Intra-Operative - ESRA
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Laparoscopic Cholecystectomy 2005

Intra-Operative

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • Eight studies out of ten showed a significant benefit of conventional NSAIDs compared with placebo or no treatment for reducing VAS pain scores Munro et al 1998 Click here for more information
  • Five studies out of ten showed a significant benefit of conventional NSAIDs compared with placebo or no treatment for reducing supplementary analgesic use Forse et al 1996 Click here for more information
  • One study out of one showed that IM ketorolac (60 mg), administered intra-operatively pre-procedure (n=31), significantly increased the time to first analgesic request (p<0.05) compared with placebo (n=23) and IM ketorolac, administered intra-operatively post-procedure (n=20) Lane et al 1996
  • One study measured parameters of pulmonary function and found that the values of FEV1 and FEF25–75 were significantly higher at 4 h after surgery in the ketorolac group compared with the placebo group (p<0.05) Liu et al 1993
  • One study out of one showed that tenoxicam (20 mg) + ondansetron (4 mg), administered in 20 ml saline before induction of anaesthesia, significantly reduced the time to first flatus compared with ondansetron alone (p<0.05) Elhakim et al 1995

Arguments against…

  • Two studies out of seven that recorded the incidence of nausea and/or vomiting, showed that conventional NSAIDs significantly reduced the incidence of nausea and/or vomiting compared with placebo or no treatment Elhakim et al 1995Click here for more information
  • One study out of one found no significant difference for the duration of hospital stay between IM ketorolac, administered intra-operatively pre- and post-procedure, and placebo Lane et al 1996
  • One study out of one found no significant difference for the time to hospital discharge between IM diclofenac, administered after induction of anaesthesia (n=26), and placebo (n=23) Wilson et al 1994
  • One study which compared IM ketorolac with IM diclofenac, administered 30 min prior to end of surgery, showed that there was no significant difference in VAS pain scores, opioid use and incidence of nausea or vomiting between groups Fredman et al 1995
  • Study details Fredman et al 1995 Click here for more information
  • Table 1. Systemic conventional NSAIDs versus placebo or no treatment: Study details Elhakim et al 1995 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • Intra-operative IM dextromethorphan + IM chlorpheniramine maleate significantly increased the time to first pethidine request compared with IM chlorpheniramine maleate alone (p<0.05) Wu et al 1999
  • IV ketamine infusion significantly reduced pain compared with placebo: VAS pain scores at rest at 2–4 h (p<0.05 in each case) but not at 0, 1, 8 or 20 h; VRS pain scores at 2 and 3 h (p<0.05 in each case), but not at other time points Ayoglu et al 2005
  • IV ketamine infusion significantly reduced cumulative opioid use compared with placebo at 2 and 3 h (p<0.05 in both cases), but not at other time points Ayoglu et al 2005
  • IV ketamine infusion significantly reduced VAS pain scores at rest compared with magnesium at 4 and 20 h (p<0.05 in both cases), but not at 0–4 or at 8 h; ketamine also significantly reduced VRS pain scores compared with magnesium at 4 h (p<0.05), but not at other time points Ayoglu et al 2005

