Analgesia after laparoscopic sterilization Effect of 2% lignocaine gel applied to Filshie clips

We performed a randomised controlled study in patients undergoing day case laparoscopic sterilisation to assess whether coating Filshie clips with 2% lignocaine gel prior to application to the Fallopian tubes would reduce postoperative pain. Sixty-two patients were studied, in 33 of whom the Filshie clips were coated in sterile 2% lignocaine gel. Pain scores in the lignocaine gel group were significantly lower than in the control group at 1 h after return to the ward, but no differences were found immediately on return to the ward, or at discharge or at 24 h. There were no significant differences between the two groups in postoperative analgesic requirements or in side effects.     

Intravenous buscopan for analgesia following laparoscopic sterilisation

Following reports that tubal smooth muscle spasm may contribute to pelvic pain following laparoscopic sterilisation, we studied the effect of buscopan (an anticholinergic agent used to relieve smooth muscle spasm) on 45 patients undergoing general anaesthesia for day-case laparoscopic sterilisation. Patients were randomly allocated to receive either buscopan 20 mg or saline placebo after induction of anaesthesia. There were no significant differences in pain scores or postoperative analgesic requirements between the two groups. We conclude that intravenous buscopan confers no benefit in day-case laparoscopic sterilisation.     

Pre-operative oral administration of morphine in day-case gynaecological laparoscopy

The analgesic effect of morphine sulphate 10 mg by mouth given pre-operatively on pain after gynaecological laparoscopy was studied in a randomised, prospective, double-blind, placebo-controlled comparison. Two groups of 56 patients were studied, one group undergoing diagnostic laparoscopy and the other laparoscopic sterilisation. All patients received a standard anaesthetic after premedication with morphine or placebo 1 h before the operation. Morphine premedication did not significantly influence postoperative pain as assessed on a visual analogue scale in either group and postoperative opioid consumption was unaffected. Premedication with morphine Wmg orally does not significantly decrease pain after day-case gynaecological laparoscopy.     

An investigation of the effectiveness of bupivacaine applied to the abdominal wall and fallopian tubes in reducing pain after laparoscopic tubal ligation

Sixty women having laparoscopic sterilisation performed under general anaesthesia were randomly allocated to one of two groups. Intraoperatively, one group had bupivacaine applied topically to the fallopian tubes and injected into the skin wounds, while the other group received no local anaesthetic. A double-blind investigation utilising a visual analogue scale failed to demonstrate a statistically significant difference in postoperative pain between the two groups. In both groups there was a significant reduction in mean pain scores between 1/2 and 7 hours, but there was no further reduction between 7 hours and 17 hours. At 7 hours, only 10% of patients scored their pain as 3 or greater (out of a possible 10). It is concluded that the use of bupivacaine as described is not a useful adjuvant to general anaesthesia and that the low incidence of even moderate pain at 7 hours confirms the view that these patients are suitable for management in the day-stay unit.     

Preoperative rectal indomethacin for analgesia after laparoscopic sterilisation.

A randomised, double-blind, placebo-controlled study was conducted among 56 day-case patients to determine the effect of the preoperative administration of rectal indomethacin on postoperative pain and opioid requirements after laparoscopic sterilisation. Outcome in women receiving indomethacin did not differ significantly from the placebo group, but there was a trend to lower subjective pain scores, reduction in early postoperative pain assessed objectively and lower parenteral pethidine requirements in the first three hours postoperatively. Indomethacin did not appear either to cause side-effects or to significantly reduce morbidity from the other postoperative sequelae of laparoscopy. Despite evidence for postoperative analgesic effect, the clinical benefits of premedication with rectal indomethacin were minor.     

