Intraperitoneal Levobupivacaine with or without Clonidine for Pain Relief after Laparoscopic Cholecystectomy: A Randomized, Double-blind, Placebo-controlled Trial

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.

Intraperitoneal nebulization of ropivacaine for control of pain after laparoscopic cholecystectomy -A randomized control trial

Background and Aims:

Use of high dose opioids following laparoscopic surgery delays discharge from the hospital. Unlike intraperitoneal instillation, nebulization has been reported to provide a homogeneous spread of local anesthetics and provide better analgesia. In our study, we aimed to assess the efficacy of intraperitoneal nebulization of local anesthetic in alleviating postoperative pain in patients undergoing laparoscopic cholecystectomy.

Material and Methods:

This randomized control double-blinded study was conducted after obtaining approval from the hospital ethics committee and informed consent from patients undergoing laparoscopic cholecystectomy under general anesthesia. Patients recruited were divided into two equal groups of 20 each. Group B received intraperitoneal nebulization with 4 ml of 0.75% ropivacaine and Group C received intraperitoneal nebulization with 4ml of saline before surgical dissection. Postoperative pain score using a numeric rating scale was monitored until 24 h, the need for rescue analgesics and associated complications were noted. Chi-square test, Student's test, and Mann–Whitney U test were used for statistical analysis.

Results:

The pain score was significantly less in Group B during rest and deep breathing up to 24 h with a P value <0.05. The pain score on movement was also less in Group B and this difference was statistically significant at 6 and 24 h (P = 0.004 and 0.005, respectively). Tramadol consumption was less in Group B and was statistically significant at 24 h with P value of 0.044. No adverse events were noted.

Conclusion:

Intraperitoneal nebulization of ropivacaine is effective and safe in providing postoperative analgesia in patients undergoing laparoscopic cholecystectomy.

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.

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.

Comparison between intravenous and intratecal clonidine for postoperative analgesia of patients submitted to laparoscopic cholecystectomy: randomized clinical trial

Introduction and objectives

Alpha2 adrenergic agonists, such as clonidine, are used as adjuvants during anesthesia due to their analgesic, sedative, and cardiovascular effects. The objective of the present study was to compare the effect of clonidine administered intravenously and intrathecally on the postoperative pain score of patients undergoing laparoscopic cholecystectomy, according to the route of administration and postoperative opioid consumption.

Methods

This randomized clinical trial, blind to patients and evaluator, assessed 60 patients, candidates for elective laparoscopic cholecystectomy under standardized general anesthesia techniques. Patients were randomly allocated into three groups (20 in each group): Control Group (CG), Intrathecal Clonidine Group (ITCG), and Intravenous Clonidine Group (IVCG). The primary outcome was the comparison of pain, Blood Pressure (BP) and Heart Rate (HR) scores among groups. The secondary outcome was report of adverse effects such as bradycardia, hypotension and sedation, and the need for rescue medication.

Results

The mean age was 37.2 ± 8.2 years, and the mean body mass was 28.3 ± 3.6 kg.m^-2. Regarding HR (p = 0.003) and pain (p = 0.027), patients in ITCG and CG showed a different profile over time, with CG showing higher consumption of morphine as rescue medication (p = 0.005).

Conclusion

The administration of intrathecal and intravenous clonidine in low doses can reduce hemodynamic parameters and decrease postoperative requirement of analgesics. Further studies should investigate the ideal dose and method.

The Impact of Intraperitoneal Levobupivacaine on Pain Relief After Laparoscopic Cholecystectomy: A Meta-analysis of Randomized Controlled Studies

INTRODUCTION

The influence of intraperitoneal levobupivacaine on pain relief after laparoscopic cholecystectomy remains controversial. We conducted a systematic review and meta-analysis to explore the impact of intraperitoneal levobupivacaine versus placebo on pain intensity after laparoscopic cholecystectomy.

MATERIALS AND METHODS

We searched the PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases through March 2019 for randomized controlled trials assessing the effect of intraperitoneal levobupivacaine versus placebo on pain intensity after laparoscopic cholecystectomy. This meta-analysis is performed using the random-effect model.

RESULTS

Six randomized controlled trials are included in the meta-analysis. Overall, compared with the control group after laparoscopic cholecystectomy, intraperitoneal levobupivacaine is associated with substantially reduced pain scores at 2 hours [standard mean difference (SMD)=-0.70; 95% confidence interval (CI)=-1.04 to -0.37; P<0.0001], 4 hours (SMD=-0.61; 95% CI=-0.90 to -0.32; P<0.0001), and 12 hours postoperatively (SMD=-0.31; 95% CI=-0.60 to -0.03; P=0.03), and analgesic requirement (SMD=-0.83; 95% CI=-1.48 to -0.19; P=0.01), but reveals no obvious impact on pain scores at 24 hours postoperatively (SMD=0.09; 95% CI=-0.64 to 0.83; P=0.80) and the incidence of nausea or vomiting (risk ratio=0.69; 95% CI=0.40-1.20; P=0.19). Total adverse events in the levobupivacaine group seem to be lower than that in the control group (risk ratio=0.57; 95% CI=0.38-0.85; P=0.006).

CONCLUSION

Intraperitoneal levobupivacaine provides additional benefits for pain relief after laparoscopic cholecystectomy.

Optimising Surgical Technique in Laparoscopic Cholecystectomy: a Review of Intraoperative Interventions

BACKGROUND

Laparoscopic cholecystectomy (LC) is one of the most commonly performed procedures worldwide but there is considerable variance amongst surgeons regarding intraoperative technique. This review aims to provide a comprehensive summary, with evidence-based recommendations, of intraoperative interventions in LC.

METHODS

A literature search was performed using PubMed, EMBASE, Google Scholar and Cochrane Review databases. Articles were screened for eligibility with inclusion criteria based on study design, surgical approach, surgical timing, pathology and intervention type. The most contemporary, comprehensive or relevant articles were used as the primary evidence for the final analysis and discussion.

RESULTS

A total of 25 systematic reviews and/or meta-analyses and 19 individual trials were identified from the literature and grouped into ten clinical intervention topics. Three intraoperative interventions offer clinical benefit and are recommended: wound/intraperitoneal local anaesthetic, low-pressure pneumoperitoneum and manoeuvres to reduce residual pneumoperitoneum. No benefit was demonstrated for routine subhepatic drain placement and gallbladder aspiration. Techniques which appear to demonstrate improvements but do not translate into clinical efficacy are the use of warmed/humidified carbon dioxide, installation of intraperitoneal saline and the use of advanced imaging techniques. Techniques demonstrating equipoise, and for which no recommendations can be made, are type of energy source and cystic duct occlusion methods.

DISCUSSION

This review highlights and suggests specific intraoperative techniques during uncomplicated LC that should be employed, avoided or considered by the individual surgeon. Optimising surgical technique in this way can lead to improved patient outcomes.