| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
 
|
|
|
||
|
|
© 1999 International Anesthesia Research Society
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Pain is the dominant complaint after laparoscopic cholecystectomy. No study has examined the combined effects of a somato-visceral blockade during laparoscopic cholecystectomy. Therefore, we investigated the effects of a somato-visceral local anesthetic blockade on pain and nausea in patients undergoing elective laparoscopic cholecystectomy. In addition, all patients received multi-modal prophylactic analgesic treatment. Fifty-eight patients were randomized to receive a total of 286 mg (66 mL) ropivacaine or 66 mL saline via periportal and intraperitoneal infiltration. During the first 3 postoperative h, the use of morphine and antiemetics was registered, and pain and nausea were rated hourly. Daily pain intensity, pain localization, and supplemental analgesic consumption were registered the first postoperative week. Ropivacaine reduced overall pain the first two hours and incisional pain for the first three postoperative hours (P < 0.01) but had no apparent effects on intraabdominal or shoulder pain. During the first 3 postoperative h, morphine requirements were lower (P < 0.05), and nausea was reduced in the ropivacaine group (P < 0.05). Throughout the first postoperative week, incisional pain dominated over other pain localizations in both groups (P < 0.01). We conclude that the somato-visceral local anesthetic blockade reduced overall pain during the first 2 postoperative h, and nausea, morphine requirements, and incisional pain were reduced during the first 3 postoperative h in patients receiving prophylactic multi-modal analgesic treatment.
Implications: A combination of incisional and intraabdominal local anesthetic treatment reduced incisional pain but had no effect on deep intraabdominal pain or shoulder pain in patients receiving multi-modal prophylactic analgesia after laparoscopic cholecystectomy. Incisional pain dominated during the first postoperative week. Incisional infiltration of local anesthetics is recommended in patients undergoing laparoscopic cholecystectomy.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Early postoperative pain is the most common complaint after elective laparoscopic cholecystectomy (1). Pain intensity peaks during the first postoperative hours and usually declines over the following 2–3 days (1,2). The use of regional local anesthetics, in combination with general anesthesia, has been investigated in several interventional studies during laparoscopic cholecystectomy (2–15). Thus, variable analgesic effects of periportal infiltration of local anesthetics (4), infiltration of the periportal parietal peritoneum (3,5), intraperitoneal spraying above the gallbladder (7,8,14), infiltration into the gallbladder bed parenchyma (6–8), instillation into the subdiaphragmatic space (2,7–14), and into the subhepatic space covering the area of the hepato-duodenal ligament have been reported (7,8,14,15). Approximately half of these studies reduced pain significantly (3,4,6–9,14,15) but without a clear relation between dose or application sites. In seven controlled studies of patients undergoing laparoscopic cholecystectomy, preemptive analgesic effects of nonsteroid antiinflammatory drugs (NSAIDs) (16,17), incisional local anesthetics (3–5), or intraperitoneal local anesthetics (8,14) have been investigated. None of these studies benefited from preemptive analgesia compared with postoperative analgesic treatment. No study has investigated the effects of a combined somato-visceral local anesthetic blockade on pain and nausea after elective laparoscopic cholecystectomy.
Therefore, our study was designed to examine the effects on postoperative pain and nausea after a combined somato-visceral multi-regional local anesthetic blockade. The blockade included a combination of all the above-mentioned application sites and a large-dose of local anesthetics.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
We randomized 58 patients in a double-blinded, placebo-controlled study from October 1997 to May 1998. The patients underwent elective laparoscopic cholecystectomy under general anesthesia and a multi-regional blockade with ropivacaine or saline (placebo). The criteria for exclusion were ASA physical status III or greater, and patients having papillotomy by endoscopic retrograde cholangiopancreatography within 1 mo before operation. Moreover, patients were excluded for chronic pain diseases other than gallstone disease, if they received opioids or tranquilizers (treatment for more than 1 wk before the cholecystectomy), or had a history of alcohol or drug abuse. Patients were excluded if they had operation for acute cholecystitis or if the operation was converted to an open procedure. Also, to study the real analgesic effects of local anesthetics, patients were excluded when they had postoperative complications, which could increase postoperative pain.