Assessment of wound infiltration with bupivacaine in women undergoing day-case gynecological laparoscopy

BACKGROUND AND OBJECTIVES: The effectiveness of local anesthetic wound infiltration for treatment of postoperative pain appears to be variable and partly dependent on the surgical procedure. Although evidence was lacking, it was common practice at our institution to infiltrate the trocar wound of patients undergoing day-case laparoscopic procedures with long acting local anesthetic agents. The aim of this study was to investigate the analgesic efficacy, and the influence of the timing, of local anesthetic infiltration into surgical wounds for day-case diagnostic gynecological laparoscopy. METHODS: A double-blind, randomized trial was conducted on 100 women having general anesthesia for day-case gynecological laparoscopy. Ninety-two patients who had been randomized to 1 of 4 groups for trocar wound infiltration with 30 mL of 0.25% bupivacaine or saline either before or after surgery completed the study. Incisional pain, pain on pressing the umbilicus, severity of nausea, and patient satisfaction with anesthetic technique were all assessed postoperatively until discharge and on the following day through a telephone interview. A P value of <.05 was considered significant. RESULTS: There was no difference between groups in the mean pain scores or analgesic requirements for incisional pain, pain on pressing firmly on the umbilicus, or for patient satisfaction. There was a trend for those patients who had received bupivacaine to use less postoperative morphine (P =.079). CONCLUSIONS: Wound infiltration with local anaesthetic did not significantly reduce pain or opioid requirement after gynecological laparoscopy.     

Acetazolamide reduces referred postoperative pain after laparoscopic surgery with carbon dioxide insufflation

BACKGROUND: Carbon dioxide is the preferred insufflating gas for laparoscopy because of greater safety in the event of intravenous embolism, but it causes abdominal and referred pain. Acidification of the peritoneum by carbonic acid may be the major cause of pain from carbon dioxide insufflation. Carbonic anhydrase is an enzyme that increases the rate of carbonic acid formation from carbon dioxide. Because acetazolamide inhibits carbonic anhydrase, the authors hypothesized that the pain caused by carbon dioxide insufflation may be decreased by the administration of acetazolamide. METHODS: A prospective, randomized, double-blind study of 38 patients undergoing laparoscopic surgery during general anesthesia was performed. Acetazolamide (5 mg/kg) or a saline placebo was administered intravenously during surgery. Pain was rated on a visual analog scale (0-10) at four times: when first awake, at discharge from the recovery room, when discharged from the hospital, and on the day after surgery. The site and quality of pain were recorded, as were medications and side effects. RESULTS: Initial referred pain scores were lower after acetazolamide (1.00 +/- 1.98; n = 18) than after placebo (3.40 +/- 3.48; n = 20; P = 0.014), and 78% of patients in the acetazolamide group had no referred pain; however, only 45% patients in the placebo group had no referred pain. Incisional pain scores were not statistically different, and referred pain scores were similar at later times. CONCLUSIONS: Acetazolamide reduces referred but not incisional pain after laparoscopic surgical procedures. The duration of pain reduction is limited to the immediate postsurgical period.     

静脉应用不同剂量曲马多超前镇痛对妇产科腹腔镜手术后疼痛的影响

目的 观察曲马多术前给药用于妇产科腹腔镜全麻术后镇痛的效果.方法 全麻下行妇产科腹腔镜手术80例,随机分为4组,每组20例,分别在手术切皮前静注:Ⅰ组生理盐水2 ml、Ⅱ组曲马多1.5 ms/ks、Ⅲ组曲马多2 ms/kg、Ⅳ组曲马多2.5 ms/kg.采用VAS评分和Ramsay镇静评分对患者拔管后、离室前以及术后1 h,2 h,4 h,8 h、12 h、24 h进行疼痛和镇静程度评分,并记录恶心、呕吐、头晕、嗜睡、躁动、恶梦、瘙痒、多汗等副作用.结果 与对照组Ⅰ相比,Ⅱ、Ⅲ、Ⅳ组在术后8 h内VAS评分显著降低,在3种剂量下未见量效相关性.4组Ramsay镇静评分均为0～2分.与Ⅰ组相比,Ⅱ、Ⅲ、Ⅳ组恶心、呕吐以及出汗的发生例数较多,Ⅳ与Ⅰ组相比有统计学差异,P<0.05或P<0.01;而Ⅱ、Ⅲ组与Ⅳ组之间的比较则无统计学差异.结论 妇产科腹腔镜全麻术前单次注射曲马多1.5 ms/kg～2 ms/kg可有效缓解术后疼痛,减少辅助镇痛药用量,副作用较少,是临床上较好的镇痛方法.     