Arguments against…

  • Intra-operative IM dextromethorphan + IM chlorpheniramine maleate did not significantly reduce the ‘worst pain’ score compared with IM chlorpheniramine maleate alone Wu et al 1999
  • Intra-operative IM dextromethorphan significantly increased the ‘worst pain’ score compared with pre-operative IM dextromethorphan (p<0.0001) Wu et al 1999
  • Intra-operative IM dextromethorphan + IM chlorpheniramine maleate and IM chlorpheniramine maleate alone groups were similar for total pethidine consumption and the number of patients requiring pethidine (1 mg/kg IM pethidine was given if requested) Wu et al 1999
  • Intra-operative IM dextromethorphan + IM chlorpheniramine maleate and IM chlorpheniramine maleate alone groups were similar for the incidence of nausea and vomiting Wu et al 1999
  • Pre-operative IM dextromethorphan significantly increased the time to first pethidine request compared with intra-operative IM dextromethorphan (p<0.05) Wu et al 1999
  • Total pethidine consumption (1 mg/kg IM pethidine was given if requested) was significantly higher in the intra-operative IM dextromethorphan group compared with the pre-operative IM dextromethorphan group (p<0.0001) Wu et al 1999
  • Intra-operative IM dextromethorphan was associated with significantly increased bed rest time compared with pre-operative IM dextromethorphan (p<0.001) Wu et al 1999
  • There were no significant differences between pre-operative and intra-operative IM dextromethorphan treatment groups for the incidence of nausea and vomiting Wu et al 1999
  • IV magnesium infusion did not significantly reduce VAS or VRS pain scores compared with placebo at any time during 0–20 h Ayoglu et al 2005
  • Ketamine, magnesium and placebo infusion were similar for the incidence of nausea and vomiting, and for pulmonary function parameters Ayoglu et al 2005
  • IV magnesium infusion did not significantly reduce cumulative opioid use compared with placebo at any time during 0–20 h (postoperative opioid was PCA bolus of 1 mg morphine, 10-minute lockout, maximum 4 h dose 20 mg) Ayoglu et al 2005
  • IV ketamine and IV magnesium infusion were associated with similar cumulative opioid use during 0–20 h (postoperative opioid was PCA bolus of 1 mg morphine, 10-minute lockout, maximum 4 h dose 20 mg) Ayoglu et al 2005
  • IV ketamine and magnesium infusion were similar for the incidence of nausea and vomiting, and for pulmonary function parameters Ayoglu et al 2005
  • Study details Wu et al 1999 Click here for more information
  • Dextromethorphan
  • Ketamine

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • IM pethidine significantly reduced opioid use in the recovery room (0.25 mg/kg IV pethidine was given every 10 minutes, as needed, up to 4 doses in the first hour postoperatively) compared with placebo (p<0.05) Lane et al 1996
  • Fewer patients receiving IV morphine requested rescue opioid (2–3 mg/kg IV pethidine was given every 10 minutes, as needed, up to 4 doses in the first hour postoperatively) compared with patients receiving placebo (unclear if significant for this particular comparison Munoz et al 2002

Arguments against…

  • There were no significant differences between IV morphine and placebo for VAS pain scores at rest or on coughing at any time point (0–180 min) and both groups took a similar length of time to first analgesic request Munoz et al 2002
  • There were no significant differences in VAS pain scores between IM pethidine and placebo groups over the first 24 h following surgery Lane et al 1996
  • There were no significant differences between groups receiving pre-operative, intra-operative or postoperative IV morphine for VAS pain scores at rest or on coughing at any time point (0–180 min) Munoz et al 2002
  • There was no significant difference between the IV morphine and placebo groups for the incidence of postoperative emesis Munoz et al 2002
  • There were no significant differences between groups receiving pre-operative, intra-operative or postoperative IV morphine for opioid use or the incidence of emesis. All IV morphine groups took similar length of time for first analgesia request Munoz et al 2002
  • IM pethidine and placebo groups took a similar length of time to first analgesic request Lane et al 1996
  • There was no significant difference between the IM pethidine and placebo groups for the duration of hospital stay Lane et al 1996
  • Study details Lane et al 1996 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Argument for…

  • Nine out of 11 studies showed a significant benefit of LA wound infiltration over placebo or no treatment for reducing VAS pain scores, see Table 2a for details Click here for more information
  • In one study out of one, the proportion of patients with most severe pain located to the right lower abdominal wall on day 2 was significantly lower in the LA (bupivacaine) infiltration group compared with the placebo group (p=0.012) Ure et al 1993
  • In one study out of one, the proportion of patients with no pain after 5 h was significantly higher in the LA wound infiltration group compared with the placebo group (p=0.03) Ure et al 1993
  • Two studies out of two found that LA wound infiltration significantly increased the time to first analgesic demand compared with placebo (p<0.05 in both cases) Papaziogas et al 2001
  • Six studies out of 11 reported that LA wound infiltration reduced analgesic consumption compared with placebo or no treatment, see Table 2a for details; each of those studies also showed significantly reduced VAS pain scores with LA wound infiltration Click here for more information
  • In one study out of one, the rate of same-day discharge was significantly higher in the LA wound infiltration (bupivacaine + epinephrine) group compared with the placebo group (p<0.05) Dath and Park 1999
  • There were no significant differences between IP LA and intrawound LA for VAS pain scores at 1, 2, 4 or 8 h postoperatively, or at discharge, or for total analgesic use (postoperative analgesia was IM Cyclimorph or 2 x co-proxamol tablets, as required) Johnson et al 1999

