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

Liver Bed Infiltration With Isobaric Levobupivacaine Versus Intravenous Paracetamol Analgesia for Postoperative Pain Management in Patients Undergoing Laparoscopic Cholecystectomy

Objectives The study aimed to compare the use of isobaric levobupivacaine for liver bed infiltration and intravenous analgesia with paracetamol (acetaminophen) in managing postoperative pain in patients undergoing laparoscopic cholecystectomy. Methods An observational study was conducted on 80 patients scheduled for elective laparoscopic cholecystectomy. Inclusion criteria comprised adults of American Society of Anesthesiologists grade I, aged 18-65, undergoing elective surgeries. Exclusion criteria were contraindications to local anesthetics, history of chronic pain disorders, or ongoing opioid therapy. Participants were divided into two groups: Group LB receiving 30-40 ml 0.5% isobaric levobupivacaine for liver bed infiltration, and Group P receiving paracetamol 1 g intravenous during surgery just after removing the gallbladder out of the laparoscopic port. Primary outcomes included pain scores assessed using the visual analog scale (VAS) at one hour, six hours, 12 hours, 18 hours, and 24 hours postoperatively. Secondary outcomes included the total analgesic consumption, patient satisfaction scores, and any adverse effects experienced. Results In Group LB, the VAS scores showed a declining trend, starting at 6.4 ± 0.8 at one hour and decreasing to 4.5 ± 1.5 at six hours, 4.1 ± 1.7 at 12 hours, 2.6 ± 1.3 at 18 hours, and 1.3 ± 0.6 at 24 hours. In Group P, the VAS scores also decreased, beginning at 7.2 ± 1.1 at one hour, then dropping to 5.2 ± 1.2 at six hours, 4.8 ± 1.1 at 12 hours, 3.2 ± 0.9 at 18 hours, and 1.8 ± 0.5 at 24 hours. However, statistically, VAS scores were significantly lower in Group LB as compared to Group P at all time points: one hour, six hours, 12 hours, 18 hours, and 24 hours (p<0.05). Group LB demonstrated significantly better outcomes compared to Group P, including a longer time to first rescue analgesia (12 vs. five hours, p<0.0001), a reduced dose of additional analgesic requirement (3 ± 1 vs. 6 ± 2 µg/kg, p<0.0001), and higher patient satisfaction (38 (95%) vs. 23 (57.5%), p=0.0001). The incidence of nausea (3 (7.5%) vs. 6 (15%), P=0.481) and vomiting (5 (12.5%) vs. 8 (20%), p=0.363) was comparable between Group LB and Group P. Conclusion The use of levobupivacaine for liver bed infiltration provided adequate pain relief following laparoscopic cholecystectomy in comparison to paracetamol intravenous analgesia. Side effects like nausea and vomiting were statistically comparable in both groups. Overall, levobupivacaine for liver bed infiltration is a safe and effective option for controlling pain and increasing satisfaction among patients undergoing laparoscopic cholecystectomy.

Regional anaesthesia for postoperative pain management following laparoscopic, visceral, non-oncological surgery a systematic review and meta-analysis

BACKGROUND

Postoperative pain management following laparoscopic, non-oncological visceral surgery in adults is challenging. Regional anaesthesia could be a promising component in multimodal pain management.

METHODS

We performed a systematic review and meta-analysis with GRADE assessment. Primary outcomes were postoperative acute pain intensity at rest/during movement after 24 h, the number of patients with block-related adverse events and the number of patients with postoperative paralytic ileus.

RESULTS

82 trials were included. Peripheral regional anaesthesia combined with general anaesthesia versus general anaesthesia may result in a slight reduction of pain intensity at rest at 24 h (mean difference (MD) - 0.72 points; 95% confidence interval (CI) - 0.91 to - 0.54; I2 = 97%; low-certainty evidence), which was not clinically relevant. The evidence is very uncertain regarding the effect on pain intensity during activity at 24 h (MD -0.8 points; 95%CI - 1.17 to - 0.42; I2 = 99%; very low-certainty evidence) and on the incidence of block-related adverse events. In contrast, neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) may reduce postoperative pain intensity at rest in a clinical relevant matter (MD - 1.19 points; 95%CI - 1.99 to - 0.39; I2 = 97%; low-certainty evidence), but the effect is uncertain during activity (MD - 1.13 points; 95%CI - 2.31 to 0.06; I2 = 95%; very low-certainty evidence). There is uncertain evidence, that neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) increases the risk for block-related adverse events (relative risk (RR) 5.11; 95%CI 1.13 to 23.03; I2 = 0%; very low-certainty evidence).

