| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
 
|
|
|
||
|
|
Anesth Analg 2002;95:450-456 © 2002 International Anesthesia Research Society
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Postoperative pain has been an important limiting factor for ambulatory laparoscopic cholecystectomy. We anesthetized 40 ASA physical status I–II patients using propofol for the induction and sevoflurane in oxygen and air for the maintenance of anesthesia. At the end of the anesthesia, the patients were randomized into one of two groups: Group P (Placebo) and Group R (0.5% Ropivacaine). Twenty milliliters of normal saline or ropivacaine, respectively, were injected intraperitoneally at the end of surgery via a catheter placed in the bed of the gall bladder. Postoperatively, intermittent injections (10 mL) of the study solution were given when required for pain. Ketobemidone 1–2 mg was given IV as rescue medication. Pain was assessed using a visual analog scale at 1, 2, 3, 4, 8, 12, 16, and 20 h after surgery and once each day for 1 wk at rest (deep pain), shoulder and incision sites, and pain during coughing. Recovery was assessed by the time to transfer from Phase 1 to 2, the ability to walk, drink, and eat, and the ability to void. Plasma concentrations of ropivacaine were measured in eight patients. Time to ability to walk, defecation, driving a car, and return to normal activities were also recorded through a questionnaire sent home with the patient. During the first 4 postoperative h, patients in Group R had lower scores for deep pain and during coughing compared with Group P (P < 0.05). No differences were found in the postoperative consumption of ketobemidone. Median times to recovery at home were similar between the groups. By the seventh day, 93% of the patients had returned to normal activities of daily living. We conclude that the early postoperative pain after ambulatory laparoscopic cholecystectomy could be relieved using intermittent injections of ropivacaine 0.5% into the bed of the gall bladder.
IMPLICATIONS: Early postoperative pain can be relieved by intermittent injections of ropivacaine 0.5% through a catheter placed in the bed of the gall bladder after ambulatory laparoscopic cholecystectomy.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Laparoscopic cholecystectomy is increasingly accepted as the method of choice for treating symptomatic gallstones. Recent literature and experience from our own institution suggests that ambulatory laparoscopic cholecystectomy is less expensive and associated with minimal postoperative complications in carefully selected patients. Even elderly and high-risk patients are being operated on successfully and without any increased risk for readmission (1). Postoperative nausea and vomiting (PONV) and pain are two of the common complications seen after ambulatory laparoscopic cholecystectomy.
Postoperative pain varies considerably among patients and has been one of many limiting factors for ambulatory laparoscopic cholecystectomy (2). Many methods have been used to reduce postoperative pain including nonsteroidal antiinflammatory drugs (NSAIDs), local anesthetics (LAs), and opioids with varying success (2,3). When LAs have been administered for pain relief, they have been used in different doses and at different sites with varying success (4).
The aim of this study was to assess the effects of intermittent injections of ropivacaine during the first postoperative 20 h when injected through an indwelling catheter placed in the gall bladder bed at the end of the operation.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
After approval from the Hospital Ethics Committee, 40 patients in the ASA physical status I–II group were recruited for this study, and informed consent was obtained from each patient. Only those who were likely to have a simple laparoscopic cholecystectomy without duct exploration or other invasive procedures were included. Patients were excluded if there were complications during the operation, a more invasive operation was performed than planned, e.g., insertion of a T-drain, or the operation had to be converted to an open cholecystectomy.
This was a prospective, randomized, double-blinded study with 20 patients in each group. Computer generated random numbers were put into sealed envelopes and opened at the end of the operation once we were satisfied that there were no problems or complications during the operation. The person mixing the drugs did not take part in any phases of the study.
All patients were anesthetized using propofol for the induction of anesthesia, rocuronium for intubation and muscle relaxation, and fentanyl and sevoflurane in oxygen and air (fraction of inspired oxygen = 0.33) for maintenance of anesthesia in a low-flow semiclosed system using controlled ventilation. Monitoring included continuous electrocardiogram, heart rate, SpO2, end-tidal CO2, sevoflurane concentration, intermittent blood pressure, and neuromuscular block. The neuromuscular block was reversed with glycopyrrolate and neostigmine when required.