Arguments against…

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

Arguments against…

  • One study out of one found that the duration of hospital stay was similar in the LA wound infiltration/IP LA (bupivacaine/lidocaine combination) group and the placebo group Lepner et al 2003
  • Study details Click here for more information
  • Table 2b. Combined LA wound infiltration/intraperitoneal (IP) LA versus placebo or no treatment: Study details Bisgaard et al 1999 Click here for more information
  • Combined LA wound infiltration/intraperitoneal (IP) LA versus placebo or no treatment

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • Fourteen studies out of 23 showed a significant benefit of intraperitoneal LA over placebo or no treatment for reducing VAS pain scores, see Table 3 for details; in two out of nine studies that did not find significant differences between groups, the comparator was IV strong opioid Click here for more information
  • Four studies out of six showed a significant benefit of intraperitoneal LA over placebo for reducing VRS pain scores, see Table 3 for details
  • In one study, the same day discharge rate was significantly higher in all groups receiving intraperitoneal LA (15 ml 0.5% bupivacaine) compared with the placebo group (p<0.02) Paulson et al 2003
  • Three systematic reviews of local anaesthesia in laparoscopic cholecystectomy have found some evidence that intraperitoneal LA reduces pain after surgery, although the overall quality of the studies was not high and there were some conflicting results Bisgaard 2006
  • Administration of IP bupivacaine at the start of surgery significantly reduced VAS pain scores compared with IP bupivacaine administration at the end of surgery at 8, 12 and 24 h following surgery (p<0.05 in each case), but not at 0 or 4 h, and VRS pain scores at 4, 8 and 24 h (p<0.05 in each case), but not at 0 or 12 h Pasqualucci et al 1996
  • Administration of IP bupivacaine at the start and end of surgery was significantly superior to administration at the end of surgery alone for reducing VAS pain scores at 0, 4, 8 and 24 h following surgery (p<0.05 in each case) but not at 12 h in one study Pasqualucci et al 1994
  • Administration of IP bupivacaine at the start and end of surgery sugnificantly reduced VRS pain scores at 0, 4, 8 and 12 h compared with administration at the end of surgery alone (in all cases, p<0.05) but not at 24 h postoperatively in one study Pasqualucci et al 1994
  • Administration of IP bupivacaine at the start and end of surgery was significantly superior to administration at the start of surgery alone for reducing VAS pain scores at 0 and 4 h (in both cases, p<0.05) Pasqualucci et al 1996
  • Administration of IP bupivacaine at the start and end of surgery was significantly superior to administration at the start of surgery alone for reducing VRS pain scores at 0 h (p<0.05) Pasqualucci et al 1996
  • Administration of IP bupivacaine at the start of surgery significantly reduced analgesic use (30 mg IV ketorolac was given, as necessary) compared with IP bupivacaine administration at the end of surgery (p<0.05) Pasqualucci et al 1996
  • Administration of IP bupivacaine at the start and end of surgery significantly reduced analgesic (30 mg IV ketorolac was given, as necessary) requirement compared with administration at the end of surgery alone (p<0.05) Pasqualucci et al 1994
  • The incidence of nausea and vomiting was lower in the start of surgery IP LA administration group compared with the end of surgery IP LA administration group, although p values were not given Pasqualucci et al 1996
  • Administration of IP bupivacaine at the start and end of surgery reduced the incidence of nausea and vomiting compared with administration at the end of surgery alone Pasqualucci et al 1994
  • IP LA + IP NSAID and IP LA + IV NSAID significantly reduced VAS pain scores compared with placebo in two studies Jabbour-Khoury et al 2005 Click here for more information