CONCLUSION

This meta-analysis confirms that regional anaesthesia might be an important part of multimodal postoperative analgesia in laparoscopic visceral surgery, e.g. in patients at risk for severe postoperative pain, and with large differences between surgical procedures and settings. Further research is required to evaluate the use of adjuvants and the additional benefit of regional anaesthesia in ERAS programmes.

PROTOCOL REGISTRATION

PROSPERO CRD42021258281.

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.

Evaluation of post laparoscopic cholecystectomy pain after subcutaneous injection of lidocaine at port site versus lidocaine spray on gallbladder bed after cholecystectomy: a randomized controlled trial

PURPOSE

The efficacy of intraperitoneal (IP) and incisional use of local anesthesia in laparoscopic cholecystectomy is a promising subject regarding post-operative pain control. In this study, we aim to compare these methods using lidocaine as the local anesthetic.

METHODS

This study was a double-blinded randomized controlled trial. Eighty-two patients, candidates for laparoscopic cholecystectomy, were included. Participants were randomly divided into two equal groups; the instillation group and the infiltration group. In the instillation group, a 2% lidocaine ampule was instilled in the gallbladder bed after removal of the gallbladder. In the infiltration group, a 2% lidocaine ampule was injected subcutaneously into the port sites before making the incisions for the insertion of laparoscopic ports.

RESULTS

The mean age of patients were 41.66 ± 14.44 and 48.05 ± 17.03 years in the instillation and infiltration groups, respectively. The etiologies recorded in this study were: acute calculous cholecystitis (29.3%), symptomatic gallstone (68.3%), and polyp (2.4). The pain severity, evaluated at six different times, from immediately after awakening from anesthesia to 24 h after the operation, was not significantly different between the two groups (p-value = 0.329). Consumption of nonsteroidal anti-inflammatory drugs and narcotics, were statistically lower in the instillation group (p-value = 0.013 and 0.003, respectively). However, hospitalization period, time spent to return to normal bowel movements and oral diet, and postoperative nausea/vomiting were not significantly significant between the groups.

CONCLUSION

IP instillation of lidocaine following laparoscopic cholecystectomy offers post-operative pain relief and is associated with lower analgesic consumption in comparison to subcutaneous injection of this agent at the port site.

Evaluating the Efficacy of Pre-incisional Infiltration and Intraperitoneal Instillation of a Local Anesthetic Agent on Postoperative Analgesia and Hemodynamics in Patients Undergoing Laparoscopic Cholecystectomy Under General Anesthesia

Aim

The study aimed to compare the effects of 0.5% bupivacaine injection at pre-incisional port sites and intraperitoneal application on postoperative pain in laparoscopic cholecystectomy cases.

Methods

After taking ethical clearance, a total of 60 patients of the American Society of Anaesthesia (ASA) grades 1 and 2 scheduled to undergo laparoscopic cholecystectomy were enrolled in the study and were randomized into two groups. Group 1 (n=30) received 20 ml of 0.5% bupivacaine infiltration subcutaneously over the port sites before being given incision. Group 2 (n=30) received 20 ml of 0.5% bupivacaine applied in the intraperitoneal subdiaphragmatic space and in the gall bladder fossa after removal of the gall bladder. The efficacy in terms of abdominal pain, hemodynamics, complications, and total analgesic requirements were assessed at regular intervals throughout the postoperative period for 24 hours.

Results

No significant difference in terms of demographic variables in the groups. The mean visual analog score (VAS) score for abdominal pain was found to be significantly lower in group 1 from the first postoperative hour till the twenty-fourth hour. Also, no significant difference was seen between the groups regarding hemodynamic parameters. No significant difference between the groups was seen regarding postoperative nausea and vomiting (PONV). The supplemental analgesic requirement was significantly higher in group 2 than in group 1.

Conclusion

It was observed from this study that pre-incisional infiltration of a local anesthetic agent produces effective postoperative analgesia in the immediate postoperative hours and reduces additional analgesic requirements without causing any adverse reactions.