All surgeons who performed operations were experienced in performing laparoscopic cholecystectomy and were assisted by a surgeon-in-training. Standard operative method was used with a four-trocar technique. Intraoperative cholangiography was performed in all patients, which is routine in our hospital.
A silicone catheter (epidural catheter, B/Braun, Mellsungen, Germany) was inserted through a Tuohy needle, which was inserted through the lateral trocar position, under direct vision via the laparoscope so that the tip of the catheter was placed in the bed of the gall bladder. A bacterial filter was placed at the proximal end of the catheter to reduce the risk of infection when the LA was injected. Ropivacaine 0.5% (total, 10 mL) was injected into the site of incision and in all portals at the end of the surgery in all patients. One of the following two solutions was injected through the catheter after the instruments had been removed and the wound closed and bandaged: 20 mL of 0.9% NaCl for Group P (placebo) or 20 mL of 0.5% ropivacaine (100 mg) for Group R (ropivacaine).
After surgery, intermittent injections (10 mL) of placebo or ropivacaine were self-administered for pain when required through the catheter using an elastometric home-pump (5). This pump was opened for a period of 6 min to deliver 10 mL of one of the above solutions. If the patients continued to have moderate to severe pain unrelieved by the injection of these solutions, ketobemidone (a synthetic opioid that is equipotent with morphine) 1–2 mg was given IV for rescue medication. All patients were given paracetamol 1 g every 6 h for pain relief, which is a routine in our hospital, starting with the first dose before the operation. To minimize the risk of LA toxicity, injections of the test solutions were not made more frequently than once every hour (see below).
Pain was assessed at 1, 2, 3, 4, 8, 12, 16, 20, and 24 postoperative h and once each day for 1 wk on a 10-cm visual analog pain scale (VAS) at rest. Pain was assessed at the shoulder tip, incision site, deep intraabdominal, and on coughing.
Laboratory tests including C-reacting proteins, white blood cell count, and catheter tip cultures were taken at the time of catheter withdrawal to exclude infection. Any postoperative complications were registered. The catheter was removed after 20 h, and the patients were discharged home thereafter.
Blood samples were taken 30, 60, 90, and 120 min after the injection of the placebo/LA, and after 20–24 h in 8 patients who had received two or more injections of the solution during the 24-h observation period. The samples were centrifuged immediately and frozen to a temperature of -20°C. Plasma concentrations of ropivacaine were measured by liquid chromatography.
To assess recovery, the following variables were measured: (a) time to transfer from Phase 1 to Phase 2 recovery, (b) time to sit up in bed, (c) time to stand and walk without support, (d) time to drink and eat, (e) time to void, and (f) time to discharge home. Patients were transferred to the Phase 2 recovery area when they fulfilled the modified Aldrete score of 
9, which is the routine in our hospital. The criteria for home discharge were a fully awake patient with stable hemodynamics, able to drink water and walk unaided, no PONV, minimal pain (VAS pain score <3 cm), and no evidence of any surgical or anesthetic complication. However, no patient was discharged within 20 h so we could obtain the required blood tests. A questionnaire was sent home to all patients in which pain and activities of daily living (ADL) were assessed each day during the first week.
We agreed that a difference between groups of 2 cm on the VAS for the primary variable (pain) would be interesting to detect. Because the SD from earlier work was also 2, a standardized difference of 1.0 was calculated, which gave a sample size of 34, i.e., 17 in each group (assuming a power of 80% and a significance level of 0.05). We therefore recruited 40 patients in all. Results are expressed as mean ± SD and range or median and range (for nonparametric data). A one-way analysis of variance with repeated measurements was used to study differences between groups in the pain intensity. Demographic data were studied using a Student’s (unpaired) t-test, whereas differences in the incidence of PONV were studied using the 
2 test. Postoperative recovery variables were analyzed using the Mann-Whitney U-test. A P value < 0.05 was considered to be statistically significant.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Thirty-nine patients were included in the data analysis. The first patient was excluded because of a misunderstanding that resulted in the use of a patient-controlled analgesic pump instead of the study drug after surgery. All patients except one could be discharged from the hospital within 24 h as planned (see below).
No differences were found in the age (56 ± 9 yr versus 50 ± 16 yr), weight (76 ± 16 kg versus 76 ± 11 kg), or the duration of operation (61 ± 17 min versus 70 ± 18 min) between Groups P and R, respectively.