The same three surgeons performed all operations. Laparoscopic cholecystectomy was performed by the standard "French" technique (18). If necessary, a lateral umbilical fascial incision was made to ease retraction of the gallbladder (1/2–1 cm). Intraoperative cholangiography was not performed. All patients were given gentamicin (160 mg) at the beginning of surgery. During laparoscopy, intraabdominal pressure was maintained at 12 mm Hg. The CO2 was carefully evacuated at the end of surgery by manual compression of the abdomen with open trocars. A surgical difficulty score (very easy, moderate, difficult, very difficult) for each patient was given by the surgeon at the end of operation.
Full information sheets, contact telephone numbers, and structured pain questionnaires for daily registrations were given to all patients on discharge. The patients were instructed to record supplementary analgesics daily.
All patients received the same general anesthetic technique. No premedication was used. General anesthesia was induced with IV fentanyl (0.003 mg/kg) and propofol (2.0–2.5 mg/kg). Orotracheal intubation was facilitated by cisatracurium (0.15 mg/kg). Patients were maintained with oxygen in air (1:2), propofol (10 mg · kg-1 · h-1) and supplemental doses of alfentanil (0.5–1.0 mg) if required, given at the discretion of the anesthesiologist. Minute ventilation was adjusted to keep end-tidal PCO2 at 4.5–5.5 kPa.
We used coded, blinded ampule sets (consecutively numbered and marked 0.75% and 0.2% by the manufacturer) containing ropivacaine (Astra, Södertälje, Sweden) or saline 0.9%. In the ropivacaine group, a total of 286 mg of ropivacaine was given as follows. For the abdominal layers (trocar sites), 0.75% ropivacaine was used (a total of 210 mg). Before the supraumbilical incision, the drug was infiltrated intracutaneously (2 mL). After skin incision, the fascia, muscle, preperitoneal space, and the parietal peritoneum were infiltrated (4 mL). A supplementary dose (4 mL) was infiltrated in the periumbilical fascia to block the area of the fascial incision required for gallbladder retraction at the end of surgery (thus total 10 mL 0.75% at the umbilical site). In each of the remaining trocar sites the cutis was infiltrated using 2 mL of 0.75% solution. The abdominal wall and parietal peritoneum were penetrated with a needle (under direct laparoscopic vision), the needle was withdrawn, and a bleb was raised by application of local anesthetic in the preperitoneal space (3). The fascia, muscle, and preperitoneal space were infiltrated using 4 mL (thus using a total of 6 mL at each trocar site). For intraperitoneal instillation, 0.2% ropivacaine was used (a total of 76 mg). A 40-cm laparoscopic needle, with an internal diameter of 1.2 mm, was inserted into the left subcostal trocar under direct laparoscopic vision. The visceral peritoneum covering the hepato-duodenal ligament was infiltrated (4 mL) before clamping and division of the cystic duct and artery. The gallbladder bed was infiltrated (10 mL) after partial retrograde release of the gallbladder. At the end of surgery, 2 x 8 mL of 0.2% ropivacaine or saline was sprayed at the upper, right, and left surface of the liver and subdiaphragmatic space. Before retraction of the trocars, an additional 8 mL was instilled into the right subhepatic space.
All patients received the following multi-modal prophylactic analgesic treatment: IV ketorolac (30 mg) approximately 20 min before the end of surgery. Immediately after surgery, and in the recovery room 2 g paracetamol was given as suppositories. Three hours after surgery, all patients commenced oral treatment with ibuprofen (600 mg, every 8 hours for 4 days). In Table 1 the supplementary needs for analgesic medication (in addition to the prophylactic analgesic standard treatment) is noted. The supplementary analgesic treatment included: opioids administered on request (5 mg IV in the recovery room, in the ward 30 mg orally or 5–10 mg IV), and for postoperative nausea, patients were given IV ondansetron (8 mg) on request. If supplementary medication was required in addition to the standard treatment, it was noted in a logbook kept by the patients (Table 1).
|
Before surgery, for measuring pain and nausea, the patients were instructed to use a 100-mm visual analog scale (VAS) (VAS: endpoints labeled "no pain" or "no nausea" and "worst possible pain" or "worst possible nausea") and a verbal rating scale (VRS) (VRS: no = 0, light = 1, moderate = 2, or severe = 3 pain or nausea). During the early part of the study, pain was registered at the first, second, and third postoperative hour using VAS and VRS at rest (supine) and after mobilization (supine to sitting). Nausea was assessed at rest at the same intervals. At the third postoperative hour, patients were asked to rate incisional, intraabdominal, and shoulder pain by a comparison of pain severity between the three pain localizations (no pain, least severe, less severe, severest pain). Comparison was performed at rest and during mobilization. Incisional pain was defined as superficial pain, wound pain, or pain located in the abdominal wall (2). Intraabdominal pain was defined as pain inside the abdomen, which may be deep, dull, and more difficult to localize, and may resemble biliary colic (2). Shoulder pain was defined as a sensation of pain in the shoulder (2).
