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

Safety and Feasibility of Paediatric Day Case Laparoscopic Upper Gastrointestinal Surgery: Significance of Nurse-led Discharge

BACKGROUND

Day case (DC) surgery is defined as a surgical procedure that allows patients to go home the same day as their operation. Laparoscopic upper gastrointestinal surgery (LUGIS) has become the standard treatment for symptomatic gallstone disease, refractory gastroesophageal reflux disease, and achalasia cardia. This study aims to assess the feasibility and safety of performing paediatric DCLUGI surgery with discharge implemented by a nurse-led team according to preset criteria.

METHODS

Electronic records were evaluated for all neurologically normal patients who underwent LUGIS from July 2015 to July 2023 following a dedicated clinical care pathway. Data collection included demographics, length of stay (DC, ≤23-h, ≥24-h), surgeon level, complications and postoperative pain management. Nurse-led discharge (NLD) was implemented for all patients according to preset criteria.

RESULTS

Seventy-four patients underwent LUGIS (31 cholecystectomies, 31 fundoplications and 12 Heller myotomies) with a DC rate of 12 %. Twenty-five (34 %) patients were ≤23-h stay. All early discharge (DC and ≤23-h) patients (46 %) were safely managed according to the NLD criteria without postoperative medical review. There were no thirty-day readmissions.

CONCLUSIONS

DC or ≤23-h LUGIS can be performed safely in high-volume paediatric specialist centres with good outcomes. Implementing protocols that provide nursing staff with the necessary guidance to ensure timely discharge of children and young people is fundamental to achieving high levels of satisfaction and the delivery of an efficient service.

Effect of a Local Anesthetic Injection Kit on Pain Relief and Postoperative Recovery After Transumbilical Single-Incision Laparoscopic Cholecystectomy

Purpose

This study was conducted to explore whether incisional infiltration using a local anesthetic injection kit could better relieve postoperative pain and enhance the quality of recovery compared with ultrasound-guided rectus sheath block (RSB) or conventional local anesthetic infiltration in patients undergoing transumbilical single-incision laparoscopic cholecystectomy (SILC).

Patients and Methods

A total of 60 patients undergoing SILC with American Society of Anesthesiology functional status scores of I-II were randomized into the rectus sheath block group (RSB group), conventional local wound infiltration group (LAI-I group) and incisional infiltration using a local anesthetic injection kit group (LAI-II group). The primary outcomes were the patient-controlled intravenous analgesia (PCIA) demand frequency within 48 hours after the operation and postoperative pain measured by a visual analog scale (VAS) at 2 h, 4 h, 8 h, 24 h, and 48 h after surgery. Secondary outcomes were the total procedure times, cumulative consumption of anesthetic drugs, duration of surgery, duration and awaking time of anesthesia, early recovery indicator and side effects.

Results

The PCIA demand frequency in LAI-II group was significantly lower compared with patients in the RSB and LAI-I group (both P < 0.001). Moreover, the total procedure times in LAI-I and LAI-II group was significantly shorter than that in the RSB group (P < 0.001, respectively), but it was comparable between LAI-I and LAI-II group (P = 0.471). Though lower at 2h and 4h postoperative in LAI-II group, pain scores at each time point had no statistical differences among three groups. There were no significant differences among three groups for other outcomes as well.

Conclusion

The effect of ultrasound-guided RSB and conventional local anesthetic infiltration in SILC patients were found to be similar in terms of relieving postoperative pain and promoting recovery. Incisional infiltration using a local anesthetic injection kit can significantly reduce the demand frequency of PCIA, which serves as a rescue analgesic.

OUP accepted manuscript

Background

Local anaesthetic infiltration is widely used to reduce pain after laparoscopic cholecystectomy (LC). This trial evaluated the effect of depth of local anaesthetic infiltration on postoperative pain reduction after LC.

Methods

Patients undergoing elective LC between March 2018 and February 2019 were randomized into no infiltration, subcutaneous infiltration, and rectus sheath infiltration using bupivacaine. The primary outcome was 24-h postoperative cumulative morphine use, and the secondary outcomes were mean 24-h Numerical Rating Scale (NRS) for pain, and nausea, and vomiting. Subgroups were compared and multivariable analyses were performed.