Statistically significant differences (P < 0.05) were found in pain intensity between Group P and R, respectively, during the first 4 h in deep pain (VAS, 3.6 ± 2.0 cm versus 1.2 ± 1.8 cm) and during coughing (VAS, 4.0 ± 2.1 cm versus 2.5 ± 2.3 cm) but not in incision (VAS, 1.9 ± 2.02 cm versus 1.8 ± 2.3 cm) or shoulder tip (VAS, 0.2 ± 0.8 cm versus 0.3 ± 0.7 cm) pain (see Fig. 1–4). No differences were found between the groups in the VAS scores after 4 h when the pain was, in general, mild in intensity in both groups.
|
|
|
|
The total amount of ketobemidone consumed was similar between the groups at 0–20 postoperative h (4.8 ± 5.04 mg [0–15 h] and 3.3 ± 3.85 mg [0–12 h] in Groups P and R, respectively; P > 0.05). The number of patients not requiring any postoperative ketobemidone was similar between the groups (7 (35%) patients in Group P and 8 (42%) patients in Group R). Similarly, the number of patients requiring >10 mg of ketobemidone was similar between the groups (4 of 20 patients and 2 of 19 patients in Groups P and R, respectively). One patient in Group R was admitted to the hospital for 3 days because of persistent intractable pain that was only relieved by a combination of paracetamol, NSAIDs, and opioids. This patient was discharged on the third postoperative day and felt happy with her treatment on discharge. In general, the pain intensity during the first week was mild. No statistical differences were found between the groups in postoperative pain during the 1-wk follow-up. The total amount of analgesics consumed was also similar between the groups. The mean total ropivacaine dose per patient during 0–4 h and 4–24 h was 112.5 mg and 130 mg, respectively, in Group R.
The variables of postoperative recovery are shown in Table 1. The time to transfer from Phase 1 to Phase 2 recovery, the time to sit up in bed, the time to stand and walk without support, the time to drink and eat, the time to void, and the time to discharge home were similar between the groups. Because patients were obliged to stay in the hospital for measurement of plasma concentrations of ropivacaine, discharge times from the hospital are not true time to discharge home but the actual time when the patients went home.
|
There were no systemic, toxic reactions to the LA in any patient. The plasma concentration of ropivacaine measured in eight patients is shown in Figure 5. Total plasma concentration decreased with time (0–120 min), and the maximum median total concentration was 0.9 µg/mL (range, 0.3–1.8 µg/mL). The free plasma concentration was 0.019 µg/mL (range, 0.005–0.032 µg/mL).
|
The most common postoperative complication reported was nausea with an incidence of 30% and 50% in Groups P and R, respectively (P > 0.05). Vomiting was recorded in 30% and 25%, respectively, in Groups P and R. Two patients (one man and one woman) in Group R had to be catheterized because of difficulty in voiding. No catheter-related infections were seen in any patient as judged by a normal C-reacting protein, normal white blood cell count, and absence of pathogenic culture from the catheter tip at 20 h. No patient had clinical symptoms suggestive of infection during the 1-wk follow-up.
In all, 33 of 39 patients returned the questionnaire (85%). No differences were seen between the groups in pain intensity during 1–7 days follow-up (Fig. 1–4) or in the analgesic consumption during the first week. The median times to start eating regularly, walking normally, defecation, driving the car, and return to normal ADL (full recovery) were also similar between the groups (Table 2). Of the 30 patients who responded to the question regarding return to normal ADL, 28 (93%) felt that they had returned to normal life on the seventh day. No differences were seen between the groups. No patient was readmitted after discharge home.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
We found a significant reduction in deep (visceral) postoperative pain and pain during coughing during the first four postoperative hours in patients given ropivacaine intermittently into the gall bladder bed. In general, the pain intensity was mild, even in the placebo group. The surgeons did not have any difficulty in placing the catheter in position. No complications were seen using this technique in the 39 patients studied. By the seventh day, 93% of the patients had returned to normal ADL.
Pain after laparoscopic cholecystectomy is usually moderate in intensity with a considerable interindividual difference. Inadequate pain relief is responsible for overnight admission in 26%–41% of patients. The causes for this pain are multifactorial (6), and it is important to differentiate postoperative pain into its various components (7).