The late part of the study was based on self-reported registrations by the patients. Six hours after surgery and during the following 7 days at 8 PM, patients registered average VAS pain scores during the preceding 24 h and rated incisional, intraabdominal, or shoulder pain as described above. At the seventh postoperative day, patients reported the average pain during the first postoperative week by VRS.
In a prospective, uncontrolled study of 50 consecutive patients from our department, it was shown that about 30% of patients after laparoscopic cholecystectomy had severe overall pain at early postoperative mobilization or coughing (19). In the present study, the multi-regional local anesthetic regimen involved several infiltration procedures. Furthermore, postlaparoscopic cholecystectomy pain mostly declines within a few days (1,2). Therefore, we decided that a clinically relevant treatment should reduce the incidence of severe or moderate overall pain to 0% (Minimal Relevant Difference = 30%). With a type I error of 0.05 and a type II error of 0.20, the necessary sample size would be 42 patients (21 patients in each group). We chose to study a minimum of 50 evaluable patients. The Mann-Whitney U-test and the Fisher’s exact test were used for comparisons between groups. To avoid repeated comparisons at different time points, pain scores were added (total pain scores [TPS]) over the first 3 postoperative h and over the first postoperative week. Also, total nausea scores (TNS) were obtained. TPS were used for intergroup comparisons of pain intensity and pain localization and TNS for inter-group comparisons. Similarly, daily incidences of pain localization were added within study groups. In addition, Friedman’s rank sum test was used for inter- and intragroup comparisons of VAS pain scores during the first postoperative week. All values are presented as median (range) and percentages when appropriate. The Local Ethics Committee and the Danish Health Authorities approved the study, and all patients gave their written, informed consent to participate.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Fifty-eight patients were randomized. The pharmaceutical company provided 60 randomized ampules, but two sets of ampules were defective at the time of delivery. Eight patients were excluded from the first part of the study, leaving 25 patients in each study group. The eight exclusions were as follows: one patient was readmitted 3 days after operation as a result of an intraabdominal abscess. One patient was readmitted 5 days after operation with a retained stone in the common bile duct (despite normal preoperative blood tests and a normal ultrasound examination of the common bile duct). One patient developed an umbilical hematoma (2 x 3 cm) 1 h after surgery. One patient underwent open duodenorraphia as a result of severe chronic cholecystitis and a duodenal fistula in the gallbladder. One patient was converted to open procedure because of adhesions, and two patients received intra- and postoperative drainage of the subhepatic space (one bleeding and one insecure clamping of the cystic duct). One patient was excluded because of infiltration procedure failure (no subdiaphragmatic and subhepatic instillation). Furthermore, two patients were excluded from the late part of the study, leaving 25 in the ropivacaine group and 23 in the placebo group. One patient developed an infection in the umbilical incision (skin opened 5 days after operation for drainage), and one patient’s postoperative pain registration questionnaire was lost in the mail.
The two groups were comparable in terms of baseline characteristics (clinical, operative, and anesthesia data) (Table 1). No signs of side effects of the study drug were observed in our patients.
Pain and Nausea, Postoperative Hours 1–3
Ropivacaine reduced overall pain significantly for the first 2 postoperative h (Figure 1). At the third postoperative hour, incisional pain was reduced significantly in the ropivacaine group with no apparent effects on intraabdominal and shoulder pain (Figure 2). Moreover, morphine requirements were significantly reduced in the ropivacaine group (Table 1). Six patients in the ropivacaine group, compared with 14 in the placebo group, required morphine for postoperative analgesia (P < 0.05). TNS-VAS and TNS-VRS were reduced in the ropivacaine group (P < 0.05). Median TNS-VAS in the ropivacaine group was 0 (0–90) versus 10 (0–124) in the placebo group (P < 0.05), and median TNS-VRS was 0 (0–4) in the ropivacaine group versus 1 (0–4) in the placebo group (P < 0.05). Three patients in the placebo group and one patient in the ropivacaine group did not receive alfentanil during anesthetic maintenance (Table 1). In these patients, pain intensity was comparable within the treatment groups. Exclusion of the four patients from a statistic re-analysis did not change the results shown in Figure 1. Seven patients in the ropivacaine group, compared with 15 patients in the placebo group, experienced nausea (slight, moderate, or severe) after the operation (P < 0.05).
