Intraperitoneal Levobupivacaine Alone or with Dexmedetomidine for Postoperative Analgesia after Laparoscopic Cholecystectomy

Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Effect of dexmedetomidine supplementation for thoracoscopic surgery: a meta-analysis of randomized controlled trials

Introduction

The efficacy of dexmedetomidine supplementation for thoracoscopic surgery remains controversial. We conduct a systematic review and meta-analysis to explore the impact of dexmedetomidine for thoracoscopic surgery.

Methods

We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through September 2020 for randomized controlled trials (RCTs) assessing the effect of dexmedetomidine supplementation on thoracoscopic surgery. This meta-analysis is performed using the random-effect model.

Results

Six RCTs involving 510 patients are included in the meta-analysis. Overall, compared with control group for thoracoscopic surgery, dexmedetomidine supplementation results in significantly reduced pain scores (SMD = − 1.50; 95% CI = − 2.63–− 0.37; P = 0.009), anesthetic consumption (SMD = − 3.91; 95% CI = − 6.76–− 1.05; P = 0.007), mean heart rate (SMD = − 0.41; 95% CI = − 0.65–− 0.18; P = 0.0007), and the risk ratio (RR) of ICU stay (RR = 0.39; 95% CI = 0.19–0.80; P = 0.01), but showed no obvious effect on mean blood pressure (SMD = − 0.07; 95% CI = − 0.45–0.31; P = 0.72) or hospital stay (SMD = − 0.61; 95% CI = − 1.30–0.08; P = 0.08).

Conclusions

Dexmedetomidine supplementation can substantially improve the analgesic efficacy for thoracoscopic surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01803-z.

Intraperitoneal local anaesthetic instillation versus no intraperitoneal local anaesthetic instillation for laparoscopic cholecystectomy

BACKGROUND

Pain is one of the important reasons for delayed discharge after laparoscopic cholecystectomy. Use of intraperitoneal local anaesthetic for laparoscopic cholecystectomy may be a way of reducing pain. A previous version of this Cochrane Review found very low-certainty evidence on the benefits and harms of the intervention.

OBJECTIVES

To assess the benefits and harms of intraperitoneal instillation of local anaesthetic agents in people undergoing laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and three other databases to 19 January 2021 together with reference checking of studies retrieved. We also searched five online clinical trials registries to identify unpublished or ongoing trials to 10 September 2021. We contacted study authors to identify additional studies.

SELECTION CRITERIA

We only considered randomised clinical trials (irrespective of language, blinding, publication status, or relevance of outcome measure) comparing local anaesthetic intraperitoneal instillation versus placebo, no intervention, or inactive control during laparoscopic cholecystectomy, for the review. We excluded non-randomised studies, and studies where the method of allocating participants to a treatment was not strictly random (e.g. date of birth, hospital record number, or alternation).

DATA COLLECTION AND ANALYSIS

Two review authors collected the data independently. Primary outcomes included all-cause mortality, serious adverse events, and quality of life. Secondary outcomes included length of stay, pain, return to activity and work, and non-serious adverse events. The analysis included both fixed-effect and random-effects models using RevManWeb. We performed subgroup, sensitivity, and meta-regression analyses. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs). We assessed risk of bias using predefined domains, graded the certainty of the evidence using GRADE, and presented outcome results in a summary of findings table.

MAIN RESULTS

Eighty-five completed trials were included, of which 76 trials contributed data to one or more of the outcomes. This included a total of 4957 participants randomised to intraperitoneal local anaesthetic instillation (2803 participants) and control (2154 participants). Most trials only included participants undergoing elective laparoscopic cholecystectomy and those who were at low anaesthetic risk (ASA I and II). The most commonly used local anaesthetic agent was bupivacaine. Methods of instilling the local anaesthetic varied considerably between trials; this included location and timing of application. The control groups received 0.9% normal saline (69 trials), no intervention (six trials), or sterile water (two trials). One trial did not specify the control agent used. None of the trials provided information on follow-up beyond point of discharge from hospital. Only two trials were at low risk of bias. Seven trials received external funding, of these three were assessed to be at risk of conflicts of interest, a further 17 trials declared no funding. We are very uncertain about the effect intraperitoneal local anaesthetic versus control on mortality; zero mortalities in either group (8 trials; 446 participants; very low-certainty evidence); serious adverse events (RR 1.07; 95% CI 0.49 to 2.34); 13 trials; 988 participants; discharge on same day of surgery (RR 1.43; 95% CI 0.64 to 3.20; 3 trials; 242 participants; very low-certainty evidence). We found that intraperitoneal local anaesthetic probably results in a small reduction in length of hospital stay (MD -0.10 days; 95% CI -0.18 to -0.01; 12 trials; 936 participants; moderate-certainty evidence). No trials reported data on health-related quality of life, return to normal activity or return to work. Pain scores, as measured by visual analogue scale (VAS), were lower in the intraperitoneal local anaesthetic instillation group compared to the control group at both four to eight hours (MD -0.99 cm VAS; 95% CI -1.19 to -0.79; 57 trials; 4046 participants; low-certainty of evidence) and nine to 24 hours (MD -0.68 cm VAS; 95% CI -0.88 to -0.49; 52 trials; 3588 participants; low-certainty of evidence). In addition, we found two trials that were still ongoing, and one trial that was completed but with no published results. All three trials are registered on the WHO trial register.

