Placement of 0.5% bupivacaine-soaked Surgicel in the gallbladder bed is effective for pain after laparoscopic cholecystectomy

Efficacy of High-Volume Low-Concentration Intraperitoneal Bupivacaine Irrigation for Postoperative Analgesia in Patients Undergoing Laparoscopic Cholecystectomy: Bupivacaine Irrigation for Analgesia

Background: Intraperitoneal irrigation with a low-volume, high-concentration local anaesthetic in laparoscopic cholecystectomy (LC) provides less pain relief. We investigated the impact of high-volume, low-concentration bupivacaine on postoperative pain and opioid requirement. Methods: Patients undergoing LC were randomised into Group B (20 mL of 0.5% bupivacaine in 480 mL normal saline) or Group S (500 mL of normal saline). Fifteen patients were included in both the groups but one patient was excluded from Group S because of bile duct injury. The primary outcome was Duration of Analgesia (DOA). The secondary outcomes were the Numeric Pain Rating Scale (NRS) at extubation, at 15 min, 30 min and 1, 2, 4, 8, 12 and 24 h. Cumulative rescue analgesics, incidence of postoperative nausea, vomiting and shoulder pain. Results: Mean (median/range) duration of analgesia was 6.45 ± 5.57 h (6/0.15-24) in Group B vs 3.18 ± 4.21 h (0.3/0.15-12) in Group S. Cumulative requirement of rescue analgesic was higher in saline group being 56.25 ± 33.92 mg for diclofenac and 83.57 ± 66.75 mg for tramadol vis-à-vis 40.9 ± 39.17 mg and 30.00 ± 52.78 mg, respectively, in bupivacaine group. Conclusion: Irrigation of the peritoneal cavity with high-volume low-concentration bupivacaine in LC increases the duration of analgesia and decreases the analgesic requirement in the postoperative period. Trial Registration: ClinicalTrials.gov identifier: CTRI/2019/02/017802 dated 25/02/2019.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

A prospective randomized controlled study on the role of restoring liver diaphragm surface tension and pain control at port sites in optimizing pain management following laparoscopic cholecystectomy

Introduction

After laparoscopic cholecystectomy (LC), pain is still a significant concern leading to extended hospital stays or readmissions. A standardized strategy is needed to offer effective pain relief postoperatively. The pain in the early postoperative period is mainly due to elimination of intraperitoneal surface tension. The aim of this study is to evaluate the restoration of intraabdominal surface tension and the use of bupivacaine-soaked tachosil to control parietal abdominal pain at the port sites to optimize postoperative pain management.

Patients and methods

Between March 2020 to December 2021, 816 patients undergoing LC were randomized into two groups after exclusion of 12 patients: Group A-interventional contained 402 patients; Group B-control contained 402 patients. Data to be compared were made in terms of operative time, shoulder pain, upper abdominal pain, and number of analgesic doses and hospital stay. Pain intensity was assessed by using the visual analog scale.

Results

There was no significant variation in the demographic data between the two groups. There was significant statistical difference between Groups (A) and (B) regarding severity of shoulder pain and port site pain and number of analgesic doses and hospital stay in favor of Group (A). The results were evaluated within 95% confidence intervals and significance was determined as P < .05.

Conclusion

The restoration of intraabdominal surface tension by absorbing as much CO2 as possible at the end of laparoscopic cholecystectomy via the epigastric port route, as well as the use of bupivacaine-soaked tachosil to control parietal abdominal pain at the port sites; both steps significantly improved postoperative pain management, reduced the number of analgesic doses, and decreased the length of hospital stay.

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.