  • One of two studies showed that IP LA + IP NSAID and IP LA + IV NSAID significantly reduced shoulder VAS pain scores compared with placebo at 0 and 6 h and at 0, 1 and 6 h, respectively (p<0.05, in all cases) Jabbour-Khoury et al 2005
  • Incisional and intra-abdominal VAS pain scores at rest and during coughing were significantly reduced in the IP LA + IV strong opioid group compared with the placebo group at 1 and 2 h following surgery (p<0.05, in all cases), but not at other time points (4, 6, 12 or 24 h postoperatively); shoulder-tip pain VAS scores and VRS pain relief scores were also similar Hernandez-Palazon et al 2001
  • Abdominal and shoulder VAS pain scores were significantly lower in the IP LA + saline lavage and suction group compared with the placebo group (p<0.05) Tsimoyiannis et al 1998
  • Adding ketamine or magnesium to IP bupivacaine resulted in a significant reduction in VAS shoulder pain scores compared with both IP LA alone and placebo (p<0.05 in each case) Abdel-Raouf + Amer 2004
  • One out of two studies showed that IP LA + IP NSAID and IP LA + IV NSAID treatment increased the time to first analgesic request compared with placebo, although p values were not presented Elhakim et al 2000a
  • Adding ketamine or magnesium to IP bupivacaine resulted in a significantly longer time to first analgesic request compared with both IP LA alone and placebo (p<0.05 in each case) Abdel-Raouf + Amer 2004
  • The number of patients needing rescue analgesics was significantly lower in the IP LA + IV NSAID group, but not the IP LA + IP NSAID group, compared with the placebo group Jabbour-Khoury et al 2005
  • IP LA + IP NSAID and IP LA + IV NSAID reduced opioid consumption over the first 24 h postoperatively, but the difference was significant only for the IP LA + IP NSAID versus placebo comparison Elhakim et al 2000a
  • Postoperative PCA metamizol use was significantly lower in the IP LA + IP strong opioid group compared with the placebo group 0–6 h postoperatively (p<0.05), and significantly lower in the IP LA + IV strong opioid group compared with the placebo group 0–24 h following surgery (p<0.05) Hernandez-Palazon et al 2003
  • IP LA + saline lavage and suction reduced supplemental analgesic requirements compared with placebo Tsimoyiannis et al 1998 Click here for more information
  • Adding ketamine or magnesium to IP bupivacaine resulted in a significant reduction in supplemental analgesic use compared with both IP LA alone and placebo at all time points (0–6, 6–12, 12–18, 18–24 and 0–24 h) (postoperative analgesia was PCA IV morphine boluses, 1 mg increments, 10 min lockout, 10 mg max dose/h) (p<0.05 in each case) Abdel-Raouf + Amer 2004
  • The proportion of patients requiring no analgesia was significantly lower in the IP LA group compared with the saline lavage + suction group (p<0.05) Tsimoyiannis et al 1998
  • In one of two studies, the incidence of vomiting was significantly lower in the IP LA + IV NSAID group, but not the IP LA + IP NSAID group, compared with the placebo group (p<0.05) Jabbour-Khoury et al 2005
  • The incidence of nausea and vomiting was significantly lower in the IP LA + saline lavage and suction group compared with the placebo group (p<0.05, in both cases) Tsimoyiannis et al 1998
  • The incidence of nausea and vomiting and the duration of hospital stay were not significantly different between the IP LA group and the saline lavage and suction group Tsimoyiannis et al 1998
  • In one study, patients receiving IP tenoxicam (20 mg) and 200 ml lidocaine (0.1%) + 2 ml IV saline, administered at the end of surgery, took significantly less time to bowel recovery compared with the placebo group (p<0.05) Elhakim et al 2000a
  • There were no significant differences between IP LA and intrawound LA for VAS pain scores at 1, 2, 4 or 8 h postoperatively, or at discharge, or for total analgesic use (postoperative analgesia was IM Cyclimorph or 2 x co-proxamol tablets, as required) Johnson et al 1999