Sodium Bicarbonate Sub-Diaphragmatic Irrigation Relieves Shoulder Pain After Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

Study Objective

To determine whether sub-diaphragmatic irrigation with sodium bicarbonate would relieve post-laparoscopic shoulder pain (PLSP) after total laparoscopic hysterectomy.

Design

Randomized double-blinded trial.

Setting

Teaching hospital.

Patients

Seventy patients undergoing total laparoscopic hysterectomy (TLH) for benign indications.

Intervention

We randomly allocated patients to intervention or control groups where sodium bicarbonate containing flushing liquid or normal saline was irrigated sub-diaphragm before sewing.

Measurement & Main Results

The primary outcome was PLSP following surgery measured by a numerical rating scale (NRS) (0 = no pain; 10 = worst pain imaginable). Secondary outcomes were abdominal incisional and visceral pain, analgesic use, and sodium bicarbonate related side effects. The incidence of PLSP in intervention group was significantly lower than that in control group (P < 0.05). Contrarily, incisional and visceral pain was similar in both groups (P = 0.1). The consumption of rescue analgesics in the intervention group was lower than that in the control group. Side effects were comparable in both study groups.

Conclusion

Sub-diaphragmatic irrigation with sodium bicarbonate could effectively reduce shoulder pain, but not abdominal incisional and visceral pain, in patients undergoing TLH without an increase in side effects.

Registration information

Clinical trial registry number: http://www.chictr.org.cn/ (ChiCTR2100041765).

Registration findings

http://www.chictr.org.cn/showproj.aspx?proj=66721 Link to clinical trial page and data repository: http://www.medresman.org.cn/pub/cn/proj/projectshshow.aspx?proj=2992.

Evaluation of intraperitoneal administration of morphine on post-operative pain management after ovariohysterectomy in dogs

The present prospective randomized experimental study was designed to assess pain control with intraperitoneal morphine following ovariohysterectomy in dogs. A group of 12 mixed breed female dogs, aged 1-2 years, weighing 19.95 ± 0.95 kg were included. Forty minutes after sedation with 0.05 mg/kg intramuscular acepromazine 1%, anaesthesia was induced with propofol (4 mg/kg). The dogs were connected to the inhalation anaesthesia circuit using isoflurane. Ovariohysterectomy was performed, and before the closure of linea alba, the animals received intraperitoneal morphine (0.5 mg/kg) (in group M) and saline (0.2 ml/kg) (in group S). No significant difference was detected in total protein and glucose levels between the groups, while the cortisol level in group M was significantly lower than group S 1, 3 and 6 h after surgery. Furthermore, the comparison of the rectal temperature, heart rates and respiratory rates showed no major differences. Additionally, no significant alterations were detected between the groups considering the changes in the pain scores with simple descriptive score, Glasgow, University of Melbourne pain scale, sedation status and Sammarco methods. Finally, three cases in group S and two cases in group M were given an intramuscular analgesic rescue dose of morphine. Although a significant decline was observed in cortisol levels following intraperitoneal morphine administration, there were no beneficial changes in the efficiency of post-operative analgesia in status and clinical signs compared to the control group. Further studies are required to investigate intraperitoneal morphine effectiveness in post-operative pain management.

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.

Efficacy of ultrasound-guided Transversus Abdominis Plane (TAP) block in inguinal hernia surgery and the immunomodulatory effects of proinflammatory cytokines: prospective, randomized, placebo-controlled study

Background

Tumor Necrosis Factor-α (TNF-α) and Interleukin-1β (IL-1β) are among the cytokines released secondary to the surgical stress response. The objective of this study was to investigate the effect of a Transversus Abdominis Plane (TAP) block on postoperative pain and its immunomodulatory activity through proinflammatory cytokines.

Methods

TAP (study group; n = 40) or p-TAP (placebo group; n = 40). Patients in the TAP group underwent an Ultrasound (US) guided unilateral TAP block using 20-cc 0.5% bupivacaine solution. Patients in the p-TAP group underwent a sham block using 20-cc isotonic solution. The TNF-α and IL-1β levels were measured three times at preoperative hour-0 and postoperative hours 4 and 24. Visual Analog Scale (VAS) scores were recorded at 0-hours, 30-minutes, 4-hours, and 24-hours. Analgesic use within the first 24-hours following surgery was monitored.