Results

Out of 170 eligible patients, 162 were selected and 150 patients were analysed: 48 in the no-infiltration group, 50 in the subcutaneous infiltration group, and 52 in the rectus sheath infiltration group. The groups had similar clinical features, although mean BMI was higher in the subcutaneous infiltration group (P = 0.001). The 24-h cumulative morphine use in the rectus sheath infiltration group was significantly lower than in the no-infiltration group (P = 0.043), but no difference was observed between the subcutaneous infiltration and no-infiltration groups (P = 0.999). One hour after surgery, the rectus sheath infiltration group had a significantly lower NRS score than the no-infiltration and subcutaneous infiltration groups respectively (P = 0.006 and P = 0.031); however, the score did not differ among the three groups at any of the time points from 2 h after the surgery. The incidence of nausea or vomiting was comparable among the three groups. Multivariable analysis documented that a lower dose of morphine use was associated with rectus sheath infiltration (P = 0.004) and diabetes (P = 0.001); whereas, increased morphine use was associate with age (P = 0.040) and a longer duration of surgery (P = 0.007).

Conclusions

Local anaesthetic infiltration into the rectus sheath reduced postoperative cumulative morphine use and the immediate NRS score in patients undergoing LC; however, the pain scores were comparable 2 h after surgery.

Registration number

TCTR20201103002 (http://www.thaiclinicaltrials.org).

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.

Comparison of Intravenous Ibuprofen and Paracetamol for Postoperative Pain Management after Laparoscopic Sleeve Gastrectomy. A Randomized Controlled Study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is defined as the first-step bariatric surgery for the treatment of obesity. Opioid analgesics are often preferred for pain management because of their strong analgesic potentials. However, opioids have undesirable adverse effects.

OBJECTIVES

The objective of this study is to evaluate and compare the influence of IV forms of ibuprofen and paracetamol on pain management and opioid consumption on patients undergoing LSG surgery.

SETTING

This study was conducted at Istanbul Medipol University Hospital.

METHODS

Patients were stratified into three groups. Group I (group ibuprofen, n = 30) was administered 800 mg of IV ibuprofen, group P (group paracetamol, n = 30) was administered 1000 mg of IV paracetamol, and group C (control group, n = 30) was given 100 ml of saline solution. We evaluated opioid consumption and VAS scores postoperatively.

RESULTS

This study included 90 patients who underwent LSG. The use of rescue medication in group I was statistically lower than the other groups. VAS scores in group I and group P at recovery and at 2, 4, 8, 12, and 24 h were lower than those in group C. In particular, the VAS scores in group I at the first 2 h postoperatively were significantly lower than those in group P (p < 0.05). Opioid consumption in group C was significantly higher than the other groups (p < 0.05).

CONCLUSION

Our study suggested that IV ibuprofen resulted in lower pain scores compared to paracetamol by reducing postoperative opioid use in the first 24 h in patients undergoing LSG surgery.

Effect of Trocar Site Bupivacaine Administration, Time of First Passage of Flatus, and Duration of the Surgery on Postoperative Pain After Sleeve Gastrectomy: a Case Control Study

INTRODUCTION

The effect of local anesthetic applications to trocar sites on postoperative pain control has been studied many times, and different results have been obtained. We planned a controlled study evaluating the effect of bupivacaine administration and other contributing factors on postoperative pain following sleeve gastrectomy.

MATERIAL AND METHODS

Patients who underwent laparoscopic sleeve gastrectomy were included in the study. Patients were randomized into two groups according to local application as either a local or non-local group. Also, the patients were grouped separately from local group allocation according to time to first passage of flatus (< 12 h, ≥ 12 h) and duration of surgery (> 50 min, ≤ 50 min). A visual analogue scale (VAS) was performed at 4, 8, 12, 24, and 48 h postoperatively. Opioid analgesics (pethidine HCl) were administered if the patient's VAS score was greater than 5. Demographic characteristics, such as age, gender, height, weight, body mass index (BMI), and operative time, were recorded. Demographic characteristics and VAS scores were compared between groups.