|
|
Pain, First Postoperative Week
There was no overall inter-group difference in VAS pain scores (Friedman’s test for difference P = 0.40, Mann-Whitney U-test for comparison of TPS P = 0.31) and no difference in retrospective VRS pain score during the week (P = 0.27). In both study groups pain decreased during the first postoperative week (Friedman’s test P < 0.001) (Figure 3A). Supplementary analgesic and antiemetic consumption were comparable in the two study groups (Table 1).
|
= incisional pain, 
= intraabdominal pain, 
= shoulder pain. C, Number of patients in the placebo group reporting daily localization of severest incisional pain, intraabdominal pain, and shoulder pain. When comparing the cumulative daily incidences of the different pain localizations during the first postoperative week (Figure 3B), incisional pain dominated over other pain localizations in both study groups. Thus, the cumulative daily incidences during the first postoperative week was significantly higher for incisional pain compared with intraabdominal pain (Mann-Whitney U-test, ropivacaine group P < 0.001, placebo group P < 0.01) and shoulder pain (Mann-Whitney U-test, ropivacaine group P < 0.01, placebo group P < 0.01), but with no difference between cumulative daily incidence of intraabdominal and shoulder pain (Mann-Whitney U-test ropivacaine group P = 0.19, placebo group P = 0.88).
Similarly, when comparing the localization of the severest pain, the cumulated daily incidences showed that incisional pain was severest in both study groups during the first postoperative week. Thus, the cumulated daily incidence of the severest pain during the first postoperative week was significantly higher for incisional pain compared with intraabdominal pain (Mann-Whitney U-test, ropivacaine group P < 0.01, placebo group P < 0.001) and shoulder pain (Mann-Whitney U-test, ropivacaine group P < 0.01, placebo group P < 0.001). In the ropivacaine group, cumulative daily incidence of severest pain during the first postoperative week were significantly higher for intraabdominal pain compared with shoulder pain (Mann-Whitney U-test, P < 0.05). The cumulative daily incidences of severest pain during the first postoperative week were comparable between intraabdominal and shoulder pain localizations in the placebo group (Mann-Whitney U-test, P = 0.28).
For illustrative reasons, Figure 3, B and C, only shows the placebo group, becuase there was no statistically significant intergroup difference according to pain localizations.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Our principal finding was that a combined somato-visceral ropivacaine blockade reduced overall pain during the first two postoperative hours, and incisional pain, nausea, and morphine requirements during the first three postoperative hours in patients receiving multi-modal prophylactic analgesia after laparoscopic cholecystectomy.
Fourteen previous, double-blinded, randomized studies have investigated the analgesic effects of a somatic (3–5) or visceral local anesthetic blockade (2,6–15) in patients undergoing laparoscopic cholecystectomy. The somatic block produced significant analgesia in two of three studies (3,4), and a visceral block produced significant analgesia in six of eleven studies (6–9,14,15). Overall, in the visceral block studies, there was no clear relation between the obtained level of analgesia and the local anesthetic dose, volume, or regional application sites.
