Intraperitoneal administration of local anesthesia is often used to improve pain relief after laparoscopic cholecystectomy. We have conducted a meta-analysis to establish the efficacy of this technique in reducing early postoperative abdominal pain. A systematic literature search revealed 24 randomized, controlled trials assessing intraperitoneal local anesthetic use in laparoscopic cholecystectomy that met inclusion criteria. Of these, 16 studies reported sufficient data to allow pooled quantitative analysis. The weighted mean differences (WMD) in visual analog pain score at 4 h after surgery were pooled using a random effects model. Overall, the use of intraperitoneal local anesthesia resulted in a significantly reduced pain score at 4 h (WMD, -9 mm; 95% confidence interval [CI], -13 to -5). Subgroup analysis suggested that the effect was greater when the local anesthetic was given at the start of the operation (WMD, -13 mm; 95% CI, -19 to -7) compared with instillation at the end (WMD, -6 mm; 95% CI, -10 to -2). No adverse events related to local anesthetic toxicity were reported. We conclude that the use of intraperitoneal local anesthesia is safe, and it results in a statistically significant reduction in early postoperative abdominal pain.

The effect of intraperitoneal local anesthesia in laparoscopic cholecystectomy: a systematic review and meta-analysis.

With the advent of minimally invasive gallbladder surgery, and now with natural orifice techniques emerging, visceral nociception has been neglected as a cause of postoperative pain A systematic review and metaanalysis was carried out to investigate the use of intraperitoneal local anesthetic (IPLA) in order to assess its role in laparoscopic cholecystectomy (LC) The aim of this systematic review was to appraise the clinical effects of this modality Comprehensive searches were conducted independently without language restriction Studies were identified from the following databases from inception to September 2009: Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Cochrane Library, Medline, PubMed, Excerpta Medica Database (EMBASE), and Cumulative Index to Nursing and Allied Health Literature (CINHAL) Relevant meeting abstracts and reference lists were manually searched Data analysis was performed using Review Manager Version 50 software Thirty randomized controlled trials were identified for review The clinical heterogeneity of IPLA use was high However, there appeared to be reduced pain, opioid use, and need for rescue analgesia, and reduced postoperative cortisol and glucose responses There is evidence in favor of IPLA in LC Further trials of this modality in LC are not needed as these are unlikely to reduce clinical heterogeneity IPLA should be trialled as future minimally invasive surgical techniques approach

https://onlinelibrary.wiley.com/doi/pdf/10.1007/s00534-010-0271-7

Intraperitoneal use of local anesthetic in laparoscopic cholecystectomy: systematic review and metaanalysis of randomized controlled trials

This study aimed to evaluate the optimal timing of preemptive analgesia with bupivacaine peritoneal instillation in a prospective, randomized, double-blind, placebo-controlled trial. In this study, 120 patients qualified for laparoscopic cholecystectomy were randomized to four groups. Group A received 2 mg/kg of bupivacaine in 200 ml of normal saline before creation of pneumoperitoneum. Group B received 2 mg/kg of bupivacaine in 200 ml of normal saline after creation of pneumoperitoneum. Group C received 200 ml of normal saline before creation of pneumoperitoneum. Group D received 200 ml of normal saline after creation of pneumoperitoneum. Local wound infiltration with bupivacaine was used before skin incisions. The primary end points of the study were postoperative pain intensity on a visual analog scale and incidence of shoulder tip pain. The secondary end points included the latency of nurse-controlled analgesia activation, the analgesia request rate, and analgesic consumption. Significantly lower visual analog scores were observed in group A versus groups C and B versus group D during the initial 48 and 24 h, respectively. The patients in group A versus group B reported significantly lower pain at 4 h (p < 0.001) and 8 h (p = 0.003) postoperatively, but the difference was not significant after 12, 24, and 48 h. None of the group A patients reported shoulder tip pain, whereas it was reported by 3 patients in group B, 6 patients in group C, and 7 patients in group D (p < 0.01). The latency of nurse-controlled analgesia activation was 426.8 ±57.2 min in group A, as compared with 307 ± 39.8 min in group B, 109.3 ± 51 min in group C, and 109 ± 46.5 min in group D (p < 0.001). A significantly lower analgesia request rate was observed in group A versus C, as compared with group B versus D, throughout the entire study period (p < 0.05). Preemptive analgesia with bupivacaine peritoneal instillation is much more effective for pain relief if used before creation of pneumoperitoneum. Although the effect of bupivacaine peritoneal instillation is also noticeable when used after creation of pneumoperitoneum, it confers significantly lower benefits.

Superiority of preemptive analgesia with intraperitoneal instillation of bupivacaine before rather than after the creation of pneumoperitoneum for laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study.

Local anaesthesia for pain relief after laparoscopic cholecystectomy--a systematic review.

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

SummaryBackground and objective: Intraperitoneal administration of a local anaesthetic in combination with an opioid, for the relief of postoperative pain, has already been reported except after laparoscopic cholecystectomy. This study was aimed at assessing the analgesic effect of the intraperitoneal administration of bupivacaine and morphine in patients undergoing laparoscopic cholecystectomy.Methods: At the end of laparoscopic cholecystectomy, in a double-blind, randomized manner, one of the following injections was given intraperitoneally. There were 30 patients in each group: Group 1, physiological saline 30 mL; Group 2, bupivacaine 0.25% 30 mL; Group 3, bupivacaine 0.25% 30 mL plus morphine 2 mg. In addition, Group 2 received 2 mg intravenous (i.v.) morphine in 2 mL saline, and Groups 1 and 3, 2 mL saline intravenously. Patients' postoperative pain was evaluated using a visual analogue scale and a verbal rating score. The postoperative analgesic requirement was assessed by the total dose of metamizol administered by an i.v. patient-controlled analgesia (PCA) device. Pain, vital signs, supplemental analgesic consumption and side-effects were recorded for all patients for 24 h.Results: There were no differences between the three groups regarding pain scores (at rest and coughing) during the study except in the first 2 h, when scores were lower for patients receiving intraperitoneal bupivacaine plus i.v. morphine (P < 0.05). Supplemental consumption of metamizol was significantly lower (P < 0.05) in Group 3 than in Group 1 during the first 6 h after surgery. However, the cumulative doses of metamizol were also lower in Group 2 than in Groups 1 and 3 over the entire study (2025 ± 1044 mg vs. 4925 ± 1238 and 4125 ± 1276 mg; P < 0.05).Conclusions: In patients undergoing laparoscopic cholecystectomy, the intraperitoneal administration of morphine plus bupivacaine 0.25% reduced the analgesic requirements during the first 6 postoperative hours compared with the control group. However, the combination of intraperitoneal bupivacaine 0.25% and i.v. morphine was more effective for treatment of pain after laparoscopic cholecystectomy.

Intraperitoneal application of bupivacaine plus morphine for pain relief after laparoscopic cholecystectomy

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Intraperitoneal application of bupivacaine plus morphine for pain relief after laparoscopic cholecystectomy