Laparoscopic Cholecystectomy 2017

Recommended: Pre-/intra-operative interventions

• Unless otherwise stated, ‘pre-operative’ refers to interventions applied before surgical incision and ‘intra-operative’ refers to interventions applied after incision and before wound closure
• Analgesics should be administered at the appropriate time (pre- or intra-op) to provide sufficient analgesia in the early recovery period

• Pre-operative oral paracetamol is recommended for routine use (Grade A) based on analgesic efficacy in several studies in this and the previous review (LoE 1 and 2)
• If not given pre-operatively, intra-operative IV paracetamol is recommended for routine use (Grade A, LoE 1)

• Pre-operative oral NSAIDs/COX-2-selective inhibitors are recommended for routine use (Grade A) based on several studies showing analgesic efficacy in this and the previous review (LoE 1 and 2)
• If not given pre-operatively, intra-operative IV NSAIDs/COX-2-selective inhibitors are recommended for routine use (Grade B, LoE 2)

• Pre-operative dexamethasone is recommended for routine use (Grade A) based on evidence of analgesic and anti-emetic effects (LoE 1 and 2)

• Port site LA is recommended, preferably administered before incision, using a long-acting LA to prolong its effect (Grade A), based on evidence of analgesic benefit (LoE 1 and 2)

• Low-pressure pneumoperitoneum (10–12 mm Hg) is recommended if surgically possible (Grade A) based on evidence of analgesic benefit in a majority of studies (LoE 1 and 2)

• Local lavage with saline and then suction is recommended after removal of the gallbladder (Grade A) based on evidence of a reduction in pain scores or analgesic consumption (LoE 1). The lavage should be done with adequate suction of the remaining pneumoperitoneum (Grade A)

• Aspiration of pneumoperitoneum gas is recommended (Grade A) based on evidence of a reduction in pain scores (LoE 1 and 2)

• A mini-port laparoscopic technique is recommended as it reduced pain in one study (LoE 1), but the cost and availability of equipment should be taken into consideration (Grade B)

Recommended when ‘basic’ analgesia is not possible: Pre-/intra-operative interventions

(‘Basic’ analgesia: paracetamol, NSAID/COX-2-selective inhibitor, dexamethasone, port-site LA infiltration)

• Preoperative gabapentinoids are not recommended for routine use but may be considered if ‘basic’ analgesia is not possible (Grade D)
• Although several studies have reported reduced postoperative opioid requirements (LoE 1 and 2) with pre-operative gabapentinoids, they may not add to the effectiveness of the ‘basic’ analgesic technique of paracetamol, NSAID/COX-2-selective inhibitors, and surgical site infiltration
• Also, the optimal dose is unknown, and there is a need to balance analgesic benefits with potential adverse effects such as increased potential for sedation

• TAP or OSTAP blocks are not recommended for routine use (Grade D), despite several studies reporting reduced postoperative opioid requirements and pain scores (LoE 1 and 2), as they may not add benefit beyond the ‘basic’ analgesic protocol. However, they may be considered if ‘basic’ analgesia is not possible

Recommended: Post-operative interventions

• Unless otherwise stated, ‘postoperative’ refers to interventions applied at or after wound closure
• Analgesics should be administered at the appropriate time (pre- or intra-op) to provide sufficient analgesia in the early recovery period

• Paracetamol is recommended for routine use, continued postoperatively (Grade A), based on evidence of analgesic benefit (LoE 2)

• NSAIDs/COX-2-selective inhibitors are recommended for routine use, continued postoperatively (Grade A), based on evidence of analgesic benefit (LoE 1 and 2)

• Opioid analgesia should be reserved for rescue analgesia only (Grade B) to avoid potential side effects where possible (LoE 1 and 2)

Interventions that are NOT recommended

• Alpha-2 agonists, such as dexmedetomidine and clonidine, are not recommended because of limited evidence and potential adverse effects (Grade D)

• Ketamine has shown mixed results regarding reduction of pain and analgesic requirement, and overall it is not recommended (Grade D, LoE 4). Additionally, there are concerns about adverse effects such as hallucinations

• Magnesium is not recommended (Grade D) despite some evidence of analgesic effect (LoE 1). Magnesium during operation may cause adverse effects such as potentiation of neuromuscular blocking agents and increasing the incidence of residual muscle paralysis

• IV lidocaine infusions are not recommended (Grade D), despite evidence of analgesic benefit (LoE 1), owing to the need for close monitoring and the possibility of overdose

• Esmolol infusions are not recommended (Grade D), despite evidence of analgesic benefit (LoE 1 and 2), owing to the need for close monitoring and the possibility of overdose

• TAP or OSTAP blocks are not recommended (Grade D), despite several studies reporting reduced postoperative opioid requirements and pain scores (LoE 1 and 2), as they may not add benefit beyond the ‘basic’ analgesic protocol

• IP LA instillation is not recommended (Grade D), despite a majority of studies reporting reduced postoperative opioid requirements and pain scores (LoE 1), as it may not add benefit beyond the ‘basic’ analgesic protocol
• The addition of IP LA with port site local infiltration could potentiate LA toxicity. If IP LA is used, care should be taken to control the maximum dosage while still giving adequate port site LA

• Regional anaesthesia techniques such as epidural anaesthesia, paravertebral block, intrathecal opioids, and rectus sheath block are not recommended because of limited, small trial evidence and potential for complications or failure of anaesthetic technique (Grade D)
• Epidural anaesthesia is also counterintuitive in the ambulatory setting

• Warmed CO₂ and humidified CO₂ are not recommended (Grade D) due to limited evidence

• Single port techniques are not recommended (Grade A) as a majority of studies found no significant benefit for analgesia (LoE 1 and 2)

Not recommended:

• Ketamine
• Magnesium
• Alpha-2-agonist
• Epidural anaesthetic
• IV lidocaine infusion
• Esmolol infusion
• Single port technique
• Warmed CO₂ insufflation
• Humidified CO₂ insufflation