Regional Anesthesia and Pain Control
STEEN MØINICHE, HENRIK JØRGENSEN, JØRN WETTERSLEV AND JØRGEN BERG DAHL
Department of Anesthesiology, Herlev University Hospital, Herlev, Denmark
Anesth. Analg., 90: 889–912, 2000
Several trials published in the last decade have suggested that the peripheral use of local anesthetics (LA) after laparoscopic surgery can provide clinically relevant pain relief in the early postoperative period. Using evidence from doubled-blinded, randomized controlled trials (RCTs), investigators evaluated the effects of various peripherally applied LA on postoperative pain in patients undergoing laparoscopic surgery.
Reports were identified by using the Cochrane Library (1999) and the MEDLINE (1966–1999) databases; reference lists of retrieved articles and review articles were consulted for additional reports. Eligible studies compared intraperitoneal instillation, port-site wound infiltration, and visceral infiltration/application of local anesthetics with placebo (saline) and no treatment for postoperative pain treatment after laparoscopic surgery. Forty-one trials with data from 2,794 patients were judged appropriate for analysis.
There were 13 RTCs of intraperitoneal LA after cholecystectomy, 4 of intraperitoneal LA after other procedures, 8 of port-site infiltration after various procedures, 12 of mesosalpinx or fallopian tube block after sterilization, and 4 of combined LA regimens. Four different local anesthetics (bupivacaine, lidocaine, etidocaine, and ropivacaine) were used in 1,510 patients. Quantitative and/or qualitative analyses were performed on visual analog scale (VAS) pain scores, supplemental analgesic consumption, and time to first analgesic request. Seven of 13 RTCs of intraperitoneal LA after cholecystectomy and 4 RTCs of other procedures reported improved pain relief. There was a statistically significant weighted mean difference of −13 mm VAS in favor of treatment groups after cholecystectomy. Port-site infiltration was ineffective, but all RTCs of mesosalpinx or fallopian tube block after sterilization showed improved pain relief. The latter trials had a statistically significant weighted mean VAS difference of −19 mm in favor of treatment groups. Data from combined regimens were inadequate for conclusions to be drawn.
Both intraperitoneal and mesosalpinx local anesthetic block provided some postoperative pain relief after laparoscopy, but port-site infiltration was generally ineffective. The 12 RTCs reporting side effects or toxicity found none attributable to local anesthetics.
The authors of this paper reviewed the results of 41 clinical trials with 2,794 patients comparing postoperative analgesia with placebo or no local anesthesia to that of local anesthetics in patients having laparoscopic surgery. This review suggests that mesosalpinx block or intraperitoneal administration of local anesthetic may have some impact on postoperative pain after laparoscopy. Despite statistical significance, the authors question the clinical relevance or significance of this finding. The authors commented that there were no significant side effects associated with this local anesthetic administration, and perhaps if this is part of a multimodal approach with emphasis on rapid convalescence, there may be an advantage of these minimally invasive/low side effect techniques. I agree.
Ferne B. Sevarino M.D.