Laparoscopic Cholecystectomy-specific evidence
Expand allLA wound infiltration versus placebo or no treatment
Pre-, intra-, postoperative
Eleven studies compared LA wound infiltration with placebo or no treatment; see Table 2a for details of regimens
LA wound infiltration, time of administration
Pre- versus postoperative
Two studies compared pre-incisional with postoperative administration of bupivacaine (0.25%; 12 or 15 ml) at trocar sites (Sarac 1996; LoE 2; n=20 pre-operative/25 postoperative) (Uzunköy 2001; LoE 1; n=15/group)
LA wound infiltration: LA versus other LA
Pre-operative
One study compared pre-incisional infiltration of trocar insertion sites with 20 ml ropivacaine (1%) (n=20) versus pre-incisional infiltration of trocar insertion sites with 20 ml levobupivacaine (0.5%) (n=19) (Papagiannopoulou 2003; LoE 1)
LA wound infiltration + IV ketamine versus placebo
Pre-operative
In one study, pre-incisional IV ketamine (1 mg/kg) + local infiltration with 20 ml ropivacaine (10 mg/ml) was compared with placebo (n=18/group) (Papaziogas 2001; LoE 1)
Wound infiltration with strong opioid ± LA versus no treatment control
Pre-operative
In one study, pre-operative local infiltration at trocar insertion points with 2 mg morphine in 20 ml saline (0.9%), or 2 mg morphine in 20 ml bupivacaine (25%), was compared with no treatment control (n=30/group) (Zajaczkowska 2004; LoE 1)
Strong opioid + conventional NSAID, followed by LA wound infiltration versus placebo
One study compared: IM bolus of pethidine (0.6 mg/kg) + ketorolac (0.5 mg/kg), administered 45 minutes before induction of anaesthesia, followed by bupivacaine (0.5%) infiltration into the skin, and subcutaneous tissue, and peritoneum, at the site of puncture, 10 minutes before intraumbilical and supra-pubic incision (n=21) versus placebo (two bolus IM injections of saline) (n=24) (Michaloliakou 1996; LoE 1)
|
Study |
n treatment/control |
Comparison |
Supplemental analgesia |
VAS Scores and type of pain, where specified |
Time to first analgesic request |
Use of supplemental analgesic |
Other important outcomes | |
|
|
40/40 |
At the time of induction: 20 ml bupivacaine (0.25%) injected around the four port entry sites at the level of the parietal peritoneum and 20 ml bupivacaine (0.25%) in the subcutaneous tissue around the four ports (Bup) vs. 20 ml bupivacaine (0.5%) in the subcutaneous tissue around the four ports (Cont) |
Postop: oral naproxen (2 x 550 mg tablets) and/or IM pethidine (50 mg), as required |
Bup superior at 6 h at rest (p<0.01) and on movement (p<0.05) and at 18 h at rest and on movement (p<0.01) |
__ |
Pethidine and naproxen (mg/ patient): NS |
__ | |
|
|
50/47 |
Before closure: infiltration of 20 ml 100 mg bupivacaine (0.5%) with epinephrine (Bup+Ep) vs. no instillation of bupivacaine (Cont) |
Postop: morphine (2–4 mg) on demand in PACU; IM mepiridine or acetaminophen with codeine (30 mg) at 4 h intervals, as requested |
Bup+Ep superior at <2 h (p<0.001) and 6 h (p<0.025); NS at 10 h and next morning |
__ |
NS in PACU and short-stay unit |
Hospital Discharge Rate of same-day discharge: Bup+Ep superior (p=0.034) | |
|
|
22/21/25 |
Pre-op peri-portal bupivacaine (PreBup) vs. postop peri-portal bupivacaine (PostBup) vs. no treatment (NT) |
Postop: IM ketorolac (30 mg), every 8 h for 48 h + additional 30 mg IV, if requested; IM demerol (25 mg), if needed |
Incisional pain: both PreBup and PostBup superior to NT (p<0.05) at 1 and 2 h; PreBup superior to NT at 3 h (p<0.05); intra-abdominal pain: NS at all times (i.e. at 1, 2, 3, 6, 9, 12, 24, 36 and 48 h) |
__ |
Ketorolac requirements for 48 h: PreBup superior to NT (p<0.05) |
Pain Shoulder pain, epigastric pain, right flank pain and back pain: NS PONV Nausea and vomiting: NS, but highest incidence in NT group | |
|
|
20/20 |
Before wound closure, infiltration with 80 ml bupivacaine (0.125%) + phenylephrine (5 mg) (Bup) vs. infiltration with saline (Cont) |
Postop: IM diclofenac (75 mg twice/day on 1st day) and then oral (100 mg twice/day for next 2 days) and IV/IM pethidine, on request |
Bup superior at 3–24 h (p<0.007) |
__ |
Number patients requiring pethidine: Bup superior (p<0.05) |
PONV Nausea and vomiting: NS Hospital Stay Length of hospital stay: NS | |
|
|
20/19/18 |
Pre-incisional local infiltration with 20 ml ropivacaine (1%) (Rop) vs. 20 ml levobupivacaine (0.5%) (Levobup) vs. 0.9% saline solution (Cont) |
Postop: patients with VAS scores > 3 given diclofenac 50–100 mg rectally; patients with persistent pain given parenteral opioids (e.g. dextropro-poxyphene) |