The establishment of laparoscopic cholecystectomy as an outpatient procedure (19,20) has accentuated the clinical importance of reducing early postoperative pain and nausea. Pain and opioids both may induce nausea. Thus, improved postoperative pain treatment using opioid-sparing regimens (21) may facilitate a high success rate of outpatient laparoscopic cholecystectomy. Early pain after laparoscopic cholecystectomy is complex and includes different pain components secondary to different pain mechanisms, such as abdominal wall trauma, intraabdominal trauma secondary to gallbladder removal, abdominal distension, and pneumoperitoneum using CO2, etc. Optimally, therefore, pain should be treated multi-modally. We specifically focused on the effects of a combined somato-visceral local anesthetic blockade in combination with a prophylactic multi-modal analgesic treatment. Thus, patients received a near total analgesic blockade including NSAID, paracetamol, morphine, and a somato-visceral local anesthetic blockade or prophylactic multi-modal analgesic treatment without local anesthetics. Michaloliakou et al. (22) investigated the effect of a multi-analgesic nociceptive blockade or placebo in a randomized, placebo-controlled study of 45 patients undergoing laparoscopic cholecystectomy. The treatment group received a combination of preoperative IM opioid, ketorolac, and a somato-visceral local anesthetic blockade and general anesthesia. This multi-regimen reduced early postoperative pain, morphine requirements, and the incidence of early postoperative nausea. However, as several analgesic techniques were used in the treatment group, the specific effects of the somato-visceral local anesthetic blockade were not addressed, and the effect of local anesthetics, per se, could not be differentiated.
Although the daily median VAS pain scores were low in our study, incisional pain still dominated other pain localizations throughout the first postoperative week. In a prospective laparoscopic cholecystectomy series using no local anesthetics including 382 patients (1), incisional pain dominated in incidence and severity during the first two days after operation. These findings were opposed by Joris et al. (2), who found that intraabdominal pain dominated during the first 48 hours after elective laparoscopic cholecystectomy in 20 patients receiving intraperitoneal placebo versus 20 patients receiving intraperitoneal bupivacaine. Joris et al. (2) kept the intraabdominal CO2 pressure at 14 mm Hg and desufflated pneumoperitoneum at the end of the procedure. In this study, the authors did not use prophylactic pain treatment. Instead, postoperative alternate IV administration of NSAID and proparacetamol was given as necessary (up to every six hours), as well as morphine if required. The differences between analgesic treatment regimens and the higher pneumoperitoneum pressure used by Joris et al. may in part explain the different findings in the two studies. In our study, we kept the CO2 pressure constantly at 12 mm Hg, and CO2 was very carefully evacuated at the end of operation. It has been shown that CO2, trapped beneath the right hemidiaphragm and/or diaphragmatic distention, may cause postlaparoscopy abdominal pain (23,24). Furthermore, abdominal pain has been shown to relate positively to the CO2 insufflation pressure (23–25). Our low incidence of intraabdominal and shoulder pain may, in part, explain the lack of demonstrable effects of the multi-regional regimen on intraabdominal and shoulder pain. Another explanation for the lack of efficacy may be that our dose or volume of intraperitoneal local anesthetic for coverage of intraabdominal organ surfaces was too small. However, Scheinin et al. (11) used a large-dose of 150 mg (100 mL) intraperitoneal bupivacaine into the right subdiaphragmatic space and was unable to demonstrate any analgesic effects. We infiltrated local anesthetics into the hepato-duodenal ligament, in addition to gallbladder bed infiltration, and sprayed local anesthetics to the subdiaphragmatic, as well as the subhepatic space, to perform a near total block of all sites where surgical manipulation was performed. Because of the negative findings on intraabdominal and shoulder pain, we do not recommend routine use of intraabdominal local anesthetics. However, routine use of local anesthetics at the port sites is recommended based upon our results and others (3,4).
In conclusion, a combined somato-visceral local anesthetic regimen using ropivacaine 286 mg reduced overall pain the first two postoperative hours and incisional pain, morphine requirements, and nausea during the first three postoperative hours in patients receiving prophylactic multi-modal analgesic treatment after laparoscopic cholecystectomy. The multi-regional local anesthetic regimen had no apparent effect on intraabdominal or shoulder pain. Since incisional pain dominated throughout the first postoperative week, longer lasting local anesthetics producing analgesia for several days may be desirable.
|
Acknowledgments |
|---|
This study was supported by grants from the University of Copenhagen and The Danish Medical Research Council (j. nr. 9601607).
