Intraperitoneal Local Instillation of Levo-Bupivacaine versus Magnesium Sulfate versus Levobupivacaine Plus Magnesium Sulfate for Postoperative Pain Relief after Laparoscopic Sleeve Gastrectomy: Prospective Randomized Clinical Trial

Abstract

urrently, laparoscopic sleeve gastrectomy is the gold standard option for the management of morbid obesity,it is a less invasive procedure with better cosmetic results and shorter operative time and hospital stay Moreover, the current body of evidence shows that laparoscopic interventions are generally associated with less postoperative pain and analgesic requirements On the other hand, laparoscopic procedures are associated with variable degrees of early postoperative pain; post-laparoscopic abdominal pain, mainly visceral, is proposed as a consequence of abdominal incision, tissue injuries, and pneumoperitoneum with subsequent peritoneal stretch. Moreover, concurrent shoulder tip pain may occur as a result of peritoneal irritation by carbone dioxide and phrenic nerve irritation by diaphragmatic muscle fibers stretch. Inadequate management of acute post-laparoscopic pain can significantly affect patient satisfaction, prolong hospitalization, and increase the risk of morbidities and development of chronic pain. Previous reports have shown that the post-laparoscopic pain is inadequately treated in approximately one-half of all surgical procedures. Thus, effective analgesia through a multimodal approach can modify these consequences and improve patient recovery and quality of life. Different multimodal approaches including non-steroidal anti-inflammatory drugs (NSAIDs), opioids and local wound infiltration have been described. However, NSAIDs may precipitate ischemic renal insufficiency and coagulopathy. Opioids are associated with respiratory depression, postoperative nausea and vomiting (PONV), and dependence. Intraperitoneal instillation of drugs has been proposed as an effective option for post- laparoscopic pain management. Potentially block the visceral afferent signalling and inhibit the release and action of prostaglandins. Moreover, after systemic absorption from through the large peritoneal surface, they may further modulate peritoneal and visceral signalling to the brain, thereby attenuating the metabolic impact of visceral manipulations The current body of evidence shows that the intraperitoneal local anesthetics led to lower postoperative pain scores and rare serious adverse effects among patients who underwent laparoscopic surgeries, regardless of the instillation time which may be pre-pneumoperitoneum or near the end of surgery by different types of drugs including bupivacaine, magnesium, and corticosteroids. There is significant role of glutamate receptors on peripheral nociceptive sensation; thus, an effective blockade of glutamate receptors, such as N-methyl-D-aspartate (NMDA) receptor, can alleviate different type of pain including postoperative pain. Intraperitoneal magnesium has emerged as an effective, adjuvant, local and systemic analegsic due to its effective blockade of NMDA receptors and calcium channels after systemic absorption through the large peritoneal surface. It also increases the number of nerve fibers affected by bupivacaine and therefore potentiates its conduction block.