Randomized controlled trial investigating the effect of transcervical papaverine and bupivacaine on postoperative analgesia following laparoscopic sterilization

BACKGROUND AND OBJECTIVE: A critical factor that delays patient discharge following day-surgery is severe postoperative pain and the requirement for strong analgesics. Laparoscopic sterilization is a day case procedure and is associated with additional postoperative pain compared with diagnostic laparoscopy. This pain, associated with application of Filshie clips, may be ischaemic or spasmodic in aetiology. Papaverine relaxes smooth muscle, and the aim of the study was to investigate if papaverine would be effective in improving postoperative pain if administered directly to the Fallopian tubes. Bupivacaine is used commonly in day-surgery and so we compared the effect of this local anaesthetic with saline placebo. METHODS: Sixty-six ASA I-II females undergoing laparoscopic sterilization were entered into the prospective, randomized, double-blind, placebo-controlled clinical trial. They received intrauterine papaverine (30 mg) or bupivacaine (0.375% 30 mL) or normal saline (30 mL) via the transcervical route before application of Filshie clips. RESULTS: There were no significant differences in the postoperative period between the three groups in the number of patients needing analgesia in the first 60 min postoperatively, the time to first analgesia, the rescue analgesic or antiemetic consumption, the incidence of postoperative nausea and vomiting, and the sedation and visual analogue pain scores. CONCLUSIONS: From the data presented, we would not recommend routine transcervical administration of papaverine or bupivacaine for pain following laparoscopic sterilization.     

Rectus sheath and mesosalpinx block for laparoscopic sterilization

Thirty patients scheduled to undergo laparoscopic sterilisation were allocated at random to receive either a standardised general anaesthetic and rectus sheath block (group A), or standardised general anaesthetic combined with both rectus sheath and mesosalpinx blocks (group B). Group B patients had significantly less postoperative pain, as assessed by linear analogue scores (p less than 0.025), and analgesic requirement (p less than 0.05). By the 8th postoperative hour all 15 group B patients had been discharged from hospital, whilst only seven of 15 patients in group A were considered suitable for discharge at this time, (p less than 0.05).     

Buscopan for the treatment of pain after laparoscopic sterilisation

We investigated the effect of Buscopan 20 mg, given at the end of surgery, on analgesic requirements in 44 ASA I and II patients presenting as day cases for laparoscopic sterilisation using Filshie clips. Patients were randomly allocated to receive either intravenous Buscopan 20 mg or saline placebo at the end of surgery. There was no significant difference in pain scores, analgesic requirements or the incidence of nausea and vomiting between the two groups. We conclude that intravenous Buscopan 20 mg was not effective for pain relief following laparoscopic sterilisation.     

腹股沟区压迫装置对腹股沟疝手术后生活质量及血清肿发生率影响的研究

目的观察压迫装置对腹股沟疝手术患者术后生活质量及并发症的影响。 方法观察分析首都医科大学附属北京朝阳医院进行腹股沟疝日间手术80例患者的临床资料,其中腹腔镜手术53例,开放手术27例,全部患者手术后采用加压装置对手术区域进行加压,分析患者术后疼痛评分、卡罗来纳舒适量表生活质量评分（CCS）及血清肿相关情况。 结果腹腔镜组和开放组患者的术后1周CCS评分分别为（25.88±5.77）和（27.32±6.23）分,差异无统计学意义（P>0.05）。开放组与腹腔镜组使用加压装置前的2组的疼痛评分分别为（5.12±1.41）和（4.53±1.62）分,使用加压装置当天疼痛评分分别为（3.54±0.67）和（3.55±0.72）分,术后7 d的疼痛评分分别为（1.19±0.21）和（1.09±0.19）分,差异均无统计学意义（P>0.05）。手术当天使用加压装置后能够改善患者的疼痛程度,对术后加压装置整体评估满意度2组患者分别为90.56%和85.19%,差异无统计学意义（P>0.05）。2组患者血清肿发生率比较,差异无统计学意义（P>0.05）。 结论压迫装置能够改善腹股沟疝患者术后疼痛情况并且提升术后生活质量,患者的整体使用满意度较高,并且对症状性血清肿的预防能够起到一定的预防作用。     