Arguments against…

  • Five out of six studies found no benefit of IP LA for reducing the incidence of shoulder pain compared with placebo; see Table 3 Elhakim et al 2000 Click here for more information
  • In one study that compared IP bupivacaine or bupivacaine + epinephrine with placebo or no treatment, the proportion of patients with strong or unbearable pain was found to be similar in the three groups Scheinin et al 1995
  • Two out of three studies found that IP LA treatment did not increase the time to first analgesic request compared with placebo; see Table 3
  • Thirteen out of 20 studies showed no significant benefit of intraperitoneal LA over control or no treatment for reducing supplemental use of analgesia, see Table 3 for details Elhakim et al 2000 Click here for more information
  • In seven out of nine studies, the incidence of nausea and/or vomiting was similar in both IP LA and control groups (in one study the comparator used was IV strong opioid); in the remaining two studies Pasqualucci et al 1994 Click here for more information
  • In six out of six studies, there were no significant differences between IP LA and control groups for the duration of hospital stay (see Table 3 for details) Click here for more information
  • In three out of five studies, there were no significant differences between the IP LA and control groups for respiratory function parameters; see Table 3 for details Rademaker et al 1994 Click here for more information
  • There were no significant differences between the IP LA + IP strong opioid group compared with the placebo group at any time (i.e. at 1, 2, 4, 6, 12 or 24 h postoperatively) for incisional, intra-abdominal or shoulder VAS pain scores, at rest or during coughing, or for VRS pain relief scores Hernandez-Palazon et al 2003
  • IP LA was associated with significantly increased abdominal and shoulder VAS pain scores compared with the saline lavage + suction group (p<0.05) Tsimoyiannis et al 1998
  • There were no significant differences between IP ropivacaine doses groups [20 ml (300 mg) 0.75% and 20 ml (100 mg) 0.25%], administered once at the start of surgery and once at the end of surgery, for visceral or parietal VAS pain scores at rest, during coughing or during mobilisation Labaille et al 2002
  • One study showed that the addition of epinephrine to IP LA solution did not confer any benefit for reducing pain scores: VRS pain score at rest or on movement; the incidence of shoulder pain and the proportion of patients with strong or unbearable pain Scheinin et al 1995
  • One study that compared two different doses of ropivacaine, 20 ml (300 mg) 0.75% ropivacaine with 20 ml (100 mg) 0.25% ropivacaine, administerd once at the start and once at the end of surgery, showed that both dose groups consumed similar amounts of opioids (see Table 2.1 for details) Labaille et al 2002
  • One study that compared bupivacaine (0.125%) with bupivacaine (0.25%), both regimens administered at the end of surgery, showed no significant difference for VAS pain scores at rest, on deep inspiration or on coughing Raetzel et al 1995
  • One study that compared bupivacaine (0.125%) with bupivacaine (0.25%), both regimens administered at the end of surgery, showed that both dose groups consumed similar amounts of opioids Raetzel et al 1995
  • One study compared 0.25% IP bupivacaine + 2 mg IP or IV morphine, administered at the end of surgery, with placebo showed that there was no significant difference between the groups for incidence of nausea/vomiting Hernandez-Palazon et al 2003
  • One study that compared bupivacaine (0.125%) with bupivacaine (0.25%), both regimens administered at the end of surgery, showed no significant difference between both dose groups for incidence of nausea and vomiting Raetzel et al 1995
  • A study that compared 125% IP bupivacaine with 0.25% IP bupivacaine, both regimens adminstered at the end of surgery showed that FVC was significantly more impaired in the group receiving the higher dose of bupivacaine (0.25%) compared with the lower dose (0.125%) Raetzel et al 1995
  • One study showed that the addition of epinephrine to IP LA solution did not reduce supplemental analgesic requirements Scheinin et al 1995 Click here for more information
  • A study that compared IP LA + IP or IV NSAID versus control showed that the duration of hospital stay was similar in all groups Elhakim et al 2000a
  • A study that compared IP LA + saline lavage and suction with control showed no significant difference between groups for the duration of hospital stay Tsimoyiannis et al 1998
  • One study showed that the addition of epinephrine to IP LA solution did not reduce the duration of hospital stay Scheinin et al 1995
  • Study details Busley et al 1999 Click here for more information
  • Table 3. IP LA versus placebo, no treatment or IV analgesia: Study details and qualitative outcomes Busley et al 1999Click here for more information
  • IP LA versus placebo, no treatment or IV analgesia
  • IP local anaesthetic, timing of administration
  • IP LA, miscellaneous studies

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • A study that compared IP strong opioid (pethidine) versus IM/IV strong opioid (pethidine) on a background of IP LA showed that IP pethidine significantly reduced VAS pain scores at rest and on movement compared with IM pethidine at all time points (i.e. 30 minutes, 2, 4, 8 and 24 h postoperatively) (p<0.001 in all cases) O’Hanlon et al 2002
  • A study that compared IP strong opioid (pethidine) with IM/IV strong opioid (pethidine) on a background of IP LA showed that total PCA opioid consumption during the first 24 h after surgery was significantly lower in the IP pethidine group compared with the IM pethidine group (p<0.001) O’Hanlon et al 2002