RESULTS

A total of 168 patients were included in the study. Of these, 84 patients were included in both of the local and non-local groups. The demographic characteristics between groups were similar. There was no significant difference between groups in terms of VAS scores (p > 0.05). In the analysis according to the time to first passage of flatus, the 48th-hour VAS scores were lower in the early flatus group (p = 0.036). According to the duration of surgery, first flatus was detected earlier, and VAS scores at the 8th and 12th hours were less in the short operation group (p < 0.001, p = 0.005, p = 0.031, respectively).

DISCUSSION

Although we did not show any effect of local administration of bupivacaine in LSG on pain, we concluded that other factors like duration of surgery and first flatus time have an impact on this issue.

Laparoscopic-Guided Transversus Abdominis Plane (TAP) Block as Part of Multimodal Analgesia in Laparoscopic Roux-en-Y Gastric Bypass Within an Enhanced Recovery After Surgery (ERAS) Program: a Prospective Randomized Clinical Trial

BACKGROUND

Despite the ultrasound guidance of transversus abdominis plane (TAP) blocks has allowed greater precision of needle placement in the desired tissue plane, visualization of the abdominal wall muscles can be hindered by morbid obesity and could lead to failed regional anesthesia. The aim of this study was to assess the feasibility and effect of laparoscopic-guided TAP block in patients undergoing Roux-en-Y gastric bypass and to compare it with port-site infiltration.

PATIENTS AND METHODS

A prospective randomized clinical trial was performed. Patients were randomized into two groups: patients undergoing laparoscopic-guided TAP (TAP-lap) and patients undergoing port-site infiltration (PSI). Pain quantification as measured by visual analogic scale (VAS) and morphine needs during the first 24 h were evaluated.

RESULTS

One hundred and forty patients were included, 70 in each group. The mean operation time was 83.3 + 15.6 min in TAP-lap and 80.5 + 14.4 min in PSI (NS). The mean postoperative pain, as measured by VAS, 24 h after surgery was 16.8 + 11.2 mm in PSI and 10 + 8.1 mm in TAP-lap (p = 0.001). Morphine rescues were necessary in 13.2% in PSI and 2.9% in TAP-lap (p = 0.026). The mean hospital stay was 2.1 + 1.2 days in TAP-lap and 2.9 + 1.3 days in PSI (p = 0.019). Hospital discharge during the first 48 h after surgery was possible in 52.9% of the patients in PSI and 71% in TAP-lap (OR 4.75; 95% CI 2.1-10.8; p = 0.029).

CONCLUSION

Laparoscopic-guided TAP block can reduce postoperative pain, opioid needs, and hospital stay, when compared with port-site infiltration with the same anesthetic drug, without increasing operation time.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03203070.

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.

Effects of preincisional analgesia with surgical site infiltration of ketamine or levobupivacaine in patients undergoing abdominal hysterectomy under general anesthesia; A randomized double blind study

CONTEXT

Postoperative pain management remains a cornerstone in patient's management to ensure a better quality of life. Preemptive analgesia is reported to inhibit the persistence of postoperative pain.

AIMS

The aim of this study is to assess the analgesic effectiveness of preincisional infiltration of ketamine following elective abdominal hysterectomy as compared to levobupivacaine.

SETTINGS AND DESIGN

This was a prospective, randomized, double-blind study.

SUBJECTS AND METHODS

This study included 48 patients undergoing abdominal hysterectomy under general anesthesia. They were randomized into two equal groups; Group K received subcutaneous infiltration of 20 ml containing ketamine 2 mg/kg and Group L received subcutaneous infiltration of 20 ml of levobupivacaine 0.25% along the Pfannenstiel incision 5 min before incision. Postoperative pain was assessed using visual analog scale (VAS) at rest and on coughing with evaluation of additional opioid analgesic requirements.

STATISTICAL ANALYSIS USED

Numerical variables were presented as mean and standard deviation or median and range as appropriate. The intergroup differences were compared using the independent-sample Student's t-test or Mann-Whitney test for numerical variables.