A comparison of the incidence of nausea after laparoscopic cholecystectomy and diagnostic laparoscopy

Thirty-four patients undergoing gynecologic diagnostic laparoscopy and 30 patients undergoing laparoscopic cholecystectomies were followed prospectively for nausea and vomiting 24 hours postoperatively. Diagnostic laparoscopy patients had a significantly higher incidence of nausea and vomiting than laparoscopic cholecystectomy patients with similar anesthetic techniques, duration of surgery, and population parameters. All patients had their stomach contents suctioned after induction. While both procedures involve bowel manipulation, patient position and organ manipulation differ: diagnostic laparoscopy involves the Trendelenburg position and laparoscopic cholecystectomy involves the reverse Trendelenburg; diagnostic laparoscopy involves the uterus, ovaries, and fallopian tubes while laparoscopic cholecystectomy involves mainly the gall-bladder and its appendages. These factors may contribute to the differences found in this study.     

Acetazolamide Reduces Referred Postoperative Pain after Laparoscopic Surgery with Carbon Dioxide Insufflation

Background: Carbon dioxide is the preferred insufflating gas for laparoscopy because of greater safety in the event of intravenous embolism, but it causes abdominal and referred pain. Acidification of the peritoneum by carbonic acid may be the major cause of pain from carbon dioxide insufflation. Carbonic anhydrase is an enzyme that increases the rate of carbonic acid formation from carbon dioxide. Because acetazolamide inhibits carbonic anhydrase, the authors hypothesized that the pain caused by carbon dioxide insufflation may be decreased by the administration of acetazolamide.

Methods: A prospective, randomized, double-blind study of 38 patients undergoing laparoscopic surgery during general anesthesia was performed. Acetazolamide (5 mg/kg) or a saline placebo was administered intravenously during surgery. Pain was rated on a visual analog scale (0-10) at four times: when first awake, at discharge from the recovery room, when discharged from the hospital, and on the day after surgery. The site and quality of pain were recorded, as were medications and side effects.

Results: Initial referred pain scores were lower after acetazolamide (1.00 +/- 1.98; n = 18) than after placebo (3.40 +/- 3.48; n = 20; P = 0.014), and 78% of patients in the acetazolamide group had no referred pain; however, only 45% patients in the placebo group had no referred pain. Incisional pain scores were not statistically different, and referred pain scores were similar at later times.     

Wound closure tramadol administration has a short-lived analgesic effect

PURPOSE: To evaluate the effects of tramadol administration at wound closure on postoperative pain and analgesic requirements in patients undergoing laparoscopic cholecystectomy. METHODS: In a prospective, randomized, double-blind study 80 patients were allocated into two groups (n = 40 in each) to receive either 200 mg tramadol or placebo i.v. at the time of wound closure. Postoperatively, all patients received tramadol from a patient-controlled analgesia (PCA) device. Pain, analgesic consumption, vital signs and side effects were recorded postoperatively for 24 hr. RESULTS: Administration of 200 mg tramadol at the time of wound closure was associated with a short-lived (60 min) reduction in pain scores and PCA consumption compared with placebo. Although the time to first request for analgesia after surgery was longer in patients who received tramadol at wound closure, there was no difference between the two groups with respect to pain scores or to the requirements of postoperative analgesia over the next 23 hr. The cumulative PCA consumption of tramadol in 24 hr was 139.4+/-108 and 102.4+/-106 mg in the placebo and tramadol groups, respectively (P = 0.06). CONCLUSIONS: Wound closure administration of 200 mg tramadol had a short-lived (60 min) analgesic effect but did not affect the long-term pain scores or analgesic requirements after laparoscopic cholecystectomy.     

