Recent Modalities of Perioperative Pain Management for Laparoscopic Surgeries

Abstract

SUMMARY W ith the developments in medical technology and increased surgical experience, advanced laparoscopic surgical procedures are performed successfully. Laparoscopic abdominal surgery is one of the best examples of advanced laparoscopic surgery. Today, laparoscopic abdominal surgery in general surgery clinics is the basis of all abdominal surgical interventions. Advantages of laparoscopy include reduced pain, small scars and early return to work, however there are several pathophysiological effects due to the capnoperitoneum and positioning during surgery that need perfect anesthetic management. These effects are mainly haemodynamic, respiratory, cerebrovascular and renal. Although laparoscopic surgery, a widely performed surgery, is known for less pain compared to that of laparotomy, many patients actually complain of considerable pain after the operation. Pain after laparoscopy is multifactorial, and there are three types of pain are reported after Laparoscopic surgery. The first is parietal pain, caused by the holes made in the abdominal wall for the trocars. The second is visceral pain, caused by surgical handling, tissue injury and the stretching of nerve endings. The third is shoulder tip pain, which is caused by rapid distension of the peritoneum (associated with the tearing of blood vessels, traumatic traction of the nerves and the release of inflammatory mediators) and irritation of the phrenic nerve with carbon dioxide as an insufflating gas. Visceral pain make up a large portion of abdominal pain after laparoscopic surgery compared to parietal or shoulder pain. Different treatments have been proposed to provide pain relief. Multimodal analgesia is now recommended to prevent and treat post-laparoscopy pain. One of these modalities is the TAP block which is efficient in controlling the parietal pain resulting from the incisions in the anterior abdominal wall for the trocars. However, its effect is for incisions below the umbilicus mainly. Recently, OSTAP block another type of TAP block proved efficiency over the classic TAP block and intravenous opioid analgesia in controlling parietal pain for incisions above the umbilicus as in laparoscopic cholecystectomy. Dexmedetomidine serves as a very useful anaesthesia adjuvant to control haemodynamic stress response to intubation, pneumoperitoneum and extubation in patients undergoing laparoscopic surgery. It also provides lighter sedation and reduces the post-operative analgesic requirements without any significant adverse effects. In laparoscopic bariatric surgeries, dexmedetomidine can be used in a sedative analgesic dose which had reduced the narcotic need and facilitated early recovery of morbid obese patients. Intravenous Lidocaine infusion another mode of analgesia in laparoscopy as it improves postoperative quality of recovery in patients postoperatively. Patients who received lidocaine had less opioid consumption, which was translated to a better quality of recovery. Intravenous lidocaine has been shown to provide good pain relief in patients who underwent retropubic prostatectomy, laparoscopic colon resection and laparoscopic cholecystectomy. In laparoscopic colon resection, perioperative intravenous lidocaine infusion for pain control proved to produce quicker recovery of bowel function as evidenced by earlier time of first flatus as well as first bowel movement. Intravenous infusion of lidocaine during laparoscopic prostatectomy and for the first postoperative day attenuated the deterioration in functional walking capacity which was used as a measure for pain control, and had an opioid sparing effect. In laparoscopic gynaecological surgeries also intravenous lidocaine infusion improves postoperative pain levels and shortens the time to return of bowel function. A combination of Dexmedetomidine and intravenous lidocaine infusion was used recently in an opioid free anesthesia as an alternative to opioid based one and there was a significant decrease in postoperative pain evidenced by the decrease in postoperative fentanyl consumption and PONV compared to opioid based anesthesia.