We used 0.5% ropivacaine locally at the site of trocar insertion in all patients at the end of the operation. This may explain the overall low pain intensity at the sites of incision in both groups during the first 24 h. Incision pain is often worst during the first few hours to one day and reduces in intensity with time (7,8). In one study, most patients reported that the umbilical incision was the site of the most severe pain after laparoscopic cholecystectomy (9). Various techniques have been used to reduce incision pain, including the use of smaller-sized trocars and LA infiltration into the sites of incision (4). Our findings are consistent with two other studies using LAs (4,10). In our patients, incision pain continued to be mild in intensity even during the one-week observation period, suggesting that this is probably not the main cause of pain after laparoscopic cholecystectomy.
We used ropivacaine instead of bupivacaine because of its lower cardiac toxicity (11,12) because we were concerned about the rapid absorption of large quantities of LA from the peritoneal cavity. No systemic toxic reactions were seen with the ropivacaine injected. Plasma concentrations of ropivacaine were far less than those that can be considered toxic in volunteers (13). We found an overall reduction in pain intensity up to 30%–40% in patients who received ropivacaine compared with placebo during the first four hours when the pain was worst. Deep pain, like incision pain, tends to be worst during the first 24–48 hours and is sometimes more severe than incision or shoulder pain (14). Infiltration of LA intraabdominally has had mixed effects with approximately half the studies showing a beneficial effect (6). The reasons for this variation in results is not known, but the time of injection (before versus after surgery), the site of injection (subdiaphragmatic versus intraperitoneal or in the gall bladder bed), as well as the concentration of the LA used (0.25% versus 0.5% bupivacaine) may all play an important role (15,16). In our study, the pain intensity in the placebo group was only mild during the first 24 hours (mean VAS, 12–36 mm), which was surprising. Although median pain intensity during the first 24 hours after laparoscopic cholecystectomy has been described to be approximately 40 mm (7), it may exceed 50 mm in almost 30% of the patients (9). The surgeons performing these operations were experienced, and the injection of normal saline into the gall bladder bed in the placebo group may have diluted or accelerated the absorption of the local inflammatory pain mediators, thus reducing pain intensity. In one study, the intraperitoneal instillation of saline covering the liver surface reduced abdominal and shoulder pain after laparoscopic cholecystectomy (17). Similarly, we have also found that patients who had normal saline injected subacromially after shoulder surgery had less pain after the injection (18).
The intensity of pain on coughing was maximal after one hour and declined subsequently with time. Like deep pain, this was significantly less in the group given the LA compared with placebo, suggesting that the analgesic efficacy of the LA is probably similar in reducing pain on coughing as on deep pain or that the mechanism of these two pains is similar.
We found that our patients had very mild shoulder pain during the entire period of observation (<2 cm VAS). This pain was worst at Day 2 and subsided subsequently, which is in agreement with that described by others (14,19). Adequate measures to remove intraabdominal gas at the end of the operation, including the application of manual compression, are known to reduce shoulder pain (19).
All our patients received paracetamol 1 g every six hours, which is a routine in our hospital. The total dose of intraoperative fentanyl given was similar between the groups, as was the consumption of postoperative ketobemidone as rescue medication. The mean amount of ketobemidone consumed during the 20 postoperative hours was small (total, 3.5 mg and 4.5 mg in Group R and Group P, respectively), which reflects the mild pain intensity experienced by our patients. Intraoperative opiates and NSAIDs reduce postoperative analgesic requirement after laparoscopic cholecystectomy. In one study, the mean cumulative morphine requirement in the first 20 postoperative hours was 20 mg in the placebo group (20). In another study, the median consumption of meperidine in the first 24 hours was 275 mg (3). Although our study could be criticized in that we used standard doses of paracetamol and fentanyl, thus reducing overall analgesic requirement, we felt that it would be unethical to provide inferior quality pain relief to these patients by not giving these drugs. However, we would like to stress that pain is extremely variable after laparoscopic cholecystectomy and analgesic requirements vary considerably.
No significant differences were found between the groups in the various recovery variables. This may be considered somewhat surprising because a decrease in pain intensity should encourage patients to be mobilized earlier. We did not actively encourage our patients to come out of bed as soon as possible after the operation because they were going to be observed in the hospital for at least 20 hours. This may have caused some patients to remain in bed longer than required, which can be considered a criticism of our study.