RESULTS

VAS score decreased significantly in Group L from 10 to 24 h and in Group K from 8 to 24 h as compared to the immediate postoperative reading. VAS score in ketamine group was significantly lower than that in the levobupivacaine group 8, 10, and 24 h postoperatively. Ketamine group showed delayed request of additional opioid analgesia (P < 0.001) with significantly less opioid consumption (P < 0.001) as compared to levobupivacaine. The total dose of meperidine consumed during the 24 postoperative h was significantly smaller in ketamine group (P < 0.001).

CONCLUSION

Surgical site infiltration of ketamine is a promising preemptive analgesic method in the lower abdominal surgery with minimal sedation and adverse effects.

Comparative study of ultrasound-guided abdominal field blocks versus port infiltration in laparoscopic cholecystectomies for post-operative pain relief

Background and Aims:

Post-operative pain is a major concern for day care surgeries like laparoscopic cholecystectomy. This study aimed to compare the efficacy of ultrasound guided abdominal field blocks (USAFB) with port site infiltrations for post-operative analgesia in terms of quality of pain relief, opioid consumption and patient satisfaction for day care surgeries

Methods:

Eighty patients presenting for laparoscopic cholecystectomy were randomly allocated to two groups either to receive port-site infiltration of local anaesthetic (n = 40, Group A) or USAFB (n = 40, Group B group). Numeric rating scores (NRS) were measured postoperatively to primarily assess the pain severity and opioid requirements. Data were analysed using Chi-Square test/Fisher's exact test for categorical data and Mann–Whitney test/unpaired t-test for quantitative data.

Results:

The study group (Group B) had significantly reduced NRS and opioid consumption over 24 h. The overall fentanyl consumption in patients receiving port infiltrations was approximately twice (200 ΁ 100 μg) as compared to patients in USAFB group (120 ΁ 74 μg) (P < 0.0001). Maximum fentanyl consumption was 400 μg (Group A) and 262 μg (Group B) over 24 h and the minimum requirement was 50 μg and zero, respectively.

Conclusion:

Superior post-operative analgesia was observed with USAFB which may help in minimising opioid-related adverse effects and facilitating faster recovery.

Laparoscopic cholecystectomy under spinal anaesthesia vs. general anaesthesia: a meta-analysis of randomized controlled trials

BACKGROUND

Laparoscopic Cholecystectomy (LC) is conventionally performed under general anaesthesia (GA), but there are multiple studies which have found spinal anaesthesia (SA) as a safe alternative. This meta-analysis was performed after adding many recent randomized controlled trials (RCTs) to clarify this issue.

METHODS

Relevant articles published in English were identified by searching PubMed, Embase, Web of Knowledge, and the Cochrane Controlled Trial Register from January 1, 2000 to December 1, 2014. Reference lists of the retrieved articles were reviewed to identify additional articles. Primary outcomes (postoperative pain scores) and secondary outcomes (operating time (OT) and postoperative complications) were pooled. Quantitative variables were calculated using the weighted mean difference (WMD), and qualitative variables were pooled using odds ratios (OR).

RESULTS

Seven appropriate RCTs were identified from 912 published articles. Seven hundred and twelve patients were treated, 352 in SA group and 360 in GA group. LC under SA was superior to LC under GA in postoperative pain within 12 h (visual analogue score (VAS) in 2-4 h, WMD = -1.61, P = 0.000; VAS in 6-8 h, WMD = -1.277, P = 0.015) and postoperative complications (postoperative nausea and vomiting (PONV) WMD = 0.427, P = 0.001; Overall Morbidity WMD = 0.691, P = 0.027). The GA group was superior to SA group in postoperative urinary retention (WMD = 4.273, P = 0.022). There were no significant differences in operating time (WMD = 0.184, P = 0.141) between two groups.

CONCLUSIONS

SA as the sole anaesthesia technique is feasible, safe for elective LC.

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.

Is transverse abdominis plane block effective following local anesthetic infiltration in laparoscopic totally extraperitoneal hernia repair?

Background

Transverse abdominis plane (TAP) block can be recommended as a multimodal method to reduce postoperative pain in laparoscopic abdominal surgery. However, it is unclear whether TAP block following local anesthetic infiltration is effective. We planned this study to evaluate the effectiveness of the latter technique in laparoscopic totally extraperitoneal hernia repair (TEP).

