, thereby allowing for appropriate decisions in their own practice setting.