A placebo-controlled comparison of bupivacaine and ropivacaine instillation for preventing postoperative pain after laparoscopic cholecystectomy

Efficacy and safety of intraperitoneal ropivacaine in pain management following laparoscopic digestive surgery: A systematic review and meta-analysis of RCTs

BACKGROUND

Managing postoperative pain effectively with an opioid-free regimen following laparoscopic surgery (LS) remains a significant challenge. Intraperitoneal instillation of ropivacaine has been explored for its potential to reduce acute postoperative pain, but its efficacy and safety are still under debate. This study aimed to evaluate the efficacy and safety of intraperitoneal instillation of ropivacaine for acute pain management following laparoscopic digestive surgery.

METHODS

We used PRISMA 2020 and a measurement tool to assess systematic reviews 2 guidelines to conduct this review. The random-effects model was adopted using Review Manager Version 5.4 for pooled estimates.

RESULTS

We retained 24 eligible RCTs involving 1705 patients (862 patients in the intraperitoneal instillation group and 843 patients in the control group). The intraperitoneal instillation group reduced total opioid consumption during the first 24 hours postoperatively (MD = -21.93 95% CI [-27.64, -16.23], P < .01), decreased pain scores at different time (4 hours, 8 hours, 12 hours and 24 hours), shorter the hospital stay (MD = -0.20 95% CI [-0.36, -0.05], P < .01), reduced the postoperative shoulder pain (MD = 0.18 95% CI [0.07, 0.44], P < .01), and decreased postoperative nausea and vomiting (MD = 0.47 95% CI [0.29, 0.77], P < .01).

CONCLUSION

Intraperitoneal instillation of ropivacaine appears to be an effective component of multimodal pain management strategies following laparoscopic digestive surgery, significantly reducing opioid consumption and improving postoperative recovery markers. Despite these promising results, additional high-quality trials are needed to confirm the efficacy and safety of this approach.

REGISTRATION

The registration number at PROSPERO was CRD42021279238.

A comparative evaluation of intraperitoneal bupivacaine alone and bupivacaine with dexmedetomidine for post-operative analgesia following laparoscopic cholecystectomy

INTRODUCTION

Intraperitoneal instillation of local anaesthetic agents alone or in combination with opioids, α2 agonists such as Dexmedetomidine have been found to reduce postoperative pain following laparoscopic cholecystectomy. The study was designed to compare the better drug among Bupivacaine alone and Bupivacaine with Dexmedetomidine with respect to their analgesic efficacy and safety profile. in patients undergoing laparoscopic cholecystectomy.

PATIENTS AND METHODS

The study was carried out on sixty patients of the American Society of Anaesthesiologists (ASA) physical status I-II of either sex with ages ranging from 18 to 60 years posted for elective laparoscopic cholecystectomy under General Anaesthesia, equally divided into two groups, randomly allocated to one of the Groups using the table of randomization. Group B received Intraperitoneal Bupivacaine 40 ml 0.25% +5 ml normal saline and Group BD received Intraperitoneal Bupivacaine 40 ml 0.25% + Dexmedetomidine1 μg/kg diluted in 5 ml Normal saline.

RESULTS

The mean heart rate and blood pressure (systolic, diastolic and mean) readings were significantly lower in Group BD than in Group B. The mean duration of analgesia in our study was longer in Group BD (7.5 ± 0.73 hours) when compared to Group B (5.9 ± 0.55 hours) with p-value & 0.0001 and CI 1.27 to 1.9, which was statistically significant. However, the post-operative analgesic requirement (rescue/demand) in Group B was clinically earlier and statistically significant as compared to Group BD. Postoperative VAS score ≥3 was considered the benchmark for providing rescue analgesia in the form of injection of Diclofenac 75 mg IV. In our study, we observed the pain scores via VAS/NRS at 30 min, 1 h, 2 h, 4 h, 6 h, 8 h, 10 h, 12 h, 14 h, 16 h, 18 h, 20 h, 22 h and 24 h postoperatively. A comparison of pain scores from 30 min to 10hrs postoperatively showed a significant difference in both Groups with Group B having significantly higher VAS scores and lower VAS scores with Group BD.

CONCLUSIONS

Our study suggests that there is a shorter duration of action of 0.25% Bupivacaine alone as compared to 0.25% Bupivacaine + Dexmedetomidine. Since the laparoscope is still inside the abdominal cavity the drugs are easy to administer with no adverse effects and with a good safety profile because of the visualization of drug deposition in the right place. Intraperitoneal instillation of Bupivacaine with Dexmedetomidine for postoperative analgesia was very promising as a part of multimodal analgesia in laparoscopic cholecystectomy.

The impact of timing, type, and method of instillation of intraperitoneal local anaesthetic in laparoscopic abdominal surgery: a systematic review and network meta-analysis

BACKGROUND

Pain is common after laparoscopic abdominal surgery. Intraperitoneal local anaesthetic (IPLA) is effective in reducing pain and opioid use after laparoscopic surgery, although the optimum type, timing, and method of administration remains uncertain. We aimed to determine the optimal approach for delivering IPLA which minimises opioid consumption and pain after laparoscopic abdominal surgery.

METHODS

MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for randomised controlled trials comparing different combinations of the type (bupivacaine vs lidocaine vs levobupivacaine vs ropivacaine), timing (pre-vs post-pneumoperitoneum at the beginning or end of surgery), and method (aerosol vs liquid) of IPLA instillation in patients undergoing any laparoscopic abdominal surgery. A network meta-analysis was conducted to ascertain the optimum approach for delivering IPLA resulting in the least cumulative opioid consumption and pain (overall and localising to the shoulder) 24 h after surgery. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessments (PROSPERO ID: CRD42022307595).

RESULTS

Twenty-five RCTs were included, among which 15 different combinations of delivering IPLA were analysed across 2401 participants. Aerosolised bupivacaine instilled at the end of surgery, before deflation of the pneumoperitoneum, was associated with significantly less postoperative opioid consumption compared with all other approaches for delivering IPLA (98.7% of comparisons; moderate certainty), aside from liquid levobupivacaine instilled before surgery and during or after creation of the pneumoperitoneum (mean difference -11.6, 95% credible interval: -26.1 to 2.5 i.v. morphine equivalent doses). There were no significant differences between different IPLA approaches regarding overall pain scores and incidence of shoulder pain up to 24 h after surgery.

CONCLUSIONS

There are limited studies and low-quality evidence to conclude on the optimum method of delivering IPLA in laparoscopic abdominal surgery. While aerosolised bupivacaine instilled at the end of surgery but before deflation of the pneumoperitoneum minimises postoperative opioid consumption, pain scores up to 24 h did not differ between the different modalities of delivering IPLA. The generalisability of these results is limited by the lack of utilisation of non-opioid analgesics in most trials.

SYSTEMATIC REVIEW PROTOCOL REGISTRATION

PROSPERO CRD42022307595.

Single-shot regional anesthesia for laparoscopic cholecystectomies: a systematic review and network meta-analysis

BACKGROUND

Different regional anesthesia (RA) techniques have been used for laparoscopic cholecystectomy (LC), but there is no consensus on their comparative effectiveness. Our objective was to evaluate the effect of RA techniques on patients undergoing LC using a network meta-analysis approach.