High-Volume, Low-Concentration Intraperitoneal Bupivacaine Study in Emergency Laparoscopic Cholecystectomy: A Double-Blinded, Prospective Randomized Clinical Trial

Background. Laparoscopic cholecystectomy (LC) often results in postoperative pain, especially in the abdomen. Intraperitoneal local anesthesia (IPLA) reduces pain after LC. Acute cholecystitis-associated inflammation, increased gallbladder wall thickness, dissection difficulties, and a longer operative time are several reasons for assuming a benefit in pain scores in urgent LC with IPLA application. The aim was to determine the postoperative analgesic efficacy of high-volume, low-dose intraperitoneal bupivacaine in urgent LC. Materials and Methods. Fifty-seven patients who were American Society of Anesthesiologists physical status I or II were randomly assigned to receive either normal saline (control group) or intraperitoneal bupivacaine (test group) at the beginning or end of urgent LC. The primary outcome was the postoperative pain score of the Visual Analogue Scale (VAS). The secondary outcomes included Visual Rating Prince Henry Scale (VRS), patient satisfaction, and analgesic consumption. Results. Postoperative VAS scores at the first and fourth hours were significantly lower in the test group than in the control group (P < .001). Postoperative VRS scores at the first, fourth, and eighth hours were significantly lower in the test group than in the control group (P < .001, P = .002, P = .004, respectively). Analgesic use was significantly higher in the control group at the first postoperative hour (P < .001). Shoulder pain was significantly lower, and patient satisfaction was significantly higher in the test group relative to the control group (both P < .001). Conclusion. High-volume, low-concentration intraperitoneal bupivacaine resulted in better postoperative pain control and reduced incidence of shoulder pain and analgesic consumption in urgent LC.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 39 studies, enrolling a total of 3027 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

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.

Glisson's capsule cauterisation is associated with increased postoperative pain after laparoscopic cholecystectomy: a prospective case-control study

INTRODUCTION Postoperative pain after laparoscopic cholecystectomy has three components: parietal, visceral and referred pain felt at the shoulder. Visceral peritoneal injury on the liver (Glisson's capsule) during cauterisation sometimes occurs as an unavoidable complication of the operation. Its effect on postoperative pain has not been quantified. In this study, we aimed to evaluate the association between Glisson's capsule injury and postoperative pain following laparoscopic cholecystectomy. METHODS The study was a prospective case-control of planned standard laparoscopic cholecystectomy with standardized anaesthesia protocol in patients with benign gallbladder disease. Visual analogue scale (VAS) abdominal pain scores were noted at 2 and 24 hours after the operation. One surgical team performed the operations. Operative videos were recorded and examined later by another team to detect presence of Glisson's capsule cauterisation. Eighty-one patients were enrolled into the study. After examination of the operative videos, 46 patients with visceral peritoneal injury were included in the study group, and the remaining 35 formed the control group. RESULTS VAS pain score at postoperative 2 and 24 hours was significantly higher in the study group than control (P = 0.027 and 0.017, respectively). CONCLUSIONS Glisson's capsule cauterisation in laparoscopic cholecystectomy is associated with increased postoperative pain. Additional efforts are recommended to prevent unintentional cauterisation.

Effect of bupivacaine soaked gauze in postoperative pain relief in laparoscopic cholecystectomy: a prospective observational controlled trial in 120 patients

Background

Symptomatic gallstone disease is one of the most common problem attended by a general surgeon. The application of minimally invasive surgical techniques for the removal of gallbladder is now an accepted and preferred method for treating this condition. The avoidance of a subcostal incision and minimal bowel handling leads to decreased postoperative pain, early returning to function and overall shorter duration of hospital stay. Nevertheless, patients do have significant postoperative pain, and newer techniques to further reduce this pain are the subject of many ongoing studies. Many intraoperative techniques for reducing postoperative pain have been described. The current practice at many institutions, including ours, is to discharge the patient on the first postoperative day on oral analgesics. Better control of postoperative pain may help establishing laparoscopic cholecystectomy as a day care procedure in selected patients. The aim of this study is to determine the effect of 0.5 % bupivacaine soaked oxidized regenerated cellulose surgical versus normal saline soaked surgical applied at the gallbladder bed on postoperative mean pain score after laparoscopic cholecystectomy for symptomatic gallstones.