Results

The postoperative VAS score was decreased in the TAP group at all time points (0, 4, and 24 hours), and the differences between groups were statistically significant (p <  0.001 for all comparisons). In the TAP group, the TNF-α and IL-1β levels at 4 and 24 hours post operation were significantly lower than the preoperative levels (p <  0.001 for all comparisons).

Conclusion

The TAP block for pre-emptive analgesia enabled effective hemodynamic control during the intraoperative period, provided effective pain control in the postoperative period, and decreased inflammation and surgical stress due to the decreased levels of the proinflammatory cytokines TNF-α and IL-1β in the first postoperative 24 hours, indicating immunomodulatory effect.

Effects of Manual Therapy on the Diaphragm in the Musculoskeletal System: A Systematic Review

OBJECTIVES

To analyze the effects at the musculoskeletal level of manual treatment of the diaphragm muscle in adults.

DATA SOURCES

Systematic review using 4 databases: PubMed, Science Direct, Web of Science, and Scopus.

STUDY SELECTION AND DATA EXTRACTION

Two independent reviewers applied the selection criteria and assessed the quality of the studies using the Physiotherapy Evidence Database scale for experimental studies. A third reviewer intervened in cases where a consensus had not been reached. A total of 9 studies were included in the review.

DATA SYNTHESIS

Manual therapy directed to the diaphragm has been shown to be effective in terms of the immediate increase in diaphragmatic mobility and thoracoabdominal expansion. The immediate improvement in the posterior muscle chain flexibility test is another of the most frequently found findings in the evaluated studies. Limited studies show improvements at the lumbar and cervical level in the range of motion and in pain.

CONCLUSION

Manual diaphragm therapy has shown an immediate significant effect on parameters related to costal, spinal, and posterior muscle chain mobility. Further studies are needed, not only to demonstrate the effectiveness of manual diaphragm therapy in the long-term and in symptomatic populations, but also to investigate the specific neurophysiological mechanisms involved in this type of therapy.

A randomized clinical trial on the effect of a lidocaine patch on shoulder pain relief in laparoscopic cholecystectomy

The incidence of laparoscopy-related shoulder pain reaches 90% in women. We evaluated the effect of lidocaine patch 5% on the shoulder pain after laparoscopic cholecystectomy (LC) in female patients. Total 63 female patients were randomly allocated to patch group (n = 31) and control group (n = 32). Patch group received lidocaine patch 5% and dressing retention tape on both shoulder, and control group received only dressing retention tape. Abdominal and shoulder pains were evaluated with rating on numeric rating scale (0 = no pain and 10 = the worst pain) at baseline and at 30 min, 6 h, 24 h, and 48 h after surgery. There were no significant differences in patient characteristics and operation details. The overall incidence of shoulder pain was significantly lower in patch group than in control group (42% vs. 78%, P = 0.005). The severity of shoulder pain also was significantly reduced in patch group compared to control group at 24 h and 48 h after surgery (P = 0.01 and P = 0.015, respectively). Complications related to lidocaine patch were not found except nausea. Lidocaine patch 5% reduced the incidence and severity of postoperative shoulder pain in female patients undergoing LC without complications.

Comparison of trocar site versus trocar site plus intraperitoneal instillation of local anesthetic for shoulder pain following laparoscopic abdominal surgery

Background:

Laparoscopic surgery in recent times has noteworthy advantages over conventional surgery, yet recovery is prolonged due to debilitating shoulder tip pain (STP) and operated site pain. Various studies have compared the effect of trocar site, intraperitoneal instillation of local anesthetic (LA) for pain relief while only a few studies have tested the combination of these two techniques. Hence, this study was undertaken to compare the combination of these two techniques versus trocar site alone for STP particularly.

Subjects and Methods:

This prospective, randomized, comparative study was conducted on 52 patients who were undergoing laparoscopic abdominal surgery. The patients were allocated into either of the two groups. Group I (n = 26): trocar site infiltration (20 mL) and intraperitoneal instillation (20 mL) of 0.25% levobupivacaine and Group II (n = 26): trocar site infiltration (20 mL) of 0.25% levobupivacaine and saline (20 mL) intraperitoneally. Postoperative STP was the primary outcome while surgical site pain, nausea, and vomiting were secondary outcomes.

Results:

There were no statistically significant differences between the groups with regard to shoulder pain, surgical site pain, total rescue analgesics, and incidence of nausea and vomiting (P > 0.05).