METHODS

We conducted a systematic review and network meta-analysis. We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Science and Social Science Citation Index) using the following PICOS criteria: (P) adult patients undergoing LC; (I) any RA single-shot technique with injection of local anesthetics; (C) placebo or no intervention; (O) postoperative opioid consumption expressed as morphine milligram equivalents (MME), rest pain at 12 h and 24 h post-operation, postoperative nausea and vomiting (PONV), length of stay; and (S) randomized controlled trials.

RESULTS

A total of 84 studies were included. With the exception of the rectus sheath block (P = 0.301), the RA techniques were superior to placebo at reducing opioid consumption. Regarding postoperative pain, the transversus abdominis plane (TAP) block (-1.80 on an 11-point pain scale) and erector spinae plane (ESP) block (-1.33 on an 11-point pain scale) were the most effective at 12 and 24 h. The TAP block was also associated with the greatest reduction in PONV.

CONCLUSIONS

RA techniques are effective at reducing intraoperative opioid use, postoperative pain, and PONV in patients undergoing LC. Patients benefit the most from the bilateral paravertebral, ESP, quadratus lumborum, and TAP blocks.

The Analgesic Efficacy of Intraperitoneal Ropivacaine Versus Bupivacaine for Laparoscopic Cholecystectomy: a Meta-Analysis

Introduction This meta-analysis aimed to compare the analgesic efficacy of intraperitoneal ropivacaine versus bupivacaine for laparoscopic cholecystectomy.

Methods We searched PubMed, EMbase, Web of Science, EBSCO, and Cochrane Library databases from inception through January 2020 and included randomized controlled trials (RCTs) evaluating the analgesic efficacy of ropivacaine versus bupivacaine for laparoscopic cholecystectomy.

Results Five RCTs are included in the meta-analysis. In patients with laparoscopic cholecystectomy, ropivacaine and bupivacaine demonstrated comparable pain scores at 2 h (SMD = –0.22; 95% CI = –0.54 to 0.10; p = 0.18), 4 h (SMD = –0.16; 95% CI = –0.42 to 0.10; p = 0.22), 8 h (SMD = –0.60; 95% CI = –1.19 to –0.01; p = 0.05), and 24 h (SMD = 0.33; 95% CI = –1.19 to 1.84; p = 0.67), as well as time to first analgesic requirement (SMD = 0.10; 95% CI = –0.23 to 0.42; p = 0.56).

Conclusions Intraperitoneal ropivacaine and bupivacaine have a similar analgesic efficacy for laparoscopic cholecystectomy.

Effect of intraperitoneal local anesthesia on enhanced recovery outcomes after bariatric surgery: a randomized controlled pilot study

Background:

Patients with extreme obesity are at high risk for adverse perioperative events, especially when opioid-centric analgesic protocols are used, and perioperative pain management interventions in bariatric surgery could improve safety, outcomes and satisfaction. We aimed to evaluate the impact of intraperitoneal local anesthesia (IPLA) on enhanced recovery after bariatric surgery (ERABS) outcomes.

Methods:

We conducted a prospective double-blind randomized controlled pilot study in adherence to an a priori peer-reviewed protocol. Patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) with an established ERABS protocol between July 2014 and February 2015 were randomly allocated to receive either IPLA with 0.2% ropivacaine (intervention group) or normal saline (control group). We measured pain scores, analgesic consumption and adverse effects. Functional prehabilitation outcomes, including peak expiratory flow (PEF) and the Six Minute Walk Test (6MWT) and Quality of Recovery Survey-40 (QoR-40) scores, were assessed before surgery, and 1 day and 7 days postoperatively.

Results:

One hundred patients were randomly allocated to the study groups, of whom 92 completed the study, 46 in each group. There were no statistically significant differences between the 2 groups in baseline characteristics or any primary or secondary outcomes. Pain scores and analgesic consumption were low in both groups. There were no adverse events. Significant declines in PEF and 6MWT and QoR-40 scores were noted on postoperative day 1 in both groups; the values returned to baseline on postoperative day 7 in both groups.

Conclusion:

Intraperitoneal local anesthesia with ropivacaine did not reduce postoperative pain or analgesic consumption when administered intraoperatively to patients undergoing LRYGB. Standardization of the ERABS protocol benefited patients, with functional prehabilitation outcomes returning to baseline postoperatively. Trial registration:ClinicalTrials.gov no. NCT 02154763

Intraperitoneal local anaesthetic instillation versus no intraperitoneal local anaesthetic instillation for laparoscopic cholecystectomy

BACKGROUND

Pain is one of the important reasons for delayed discharge after laparoscopic cholecystectomy. Use of intraperitoneal local anaesthetic for laparoscopic cholecystectomy may be a way of reducing pain. A previous version of this Cochrane Review found very low-certainty evidence on the benefits and harms of the intervention.

OBJECTIVES

To assess the benefits and harms of intraperitoneal instillation of local anaesthetic agents in people undergoing laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and three other databases to 19 January 2021 together with reference checking of studies retrieved. We also searched five online clinical trials registries to identify unpublished or ongoing trials to 10 September 2021. We contacted study authors to identify additional studies.

SELECTION CRITERIA

We only considered randomised clinical trials (irrespective of language, blinding, publication status, or relevance of outcome measure) comparing local anaesthetic intraperitoneal instillation versus placebo, no intervention, or inactive control during laparoscopic cholecystectomy, for the review. We excluded non-randomised studies, and studies where the method of allocating participants to a treatment was not strictly random (e.g. date of birth, hospital record number, or alternation).

DATA COLLECTION AND ANALYSIS

Two review authors collected the data independently. Primary outcomes included all-cause mortality, serious adverse events, and quality of life. Secondary outcomes included length of stay, pain, return to activity and work, and non-serious adverse events. The analysis included both fixed-effect and random-effects models using RevManWeb. We performed subgroup, sensitivity, and meta-regression analyses. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs). We assessed risk of bias using predefined domains, graded the certainty of the evidence using GRADE, and presented outcome results in a summary of findings table.

MAIN RESULTS

Eighty-five completed trials were included, of which 76 trials contributed data to one or more of the outcomes. This included a total of 4957 participants randomised to intraperitoneal local anaesthetic instillation (2803 participants) and control (2154 participants). Most trials only included participants undergoing elective laparoscopic cholecystectomy and those who were at low anaesthetic risk (ASA I and II). The most commonly used local anaesthetic agent was bupivacaine. Methods of instilling the local anaesthetic varied considerably between trials; this included location and timing of application. The control groups received 0.9% normal saline (69 trials), no intervention (six trials), or sterile water (two trials). One trial did not specify the control agent used. None of the trials provided information on follow-up beyond point of discharge from hospital. Only two trials were at low risk of bias. Seven trials received external funding, of these three were assessed to be at risk of conflicts of interest, a further 17 trials declared no funding. We are very uncertain about the effect intraperitoneal local anaesthetic versus control on mortality; zero mortalities in either group (8 trials; 446 participants; very low-certainty evidence); serious adverse events (RR 1.07; 95% CI 0.49 to 2.34); 13 trials; 988 participants; discharge on same day of surgery (RR 1.43; 95% CI 0.64 to 3.20; 3 trials; 242 participants; very low-certainty evidence). We found that intraperitoneal local anaesthetic probably results in a small reduction in length of hospital stay (MD -0.10 days; 95% CI -0.18 to -0.01; 12 trials; 936 participants; moderate-certainty evidence). No trials reported data on health-related quality of life, return to normal activity or return to work. Pain scores, as measured by visual analogue scale (VAS), were lower in the intraperitoneal local anaesthetic instillation group compared to the control group at both four to eight hours (MD -0.99 cm VAS; 95% CI -1.19 to -0.79; 57 trials; 4046 participants; low-certainty of evidence) and nine to 24 hours (MD -0.68 cm VAS; 95% CI -0.88 to -0.49; 52 trials; 3588 participants; low-certainty of evidence). In addition, we found two trials that were still ongoing, and one trial that was completed but with no published results. All three trials are registered on the WHO trial register.