The effect of glycopyrrolate on postoperative pain and analgesic requirements following laparoscopic sterilisation

In order to evaluate the contribution of tubal spasm to pelvic pain following laparoscopic sterilisation, we have studied the effect of glycopyrrolate, an anticholinergic agent with antispasmodic properties, on 60 ASA 1 and 2 patients presenting as day-cases for laparoscopic sterilisation using Filshie clips. In a randomised, double-blind, controlled trial, patients received either glycopyrrolate 0.3mg or saline intravenously prior to induction of anaesthesia. Compared with the control group, patients receiving glycopyrrolate had significantly reduced immediate postoperative pain scores (p < 0.02) and required significantly less postoperative morphine (p < 0.01). Nausea, vomiting and anti-emetic requirements were also reduced though not significantly. We conclude that glycopyrrolate 0.3mg at induction of anaesthesia is an effective method of improving the quality of recovery after day-case laparoscopic sterilisation using clips.     

单孔法与三孔法腹腔镜腹股沟疝修补疗效对比分析

目的探讨单孔法与三孔法腹腔镜疝修补术治疗腹股沟疝的疗效差异。方法回顾性地收集自2011年6月至2016年6月于我科就诊并行腹腔镜腹股沟疝修补术的205例病人的临床资料。按照拟行手术方式不同(是否中转更改手术方式不作为影响分组因素),将本次研究纳入的205例病人分为单孔组129例和三孔组76例,比较组间病人性别构成、年龄分布、平均体质量指数(body mass index,BMI)、手术时间、中转手术率(单孔法转三孔法或腹腔镜法转传统开放手术)以及术后并发症发生率的差异。结果组间一般资料比较显示,两组病人性别构成、平均年龄、平均BMI及疝类型(单侧、双侧)差异均无统计学意义(均P0.05);单孔组手术时间为(55.3±22.8)min,三孔组为(49.4±14.9)min,组间差异无统计学意义(P=0.06);单孔组无中转行三孔法手术病例,两组中转行传统开放手术率基本接近,组间差异无统计学意义(P=0.98);两组术后尿潴留、切口感染发生率差异无统计学意义(均P0.05),而单孔组病人术后疼痛程度相对较轻,术后住院时间相对较短,与三孔组相比,差异均有统计学意义(均P0.05);两组病人总体住院费用,单孔组为(2.21±0.65)万元,三孔组为(2.55±0.89)万元,差异无统计学意义(P0.05);两组病人术后血肿形成、皮下气肿、慢性疼痛发生率相比,差异均无统计学意义(均P0.05),但与三孔组相比,单孔组的上述并发症发生率均有降低趋势。结论单孔法腹腔镜腹股沟疝修补术是一种临床应用相对安全且卫生经济学指标表现更具优势的新兴微创手术方式,更好地吻合了加速康复外科的理念,值得临床进一步研究证实。     

Helium vs carbon dioxide gas Insufflation with or without saline lavage during laparoscopy

BACKGROUND: Helium is an inert gas that, if used for insufflation during laparoscopy, may be followed by less postoperative pain than carbon dioxide (CO2) insufflation, due to a more limited effect on intraabdominal pH and metabolism. Saline lavage has also recently been shown to reduce postoperative pain following laparoscopic surgery. To evaluate these possibilities and to better define the clinical safety of helium insufflation, we undertook a prospective randomized trial comparing CO2 and helium insufflation with or without saline lavage in patients undergoing elective laparoscopic upper abdominal surgery. METHODS: From January to November 2000, 173 patients undergoing elective laparoscopic cholecystectomy or fundoplication were randomized to undergo laparoscopy with either CO2 or helium insufflation. Within each group, patients were further randomized to undergo peritoneal lavage with 2 L of 0.9% saline at the end of the surgical procedure. This yielded the following four patient groups; CO2 (group 1, n = 47), CO2 + saline lavage (group 2, n = 43), helium (group 3, n = 43) and helium + saline lavage (group 4, n = 40). Patients were blinded to their randomization, and post-operative assessment was also performed by a blinded investigator, who applied a standardized scoring system to assess postoperative pain. RESULTS: The study groups were well matched for age, sex, weight, American Society of Anesthesiologists (ASA) status, duration of surgery, and volume of gas utilized, and 81% of patients were discharged within 48 h. There were no differences in the incidence of postoperative complications among the study groups, and postoperative pain scores were not significantly different when all four groups were compared. When helium (groups 3 and 4) was compared with CO2 (groups 1 and 2), no differences in pain score were seen. When no lavage (groups 1 and 3) was compared with lavage (groups 2 and 4), less pain was found in the group undergoing saline peritoneal lavage (mean 4-h pain score, 5.9 vs 5.2; 24-h pain score, 4.8 vs 4.1; p > 0.05). CONCLUSIONS: The use of helium insufflation for laparoscopic surgery, while not associated with any significant adverse sequelae, was not associated with less postoperative pain in this trial. The use of saline peritoneal lavage was associated with less pain in the early postoperative period.     