Methods

We randomly divided patients into two groups: the control group (n = 37) and TAP group (n = 37). Following the induction of general anesthesia, as a preemptive method, all of the patients were subjected to local anesthetic infiltration at the trocar sites, and the TAP group was subjected to ultrasound-guided bilateral TAP block with 30 ml of 0.375% ropivacaine in addition before TEP. Pain was assessed in the recovery room and post-surgery at 4, 8, and 24 h. Additionally, during the postoperative 24 h, the total injected dose of analgesics and incidence of nausea were recorded.

Results:

On arrival in the recovery room, the pain score of the TAP group (4.33 ± 1.83) was found to be significantly lower than that of the control group (5.73 ± 2.04). However, the pain score was not significantly different between the TAP group and control group at 4, 8, and 24 h post-surgery. The total amounts of analgesics used in the TAP group were significantly less than in the control group. No significant difference was found in the incidence of nausea between the two groups.

Conclusions

TAP block following local infiltration had a clinical advantage only in the recovery room.

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.

Evaluation of pain scores after single-incision and conventional laparoscopic cholecystectomy: a randomized control trial in a rural Indian population

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) is considered to be less invasive and have less morbidity than conventional laparoscopic cholecystectomy (CLC). However, there is a relative paucity of data regarding postoperative pain scores in rural Indian populations following SILC. Also, data pertaining to the applicability of SILC in rural Indian population are scant.

METHODS

In the present randomized control trial, pain scores after SILC and CLC were evaluated. Sixty patients with gallstone disease were randomly assigned to one of two groups with 30 patients each: the CLC group and the SILC group. Postoperative pain scores were recorded on the visual analog scale at 8 hours, 24 hours and 7 days after surgery.

RESULTS

The patients were comparable with respect to age, sex and BMI. Operative time was longer for the SILC group (47.73 ± 5.57 min vs 69.53 ± 8.96 min; P < 0.0001).The pain scores were similar in both groups at 8 hours (3.61 ± 0.41 vs 3.50 ± 0.51; P = 0.36) and 24 hours (3.30 ± 0.59 vs 3.20 ± 0.40; P = 0.44) postoperatively. On day 7, the SILC group had lower pain scores than the CLC group (2.56 ± 0.56 vs 1.16 ± 0.37; P < 0.01).

CONCLUSION

There was no distinct advantage to SILC with regard to immediate postoperative pain. Pain was significantly less (P < 0.01) in the SILC group on postoperative day 7.

Postoperative pain relief using wound infiltration with 0.5% bupivacaine in single-incision laparoscopic surgery for an appendectomy

Purpose

Recently, single-incision laparoscopic surgery (SILS) has been popular for minimally invasive surgery and cosmetic improvement. However, some papers have reported that SILS for an appendectomy (SILS-A) has had the more postoperative complaints of pain. We investigated postoperative pain relief using wound infiltration with 0.5% bupivacaine in SILS-A and compared the result with that for conventional SILS-A.

Methods

Between July 2010 and September 2012, 75 patients who underwent SILS-A were enrolled in this study. The patients were randomly assigned to two groups: conventional SILS-A group (C-SILS-A) or wound infiltrated with 0.5% bupivacaine in SILS-A group (W-SILS-A). Forty-five patients were in the C-SILS-A, and 30 patients were in the W-SILS-A. Patients with perforated appendicitis were excluded. The clinical outcomes were compared between the groups by using the verbal numerical rating scale (VNRS).

Results

Clinical outcomes were similar in both study groups except for the pain score. The W-SILS-A group showed significantly lower numbers of additional pain killers and lower VNRS scores 1, 6, and 12 hours after surgery than the C-SILS-A group.

Conclusion

W-SILS-A is a technically simple and effective method of reducing early postoperative pain. It may be applicable in SILS-A for pain control system.

Single incision versus conventional laparoscopic cholecystectomy outcomes: a meta-analysis of randomized controlled trials

BACKGROUND

Previous meta-analyses that compared the outcome of SILC and CLC have not presented consistent conclusions. This meta-analysis was performed after adding many recent RCTs, to clarify this issue.

