Intraperitoneal Versus Interpleural Morphine or Bupivacaine for Pain After Laparoscopic Cholecystectomy

The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery

“…These studies showed dierences in serum cytokine levels between laparoscopic and conventional surgery for IL-1 (1b [174]), IL-6 (1b [36,135,165,176,254,320,322]), CRP (1b [135,140,176,235,254,320], CRP (1b [133,138,174,233,252,318]) and cell-mediated immunity (1b [224]) that have not been con®rmed by other authors (1b [17,198], 2b [89]). In RCTs, postoperative immunological functions seemed to be better preserved after laparoscopic compared to conventional procedures (1b [13,45,151,176,235,276,284,308,321]): however, some trials found no dierences (1b [73,113,173,203,226,248,270,289,295]) and one trial even reported a more pronounced immunodepression after laparoscopy (1b [290]). Additional RCTs examined perioperative stress response and found adrenaline (1b [150]), noradrenaline (1b [150]), and cortisol (1b [150, 174, 303]) decreased to a lesser extent after laparoscopic than after conventional procedures, although one study did not con®rm this result (1b [112]).…”

“…The following interventions were all shown in RCTs to eectively reduce pain after laparoscopy: · Reducing IAP (1b [178,236,299,308]) · Using other insuation gases, such as N 2 O, helium, or argon (1b [2, 180,206,236,280]), · Lowering the insuation rate (1b [16]) · Warming and humidifying the insuation gas (1b [162,209,210,226,254]) · Removal of residual intraabdominal gas at the end of operation (1b [86,137,298] 87,140,244,264,270]). Since there is also evidence that postlaparoscopic instillation of normal saline or Ringers lactate reduces pain (1b [233]), it is important to distinguish between trials that used placebo controls from those that did not.…”

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy

“…Nevertheless, combined intraperitoneal and port-site incisional local anesthetics are recommended, provided that the amount of local anesthetics does not result in plasma levels that pose a toxicity risk. Although limited data suggest that interpleural LA may be effective, and that it may have benefits over incisional injection, the practicalities of this route are questionable and there is a risk of pneumothorax; therefore we do not recommend this approaches [3,139]. The instillation of intraperitoneal saline and suction has been shown to be of significant benefit in a single, well-conducted study [161].…”

“…The studies evaluated ropivacaine [49, 75,91], lidocaine [123] and bupivacaine individually [25, 31, 61, 83, 103, 116-118, 126, 137, 156, 175, 186], and bupivacaine plus epinephrine [29,63,137] or prilocaine [20]. One study was excluded from analyses as the control group received intravenous morphine [139]. Qualitative analysis of VAS scores revealed that 17 study arms reported a significant benefit for intraperitoneal analgesia [25,29,49,75,91,103,116,117,156,175,186], whereas 12 reported no significant difference between intraperitoneal analgesia and placebo [20,31,61,63,83,123,126,137].…”

Effect of intercostals neural blockade with Marcaine (bupivacaine) on postoperative pain after laparoscopic cholecystectomy

“…In 1995, SchulteSteinberg showed the statistically significant effect of interpleural bupivacain injection 6 h after the LC [13]. In 1998, Maidasti et al [9], using bupivacain, showed the good effect of intercostals neural blockade (INB) (T7-T11) on open cholecystectomy and recommended INB as a complement to the postoperative intravenous morphine injection.…”