AUTHORS' CONCLUSIONS

We are very uncertain about the effect estimate of intraperitoneal local anaesthetic for laparoscopic cholecystectomy on all-cause mortality, serious adverse events, and proportion of patients discharged on the same day of surgery because the certainty of evidence was very low. Due to inadequate reporting, we cannot exclude an increase in adverse events. We found that intraperitoneal local anaesthetic probably results in a small reduction in length of stay in hospital after surgery. We found that intraperitoneal local anaesthetic may reduce pain at up to 24 hours for low-risk patients undergoing laparoscopic cholecystectomy. Future randomised clinical trials should be at low risk of systematic and random errors, should fully report mortality and side effects, and should focus on clinical outcomes such as quality of life.

The effect of intraperitoneal ropivacaine on post-operative pain and recovery after diagnostic laparoscopy and hysteroscopy: A randomised double-blind placebo-controlled trial

BACKGROUND

Intraperitoneal local anaesthetic has shown benefit in operative laparoscopy; however, no randomised controlled trial has been reported with patients having diagnostic laparoscopy.

AIMS

To determine the effect of intraperitoneal ropivacaine on post-operative analgesic requirements, pain, nausea scores and recovery following gynaecological diagnostic laparoscopy and hysteroscopy.

MATERIALS AND METHODS

Randomised double-blind placebo-controlled trial. Well women aged 18-50 years, undergoing day case hysteroscopy and diagnostic laparoscopy for gynaecological indications were randomised to 20 mL of 150 mg intraperitoneal ropivacaine diluted in saline, or 20 mL normal saline instillation (placebo) at the end of the procedure. Women were followed up until eight hours post-discharge.

RESULTS

Slower than anticipated recruitment meant that the study was finished before the sample size of 100 patients was achieved. Fifty-nine patients were included for analysis. Thirty-one patients were randomised to ropivacaine and 28 patients to control. Sixty-one percent of patients in both arms required opioid medication in recovery. The total median equivalent morphine dose was significantly higher in the patients randomised to control (11.7 mg) vs ropivacaine (6.7 mg), P = 0.03. Time to discharge was 20 min faster in patients randomised to ropivacaine, but this finding did not reach significance. Overall pain and nausea scores in the first eight hours showed no significant differences.

CONCLUSION

There was significantly reduced opioid use in recovery when using intraperitoneal ropivacaine compared to placebo, in this randomised placebo-controlled trial on women undergoing day case diagnostic laparoscopy and hysteroscopy.

Comparison of effect of intraperitoneal instillation of additional dexmedetomidine or clonidine along with bupivacaine for post-operative analgesia following laparoscopic cholecystectomy

Background and Aims

Despite advances in minimally invasive surgery, postoperative pain remains a concern after laparoscopic cholecystectomy. This study aims to compare the effect of intraperitoneal instillation of bupivacaine with alpha-2 agonists (dexmedetomidine and clonidine) for postoperative analgesia.

Methods

One hundred and eight patients scheduled for elective laparoscopic cholecystectomy were randomised to receive either 20 mL of 0.5% bupivacaine (Group B), 20 mL of 0.5% bupivacaine with dexmedetomidine 1 μg/kg (Group BD) or 20 mL of 0.5% bupivacaine with clonidine 1 μg/kg (Group BC). Study drug made to equal volume (40 mL) was instilled before the removal of trocar at the end of surgery. Standard general endotracheal anaesthesia with intra-abdominal pressure of 12-14 mm Hg during laparoscopy was followed uniformly. The primary objective of our study was the magnitude of pain. One way analysis of variance (ANOVA) for continuous variables and Chi-square test for categorical variables was used.

Results

The Numerical Rating Scale (NRS) scores for pain intensity did not show any statistical significance at any of the pre-defined time points. Time to first request for analgesia was shortest in group BC (64.0 ± 60.6 min) when compared to the other groups (B, 78.8 ± 83.4 min; BD, 112.2 ± 93.4 min; P < 0.05). Total amount of rescue fentanyl given in groups BD (16.8 ± 29.0 μg) and BC (15 ± 26.4 μg) was significantly less than B (35.7 ± 40.0 μg); P < 0.05).

Conclusion

The addition of alpha-2 agonists to bupivacaine reduces the post-operative opioid consumption, and dexmedetomidine appears to be superior to clonidine in prolonging time to first analgesic request.

Systematic review and meta-analysis of ropivacaine use in laparoscopic hysterectomy

To assess the efficacy of all forms of ropivacaine administration for the management of pain and opioid use, specifically in patients undergoing laparoscopic hysterectomy. We searched PubMed, Cochrane CENTRAL, Web of Science, and SCOPUS for relevant clinical trials matching our eligibility criteria. Outcomes of interest included: Pain intensity (measured either by visual analog scale score or by numerical rating scale score), QoR-40 score (Overall quality of recovery tool, designed to measure physical comfort, physical independence, pain, emotional status, and need for support), and the need for opioid rescue. We performed the analysis under the fixed-effects model for homogeneous data and random-effects model for heterogeneous data. Most heterogeneous data were solved by the leave-one-out method, in cases where this was not successful, we then proceeded to conduct at least one subgroup meta-analysis in an attempt to solve heterogeneity. We assessed the risk of bias using Cochrane's risk of bias tool. A total of five clinical trials were included. Regarding the pain score, there was no significant difference between either group [standardized mean difference=-0.17, 95% confidence interval (CI): (-0.56, 0.23); p=0.41]. The analysis of the overall RoQ40 scores favored the ropivacaine group over the control group significantly [mean difference (MD)=17.68, 95% CI: (1.48, 33.87); p<0.001]. Regarding the use of opioids, the analysis revealed no significant difference between either group [MD=-2.57, 95% CI: (-6.62, 1.49); p=0.21]. Ropivacaine administration by any method does not seem to be effective in reducing pain or reducing the need for opioid use after laparoscopic hysterectomy procedures; however, the administration did show a significant improvement in the patient's "overall quality of recovery," as measured using the QoR-40 tool.