Arguments against…

  • A study that compared IP morphine with IM/IV morphine on a background of IP LA, found that incisional and intra-abdominal VAS pain scores were significantly lower in the IV morphine group compared with the IP morphine group at 1 and 2 h following surgery (in both cases, p<0.05), but not at 4, 6, 12 or 24 h Hernandez-Palazon et al 2003
  • A study that compared IP strong opioid (morphine) with IM/IV strong opioid (morphine) on a background of IP LA, showed that postoperative PCA metamizol use was significantly lower in the IV morphine group compared with the IP morphine group in the first 24 h following surgery (p<0.05) Hernandez-Palazon et al 2003
  • One of two studies that compared IP strong opioid with IM/IV strong opioid on a background of IP LA showed that IP strong opioid increased nausea scores compared with parenteral strong opioid O’Hanlon et al 2002 Click here for more information
  • Study details O’Hanlon et al 2002 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments against…

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • Combined epidural/general anaesthesia was significantly superior to total intravenous anaesthesia for reducing VAS pain scores at 2, 3 and 4 h (p<0.05 in each case), but not at 0–1 h; the incidence of abdominal and shoulder pain was similar in both groups Luchetti et al 1996
  • The recovery score (Steward test) was significantly superior in the combined epidural/general anaesthesia group compared with the total intravenous anaesthesia group at 4 and 6 minutes (p<0.05, in both cases), but not at other times Luchetti et al 1996
  • IV butorphanol was associated with a significantly lower proportion of patients with moderate-severe pain on the VRS scale compared with IV fentanyl (p<0.05; both administered 2 minutes before induction of anaesthesia)  Usmani et al 2004
  • The time to first rescue analgesic (1.5 mg/kg IV tramadol hydrochloride was given to patients complaining of moderate to severe pain) was significantly longer in the butorphanol group compared with the fentanyl group (p<0.05)  Usmani et al 2004
  • A study that compared three different doses (0.6%, 1.2% and 1.8%) of isoflurane-fentanyl combination with isoflurane alone for maintenance anaesthesia, showed that the time to tracheal extubation and to eye opening was significantly reduced in the 0.6% end-tidal isoflurane-fentanyl group compared with the isoflurane alone group (p<0.01), although the times to spontaneous breathing and to discharge to the ward were similar in all groups Munoz et al 2005
  • The time to tracheal extubation and to eye opening was significantly reduced in the 0.6% end-tidal isoflurane-fentanyl group compared with the other two groups (1.2% and 1.8%) (p<0.001), although the times to spontaneous breathing and to discharge to the ward were similar in all three groups Munoz et al 2005
  • The time to tracheal extubation and to eye opening was significantly reduced in the 1.2% end-tidal isoflurane-fentanyl group compared with the 1.8% group (p<0.05)  Munoz et al 2005
  • Remifentanil + propofol significantly increased the time to first analgesic request compared with remifentanil + desflurane (p<0.05)  Grundmann et al 2001
  • Remifentanil + propofol significantly reduced the total amount of IV piritramide used compared with remifentanil + desflurane (p<0.05) (postoperative analgesia was PCA IV piritramide, dose not specified + titrated IV loading dose if required) Grundmann et al 2001
  • The incidence of nausea, but not vomiting, was significantly reduced in the remifentanil + propofol group compared with the remifentanil + desflurane group (p<0.05) Grundmann et al 2001

Arguments against…

  • In a study that compared combined epidural/general anaesthesia with total intravenous anaesthesia, there were no significant differences between groups for the incidence of nausea or vomiting Luchetti et al 1996
  • IV butorphanol and IV fentanyl administered 2 minutes before induction of ananesthesia were associated with similar incidence of nausea and vomiting, time to orientation and discharge, and the incidence of excessive drowsiness were similar in both groups Usmani et al 2004
  • There were no significant differences between different doses (0.6%, 1.2% and 1.8%) of isoflurane-fentanyl combination and isoflurane alone for VAS pain scores at rest or on coughing at any of the time points recorded (i.e. at 0, 15, 30, 45, 60, 90 or 120 minutes postoperatively) Munoz et al 2005
  • There were no significant differences between the remifentanil + propofol and remifentanil + desflurane groups for reducing VAS pain scores (both groups had lower pain scores at 30–90 minutes after arrival in PACU than at arrival in PACU) Grundmann et al 2001
  • The proportion of patients requiring opioid and the amount of opioid used were similar between different doses of isoflurane-fentanyl combination (0.6%, 1.2% and 1.8%) and isoflurane alone Munoz et al 2005
  • There were no significant differences between three different doses (0.6%, 1.2% and 1.8%) of isoflurane-fentanyl combination and isoflurane alone for Apfels’ risk score for PONV and the incidence of nausea and vomiting was also similar in both groups Munoz et al 2005
  • Study details Munoz et al 2005 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • In one out of the two studies, the incidence of shoulder pain was significantly lower (p<0.05) in the gasless or minimal CO2 insufflation pneumoperitoneum group compared with the conventional CO2 pneumoperitoneum group Lindgren et al 1995 Click here for more information
  • In one study out of one, the number of patients with no pain in the recovery room was significantly higher in the gasless CO2 insufflation pneumoperitoneum group compared with the conventional CO2 pneumoperitoneum group Uen et al 2002
  • In one out of one study, the duration of drowsiness was significantly lower (p<0.001) in the minimal CO2 insufflation pneumoperitoneum group compared with the conventional CO2 pneumoperitoneum group  Lindgren et al 1995