The authors would like to thank ASTRA, Södertälje, Sweden for providing coded randomized ampoules of drug and placebo for the study.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
- Ure BM, Troidl H, Spangenberger W, et al. Pain after laparoscopic cholecystectomy. Intensity and localization of pain and analysis of predictors in preoperative symptoms and intraoperative events. Surg Endosc 1994;8:90–6.[Web of Science][Medline]
- Joris J, Thiry E, Paris P, et al. Pain after laparoscopic cholecystectomy: characteristics and effect of intraperitoneal bupivacaine. Anesth Analg 1995;81:379–84.[Abstract]
- Alexander DJ, Ngoi SS, Lee L, et al. Randomized trial of periportal peritoneal bupivacaine for pain relief after laparoscopic cholecystectomy. Br J Surg 1996;83:1223–5.[Web of Science][Medline]
- Sarac AM, Aktan AO, Baykan N, et al. The effect and timing of local anesthesia in laparoscopic cholecystectomy. Endosc 1996;6:362–6.
- Ure BM, Troidl H, Spangenberger W, et al. Preincisional local anesthesia with bupivacaine and pain after laparoscopic cholecystectomy: a double-blind randomized clinical trial. Surg Endosc 1993;7:482–8.[Web of Science][Medline]
- Chundrigar T, Hedges AR, Morris R, Stamatakis JD. Intraperitoneal bupivacaine for effective pain relief after laparoscopic cholecystectomy. Ann R Coll Surg Engl 1993;75:437–9.[Web of Science][Medline]
- Mraovic B, Jurisic T, Majeric VK, Sustic A. Intraperitoneal bupivacaine for analgesia after laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1997;41:193–6.[Medline]
- Pasqualucci A, de Angelis V, Contardo R, et al. Preemptive analgesia: intraperitoneal local anesthetic in laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study. Anesthesiology 1996;85:11–20.[Web of Science][Medline]
- Weber A, Munoz J, Garteiz D, Cueto J. Use of subdiaphragmatic bupivacaine instillation to control postoperative pain after laparoscopic surgery. Surg Laparosc Endosc 1997;7:6–8.[Web of Science][Medline]
-
Rademaker BM, Kalkman CJ, Odoom JA, et al. Intraperitoneal local anaesthetics after laparoscopic cholecystectomy: effects on postoperative pain, metabolic responses and lung function. Br J Anaesth 1994;72:263–6.
[Abstract/Free Full Text] - Scheinin B, Kellokumpu I, Lindgren L, et al. Effect of intraperitoneal bupivacaine on pain after laparoscopic cholecystectomy. Anaesthesiol Scand 1995;39:195–8.
- Steinberg HS, Weninger E, Jokisch D, et al. Intraperitoneal versus interpleural morphine or bupivacaine for pain after laparoscopic cholecystectomy. Anesthesiology 1995;82:634–40.[Web of Science][Medline]
- Raetzell M, Maier C, Schroder D, Wulf H. Intraperitoneal application of bupivacaine during laparoscopic cholecystectomy: risk or benefit? Anesth Analg 1995;81:967–72.[Abstract]
- Szem JW, Hydo L, Barie PS. A double-blinded evaluation of intraperitoneal bupivacaine vs saline for the reduction of postoperative pain and nausea after laparoscopic cholecystectomy. Surg Endosc 1996;10:44–8.[Web of Science][Medline]
- Pasqualucci A, Contardo R, Da BU, Colo F, et al. The effects of intraperitoneal local anesthetic on analgesic requirements and endocrine response after laparoscopic cholecystectomy: a randomized double-blind controlled study. J Laparoendosc Surg 1994;4:405–12.[Web of Science][Medline]
- Forse A, El-Beheiry H, Butler PO, Pace RF. Indomethacin and ketorolac given preoperatively are equally effective in reducing early postoperative pain after laparoscopic cholecystectomy. Can J Surg 1996;39:26–30.[Web of Science][Medline]
- Lane GE, Lathrop JC, Boysen DA, Lane RC. Effect of intramuscular intraoperative pain medication on narcotic usage after laparoscopic cholecystectomy. Am Surg 1996;62:907–10.[Web of Science][Medline]
- Dubois F, Icard P, Berthelot G, Levard H. Coelioscopic cholecystectomy: preliminary report of 36 cases. Ann Surg 1990;211:60–2.[Web of Science][Medline]
- Callesen T, Klarskov B, Mogensen T, Kehlet H. Day case laparoscopic cholecystectomy: feasibility and convalescence. Ugeskr Læger 1998;160:2095–100.[Medline]
- Mjåland O, Ræder J, Aasboe V, et al. Outpatient laparoscopic cholecystectomy. Br J Surg 1997;84:958–61.[Web of Science][Medline]
- Kehlet H, Rung GW, Callesen T. Postoperative opioid analgesia: time for a reconsideration? J Clin Anesth 1996;8:441–5.[Web of Science][Medline]
- Michaloliakou C, Chung F, Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 1996;82:44–51.[Abstract]
-
Fredman B, Jedeikin R, Olsfanger D, et al. Residual pneumoperitoneum: a cause of postoperative pain after laparoscopic cholecystectomy. Anesth Analg 1994;79:152–4.