An investigation of the effects of dexmedetomidine and fentanyl as an adjuvant to ropivacaine on pain scores and hemodynamic changes following laparoscopic cholecystectomy

Postoperative pain control is recognized as a challenging surgical issue receiving high priority in the healthcare system, and opioids are routinely prescribed for anesthesia and pain relief. This study aimed to investigate the effects of ropivacaine administered intraperitoneally alone or combined with dexmedetomidine or fentanyl on postoperative pain control following laparoscopic cholecystectomy. This randomized double-blind clinical trial recruited three equal-size block-randomized groups of patients (n = 138) scheduled for elective laparoscopic cholecystectomy at Valiasr Hospital, Arak, Iran, in 2019–2020 who received ropivacaine (40 mL/0.5%), ropivacaine (40 mL/0.5%) + dexmedetomidine (1 μg/kg), and ropivacaine (40 mL/0.5%) + fentanyl (1 μg/kg). No significant differences were observed among the three groups according to the vital signs (mean arterial pressure/heart-rate/oxygen saturation) in the study period and during surgery (P > 0.05). Lower pain was revealed in the ropivacaine + dexmedetomidine group (P = 0.001), with the lowest opioid dose in postoperative 24 hours (P = 0.001). Moreover, no clinically significant differences were observed in complications among the three groups (P = 0.483), and no patient developed ileus. Intraperitoneal ropivacaine administered with dexmedetomidine could relieve pain and reduce opioid use in postoperative 24 hours, without any complication and ileus. Therefore, intraperitoneal ropivacaine administered with dexmedetomidine is recommended for postoperative pain control in patients undergoing laparoscopic cholecystectomy. This study was approved by the Ethical Committee of Arak University of Medical Sciences (approval No. IR.ARAKMU.REC.1397.267) on December 30, 2018 and was registered in the Iranian Registry of Clinical Trials (No. IRCT 20141209020258N117) on July 13, 2019.

Post-operative analgesic effect of intraperitoneal ropivacaine with or without tramadol in laparoscopic cholecystectomy

Background and Aims

Intraperitoneal instillation of local anaesthetics has been shown to minimise post-operative pain after laparoscopic surgery. This study was aimed to evaluate the post-operative effect of intraperitoneal ropivacaine with and without tramadol in patients undergoing laparoscopic cholecystectomy.

Methods

Eighty patients undergoing laparoscopic cholecystectomy were randomised into two groups. Group R received 0.5% ropivacaine 18 mL with normal saline (NS) 2 mL and Group RT received 0.5% ropivacaine 18 mL with tramadol (100 mg, 2 mL) at the end of surgery intraperitoneally through the port. The pain score was monitored using a numerical rating scale (NRS) every 30 min till 4 h post-operatively and then at 6 h, 12 h and 24 h. The primary objective of the study was to compare the severity of pain between the groups. The secondary objectives were to compare the total dose of rescue analgesic and the time tofirst rescue analgesia between the groups Statistical analysis was performed using statistical package for the social sciences. Chi-square test and Mann Whitney U test were used for analysis.

Results

The pain score in Group RT was significantly lower than Group R at 2.5 h to 24 h (P = 0.005). Only 42.5% in Group RT demanded rescue analgesia as compared to 75% in Group R (P = 0.003). Total analgesic consumption of fentanyl was also reduced in the tramadol group (785 μg vs 1800 μg). No significant adverse effects were found.

Conclusion

Intraperitoneal instillation of ropivacaine with tramadol reduces the post-operative pain and analgesic requirement in laparoscopic cholecystectomy as compared to ropivacaine alone.

Comparison of Subcostal Transversus Abdominis Block with Intraperitoneal Instillation of Levobupivacaine for Pain Relief after Laparoscopic Cholecystectomy: A Prospective Study

Background

There are several methods employed in the management of postoperative pain after laparoscopic cholecystectomy such as conventional systemic analgesics, including paracetamol, non-steroidal anti-inflammatory drugs, systemic opioids, and thoracic epidural analgesia with all having its limitations and side effects.

Aims

The present study aims to compare ultrasound-guided subcostal transversus abdominis (STA) block with intraperitoneal instillation of levobupivacaine in reducing postoperative pain, total analgesic consumption, nausea and vomiting, and recovery time in patients after elective laparoscopic cholecystectomy.

Settings and Design

A prospective study was conducted between January 2017 and December 2017 in 80 patients undergoing elective laparoscopic cholecystectomy after approval of the Institutional Ethical Committee (Reference No: SGRR/IEC/05/16).

Materials and Methods

Patients were randomly divided into two equal-sized (n = 40) study groups. Group 1 patients received ultrasonography-guided STA block with 0.25% levobupivacaine both sides and Group 2 patients received 0.25% levobupivacaine through intraperitoneal route.

Statistical Analysis

Quantitative data were expressed in mean and standard deviation. Qualitative data were expressed in proportion and percentages. Independent t-test was applied to compare the means of quantitative data and the Chi-square test was used to compare categorical data. P < 0.05 was considered to be statistically significant. Survival curve was drawn using the log-rank test for comparing two groups.

Results

Patient characteristics regarding age, gender, and weight were comparable in the two groups. The mean Numerical Rating Scale scores were less in Group 1 than in Group 2 in the first 6 h, which was found to be statistically significant. There was no significant difference noted in pain scores after 6 h up to 24 h in postoperative area among the two groups. Pain scores for shoulder tip pain were lower in Group 2 as compared to Group 1 in the first 24 h, which was not significant statistically.

Conclusion

STA block is a better modality for analgesia compared to intraperitoneal instillation in patients undergoing elective laparoscopic cholecystectomy.

Randomized controlled study of intraincisional infiltration versus intraperitoneal instillation of standardized dose of ropivacaine 0.2% in post-laparoscopic cholecystectomy pain: Do we really need high doses of local anesthetics-time to rethink!

BACKGROUND

Earlier studies done to compare the efficacy of use of local anesthetics at intraperitoneal location versus intraincisional use had utilized equal amount of drugs at the two locations, usually 10-20 ml. Using this large amount of drug in the small space of intraincisional location as compared to similar amount of drug in large intraperitoneal space created an inadvertent bias in favor of patients receiving the drug intraincisionally so these patients naturally experienced less pain.

AIMS AND OBJECTIVES

To conduct a randomized, triple-blind, placebo-controlled study by standardizing dose of local anesthetic, to compare the effectiveness of intraperitoneal against intraincisional use of ropivacaine 0.2% for post-laparoscopic cholecystectomy pain relief.

MATERIALS AND METHODS

294 patients underwent elective 4-port laparoscopic cholecystectomy. Patients were triple blindly randomized. All patients received ~ 23 ml of solution, of which 20 ml was given intraperitoneally (1 ml/cm; 16 ml along right hemi-dome and 4 ml in gall bladder fossa) and ~ 3 ml intraincisionally (1 ml/cm of length of incision). Solution was either normal saline or drug (0.2% ropivacaine) depending on the group [controls (n = 86), intraperitoneal group (n = 100), and intraincisional group (n = 108)]. 5 different pain scales were used for assessment of overall pain. Pain scores were assessed at 5 points of time.

RESULTS

Patients in intraincisional group showed significantly less overall pain and rescue analgesia requirement (p < 0.05). Intraincisional group showed significantly less overall pain (p < 0.05) as compared to intraperitoneal group; however, use of rescue analgesia was comparable in the two groups (p > 0.05); and shoulder pain was significantly less in intraperitoneal group (p < 0.05).

CONCLUSION

The intraincisional use of injection ropivacaine at its minimum concentration of 0.2% in minimal doses of 1 ml/cm at the end of procedure provides significantly more post-operative analgesia as compared to intraperitoneal group and controls. However, for controlling shoulder pain, the use of intraperitoneal ropivacaine is desirable.