Arguments against…

  • In three out of the three studies, there were no significant differences between gasless or minimal CO2 insufflation pneumoperitoneum and conventional CO2 pneumoperitoneum groups for VAS pain scores (see Table 4 for details)
  • There were no significant differences between gasless laparoscopic cholecystectomy and low-pressure laparoscopic cholecystectomy for VAS pain scores at any time point (VAS pain scores recorded at 4, 8, 12 and 24 h postoperatively and then each morning, for 1 week) Vezakis et al 1999
  • The incidence of shoulder pain was significantly greater in the gasless laparoscopic cholecystectomy group compared with the low-pressure laparoscopic cholecystectomy group (p<0.05) Vezakis et al 1999
  • In three out of three studies, analgesic use was similar in both gasless or minimal CO2 insufflation pneumoperitoneum and conventional CO2 pneumoperitoneum groups (see Table 4 for details); in one study out of one the length of time to complete pain relief was also similar in both groups Larsen et al 2001
  • Analgesic use was similar in both gasless pneumoperitoneum and low-pressure pneumoperitoneum group Vezakis et al 1999
  • One out of the three studies reported that PONV requiring droperidol was significantly reduced in the minimal CO2insufflation pneumoperitoneum group compared with the conventional COpneumoperitoneum group (p<0.05) Lindgren et al 1995
  • There was no significant difference between gasless pneumoperitoneum and low-pressure pneumoperitoneum groups for the incidence of nausea or vomiting Vezakis et al 1999
  • In two studies out of two, there were no significant differences between the gasless pneumoperitoneum and conventional carbon dioxide (CO2) pneumoperitoneum groups for the duration of hospital stay Larsen et al 2001 Click here for more information
  • The duration of hospital stay was similar in gasless pneumoperitoneum and low-pressure pneumoperitoneum groups Vezakis et al 1999
  • Study details Vezakis et al 1999 Click here for more information
  • Table 4. Gasless pneumoperitoneum versus conventional CO2 pneumoperitoneum: Study Details and Qualitative Outcomes Larsen et al 2001 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • Three studies out of four found that low pressure CO2 pneumoperitoneum significantly reduced VAS pain scores compared with conventional CO2 pneumoperitoneum, see Table 5 for details
  • In two out of three studies, the incidence of shoulder pain was significantly lower in the low pressure CO2pneumoperitoneum group compared with the conventional CO2 pneumoperitoneum group Barczynski and Herman 2003Click here for more information
  • The incidence of shoulder pain was significantly lower in the low-pressure laparoscopic cholecystecomy group compared with the gasless laparoscopic cholecystectomy group (p<0.05)  Vezakis et al 1999
  • In two studies out of four, analgesic use was significantly reduced in the low pressure CO2 pneumoperitoneum group compared with the conventional CO2 pneumoperitoneum group, see Table 5 for details Barczynski and Herman 2003
  • In one study out of one, low pressure CO2 pneumoperitoneum was significantly superior to conventional CO2pneumoperitoneum in terms of pulmonary function and duration of hospital stay Wallace et al 1997