Conclusion:

Trocar site infiltration with intraperitoneal instillation of LA or trocar site infiltration alone was found to be equally effective. However, we suggest that it is better to provide a combination of trocar site infiltration plus intraperitoneal instillation of LA if we have to restrict opioid usage such as in day-care surgeries.

Intraperitoneal Ropivacaine with Dexmedetomidine or Fentanyl for Postoperative Analgesia Following Laparoscopic Cholecystectomy: A Comparative Randomized Trial

Background:

Intraperitoneal local anesthetic is an effective analgesic approach following laparoscopic cholecystectomy.

Aims:

The aim of the present study was to compare the antinociceptive effects of intraperitoneal ropivacaine plus fentanyl with ropivacaine plus dexmedetomidine in patients undergoing laparoscopic cholecystectomy.

Settings and Designs:

This was randomized, prospective, double-blinded, observational clinical study.

Methods:

A total of 80 patients, undergoing elective laparoscopic cholecystectomy under general anesthesia were randomly assigned to one of the two equal groups to receive either of the following: Group RF (n = 40) were given 30 mL of 0.2% ropivacaine combined with 1 μg/kg fentanyl (diluted in 2 mL normal saline) and Group RD (n = 40) were given 30 mL of 0.2% ropivacaine combined with 1 μg/kg dexmedetomidine (diluted in 2 mL normal saline) through trocars. The quality of analgesia was assessed using visual analog scale score (VAS). Time to the first request of analgesia, the total dose of analgesic in the first 24 h and adverse effects were noted.

Statistical Analysis:

The data were analyzed with the Students’ t-test and Chi-square test.

Results:

VAS score at different time intervals, overall VAS in 24 h was significantly lower (1.68 ± 0.46 vs. 4.47 ± 0.94), time to first request of analgesia (min) was longest (122.7 ± 24.5 vs. 89.3 ± 13.2) and total analgesic consumption (mg) was lowest (95.3 ± 15.6 vs. 135.7 ± 75.1) in RD group than in RF group.

Conclusion:

The antinociceptive effect of the intraperitoneal instillation of ropivacaine in combination with dexmedetomidine is superior to ropivacaine combined with fentanyl.

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 Levobupivacaine Alone or with Dexmedetomidine for Postoperative Analgesia after Laparoscopic Cholecystectomy

Background and Aims:

Local anesthetic injection in the peritoneal cavity decreases intensity of postoperative pain after laparoscopic surgeries. We compared adding dexmedetomidine to intraperitoneal levobupivacaine in patients undergoing laparoscopic cholecystectomy.

Methods:

A total of 105 patients were included in this prospective, double-blinded, randomized study. Patients were randomly divided into three equal sized (n = 35) study groups. Group C patients received intraperitoneal 40 ml normal saline as controlled group. Group L was given 40 ml 0.25% levobupivacaine. Group LD received 40 ml 0.25% levobupivacaine + dexmedetomidine 1 μg/kg. The degree of postoperative pain was measured by visual analog scale (VAS) score. The time of first analgesic demand was recorded and also total dose of painkiller in the first 24 h and postoperative complications were collected. SPSS version 16 was used for statistical analysis. P < 0.05 was considered statistically significant.

Results:

Postoperative VAS at different time intervals was significantly lower, time to the first demand of painkiller (min) was longer (30.2 ± 14.4, 45.9 ± 20.1, and 56.5 ± 13.2), and total painkiller consumption (mg) was lower (203.5 ± 42.9, 117.8 ± 63.7, and 46.3 ± 41.3) in Group LD than Group L than Group C.

Conclusion:

Adding dexmedetomidine to intraperitoneal levobupivacaine is superior to and gives better results than levobupivacaine alone in patients undergoing laparoscopic cholecystectomy.

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.

Intraperitoneal bupivacaine alone or with dexmedetomidine or tramadol for post-operative analgesia following laparoscopic cholecystectomy: A comparative evaluation

Background and Aims:

Intraperitoneal instillation of local anaesthetics has been shown to minimise post-operative pain after laparoscopic surgeries. We compared the antinociceptive effects of intraperitoneal dexmedetomidine or tramadol combined with bupivacaine to intraperitoneal bupivacaine alone in patients undergoing laparoscopic cholecystectomy.