Intraperitoneal Instillation of Bupivacaine and Ropivacaine for Postoperative Analgesia in Laparoscopic Cholecystectomy

Background:

Intraperitoneal instillation of local anesthetics in laparoscopic cholecystectomy (LC) has been used to reduce postoperative pain and to decrease the need for postoperative analgesics.

Aims:

This study aimed to compare intraperitoneal instillation of bupivacaine and ropivacaine for postoperative analgesia in patients undergoing LC.

Settings and Design:

This was a prospective, randomized, double-blind study.

Materials and Methods:

After obtaining ethical committee's clearance and informed consent, sixty patients, aged 18–65 years, of either gender, and American Society of Anesthesiologists physical status I to III scheduled for LC were included and categorized into two groups (n = 30). Group A patients received 20 mL of 0.5% bupivacaine intraperitoneally after cholecystectomy and Group B patients received 20 mL of 0.5% ropivacaine intraperitoneally after cholecystectomy.

Statistical Analysis:

The data were analyzed using paired t-test. The results were analyzed and compared to previous studies. SPSS software version 22 was used, released 2013 (IBM Corp., Armonk, NY, USA).

Results:

Pulse rate, systolic blood pressure, and diastolic blood pressure were comparatively lower in Group B than in Group A. The visual analog scale (VAS) score was significantly lower in Group B. Rescue analgesia was given when VAS was >6. Verbal rating scale score was significantly lower in Group B, showing longer duration of analgesia in this group. Rescue analgesic requirement was also less in Group B.

Conclusion:

The instillation of bupivacaine and ropivacaine intraperitoneally was an effective method of postoperative pain relief in LC. It provided good analgesia in immediate postoperative period with ropivacaine, providing longer duration of analgesia.

Intraperitoneal ropivacaine instillation versus no intraperitoneal ropivacaine instillation for laparoscopic cholecystectomy: A systematic review and meta-analysis

BACKGROUND

Pain is one of the important reasons for delayed discharge and Enhanced Recovery After Surgery (ERAS) after laparoscopic cholecystectomy. To assess the benefits and disadvantage of intraperitoneal instillation of ropivacaine in people undergoing laparoscopic cholecystectomy.

METHODS

We searched the MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Science Citation Index Expanded to December 2016 to identify randomised clinical trials of relevance to this review. We analysed the data with Review Manager 5 analysis.

MAIN RESULTS

We identified 12 suitable studies. A total of 853 participants were randomised to intraperitoneal ropivacaine instillation (442 participants) versus "no intraperitoneal ropivacaine instillation" (411 participants). The pain scores as measured by the visual analogue scale (VAS) were significantly lower in the ropivacaine instillation group than the control group at 4-8 h (10 trials; 751 participants; MD -0.64 cm; 95% CI -0.86 to -0.43; p < 0.00001) and at 9-24 h (9 trials; 582 participants; MD -0.47 cm; 95% CI -0.66 to -0.28; p < 0.00001).The proportion of people who developed the adverse events were less in the ropivacaine instillation group than the control group(RR 0.60; 95% CI 0.45 to 0.79; p = 0.0002). There was no significant difference in the Post-anesthesia care unit (PACU) stay time between the two groups (3 trials; 197 participants; MD -3.77 min; 95% CI -10.24 to 2.69). The overall quality of evidence was very low. Further trials are necessary.

Preemptive Analgesia by Intraperitoneal Instillation of Ropivacaine in Laparoscopic Cholecystectomy

Background:

Preemptive analgesia has the potential to be more effective than a similar analgesic treatment initiated after surgery as it reduces immediate postoperative pain as well as chronic pain.

Aim:

To study the efficacy of preemptive analgesia with intraperitoneal instillation of ropivacaine in laparoscopic cholecystectomy (LC).

Materials and Methods:

This prospective randomized double-blind study was conducted on patients undergoing LC. Hundred patients were randomly divided into two groups of fifty each. In Group A, patients received 3 mg/kg of ropivacaine intraperitoneal instillation in 100 ml normal saline (NS) before creation of pneumoperitoneum and in Group B patients received 3 mg/kg of ropivacaine intraperitoneal instillation in 100 ml NS after completion of surgery. Postoperative visual analog scale score for abdominal and shoulder tip pain alongwith requirement of rescue analgesic were recorded for 24 h.

Results:

Significantly lower visual analog scores for pain were observed in Group A versus Group B. Group A reported significantly lower pain at 0 h (P < 0.001), 1 h (P = 0.003), 3 h (P = 0.006), 6 h (P = 0.003), and 12 h (P = 0.001) postoperatively, but the difference was not statistically significant after 12 h. The mean time of first rescue analgesic was 472.8 ± 26.32 min in Group A, as compared with 189 ± 11.87 min in Group B. A significantly lower analgesic requirement was observed in Group A versus Group B throughout the entire study period (P < 0.05).

Conclusion:

The preemptive analgesia with intraperitoneal instillation of ropivacaine before creation of pneumoperitoneum is much more effective for postoperative pain relief in comparison to intraperitoneal instillation of ropivacaine after completion of surgery.

Effect of intraperitoneal local anesthetic on pain characteristics after laparoscopic cholecystectomy

AIM: To systematically evaluate the effect of intraperitoneal local anesthetic on pain characteristics after laparoscopic cholecystectomy (LC).

METHODS: We searched MEDLINE, EMBASE, and the Cochrane Library. Randomized controlled trials in English that compared the effect of intraperitoneal administration of local anesthetics on pain with that of placebo or nothing after elective LC under general anesthesia were included. The primary outcome variables analyzed were the combined scores of abdominal, visceral, parietal, and shoulder pain after LC at multiple time points. We also extracted pain scores at resting and dynamic states.

RESULTS: We included 39 studies of 3045 patients in total. The administration of intraperitoneal local anesthetic reduced pain intensity in a resting state after laparoscopic cholecystectomy: abdominal [standardized mean difference (SMD) = -0.741; 95%CI: -1.001 to -0.48, P < 0.001]; visceral (SMD = -0.249; 95%CI: -0.493 to -0.006, P = 0.774); and shoulder (SMD = -0.273; 95%CI: -0.464 to -0.082, P = 0.097). Application of intraperitoneal local anesthetic significantly reduced the incidence of shoulder pain (RR = 0.437; 95%CI: 0.299 to 0.639, P < 0.001). There was no favorable effect on resting parietal or dynamic abdominal pain.

CONCLUSION: Intraperitoneal local anesthetic as an analgesic adjuvant in patients undergoing laparoscopic cholecystectomy exhibited beneficial effects on postoperative abdominal, visceral, and shoulder pain in a resting state.

Assessing the feasibility of a randomised, double-blinded, placebo-controlled trial to investigate the role of intraperitoneal ropivacaine in gastric bypass surgery: a protocol

INTRODUCTION

Postoperative pain control remains a major challenge for surgical procedures, including laparoscopic gastric bypass. Pain management is particularly relevant in obese patients who experience a higher number of cardiovascular and pulmonary events. Effective pain management may reduce their risk of serious postoperative complication, such as deep vein thrombosis and pulmonary emboli. The objective of this study is to evaluate the efficacy of intraperitoneal local anaesthetic, ropivacaine, to reduce postoperative pain in patients undergoing laparoscopic Roux-en-Y gastric bypass.