AUTHORS' CONCLUSIONS

We are very uncertain about the effect estimate of intraperitoneal local anaesthetic for laparoscopic cholecystectomy on all-cause mortality, serious adverse events, and proportion of patients discharged on the same day of surgery because the certainty of evidence was very low. Due to inadequate reporting, we cannot exclude an increase in adverse events. We found that intraperitoneal local anaesthetic probably results in a small reduction in length of stay in hospital after surgery. We found that intraperitoneal local anaesthetic may reduce pain at up to 24 hours for low-risk patients undergoing laparoscopic cholecystectomy. Future randomised clinical trials should be at low risk of systematic and random errors, should fully report mortality and side effects, and should focus on clinical outcomes such as quality of life.

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

Background:

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

Subjects and Methods:

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

Results:

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

Conclusion:

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

An investigation of the effects of dexmedetomidine and fentanyl as an adjuvant to ropivacaine on pain scores and hemodynamic changes following laparoscopic cholecystectomy

Postoperative pain control is recognized as a challenging surgical issue receiving high priority in the healthcare system, and opioids are routinely prescribed for anesthesia and pain relief. This study aimed to investigate the effects of ropivacaine administered intraperitoneally alone or combined with dexmedetomidine or fentanyl on postoperative pain control following laparoscopic cholecystectomy. This randomized double-blind clinical trial recruited three equal-size block-randomized groups of patients (n = 138) scheduled for elective laparoscopic cholecystectomy at Valiasr Hospital, Arak, Iran, in 2019–2020 who received ropivacaine (40 mL/0.5%), ropivacaine (40 mL/0.5%) + dexmedetomidine (1 μg/kg), and ropivacaine (40 mL/0.5%) + fentanyl (1 μg/kg). No significant differences were observed among the three groups according to the vital signs (mean arterial pressure/heart-rate/oxygen saturation) in the study period and during surgery (P > 0.05). Lower pain was revealed in the ropivacaine + dexmedetomidine group (P = 0.001), with the lowest opioid dose in postoperative 24 hours (P = 0.001). Moreover, no clinically significant differences were observed in complications among the three groups (P = 0.483), and no patient developed ileus. Intraperitoneal ropivacaine administered with dexmedetomidine could relieve pain and reduce opioid use in postoperative 24 hours, without any complication and ileus. Therefore, intraperitoneal ropivacaine administered with dexmedetomidine is recommended for postoperative pain control in patients undergoing laparoscopic cholecystectomy. This study was approved by the Ethical Committee of Arak University of Medical Sciences (approval No. IR.ARAKMU.REC.1397.267) on December 30, 2018 and was registered in the Iranian Registry of Clinical Trials (No. IRCT 20141209020258N117) on July 13, 2019.

Effect of dexmedetomidine on intraoperative Surgical Pleth Index in patients undergoing video-assisted thoracoscopic lung lobectomy

Background

The Surgical Pleth Index (SPI) is a monitoring method that reflects painful stimuli during general anesthesia, and dexmedetomidine is an analgesic adjuvant with an opioid-sparing effect. But up to now, it is still unclear whether dexmedetomidine has any influence on SPI. To investigate whether dexmedetomidine has an effect on SPI during video-assisted thoracoscopic surgery.

Methods

We enrolled 94 patients who underwent video-assisted thoracoscopic lung lobectomy. Patients were randomly assigned to a dexmedetomidine group (dexmedetomidine: 0.8 μg/kg administered for 10 min before anesthesia) or normal saline group (equal volume of normal saline). SPI and vital signs were recorded. The number rating scale (NRS) pain score was also evaluated.

Results

SPI values were significantly lower in the dexmedetomidine group than in the normal saline group at intubation and at discharge from the postanesthesia care unit. Compared with the normal saline group, mean arterial pressure and heart rate were both significantly lower in the dexmedetomidine group at intubation. Heart rate was lower at skin incision in the dexmedetomidine group. The NRS score in the normal saline group was noticeably higher vs. the dexmedetomidine group at discharge from the postanesthesia care unit.

Conclusions

Dexmedetomidine decreased intraoperative SPI and NRS scores. Our results showed that dexmedetomidine attenuated noxious stimuli.

Trial registration

Chinese Clinical Trial Registry (ChiCTR): ChiCTR-OOC-16009450, Registered 16 October, 2016.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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