[Abstract/Free Full Text] - Jackson SA, Laurence AS, Hill JC. Does post-laparoscopy pain relate to residual carbon dioxide? Anaesthesia 1996;51:485–7.[Web of Science][Medline]
- Wallace DH, Serpell MG, Baxter JN, O’Dwyer PJ. Randomized trial of different insufflation pressures for laparoscopic cholecystectomy. Br J Surg 1997;84:455–8.[Web of Science][Medline]
This article has been cited by other articles:
|
|
 |
|
  Y. Demiraran, O. Ozturk, E. Guclu, A. Iskender, M. H. Ergin, and A. Tokmak Vasoconstriction and Analgesic Efficacy of Locally Infiltrated Levobupivacaine for Nasal Surgery Anesth. Analg., March 1, 2008; 106(3): 1008 - 1011. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. J. Paech, K. F. Ilett, L. P. Hackett, M. Page-Sharp, and R. W. Parsons Disposition and Clinical Outcome After Intraperitoneal Meperidine and Ropivacaine Administration During Laparoscopic Surgery Anesth. Analg., January 1, 2008; 106(1): 278 - 286. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. P. Boddy, S. Mehta, and M. Rhodes The effect of intraperitoneal local anesthesia in laparoscopic cholecystectomy: a systematic review and meta-analysis. Anesth. Analg., September 1, 2006; 103(3): 682 - 688. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. F. White The Changing Role of Non-Opioid Analgesic Techniques in the Management of Postoperative Pain Anesth. Analg., November 1, 2005; 101(5S_Suppl): S5 - 22. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. J. Gan, G. P. Joshi, E. Viscusi, R. Y. Cheung, W. Dodge, J. G. Fort, and C. Chen Preoperative Parenteral Parecoxib and Follow-Up Oral Valdecoxib Reduce Length of Stay and Improve Quality of Patient Recovery After Laparoscopic Cholecystectomy Surgery Anesth. Analg., June 1, 2004; 98(6): 1665 - 1673. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. P. Joshi, E. R. Viscusi, T. J. Gan, H. Minkowitz, M. Cippolle, R. Schuller, R. Y. Cheung, and J. G. Fort Effective Treatment of Laparoscopic Cholecystectomy Pain with Intravenous Followed by Oral COX-2 Specific Inhibitor Anesth. Analg., February 1, 2004; 98(2): 336 - 342. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Ng and G. Smith Editorial I: Intraperitoneal administration of analgesia: is this practice of any utility? Br. J. Anaesth., October 1, 2002; 89(4): 535 - 537. [Full Text] [PDF]
|
|
|
|
|
|
A. Gupta, S. E. Thorn, K. Axelsson, L. G. Larsson, G. Agren, B. Holmstrom, and N. Rawal Postoperative Pain Relief Using Intermittent Injections of 0.5% Ropivacaine Through a Catheter After Laparoscopic Cholecystectomy Anesth. Analg., August 1, 2002; 95(2): 450 - 456. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Labaille, J. X. Mazoit, X. Paqueron, D. Franco, and D. Benhamou The Clinical Efficacy and Pharmacokinetics of Intraperitoneal Ropivacaine for Laparoscopic Cholecystectomy Anesth. Analg., January 1, 2002; 94(1): 100 - 105. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Bisgaard, B. Klarskov, J. Rosenberg, and H. Kehlet Factors Determining Convalescence After Uncomplicated Laparoscopic Cholecystectomy Arch Surg, August 1, 2001; 136(8): 917 - 921. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Moiniche, H. Jorgensen, J. Wetterslev, and J. B. Dahl Local Anesthetic Infiltration for Postoperative Pain Relief After Laparoscopy: A Qualitative and Quantitative Systematic Review of Intraperitoneal, Port-Site Infiltration and Mesosalpinx Block Anesth. Analg., April 1, 2000; 90(4): 899 - 912. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