METHODS AND ANALYSIS

A randomised controlled trial will be conducted to compare intraperitoneal ropivacaine (intervention) versus normal saline (placebo) in 120 adult patients undergoing bariatric bypass surgery. Ropivacaine will be infused over the oesophageal hiatus and throughout the abdomen. Patients in the control arm will undergo the same treatment with normal saline. The primary end point will be postoperative pain at 1, 2 and 4 h postoperatively. Pain measurements will then occur every 4 h for 24 h and every 8 h until discharge. Secondary end points will include opioid use, peak expiratory flow, 6 min walk distance and quality of life assessed in the immediate postoperative period. Intention-to-treat analysis will be used and repeated measures will be analysed using mixed modelling approach. Post-hoc pairwise comparison of the treatment groups at different time points will be carried out using multiple comparisons with adjustment to the type 1 error. Results of the study will inform the feasibility of recruitment and inform sample size of a larger definitive randomised trial to evaluate the effectiveness of intraperitoneal ropivacaine.

ETHICS AND DISSEMINATION

This study has been approved by the Ottawa Health Science Network Research Ethics Board and Health Canada in April 2014. The findings of the study will be disseminated through national and international conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Clinicaltrial.gov NCT02154763.

Methods of intraperitoneal local anaesthetic instillation for laparoscopic cholecystectomy

BACKGROUND

Intraperitoneal local anaesthetic instillation may decrease pain in people undergoing laparoscopic cholecystectomy. However, the optimal method to administer the local anaesthetic is unknown.

OBJECTIVES

To determine the optimal local anaesthetic agent, the optimal timing, and the optimal delivery method of the local anaesthetic agent used for intraperitoneal instillation in people undergoing laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization International Clinical Trials Registry Platform portal (WHO ICTRP) to March 2013 to identify randomised clinical trials for assessment of benefit and comparative non-randomised studies for the assessment of treatment-related harms.

SELECTION CRITERIA

We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different methods of local anaesthetic intraperitoneal instillation during laparoscopic cholecystectomy for the review.

DATA COLLECTION AND ANALYSIS

Two review authors collected the data independently. We analysed the data with both fixed-effect and random-effects models using Review Manager 5 analysis. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included 12 trials with 798 participants undergoing elective laparoscopic cholecystectomy randomised to different methods of intraperitoneal local anaesthetic instillation. All the trials were at high risk of bias. Most trials included only people with low anaesthetic risk. The comparisons included in the trials that met the eligibility criteria were the following; comparison of one local anaesthetic agent with another local anaesthetic agent (three trials); comparison of timing of delivery (six trials); comparison of different methods of delivery of the anaesthetic agent (two trials); comparison of location of the instillation of the anaesthetic agent (one trial); three trials reported mortality and morbidity.There were no mortalities or serious adverse events in either group in the following comparisons: bupivacaine (0/100 (0%)) versus lignocaine (0/106 (0%)) (one trial; 206 participants); just after creation of pneumoperitoneum (0/55 (0%)) versus end of surgery (0/55 (0%)) (two trials; 110 participants); just after creation of pneumoperitoneum (0/15 (0%)) versus after the end of surgery (0/15 (0%)) (one trial; 30 participants); end of surgery (0/15 (0%)) versus after the end of surgery (0/15 (0%)) (one trial; 30 participants).None of the trials reported quality of life, the time taken to return to normal activity, or the time taken to return to work. The differences in the proportion of people who were discharged as day-surgery and the length of hospital stay were imprecise in all the comparisons included that reported these outcomes (very low quality evidence). There were some differences in the pain scores on the visual analogue scale (1 to 10 cm) but these were neither consistent nor robust to fixed-effect versus random-effects meta-analysis or sensitivity analysis.

AUTHORS' CONCLUSIONS

The currently available evidence is inadequate to determine the effects of one method of local anaesthetic intraperitoneal instillation compared with any other method of local anaesthetic intraperitoneal instillation in low anaesthetic risk individuals undergoing elective laparoscopic cholecystectomy. Further randomised clinical trials of low risk of systematic and random errors are necessary. Such trials should include important clinical outcomes such as quality of life and time to return to work in their assessment.

Intraperitoneal local anaesthetic instillation versus no intraperitoneal local anaesthetic instillation for laparoscopic cholecystectomy

BACKGROUND

While laparoscopic cholecystectomy is generally considered less painful than open surgery, pain is one of the important reasons for delayed discharge after day surgery and overnight stay laparoscopic cholecystectomy. The safety and effectiveness of intraperitoneal local anaesthetic instillation in people undergoing laparoscopic cholecystectomy is unknown.

OBJECTIVES

To assess the benefits and harms of intraperitoneal instillation of local anaesthetic agents in people undergoing laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to March 2013 to identify randomised clinical trials of relevance to this review.

SELECTION CRITERIA

We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing local anaesthetic intraperitoneal instillation versus placebo, no intervention, or inactive control during laparoscopic cholecystectomy for the review with regards to benefits while we considered quasi-randomised studies and non-randomised studies for treatment-related harms.

DATA COLLECTION AND ANALYSIS

Two review authors collected the data independently. We analysed the data with both fixed-effect and random-effects models using Review Manager 5 analysis. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included 58 trials, of which 48 trials with 2849 participants randomised to intraperitoneal local anaesthetic instillation (1558 participants) versus control (1291 participants) contributed data to one or more of the outcomes. All the trials except one trial with 30 participants were at high risk of bias. Most trials included only low anaesthetic risk people undergoing elective laparoscopic cholecystectomy. Various intraperitoneal local anaesthetic agents were used but bupivacaine in the liquid form was the most common local anaesthetic used. There were considerable differences in the methods of local anaesthetic instillation including the location (subdiaphragmatic, gallbladder bed, or both locations) and timing (before or after the removal of gallbladder) between the trials. There was no mortality in either group in the eight trials that reported mortality (0/236 (0%) in local anaesthetic instillation versus 0/210 (0%) in control group; very low quality evidence). One participant experienced the outcome of serious morbidity (eight trials; 446 participants; 1/236 (0.4%) in local anaesthetic instillation group versus 0/210 (0%) in the control group; RR 3.00; 95% CI 0.13 to 67.06; very low quality evidence). Although the remaining trials did not report the overall morbidity, three trials (190 participants) reported that there were no intra-operative complications. Twenty trials reported that there were no serious adverse events in any of the 715 participants who received local anaesthetic instillation. None of the trials reported participant quality of life, return to normal activity, or return to work.The effect of local anaesthetic instillation on the proportion of participants discharged as day surgery between the two groups was imprecise and compatible with benefit and no difference of intervention (three trials; 242 participants; 89/160 (adjusted proportion 61.0%) in local anaesthetic instillation group versus 40/82 (48.8%) in control group; RR 1.25; 95% CI 0.99 to 1.58; very low quality evidence). The MD in length of hospital stay was 0.04 days (95% CI -0.23 to 0.32; five trials; 335 participants; low quality evidence). The pain scores as measured by the visual analogue scale (VAS) were significantly lower in the local anaesthetic instillation group than the control group at four to eight hours (32 trials; 2020 participants; MD -0.99 cm; 95% CI -1.10 to -0.88 on a VAS scale of 0 to 10 cm; very low quality evidence) and at nine to 24 hours (29 trials; 1787 participants; MD -0.53 cm; 95% CI -0.62 to -0.44; very low quality evidence). Various subgroup analyses and meta-regressions to investigate the influence of the different local anaesthetic agents, different methods of local anaesthetic instillation, and different controls on the effectiveness of local anaesthetic intraperitoneal instillation were inconsistent.

