Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

Port Site Morbidities Following the Extraction of the Gallbladder from the Umbilical Port in Comparison to the Epigastric Port in Laparoscopic Cholecystectomy: A Double-Blinded, Randomized Controlled Trial

Background Port site morbidities after laparoscopic cholecystectomy may be related to the port used for the extraction of the gallbladder. Prior randomized trials that tried to address the suitable port for gallbladder extraction showed mixed results favouring epigastric, whereas others favoured umbilical. Thus, the present study was conducted with the aim of finding a suitable port for gallbladder extraction after laparoscopic cholecystectomy. Methodology A total of 104 patients undergoing laparoscopic cholecystectomy were randomized to either the epigastric (Group 1) or umbilical (Group 2) port group for gallbladder extraction. Post-operative pain (by visual analogue scale (VAS)), the frequency of surgical site infection (SSI), and port site herniation were compared. Results Post-operative pain was lower in the umbilical port group in the initial 24 hours. The SSIs and port site herniation rates were lower in the umbilical port group; however, they were statistically not significant. Conclusion Less post-operative pain at the umbilical port may help with the early discharge of patients. In contrast to other studies, our trial had fewer infections and hernias in the umbilical port group.

A Systematic Review and Meta-Analysis of Bag Extraction Versus Direct Extraction for Retrieval of Gallbladder After Laparoscopic Cholecystectomy

This analysis aims to evaluate the comparative outcomes of gallbladder extraction with a bag versus direct extraction in laparoscopic cholecystectomy (LC). A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov, and Science Direct. Comparative studies comparing bag versus direct extraction of the gallbladder in LC were included. Outcomes were surgical site infection (SSI), the extension of fascial defect to extract the gallbladder, intra-abdominal collection, bile spillage, and port-site hernia. Revman 5.4 (Cochrane, London, United Kingdom) was used for the data analysis. The results show eight studies were eligible to be included in this review with a total number of 1805 patients divided between endo-bag (n=835) and direct extraction (n=970). Four of the included studies were randomized controlled trials (RCTs) while the rest were observational studies. The rate of SSI and bile spillage were significantly higher in the direct extraction group: odds ratio (OR)=2.50, p=0.006 and OR=2.83, p=0.01, respectively. Comparable results were observed regarding intra-abdominal collection between the two groups(OR=0.01, p=0.51). However, the extension of a fascial defect was higher in the endo-bag group (OR=0.22, p=0.00001), and no difference was observed regarding the port-site hernia rate (OR-0.70, p=0.55). In conclusion, extraction of the gallbladder with an endo-bag provides a lower rate of SSI and bile spillage with similar results regarding post-operative intra-abdominal collection. Although with the endo-bag, the fascial defect will more likely need to be increased to extract the gallbladder. However, the port-site hernia rate remains similar between the two groups.

Evidence-based surgery for laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy is frequently performed for acute cholecystitis and symptomatic cholelithiasis. Considerable variation in the execution of key steps of the operation remains. We conducted a systematic review of evidence regarding best practices for critical intraoperative steps for laparoscopic cholecystectomy.

Methods

We identified 5 main intraoperative decision points in laparoscopic cholecystectomy: (1) number and position of laparoscopic ports; (2) identification of cystic artery and duct; (3) division of cystic artery and duct; (4) indications for subtotal cholecystectomy; and (5) retrieval of the gallbladder. PubMed, EMBASE, and Web of Science were queried for relevant studies. Randomized controlled trials and systematic reviews were included for analysis, and evidence quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation framework.

Results

Fifty-two articles were included. Although all port configurations were comparable from a safety standpoint, fewer ports sometimes resulted in improved cosmesis or decreased pain but longer operative times. The critical view of safety should be obtained for identification of the cystic duct and artery but may be obtained through fundus-first dissection and augmented with cholangiography or ultrasound. Insufficient evidence exists to compare harmonic-shear, clipless ligation against clip ligation of the cystic duct and artery. Stump closure during subtotal cholecystectomy may reduce rates of bile leak and reoperation. Use of retrieval bag for gallbladder extraction results in minimal benefit. Most studies were underpowered to detect differences in incidence of rare complications.

Conclusion

Key operative steps of laparoscopic cholecystectomy should be informed by both compiled data and surgeon preference/patient considerations.