Patients and methods

Patients scheduled for laparoscopic cholecystectomy were enrolled in the study after meeting the inclusion criteria. Relevant history was taken and clinical examination was done. Necessary investigations were carried out. All patients were divided to receive either 0.5 % bupivacaine soaked surgicel or normal saline soaked surgicel after laparoscopic cholecystectomy with each group having equal number of patients. The pain score was measured with a visual analogue scale (VAS) at 4, 12 and 24 h after the procedure in both groups. All data was recorded on performa and SPSS-19 was used for analysis.

Results

The demographic characteristic of the two groups has shown that studied patients were matched as regarding gender, age, weight, ASA status and duration of surgery. Post-operative abdominal pain was significantly lower in bupivacaine Group than Saline group. This difference was reported from 4 h till 12 h post-operatively. Bradycardia, Hypotension and Urinary retention were the most common perioperative symptoms reported, with an incidence of 28.3 % in the saline Group and 15 % in the bupivacaine group with no significant differences. Evaluation of postoperative details such as oral intake, time to walk and length of hospital stay revealed that bupivacaine group reported better outcomes as compared to saline group.

Conclusion

Placing bupivacaine soaked surgicel has been shown to decrease the mean postoperative pain score in patients. No significant complication was noticed with the use of surgicel. Because adequate pain control requires intravenous medications, additional methods for pain control need to be studied before laparoscopic cholecystectomy can be routinely performed as a day care case.

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.

Wound infiltration with local anaesthetic agents for laparoscopic cholecystectomy

BACKGROUND

While laparoscopic cholecystectomy is generally considered to be less painful than open surgery, pain is one of the important reasons for delayed discharge after day surgery resulting in overnight stay following laparoscopic cholecystectomy. The safety and effectiveness of local anaesthetic wound infiltration in people undergoing laparoscopic cholecystectomy is not known.

OBJECTIVES

To assess the benefits and harms of local anaesthetic wound infiltration in patients undergoing laparoscopic cholecystectomy and to identify the best method of local anaesthetic wound infiltration with regards to the type of local anaesthetic, dosage, and time of administration of the local anaesthetic.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded until February 2013 to identify studies of relevance to this review. We included randomised clinical trials for benefit and quasi-randomised and comparative non-randomised studies for treatment-related harms.