AUTHORS' CONCLUSIONS

Serious adverse events were rare in studies evaluating local anaesthetic intraperitoneal instillation (very low quality evidence). There is very low quality evidence that it reduces pain in low anaesthetic risk people undergoing elective laparoscopic cholecystectomy. However, the clinical importance of this reduction in pain is unknown and likely to be small. Further randomised clinical trials of low risk of systematic and random errors are necessary. Such trials should include important clinical outcomes such as quality of life and time to return to work in their assessment.

Outpatient laparoscopic cholecystectomy and pain control: a series of 100 cases

INTRODUCTION

We present our experience of 100 consecutive cases that underwent ambulatory cholecystectomy using a standard protocol of anesthesia and surgery.

PATIENTS AND METHOD

Prospective study of 100 consecutive patients assessed in the surgery outpatient clinic in Torrevieja Hospital (September 2008-september 2009). Both anesthetic and surgical techniques were protocolized, standardized. The protocol included the use of intraperitoneal and parietal anesthesia.

RESULTS

One hundred patients were included. Average age was 53 years and average surgical time was 29±12 min. Day-case surgery rate was 96%. Postoperative pain (VAS scale) was less than 4 in all cases. Six patients complained of nausea that eased with the administration of ev metoclopramide. Average length of stay in the day-case surgery unit was 7.4h (maximum 9.6, minimum 7). Morbidity and mortality rates were 0%. No re-admission was registered and conversion rate was 0%. Postoperative follow-up was 100%. A total of 97% of the cases were fully satisfied with the procedure.

CONCLUSION

Ambulatory laparoscopic cholecystectomy is a feasible and safe technique. Postoperative pain has classically been the reason to not perform day-case surgery, but we achieved an excellent control by the combined use of local anesthetics and warm intraperitoneal saline solution.

Effect of laparoscopic cholecystectomy techniques on postoperative pain: a prospective randomized study

PURPOSE

Minimally invasive surgical technics have benefits such as decreased pain, reduced surgical trauma, and increased potential to perform as day case surgery, and cost benefit. The primary aim of this prospective, randomized, controlled study was to compare the effects of single incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC) procedures regarding postoperative pain.

METHODS

Ninety adult patients undergoing elective laparoscopic cholecystectomy were included in the study. Patients were randomized to either SILC or CLC. Patient characteristics, postoperative abdominal and shoulder pain scores, rescue analgesic use, and intraoperative and early postoperative complications were recorded.

RESULTS

A total of 83 patients completed the study. Patient characteristics, postoperative abdominal and shoulder pain scores and rescue analgesic requirement were similar between each group except with the lower abdominal pain score in CLC group at 30th minute (P = 0.04). Wound infection was seen in 1 patient in each group. Nausea occurred in 13 of 43 patients (30%) in the SILC group and 8 of 40 patients (20%) in the CLC group (P > 0.05). Despite ondansetron treatment, 6 patients in SILC group and 7 patients in CLC group vomited (P > 0.05).

CONCLUSION

In conclusion, in patients undergoing laparoscopic surgery, SILC or CLC techniques does not influence the postoperative pain and analgesic medication requirements. Our results also suggest that all laparoscopy patients suffer moderate and/or severe abdominal pain and nearly half of these patients also suffer from some form of shoulder pain.

Postoperative pain after laparoscopic cholecystectomy: a randomized clinical trial comparing intraperitoneal bupivacaine versus intravenous pethidine

Pain is the most common complaint of patients on the first day after laparoscopic cholecystectomy (LC). This clinical trial compared the effects of intraperitoneal (IP) bupivacaine and intravenous (IV) pethidine on this pain. Forty-eight patients who underwent LC were randomly assigned to 2 groups of IP bupivacaine and IV pethidine. Postoperative pain, oral analgesic consumption, peak expiratory flow rate, and presence of nausea or vomiting was recorded at baseline and 4, 8, and 24 hours after surgery. Patients who received IP bupivacaine showed a significantly lower pain score (P = 0.022) and improved peak expiratory flow rate (P = 0.006), and received lower doses of ibuprofen (P = 0.003) within the first 24 hours after surgery. Likewise, the presence of nausea/vomiting was significantly lower in bupivacaine groups 1 and 4 hours after surgery (P = 0.003 and 0.005, respectively). Our results indicate that IP instillation of bupivacaine is more beneficial than traditional IV pethidine for pain reduction after LC.

Intraincisional vs intraperitoneal infiltration of local anaesthetic for controlling early post-laparoscopic cholecystectomy pain

BACKGROUND:

The study was designed to compare the effect of intraincisional vs intraperitoneal infiltration of levobupivacaine 0.25% on post-operative pain in laparoscopic cholecystectomy.

MATERIALS AND METHODS:

This randomised controlled study was carried out on 189 patients who underwent laparoscopic cholecystectomy. Group 1 was the control group and did not receive either intraperitoneal or intraincisional levobupivacaine. Group 2 was assigned to receive local infiltration (intraincisional) of 20 ml solution of levobupivacaine 0.25%, while Group 3 received 20 ml solution of levobupivacaine 0.25% intraperitoneally. Post-operative pain was recorded for 24 hours post-operatively.

RESULTS:

Post-operative abdominal pain was significantly lower with intraincisional infiltration of levobupivacaine 0.25% in group 2. This difference was reported from 30 minutes till 24 hours post-operatively. Right shoulder pain showed significantly lower incidence in group 2 and group 3 compared to control group. Although statistically insignificant, shoulder pain was less in group 3 than group 2.

CONCLUSION:

Intraincisional infiltration of levobupivacaine is more effective than intraperitoneal route in controlling post-operative abdominal pain. It decreases the need for rescue analgesia.

Randomized clinical trial of combined preincisional infiltration and intraperitoneal instillation of levobupivacaine for postoperative pain after laparoscopic cholecystectomy

BACKGROUND

Postoperative pain is one of the main reasons for a prolonged hospital stay after laparoscopic cholecystectomy (LC). Reduced postoperative pain might result in faster recovery and establish LC as a day-care surgical procedure. Peroperative local anaesthesia has been suggested to reduce postoperative pain. The aim of this study was to determine the effect of combined subcutaneous infiltration and intraperitoneal instillation of levobupivacaine before the start of LC on postoperative abdominal pain up to 24 h after surgery.

METHODS

Patients eligible for elective LC were randomized to receive preincisional infiltration and preoperative intraperitoneal instillation of 80 ml of either 0·125 per cent levobupivacaine (experimental group) or normal saline (placebo group). The primary outcome measure was abdominal pain estimated by means of a visual analogue scale at 0·5, 2, 4, 8 and 24 h after surgery.

RESULTS

Eighty of the 101 patients assessed for eligibility were randomized. There was no significant reduction in postoperative abdominal pain with levobupivacaine compared with placebo during the 24-h follow-up; the overall difference in pain score was 2·2 (95 per cent confidence interval - 4·9 to 9·3; P = 0·540). The duration of operation, use of anaesthesia, use of rescue analgesia, shoulder pain, duration of hospital stay and time to resumption of normal daily activities did not differ between the two groups.