Methods:

A total of 120 patients were included in this prospective, double-blind, randomised study. Patients were randomly divided into three equal sized (n = 40) study groups. Patients received intraperitoneal bupivacaine 50 ml 0.25% +5 ml normal saline (NS) in Group B, bupivacaine 50 ml 0.25% + tramadol 1 mg/kg (diluted in 5 ml NS) in Group BT and bupivacaine 50 ml 0.25% + dexmedetomidine 1 μg/kg, (diluted in 5 ml NS) in Group BD before removal of trocar at the end of surgery. The quality of analgesia was assessed by visual analogue scale score (VAS). Time to the first request of analgesia, total dose of analgesic in the first 24 h and adverse effects were noted. Statistical analysis was performed using Microsoft (MS) Office Excel Software with the Student's t-test and Chi-square test (level of significance P = 0.05).

Results:

VAS at different time intervals, overall VAS in 24 h was significantly lower (1.80 ± 0.36, 3.01 ± 0.48, 4.5 ± 0.92), time to first request of analgesia (min) was longest (128 ± 20, 118 ± 22, 55 ± 18) and total analgesic consumption (mg) was lowest (45 ± 15, 85 ± 35, 175 ± 75) in Group BD than Group BT and Group B.

Conclusion:

Intraperitoneal instillation of bupivacaine in combination with dexmedetomidine is superior to bupivacaine alone and may be better than bupivacaine with tramadol.

Comparing the impact of intraperitoneal hydrocortisone with bupivacaine on postoperative pain after laparoscopic cholecystectomy

Background:

Postoperative pain is a major complaint following laparoscopic cholecystectomy.

Objectives:

The aim of this study was to compare the impact of intraperitoneal hydrocortisone with intraperitoneal bupivacaine on pain relief after laparoscopic cholecystectomy

Patients and Methods:

In a double blind clinical trial, 63 candidates for laparoscopic cholecystectomy were randomly allocated to receive intraperitoneal instillation of either 100 mg bupivacaine in 250 mL normal saline (n = 32) or 100 mg hydrocortisone in 250 mL normal saline (n = 31) before insufflation of CO₂ into the peritoneum for postoperative pain relief. Patients were investigated regarding abdominal and shoulder pain using (visual analog scale) VAS in recovery room and at 6, 12 and 24 hours postoperatively. Patients were also followed regarding postoperative analgesic requirements, nausea and vomiting, and return of bowel function.

Results:

Sixty patients completed the study. Patients in the hydrocortisone group had no statistically significant abdominal and shoulder pain scores compared to the bupivacaine group. The patients were similar regarding postoperative analgesic requirements, return of bowel function, nausea and vomiting. No adverse effect was detected in either group.

Conclusions:

Intraperitoneal administration of hydrocortisone is as effective as bupivacaine to reduce pain and analgesic requirements after laparoscopic cholecystectomy.

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.

Intraperitoneal hydrocortisone for pain relief after laparoscopic cholecystectomy

Background:

Laparoscopic cholecystectomy is associated with shorter hospital stay and less pain in comparison to open surgery. The aim of this study was to evaluate the effect of intraperitoneal hydrocortisone on pain relief following laparoscopic cholecystectomy.

Methods:

Sixty two patients were enrolled in a double-blind, randomized clinical trial. Patients randomly received intraperitoneal instillation of either 250 ml normal saline (n=31) or 100 mg hydrocortisone in 250 ml normal saline (n=31) before insufflation of CO₂ into the peritoneum. Abdominal and shoulder pain were evaluated using VAS after surgery and at 6, 12, and 24 hours postoperatively. The patients were also followed for postoperative analgesic requirements, nausea and vomiting, and return of bowel function.

Results:

Sixty patients completed the study. Patients in the hydrocortisone group had significantly lower abdominal and shoulder pain scores (10.95 vs 12.95; P<0.01). The patients were similar regarding analgesic requirements in the recovery room. However, those in the hydrocortisone group required less meperidine than the saline group (151.66 (±49.9) mg vs 61.66 (±38.69) mg; P=0.00). The patients were similar with respect to return of bowel function, nausea and vomiting. No adverse reaction was observed in either group.

Conclusion:

Intraperitoneal administration of hydrocortisone can significantly decrease pain and analgesic requirements after laparoscopic cholecystectomy with no adverse effects.