SELECTION CRITERIA

Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing local anaesthetic wound infiltration versus placebo, no intervention, or inactive control during laparoscopic cholecystectomy, trials comparing different local anaesthetic agents for local anaesthetic wound infiltration, and trials comparing the different times of local anaesthetic wound infiltration were considered for the review.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Twenty-six trials fulfilled the inclusion criteria of the review. All the 26 trials except one trial of 30 participants were at high risk of bias. Nineteen of the trials with 1263 randomised participants provided data for this review. Ten of the 19 trials compared local anaesthetic wound infiltration versus inactive control. One of the 19 trials compared local anaesthetic wound infiltration with two inactive controls, normal saline and no intervention. Two of the 19 trials had four arms comparing local anaesthetic wound infiltration with inactive controls in the presence and absence of co-interventions to decrease pain after laparoscopic cholecystectomy. Four of the 19 trials had three or more arms that could be included for the comparison of local anaesthetic wound infiltration versus inactive control and different methods of local anaesthetic wound infiltration. The remaining two trials compared different methods of local anaesthetic wound infiltration.Most trials included only low anaesthetic risk people undergoing elective laparoscopic cholecystectomy. Seventeen trials randomised a total of 1095 participants to local anaesthetic wound infiltration (587 participants) versus no local anaesthetic wound infiltration (508 participants). Various anaesthetic agents were used but bupivacaine was the commonest local anaesthetic used. There was no mortality in either group in the seven trials that reported mortality (0/280 (0%) in local anaesthetic infiltration group versus 0/259 (0%) in control group). The effect of local anaesthetic on the proportion of people who developed serious adverse events was imprecise and compatible with increase or no difference in serious adverse events (seven trials; 539 participants; 2/280 (0.8%) in local anaesthetic group versus 1/259 (0.4%) in control; RR 2.00; 95% CI 0.19 to 21.59; very low quality evidence). None of the serious adverse events were related to local anaesthetic wound infiltration. None of the trials reported patient quality of life. The proportion of participants who were discharged as day surgery patients was higher in the local anaesthetic infiltration group than in the no local anaesthetic infiltration group (one trial; 97 participants; 33/50 (66.0%) in the local anaesthetic group versus 20/47 (42.6%) in the control group; RR 1.55; 95% CI 1.05 to 2.28; very low quality evidence). The effect of local anaesthetic on the length of hospital stay was compatible with a decrease, increase, or no difference in the length of hospital stay between the two groups (four trials; 327 participants; MD -0.26 days; 95% CI -0.67 to 0.16; very low quality evidence). The pain scores as measured by the visual analogue scale (0 to 10 cm) were lower in the local anaesthetic infiltration group than the control group at 4 to 8 hours (13 trials; 806 participants; MD -1.33 cm on the VAS; 95% CI -1.54 to -1.12; very low quality evidence) and 9 to 24 hours (12 trials; 756 participants; MD -0.36 cm on the VAS; 95% CI -0.53 to -0.20; very low quality evidence). The effect of local anaesthetic on the time taken to return to normal activity between the two groups was imprecise and compatible with a decrease, increase, or no difference in the time taken to return to normal activity (two trials; 195 participants; MD 0.14 days; 95% CI -0.59 to 0.87; very low quality evidence). None of the trials reported on return to work.Four trials randomised a total of 149 participants to local anaesthetic wound infiltration prior to skin incision (74 participants) versus local anaesthetic wound infiltration at the end of surgery (75 participants). Two trials randomised a total of 176 participants to four different local anaesthetics (bupivacaine, levobupivacaine, ropivacaine, neosaxitoxin). Although there were differences between the groups in some outcomes the changes were not consistent. There was no evidence to support the preference of one local anaesthetic over another or to prefer administration of local anaesthetic at a specific time compared with another.

AUTHORS' CONCLUSIONS

Serious adverse events were rare in studies evaluating local anaesthetic wound infiltration (very low quality evidence). There is very low quality evidence that infiltration reduces pain in low anaesthetic risk people undergoing elective laparoscopic cholecystectomy. However, the clinical importance of this reduction in pain is likely to be small. Further randomised clinical trials at 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.

A feasibility study to investigate the use of a bupivacaine-collagen implant (XaraColl) for postoperative analgesia following laparoscopic surgery

Background

XaraColl, a collagen-based implant that delivers bupivacaine to sites of surgical trauma, has been shown to reduce postoperative pain and use of opioid analgesia in patients undergoing open surgery. We therefore designed and conducted a preliminary feasibility study to investigate its application and ease of use for laparoscopic surgery.

Methods

We implanted four XaraColl implants each containing 50 mg of bupivacaine hydrochloride (200 mg total dose) in ten men undergoing laparoscopic inguinal or umbilical hernioplasty. Postoperative pain intensity and use of opioid analgesia were recorded through 72 hours for comparison with previously reported data from efficacy studies performed in men undergoing open inguinal hernioplasty. Safety was assessed for 30 days.

Results

XaraColl was easily and safely implanted via a laparoscope. The summed pain intensity and total use of opioid analgesia through the first 24 hours were similar to the values observed in previously reported studies for XaraColl-treated patients after open surgery, but were lower through 48 and 72 hours.

Conclusion

XaraColl is suitable for use in laparoscopic surgery and may provide postoperative analgesia in laparoscopic patients who often experience considerable postoperative pain in the first 24–48 hours following hospital discharge. Randomized controlled trials specifically to evaluate its efficacy in this application are warranted.

Effect of implanting fibrin sealant with ropivacaine on pain after laparoscopic cholecystectomy

AIM: To investigate the safety and efficacy of implanting fibrin sealant with sustained-release ropivacaine in the gallbladder bed for pain after laparoscopic cholecystectomy (LC).