CONCLUSION

Combined subcutaneous and intraperitoneal administration of levobupivacaine did not influence postoperative abdominal pain after LC.

REGISTRATION NUMBER

NCT01199406 (http://www.clinicaltrials.gov).

Intraperitoneal use of local anesthetic in laparoscopic cholecystectomy: systematic review and metaanalysis of randomized controlled trials

BACKGROUND/PURPOSE

With the advent of minimally invasive gallbladder surgery, and now with natural orifice techniques emerging, visceral nociception has been neglected as a cause of postoperative pain. A systematic review and metaanalysis was carried out to investigate the use of intraperitoneal local anesthetic (IPLA) in order to assess its role in laparoscopic cholecystectomy (LC). The aim of this systematic review was to appraise the clinical effects of this modality.

METHODS

Comprehensive searches were conducted independently without language restriction. Studies were identified from the following databases from inception to September 2009: Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Cochrane Library, Medline, PubMed, Excerpta Medica Database (EMBASE), and Cumulative Index to Nursing and Allied Health Literature (CINHAL). Relevant meeting abstracts and reference lists were manually searched. Data analysis was performed using Review Manager Version 5.0 software.

RESULTS

Thirty randomized controlled trials were identified for review. The clinical heterogeneity of IPLA use was high. However, there appeared to be reduced pain, opioid use, and need for rescue analgesia, and reduced postoperative cortisol and glucose responses.

CONCLUSION

There is evidence in favor of IPLA in LC. Further trials of this modality in LC are not needed as these are unlikely to reduce clinical heterogeneity. IPLA should be trialled as future minimally invasive surgical techniques approach.

Wound infiltration for surgery

Wound infiltration with local anaesthetics is a simple, effective and inexpensive means of providing good analgesia for a variety of surgical procedures without any major side-effects. In particular, local anaesthetic toxicity, wound infection and healing do not appear to be major considerations. The purpose of this review is to outline the existing literature on a procedure-specific basis and to encourage a more widespread acceptance of the technique, ensuring that all layers are infiltrated in a controlled and meticulous manner.

Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial

BACKGROUND

The attempt to further reduce operative trauma in laparoscopic cholecystectomy has led to new techniques such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS). These new techniques are considered to be painless procedures, but no published studies investigate the possibility of different pain scores in these new techniques versus classic laparoscopic cholecystectomy. In this randomized control study, we investigated pain scores in SILS cholecystectomy versus classic laparoscopic cholecystectomy.

PATIENTS AND METHODS

Forty patients (34 women and 6 men) were randomly assigned to two groups. In group A (n = 20) four-port classic laparoscopic cholecystectomy was performed. Patients in group B (n = 20) underwent SILS cholecystectomy. In all patients, preincisional local infiltration of ropivacaine around the trocar wounds was performed. Infusion of ropivacaine solution in the right subdiaphragmatic area at the beginning of the procedure plus normal saline infusion in the same area at the end of the procedure was performed in all patients as well. Shoulder tip and abdominal pain were registered at 2, 6, 12, 24, 48, and 72 h postoperatively using visual analog scale (VAS).

RESULTS

Significantly lower pain scores were observed in the SILS group versus the classic laparoscopic cholecystectomy group after the first 12 h for abdominal pain, and after the first 6 h for shoulder pain. Total pain after the first 24 h was nonexistent in the SILS group. Also, requests for analgesics were significantly less in the SILS group, while no difference was observed in incidence of nausea and vomiting between the two groups.

CONCLUSION

SILS cholecystectomy, as well as the invisible scar, has significantly lower abdominal and shoulder pain scores, especially after the first 24 h postoperatively, when this pain is nonexistent. (Registration Clinical Trial number: NTC00872287, www.clinicaltrials.gov ).

Repeated intraperitoneal instillation of levobupivacaine for the management of pain after laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis. Postoperative pain, however, can prolong hospital stay and lead to increased morbidity. In the context of a multimodal approach to analgesia, intraperitoneal local anesthetic administration optimizes analgesia and facilitates early postoperative recovery, and it may be associated with a decreased risk of side effects.

METHODS

A total of 71 patients was randomized to receive either intraperitoneal analgesic (IPA group) or not (controls). At the completion of cholecystectomy, 10 mL of levobupivacaine 0.5% were infused intraperitoneally in the IPA group and 8 h postoperatively, whereas in the controls, 10 mL of 0.9% NaCl were administered in the corresponding points of time. Differences in pain scores between groups were the primary endpoints. Opioid consumption and adverse effects were the secondary endpoints.

RESULTS

The 2 groups were homogenous in respect to age, sex, body mass index (BMI), and duration of operation. No conversion, complication, or mortality was recorded. The IPA group had a lesser visual analog scale score at rest and at movement compared with controls at all points of time measured. Moreover, fentanyl consumption in the recovery room was significantly greater in the control group, and the consumption of meperidine and the percentage of the patients that requested rescue analgesia in the ward was significantly greater in the control group. Local analgesic intraperitoneal injection as well as parecoxib for postoperative analgesia had no significant adverse effects.

CONCLUSION

Our study showed that 2 separate doses of intraperitoneally administered levobupivacaine significantly decreased postoperative pain and the need for opioids compared with placebo. This technique is simple, safe, and without adverse effects.

Endogenous opiates and behavior: 2007

This paper is the thirtieth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2007 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Preincisional and intraperitoneal ropivacaine plus normal saline infusion for postoperative pain relief after laparoscopic cholecystectomy: a randomized double-blind controlled trial

BACKGROUND

A clinical trial was designed to assess the use of preincisional and intraperitoneal ropivacaine, combined or not with normal saline, to reduce pain after laparoscopic cholecystectomy (LC).

METHODS

For this trial, 120 patients were randomly assigned to six groups. For all the patients, preincisional local infiltration of ropivacaine around the trocar wounds was performed. Group A had infusion of ropivacaine at the beginning of the LC. Group B had infusion of ropivacaine at the beginning of the LC plus normal saline infusion at the end. Group C had normal saline infusion and ropivacaine at the end of the LC. Group D had infusion of ropivacaine at the beginning of the LC plus normal saline infusion at the end and a subhepatic closed drain. Group E had ropivacaine at the end of the LC. Group F (control group) had neither ropivacaine nor normal saline infusion. Shoulder tip and abdominal pain were registered at 2, 4, 6, 12, 24, 48, and 72 h postoperatively using a visual analog score (VAS).

RESULTS

Significantly lower pain scores were observed in group B than in group A at 2, 4, 6, 12, and 24 h or in groups C, D, E, and F at 2, 4, 6, 12, 24, and 48 h. Group A also had significantly lower pain scores than groups C, D, E, and F at 2, 4, 6, 12, 24, and 48 h. Requests for analgesics also were significantly less in group B than in group A at 2, 4, 6, 12, and 24 h or in groups C, D, and E at 2, 4, 6, 12, 24, and 48 h. Demand for additional analgesia was less in group B than in groups A, C, D, E, and F at 2, 4, 6, 12, and 24 h and in group A than in groups C, D, E, and F at 2, 4, 6, and 12 h.

CONCLUSION

Preincisional local infiltration plus intraperitoneal infusion of ropivacaine at the beginning of LC combined with normal saline infusion at the end of the procedure is a safe and valid method for reducing pain after LC.