No major complications were seen in our patients. One patient (2.5%) had to be admitted to the hospital for three days for severe intractable pain. This patient was discharged on the fourth day after an uneventful recovery. The incidence of unanticipated admission varies considerably between studies (6%–39%), and the reasons for these admissions are often equally diverse. We had strict criteria for patient inclusion in this study, and intraoperative complications including conversions from laparoscopic to open cholecystectomy lead to patient exclusion. Therefore, the overall incidence of primary admissions was small. High-risk patients have a more frequent incidence of admission after surgery (40%) (1), and therefore, careful patient selection is important to have success.
The incidence of PONV was frequent (40%) but not significantly different between the groups. This frequent incidence of PONV has been reported in previous studies and remains one of the most common problems after ambulatory laparoscopic cholecystectomy (2). Fiorillo et al. (21) reported nausea as the second most common cause (after pain) for admission after laparoscopic cholecystectomy.
No differences were found between the groups during one to seven days follow-up after discharge from the hospital. Patients felt normal, and most patients (93%) could continue with the ADL after approximately seven days. In one study, patients were followed up one and six weeks after ambulatory laparoscopic cholecystectomy (22). At one week, almost 40% of the patients had some difficulty in walking, and >75% had either some difficulty in performing usual activities or could not perform them at all. In another study, only 15% of patients had returned to normal ADL one week after ambulatory laparoscopic cholecystectomy (23). Follow-up has, in most studies, been rather short and confined to the first 24 hours after the operation; therefore, it is difficult to draw any conclusions from our small sample of patients. Sick leave was taken for an average of 11.7 days after laparoscopic cholecystectomy in one study (3), whereas in a retrospective study of 231 patients, the median time to return to work was three weeks (24). Motivation is an important factor because patients who were self-employed in the latter study tended to return to work earlier. In our hospital, doctors prescribe sick leave for two weeks after laparoscopic cholecystectomy. It is possible that patients can return to part-time work after seven days because most of them were able to return to normal activities at this time, with some inter-individual variation. However, more studies are required in the literature specifically addressing this important issue.
Postoperative pain during the first week decreased with time so that at seven days it was minimal (0.5 cm on the VAS) and required minimal medication for its management. Keulemans et al. (22) found that more than two thirds of their patients had moderate to severe pain at one week and 15% had moderate pain even after six weeks. Because very few studies have observed patients during one to six weeks, it is difficult to draw any clear conclusions. The intensity of pain was slightly more (though not statistically significant) in Group R compared with the Group P, which was surprising. It is possible that patients in Group R expected that the mild early postoperative pain would continue during the week and were somewhat surprised when the pain returned after removal of the catheter.
Ambulatory laparoscopic cholecystectomy was performed successfully in all but one patient. This patient was admitted to the hospital because of intractable pain. Pain after laparoscopic cholecystectomy was found to be mild in intensity, even in Group P. Deep pain and pain on coughing could be reduced by giving intermittent injections of 0.5% ropivacaine through a catheter placed in the gall bladder bed during laparoscopy. No side effects of this technique were observed, and the plasma concentration of ropivacaine was far smaller than systemic toxic concentrations.
|
Acknowledgments |
|---|
Supported, in part, by research funds obtained from the Research Committee, University Hospital, Örebro, Sweden, and by the Olof Norlander Memorial Fund, Karolinska Hospital, Stockholm, Sweden.
We would like to thank the research nurses A.-S. Gustavsson and M. Karnetoft, as well as the personnel in the surgical theaters, ambulatory surgery unit, and postoperative ward, for their kind support during the various stages of this study. We would also like to thank AstraZeneca (Sweden) for analysis of plasma concentrations of ropivacaine.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
- Voitk AJ. Is outpatient cholecystectomy safe for the higher risk elective patient? Surg Endosc 1997; 11: 1147–9.[Web of Science][Medline]
- Saunders CJ, Leary BF, Wolfe BM. Is outpatient laparoscopic cholecystectomy wise? Surg Endosc 1995; 9: 1263–8.[Medline]
- Berggren U, Gordh T, Grama D, et al. Laparoscopic versus open cholecystectomy: hospitalisation, sick leave, analgesia and trauma responses. Br J Surg 1994; 81: 1362–5.[Web of Science][Medline]
- 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]
- Rawal N, Axelsson K, Hylander J, et al. Postoperative patient-controlled local anesthetic administration at home. Anesth Analg 1998; 86: 86–9.[Web of Science][Medline]
- Bisgaard T, Kehlet H, Rosenberg J. Pain and convalescence after laparoscopic cholecystectomy. Eur J Anaesthesiol 2001; 167: 84–96.
