Intraperitoneal Ropivacaine Instillation for Postoperative Pain Relief 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.

The evaluation of feasibility of ambulatory laparoscopic cholecystectomy using intraoperative instillation of bupivacaine: a retrospective observational study

Purpose

This study aimed to compare outcomes of opioid patients-controlled anesthesia (PCA) and intraoperative local anesthesia in terms of postoperative pain, lab results, patient surveys, and discharge scores to evaluate the feasibility of ambulatory laparoscopic cholecystectomy (LC).

Methods

Patients who underwent LC for acute cholecystitis were assigned to the outpatient surgery (OPS) group or inpatient surgery (IPS) group according to the surgeon. In the OPS group, a mixture of bupivacaine and epinephrine was injected into trocar sites and sprayed on the surgical dissection field. Oral opioid and analgesics were given twice a day. In the IPS group, patients received opioid PCA. Numeric rating scale (NRS) for walking, erythrocyte sedimentation rate (ESR), CRP, self-assessed survey on general physical condition and discharge, and discharge score of ambulatory surgery were assessed postoperatively.

Results

NRS was significantly lower in the OPS group. There were no significant differences in ESR and CRP between the groups. Self-assessed survey on general conditions and the possibility of discharge were significantly better in the OPS group. The discharge scores at 3, 6, and 9 hours were significantly higher in the OPS group.

Conclusion

Intraoperative instillation of bupivacaine at port sites and dissection fields had a better effect on short-term postoperative pain, patient surveys, and discharge criteria of ambulatory surgery than opioid PCA.

Effect of Intraperitoneal Instillation of Dexmedetomidine With Local Anesthetics in Laparoscopic Cholecystectomy: A Systematic Review and Meta-analysis of Randomized Trials

OBJECTIVE

Dexmedetomidine (DEX) can strengthen the analgesic effects of local anesthetics (LAs) when used as an adjuvant through intrathecal, perineural, and intraperitoneal routes. Many studies have used intraperitoneal instillation of DEX with LAs in laparoscopic cholecystectomy (LC) to relieve postoperative pain. We performed a systematic review and meta-analysis to synthesize evidence of the efficacy and safety of intraperitoneal instillation of DEX as an adjuvant of LAs in patients undergoing LC.

METHODS

A comprehensive literature search of the MEDLINE, PubMed, EMBASE, and Cochrane Library databases was performed to identify randomized controlled trials in which patients received intraperitoneal instillation of DEX combined with LAs during LC. A meta-analysis and sensitivity analysis of the results were conducted. We also performed a subgroup analysis to investigate the source of heterogeneity. The Egger test was used to check for publication bias.

RESULTS

Eleven randomized controlled trials involving 890 patients were analyzed. We found that the addition of DEX to LAs significantly decreased pain scores at six postoperative time points (0.5, 1, 2, 4, 12, and 24 h) and significantly prolonged the time to the first analgesic request by patients. In addition, 24-hour postoperative analgesic consumption was decreased in the experimental group, and no significant difference in the incidence of nausea and vomiting was observed.

CONCLUSION

Our findings indicate that intraperitoneal instillation of DEX with LAs can reduce postoperative pain and prolong the time to first request analgesia after LC.

Efficacy of Intraperitoneal 0.2% Ropivacaine With Dexmedetomidine Versus 0.2% Ropivacaine With Ketamine in Laparoscopic Surgeries: A Randomized Controlled Trial

BACKGROUND

Effective pain management modalities are the armamentarium for enhanced recovery in laparoscopic surgeries. Intraperitoneal instillation of local anaesthetics with adjuvants is advantageous in minimizing pain. So, we designed this study with the aim to compare the analgesic effectiveness of intraperitoneal ropivacaine with adjuvants like dexmedetomidine versus ketamine for postoperative analgesia.

OBJECTIVE

 The objective of this study is to assess the total duration of analgesia and total rescue analgesic dose requirements in the first 24 hours postoperatively.

MATERIALS AND METHODS

A total of 105 consenting patients for elective laparoscopic surgeries were enrolled and divided into three groups by computer-generated randomization as follows: Group 1: 30 ml of 0.2% ropivacaine with ketamine 0.5 mg/kg diluted to 1 ml; Group 2: 30 ml of 0.2% ropivacaine with dexmedetomidine 0.5 mcg/kg diluted to 1 ml; Group 3: 30 ml of 0.2% ropivacaine with 1 ml of normal saline. The postoperative visual analogue scale (VAS) score, total duration of analgesia, and total analgesic dose were calculated and compared among the three groups.

RESULTS

The postoperative analgesic duration after intraperitoneal instillation of Group 2 was longer as compared to Group 1. The total analgesic requirement was lower in Group 2 as compared to Group 1, and the p-value was significant (p ≤ 0.001) for both parameters. Demographic parameters and VAS scores among the three groups were not statistically significant.

CONCLUSION

We conclude that intraperitoneal instillation of local anaesthetics with adjuvants is effective for postoperative analgesia in laparoscopic surgeries, and ropivacaine 0.2% with dexmedetomidine 0.5 mcg/kg is more effective when compared to ropivacaine 0.2% with ketamine 0.5 mg/kg.

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.

Postoperative analgesic efficacy of the pulmonary recruitment manoeuvre compared to intraperitoneal hydrocortisone in laparoscopic gynaecological surgeries

Background and Aims

Laparoscopic surgeries are becoming attractive because of early recovery. Adequate postoperative pain relief may be a major concern. Several methods have been used to relieve laparoscopic postoperative pain.

Methodology

This prospective, randomised, controlled study was conducted during the period between February and June 2019. Patients were assigned into three groups. Patients in the hydrocortisone group received intraperitoneal 100mg hydrocortisone in 150 ml normal saline together with the routine method to remove carbondioxide (CO2). For patients in the pulmonary recruitment group, CO₂ was exsufflated by pulmonary recruitment manoeuvre together with the routine method to remove CO₂. In the control group CO₂ was removed by applying gentle abdominal pressure allowing passive exsufflation through the port site.

Results

A total of 57 patients were included in the study. There was no statistically significant difference between the three groups as regards demographic characteristics. There was a statistically significant difference in the 24 h postoperative analgesic consumption (primary outcome) in the hydrocortisone and pulmonary recruitment groups in comparison to the control group:P value <0.001. Also, time to first request for analgesia was significantly longer and the visual analogue scale (VAS) score was significantly lower in the hydrocortisone and pulmonary recruitment groups compared to the control group:P value <0.001.

Conclusion

Intraperitoneal hydrocortisone and pulmonary recruitment manoeuvre could both effectively reduce pain after gynaecological laparoscopic surgeries, however, intraperitoneal hydrocortisone might give a longer pain-free time.

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.

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.

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.

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.