METHODS

Relevant articles published in English were identified by searching PubMed, Embase, Web of Knowledge, and the Cochrane Controlled Trial Register from January 1997 to February 2013. Reference lists of the retrieved articles were reviewed to identify additional articles. Primary outcomes (postoperative pain scores, cosmetic score, and length of incision) and secondary outcomes (operating time, blood loss, conversion rates, postoperative complications, postoperative hospital stay, time to initial oral intake, and time to resume work) were pooled. Quantitative variables were calculated using the weighted mean difference (WMD), and qualitative variables were pooled using odds ratios (OR).

RESULTS

25 appropriate RCTs were identified from 2128 published articles. 1841 patients were treated, 944 with SILC and 897 with CLC. SILC was superior to CLC in cosmetic score (WMD = 1.155, P<0.001), shorter length of incision (WMD = -3.285, P = 0.029), and postoperative pain within 12 h (VAS in 3-4 h, WMD = -0.704, P = 0.026; VAS in 6-8 h, WMD = -0.613, P = 0.010). CLC was superior to SILC in operating time (OT) (WMD = 13.613, P<0.001) and need of additional instruments (OR = 7.448, P<0.001). Other secondary outcomes were similar.

CONCLUSIONS

SILC offered a better cosmetic result and less postoperative pain for patients with uncomplicated cholelithiasis or polypoid lesions of the gallbladder. However, SILC was associated with a longer OT and required additional instruments.

Single incision versus conventional laparoscopic cholecystectomy outcomes: a meta-analysis of randomized controlled trials

BACKGROUND

Previous meta-analyses that compared the outcome of SILC and CLC have not presented consistent conclusions. This meta-analysis was performed after adding many recent RCTs, to clarify this issue.

METHODS

Relevant articles published in English were identified by searching PubMed, Embase, Web of Knowledge, and the Cochrane Controlled Trial Register from January 1997 to February 2013. Reference lists of the retrieved articles were reviewed to identify additional articles. Primary outcomes (postoperative pain scores, cosmetic score, and length of incision) and secondary outcomes (operating time, blood loss, conversion rates, postoperative complications, postoperative hospital stay, time to initial oral intake, and time to resume work) were pooled. Quantitative variables were calculated using the weighted mean difference (WMD), and qualitative variables were pooled using odds ratios (OR).

RESULTS

25 appropriate RCTs were identified from 2128 published articles. 1841 patients were treated, 944 with SILC and 897 with CLC. SILC was superior to CLC in cosmetic score (WMD = 1.155, P<0.001), shorter length of incision (WMD = -3.285, P = 0.029), and postoperative pain within 12 h (VAS in 3-4 h, WMD = -0.704, P = 0.026; VAS in 6-8 h, WMD = -0.613, P = 0.010). CLC was superior to SILC in operating time (OT) (WMD = 13.613, P<0.001) and need of additional instruments (OR = 7.448, P<0.001). Other secondary outcomes were similar.

CONCLUSIONS

SILC offered a better cosmetic result and less postoperative pain for patients with uncomplicated cholelithiasis or polypoid lesions of the gallbladder. However, SILC was associated with a longer OT and required additional instruments.

Single-incision laparoscopic cholecystectomy: do patients care?

INTRODUCTION

Single-incision approaches to laparoscopic cholecystectomy typically involve increasing the size of the umbilical incision and eliminating three smaller incisions, but it is not intuitive that patients would view this as a benefit. We hypothesize that when patient satisfaction with standard laparoscopic cholecystectomy is assessed, most dissatisfaction will be linked to the umbilical incision and, given the option, patients would actually wish to eliminate this incision.

METHODS

Two hundred eighty-one female patients aged 18 to 40 years who underwent laparoscopic cholecystectomy over a 2-year period were identified, and data were collected on 125 patients.

RESULTS

Fewer than half of patients correctly remembered the number of incisions they had, with 57 patients (45.6%) recalling fewer incisions than were present. Of 58 patients reporting one site to be more painful, 38 (65.5%) cited the umbilical site as the most painful. Eighty-one patients (68.6%) would have preferred to eliminate an incision, with 51 of these (63.0%) choosing to eliminate the umbilical incision.