METHODS: Sixty patients (American Society of Anesthesiologists physical status was I or II and underwent LC) were randomly divided into three equal groups: group A (implantation of fibrin sealant in the gallbladder bed), group B (implantation of fibrin sealant carrying ropivacaine in the gallbladder bed), and group C (normal saline in the gallbladder bed). Postoperative pain was evaluated, and pain relief was assessed by visual analog scale (VAS) scoring.

RESULTS: The findings showed that 81.7% of patients had visceral pain, 50% experienced parietal, and 26.7% reported shoulder pain after LC. Visceral pain was significantly less in group B patients than in the other groups (P < 0.05), and only one patient in this group experienced shoulder pain. The mean VAS score in group B patients was lower than that in the other groups.

CONCLUSION: Visceral pain is prominent after LC and can be effectively controlled by implanting fibrin sealant combined with ropivacaine in the gallbladder bed.

Bupivacaine Administration and Postoperative Pain following Anterior Iliac Crest Bone Graft for Alveolar Cleft Repair

Objective:

To determine whether placement of a bupivacaine-soaked absorbable sponge (BAS) in addition to bupivacaine infiltration at the anterior iliac crest (AIC) donor site alters postoperative pain for children undergoing alveolar bone grafting (ABG) for cleft lip with or without cleft palate (CL±P). The comparison group received only bupivacaine infiltration (NO BAS) at the AIC.

Design:

Retrospective cohort. Medical records were abstracted by one investigator, blinded to BAS versus NO BAS use.

Setting and Patients:

Consecutive patients with CL±P who underwent ABG between 2000 and 2006 at one large U.S. craniofacial center.

Intervention:

BAS was used in 118 procedures and NO BAS in 89.

Outcome Measures:

Postoperative pain score, total and opioid pain medication requirement, length of hospital stay (LOS), and time to initial ambulation.

Results:

One hundred eighty-two patients underwent 207 ABG procedures. Mean pain scores were significantly lower when BAS was used compared with NO BAS (1.3 versus 1.8; p  =  .01). Patients who received BAS required significantly less pain medication than NO BAS patients: opioids (0.14 versus 0.20 mg/kg; p  =  .01) and total (0.60 versus 0.71 mg/kg; p  =  .02). Relative to the NO BAS group, those who received BAS had a shorter LOS (30.9 versus 42.4 hours; p < .0001) and less time to initial ambulation following surgery (14.4 versus 20.6 hours; p < .0001).

Conclusion:

Use of BAS at the AIC donor site significantly reduced postoperative pain score, pain medication requirement, LOS, and time to ambulation relative to children who did not receive BAS following ABG.

Pre-incision local infiltration with levobupivacaine reduces pain and analgesic consumption after laparoscopic cholecystectomy: a new device for day-case procedure

All over the World laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis; use of local long lasting anesthetics reduces post-operative pain. Levobupivacaine is one of the most effective local anesthetics. The aim of our study is to test the effectiveness of local anesthetics comparing pre- versus post-operative trocar site's infiltration. 50 patients were enrolled in our study and 25 five patients were randomized into pre-I group (pre-incisional infiltration) and 25 into post-I group (post-operative infiltration); all the operations were performed with the same technique (Anglo-Saxon with 4 accesses) by 4 expert laparoscopic surgeons; our results showed different analgesic consumption between the 2 groups of patients; in the pre-I group the mean intravenous dose of Ketorolac post-operative used was 124 mg while in the post-I group was 339 mg: this difference was statistically significant.; the mean VAS was 10.7 in the post-I group while in the pre-I group was 5.1, also the i-VAS score's difference was statistically significant: in fact in the post-I group i-VAS was 8.8 while in the post-I group 14.8. Our study demonstrated that infiltration of the trocar site with long lasting local anesthetic is extremely effective for the treatment of post-operative pain after laparoscopic cholecystectomy; pre-incisional local infiltration seems to be better in term of pain perception and intravenous post-operative analgesic consumption.