Rop superior to Cont at 2 and 4 h (p<0.001) but not 24 h Levobup superior to Cont at 2, 4 and 24 h (i.e. at all times) (p<0.001) and superior to Rop at 4 and 24 h (p<0.001) but NS at 2 h |
__ |
Diclofenac and propoxyphene consumption: both Rop and Levobup superior to Cont (p<0.001); Rop also superior to Levobup for diclofenac consumption (p<0.001), but not for propoxyphene consumption |
PONV Nausea and vomiting: recorded, but data not given | |
|
|
17/18 |
Pre-incisional IV saline plus local infiltration with 20 ml ropivacaine (10 mg/ml) (Rop) vs. pre-incisional placebos (Pb) |
Postop: diclofenac rectally (50–100 mg) or parenteral dextropro-poxyphene (75 mg), if required; IM pethidine (50 mg) if dextropro-poxyphene not sufficient |
Rop superior at 0, 3, 6, 12 and 24 h(p<0.05), but NS at 48 h |
Rop superior (p<0.05) |
Rop superior (p<0.05) for all types of analgesics |
PONV Nausea and vomiting: NS | |
|
|
75/75 |
Pre-incisional local infiltration of port sites with 20 ml ropivacaine containing 1 mg/ml (Rop) vs. 20 ml saline (Cont) |
Postop: IM diclofenac (75 mg) (if VAS >3); IM dextropro-poxyphene and pethidine if required |
Rop superior at 3 and 6 h (p<0.01), but NS at 12 and 24 h |
__ |
Opioid requirements (pethidine): Rop superior (p<0.05) |
Pain Shoulder pain: NS PONV Nausea and vomiting: NS Hospital Stay Length of hospital stay: NS | |
|
|
20/25/25 |
Pre-incisional bupivacaine (0.25%) (preBup) vs. post-procedure bupivacaine (0.25%) (postBup) vs. 0.9% saline injected SC (Cont) Solutions injected into each trocar site |
Postop: IM pethidine (1 mg/kg) if VAS > 5; parenteral pethidine IM in recovery room if required |
PostBup only superior to Cont for the 1st hour only (p<0.01); other timings (i.e. 3, 5, 7 and 12 h): NS |
__ |
Parenteral pethidine requirement: both PreBup and PostBup superior to Cont in the 1st hour only (p<0.05); total analgesic requirement: higher in Cont group, but NS |
__ | |
|
|
25/25 |
Pre-incisional infiltration with 32 ml bupivacaine (0.5%) (Bup) vs. 32 ml saline (Cont) |
Postop: PCA IV piritramide for 24 h postop; oral ibuprofen (500 mg) after 24 h, if required |
Intensity of pain (at rest, on movement, coughing): NS (recorded at 5 h, at 8 a.m. and 6 p.m. on day 1 and at 8 a.m. on the following days, up to discharge) |
__ |
Piritramid use: NS; total ibuprofen consumption: Bup superior, but NS |
Pain Number of patients with most severe pain located to the right lower abdominal wall on day 2: Bup superior (p=0.012); number of patients with no pain after 5 h: Bup superior (p=0.03) | |
|
|
15/15/15 |
Pre-incisional bupivacaine (0.25%) (preBup) vs. post-procedure bupivacaine (0.25%) (postBup) vs. no LA (Cont) at trocar sites |
Postop: diclofenac sodium (75 mg), as required |
Both PreBup and PostBup superior to Cont (p<0.05); NS for PreBup vs. PostBup comparison; pain VAS were recorded at 1, 4, 12 and 24 h, but specific times not stated for results – unclear if pain scores have been averaged over the 24 h period) |
__ |
NS |
__ | |
|
|
30/30/30 |
Preop local infiltration at trocar insertion points with: 20 ml bupivacaine (0.25%) (Bup) vs. saline (Cont) |
Postop: IV tramadol (100 mg), on request |
NS (recorded at 4, 8 and 12 h) |
Bup superior (p<0.05) |
NS |
PONV Nausea and vomiting: NS | |
LA wound infiltration versus placebo or no treatment
Quantitative outcomes:
Compared with placebo or no treatment, incisional LA significantly reduced VAS pain scores at rest at 0–2 h (three studies, WMD -14.18 mm [-19.89, -8.47], p<0.00001) Figure LC25, 3–5 h (five studies, WMD -11.52 mm [-14.85, -8.19], p<0.00001) Figure LC26, 6–8 h (three studies, WMD -10.58 mm [-14.02, -7.14], p<0.00001) Figure LC27, 12 h (three studies, WMD -10.89 mm [-13.93, -7.85], p<0.00001) Figure LC28, but not at 24 h (four studies, WMD -5.35 mm [-10.79, 0.09], p=0.05) Figure LC29
LA wound infiltration versus placebo or no treatment
Quantitative outcomes:
The proportion of patients requesting opioids was significantly lower in the LA wound infiltration group compared with the placebo or no treatment group (three studies, OR 0.40 [0.23, 0.69], p=0.001) Figure LC30
Quantitative outcomes:
The incidence of shoulder pain was similar in both LA and placebo or no treatment groups (two studies, OR 0.76 [0.41, 1.43], p=0.40) Figure LC31
Quantitative outcomes:
There was no difference between the LA wound infiltration and placebo or no treatment for the incidence of nausea (three studies, OR 0.71 [0.39, 1.30], p=0.27) Figure LC32