Laparoscopic versus open appendectomy: a prospective randomized double-blind study

SUMMARY BACKGROUND DATA: The value of laparoscopy in appendicitis is not established. Studies suffer from multiple limitations. Our aim is to compare the safety and benefits of laparoscopic versus open appendectomy in a prospective randomized double blind study. METHODS: Two hundred forty-seven patients were analyzed following either laparoscopic or open appendectomy. A standardized wound dressing was applied blinding both patients and independent data collectors. Surgical technique was standardized among 4 surgeons. The main outcome measures were postoperative complications. Secondary outcome measures included evaluation of pain and activity scores at base line preoperatively and on every postoperative day, as well as resumption of diet and length of stay. Activity scores and quality of life were assessed on short-term follow-up. RESULTS: There was no mortality. The overall complication rate was similar in both groups (18.5% versus 17% in the laparoscopic and open groups respectively), but some early complications in the laparoscopic group required a reoperation. Operating time was significantly longer in the laparoscopic group (80 minutes versus 60 minutes; P = 0.000) while there was no difference in the pain scores and medications, resumption of diet, length of stay, or activity scores. At 2 weeks, there was no difference in the activity or pain scores, but physical health and general scores on the short-form 36 (SF36) quality of life assessment forms were significantly better in the laparoscopic group. Appendectomy for acute or complicated (perforated and gangrenous) appendicitis had similar complication rates, regardless of the technique (P = 0.181). CONCLUSIONS: Unlike other minimally invasive procedures, laparoscopic appendectomy did not offer a significant advantage over open appendectomy in all studied parameters except quality of life scores at 2 weeks. It also took longer to perform. The choice of the procedure should be based on surgeon or patient preference.     

Quality of life,pain and return to normal activities following laparoscopic donor nephrectomy versus open mini-incision donor nephrectomy

PURPOSE: We evaluated pain, convalescence and health related quality of life in patients undergoing laparoscopic and open mini-incision donor nephrectomy. MATERIALS AND METHODS: We compared the records of consecutive patients who underwent laparoscopic and mini-incision open donor nephrectomy from our donor nephrectomy data base in retrospective fashion using 2 questionnaires. The first questionnaire evaluated postoperative pain, return to functioning time and satisfaction. The second questionnaire was the RAND 36-Item Health Survey, version 2, a standardized and validated health survey quality of life assessment tool. Mean patient sex, age and followup were similar for the 2 groups. All data were analyzed using the 2-tailed t test for independent variables with commercially available statistical analysis software. RESULTS: Pain in the laparoscopic group was significantly less than in the mini-incision group at all followup time points (p <0.05). Statistically significant differences demonstrated that laparoscopy led to more rapid recovery time in certain categories, including walking, discontinuation of prescribed oral pain relievers, return to driving, and resumption of normal work and home daily activities. More subjective questions in the survey showed high levels of acceptance for the 2 procedures. Using the RAND 36-Item Health Survey, version 2 health related quality of life was significantly higher in the laparoscopy group in 3 domains that measure bodily pain, physical functioning and emotional role functioning. However, each group scored at or above age matched American averages in all domains. CONCLUSIONS: The laparoscopy group had significantly less postoperative pain and required less time to return to normal functional activities than the mini-incision group. In addition, the laparoscopic group showed significantly higher quality of life scores than the mini-incision group in 3 domains.