CONCLUSION

As single-incision cholecystectomy enlarges what is already a painful and undesirable incision, and since patients often do not recall the smaller incisions, we should ask ourselves whether surgeons and industry care more about this technique than do the patients to whom we offer it.

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

BACKGROUND:

The study was designed to compare the effect of intraincisional vs intraperitoneal infiltration of levobupivacaine 0.25% on post-operative pain in laparoscopic cholecystectomy.

MATERIALS AND METHODS:

This randomised controlled study was carried out on 189 patients who underwent laparoscopic cholecystectomy. Group 1 was the control group and did not receive either intraperitoneal or intraincisional levobupivacaine. Group 2 was assigned to receive local infiltration (intraincisional) of 20 ml solution of levobupivacaine 0.25%, while Group 3 received 20 ml solution of levobupivacaine 0.25% intraperitoneally. Post-operative pain was recorded for 24 hours post-operatively.

RESULTS:

Post-operative abdominal pain was significantly lower with intraincisional infiltration of levobupivacaine 0.25% in group 2. This difference was reported from 30 minutes till 24 hours post-operatively. Right shoulder pain showed significantly lower incidence in group 2 and group 3 compared to control group. Although statistically insignificant, shoulder pain was less in group 3 than group 2.

CONCLUSION:

Intraincisional infiltration of levobupivacaine is more effective than intraperitoneal route in controlling post-operative abdominal pain. It decreases the need for rescue analgesia.

A systematic review of interventions to facilitate ambulatory laparoscopic cholecystectomy

OBJECTIVES

  We aimed to perform a systematic review of the literature to identify interventions that may facilitate ambulatory laparoscopic cholecystectomy (LC).

METHODS

The PubMed and CENTRAL databases were interrogated for key MeSH headings. To be eligible for systematic review, trials were required to include outcome measures of postoperative pain, nausea or vomiting and time to discharge following LC. Interventions were subsequently assessed for the level of evidence and grade of recommendation given.

RESULTS

A total of 331 trials were identified, 68 of which met the predefined study inclusion criteria. Interventions which met Level I, Grade A recommendation included the administration of 8 mg i.v. dexamethasone, preoperative administration of analgesia including the use of non-steroidal anti-inflammatory or COX II inhibitors, intraoperative use of an anti-emetic, pre-incisional use of bupivacaine, administration of intraperitoneal bupivacaine on establishment of pneumoperitoneum, and avoidance of drains.

CONCLUSIONS

  High-quality evidence describing interventions that minimize barriers to ambulatory LC exists. Further studies will be required to determine the optimal combination of these interventions.

Randomized clinical trial of laparoendoscopic single-site versus conventional laparoscopic cholecystectomy

BACKGROUND

Conventional laparoscopy with three or more ports remains the 'gold standard' for cholecystectomy, but a laparoendoscopic single-site (LESS) approach is emerging, designed to decrease parietal trauma and improve cosmesis. This study compared conventional laparoscopic (CL) with LESS cholecystectomy, with short-term clinical results as the main outcomes.

METHODS

A randomized trial of CL and LESS cholecystectomies involving 150 patients was undertaken. Follow-up was for 1 month after surgery. The primary endpoint was body image results evaluated by means of validated scales. Secondary endpoints were: postoperative pain measured on a visual analogue scale, analgesia requirement, morbidity, quality of life (QoL) measured with Short Form 12, duration of operation, hospital stay, time to return to work and cost analysis.

RESULTS

Operating times and complications were similar in the two groups. Two LESS procedures (3 per cent) were converted to two-port laparoscopy owing to difficulties with exposure, and one CL operation was achieved through a single port because extensive fibrous peritoneal adhesions prevented placement of other ports. There were three and four port-site seroma/haematomas in the LESS and CL groups respectively. Better pain profiles and lower analgesia requirements were recorded in the LESS group (P < 0·001). QoL, body image and scar scale results were also better (P < 0·001). Operative costs were higher for LESS procedures (P < 0·001), although median time to return to work was shorter (P = 0·003).

CONCLUSION

LESS is an alternative to CL cholecystectomy associated with better cosmesis, body image, QoL and an improved postoperative pain profile.