- Bisgaard T, Klarskov B, Kristiansen VB, et al. Multiregional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized, double-blind controlled study. Anesth Analg 1999; 89: 1017–24.
[Abstract/Free Full Text] - Scheinin B, Kellokumpu I, Lindgren L, et al. Effect of intraperitoneal bupivacaine on pain after laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1995; 39: 195–8.[Web of Science][Medline]
- 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]
- Sarac AM, Aktan AO, Baykan N, et al. The effect and timing of local anesthesia in laparoscopic cholecystectomy. Surg Laparosc Endosc 1996; 6: 362–6.[Web of Science][Medline]
- Scott DB, Lee A, Fagan D, et al. Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 1989; 69: 563–9.
[Abstract/Free Full Text] - Morrison SG, Dominguez JJ, Frascarolo P, Reiz S. A comparison of the electrocardiographic cardiotoxic effects of racemic bupivacaine, levobupivacaine, and ropivacaine in anesthetized swine. Anesth Analg 2000; 90: 1308–14.
[Abstract/Free Full Text] - Knudsen K, Beckman SM, Blomberg S, et al. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth 1997; 78: 507–14.
[Abstract/Free Full Text] - 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 JI. Pain after laparoscopy. Br J Anaesth 1997; 79: 369–78.
[Free Full Text] - Mraovic B, Majeric-Kohler V. Pain after laparoscopic cholecystectomy. Br J Anaesth 1998; 80: 406–7.
[Free Full Text] - Tsimoyiannis EC, Siakas P, Tassis A, et al. Intraperitoneal normal saline infusion for postoperative pain after laparoscopic cholecystectomy. World J Surg 1998; 22: 824–8.[Medline]
- Axelsson K, Nordenson U, Johanzon E, et al. Patient controlled regional anesthesia (PCRA) with ropivacaine after arthroscopic acromial decompression (ASD). Reg Anesth Pain Med 2001; 26: S127.
- Jorgensen JO, Gillies RB, Hunt DR, et al. A simple and effective way to reduce postoperative pain after laparoscopic cholecystectomy. Aust N Z J Surg 1995; 65: 466–9.[Medline]
- Motamed C, Bouaziz H, Franco D, Benhamou D. Analgesic effect of low-dose intrathecal morphine and bupivacaine in laparoscopic cholecystectomy. Anaesthesia 2000; 55: 118–24.[Medline]
- Fiorillo MA, Davidson PG, Fiorillo M, et al. 149 ambulatory laparoscopic cholecystectomies. Surg Endosc 1996; 10: 52–6.[Medline]
- Keulemans Y, Eshuis J, de Haes H, et al. Laparoscopic cholecystectomy: day care versus clinical observation. Ann Surg 1998; 228: 734–40.[Medline]
- Singleton RJ, Rudkin GE, Osborne GA, et al. Laparoscopic cholecystectomy as a day surgery procedure. Anaesth Intensive Care 1996; 24: 231–6.[Medline]
- McLaughlin GJ, Macintyre MC. Return to work after laparoscopic cholecystectomy. Br J Surg 1995; 82: 239–41.[Medline]
This article has been cited by other articles:
|
|
 |
|
  P. F. White, H. Kehlet, J. M. Neal, T. Schricker, D. B. Carr, F. Carli, and the Fast-Track Surgery Study Group The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care Anesth. Analg., June 1, 2007; 104(6): 1380 - 1396. [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]
|
|
|
|
|
|
A. Gupta, A. Perniola, K. Axelsson, S. E. Thorn, K. Crafoord, and N. Rawal Postoperative Pain After Abdominal Hysterectomy: A Double-Blind Comparison Between Placebo and Local Anesthetic Infused Intraperitoneally Anesth. Analg., October 1, 2004; 99(4): 1173 - 1179. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