Arguments against…

  • There were no significant differences between gasless laparoscopic cholecystectomy and low-pressure laparoscopic cholecystectomy for VAS pain scores at any time point (VAS pain scores recorded at 4, 8, 12 and 24 h postoperatively and then each morning, for 1 week) Vezakis et al 1999
  • Analgesic use was similar in both gasless pneumoperitoneum and low-pressure pneumoperitoneum group Vezakis et al 1999
  • In two out of two studies, the incidence of nausea and vomiting was similar in both low-pressure CO2pneumoperitoneum and conventional CO2 pneumoperitoneum groups  Barczynski and Herman 2003 Click here for more information
  • There was no significant difference between gasless pneumoperitoneum and low-pressure pneumoperitoneum groups for the incidence of nausea or vomiting Vezakis et al 1999
  • The duration of hospital stay was similar in both gasless pneumoperitoneum and low-pressure pneumoperitoneum groups Vezakis et al 1999
  • The time to passage of flatus was similar in both the minimal CO2 insufflation pneumoperitoneum group and the conventional CO2 pneumoperitoneum group  Uen et al 2002
  • Study details Vezakis et al 1999 Click here for more information
  • Table 5. Low CO2 pneumoperitoneum versus conventional CO2 pneumoperitoneum: Study Details and Qualitative Outcomes Barczynski and Herman 2003 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • Humidified CO2 insufflation was significantly superior to standard CO2 insufflation for reducing VAS pain scores at 6 h (p=0.02; n=32), on day 1 (p=0.03; n=27), day 2 (p=0.04, n=11) and day 3 (p=0.005; n=5) postoperatively, and also at follow-up, on day 1 (p=0.02; n=31) Mouton et al 1999
  • One study Farley et al 2004

Arguments against…

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • N2O pneumoperitoneum significantly reduced VAS pain scores compared with CO2 pneumoperitoneum at 1 h (p<0.04), 6 h (p<0.017), 23 h (p<0.002) and 24 h (p<0.026) following surgery, but not at 2, 3, 4, 5, 7, 8, 9 or 10 h postoperatively; the intensity of postoperative pain and the incidence of shoulder pain, as recorded by nurses, was similar in both groups Aitola et al 1998
  • CO2 pneumoperitoneum caused respiratory acidosis while N2O pneumoperitoneum did not (p<0.05) Aitola et al 1998

Arguments against…

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • Seven out of 12 studies found that a smaller total size of trocar incision significantly reduced VAS pain scores compared with conventional total size of trocar incision (25 mm or greater), see Table 7 for details
  • For VRS pain scores, a smaller total size of trocar incision was associated with significantly less pain in two out of three studies compared with conventional total size of trocar incision Bisgaard et al 2000 Click here for more information
  • In one study Sarli et al 2003
  • Five out of 13 studies found that a smaller total size of trocar incision significantly reduced analgesic use compared with conventional total size of trocar incision (25 mm or greater), see Table 7 for details; of those five studies, three also showed significantly lower VAS pain scores with smaller total size of trocar incision Bresadola et al 1999 Click here for more information

Arguments against…

  • Two studies out of three found no significant differences between the smaller total size and conventional (25 mm or greater) total size of trocar incision groups for the incidence of nausea and vomiting Ainslie et al 2003
  • In four out of four studies, pulmonary function values were similar in both the smaller total size and conventional (25 mm or greater) total size of trocar incision groups Ainslie et al 2003
  • There were no significant differences between the smaller total size of trocar incision and the conventional (25 mm or greater) total size of trocar incision groups for the duration of hospital stay in eight studies out of eight; see Table 7 for details Click here for more information
  • In one study out of one, the time taken to resume stool passage was similar in both the smaller total size of trocar incision and conventional (25 mm or greater) total size of trocar incision groups Sarli et al 2003
  • Study details Click here for more information
  • Table 7. Total size of trocar incision: Study Details and Qualitative Outcomes Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • Epigastric wound VAS pain scores were significantly lower in the radially expanding trocar group compared with the conventional trocar group from day 1 to day 3 following surgery (p<0.05, in all cases); subumbilical VAS pain scores over the same period were similar Lam et al 2000
  • Study details Lam et al 2000 Click here for more information

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • VRS pain scores were significantly lower in the ‘French’ technique group compared with the ‘American’ technique group at 48 h following surgery (lying VAS p=0.034; sitting VAS p=0.021), but not at 6 or 24 h Kum et al 1996
  • One study Kum et al 1996
  • One study that compared the ‘French’ and ‘American’ technique showed that FEV1 was significantly greater in the ‘French’ technique group compared with the ‘American’ technique group at 6, 24 and 48 h postoperatively (p=0.001 in all cases) Kum et al 1996

Arguments against…

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • In one study out of two, postoperative VAS pain scores were significantly lower in the ultrasonic shears group compared with the electrocautery group at 4 and 24 h (p=0.002; p=0.003, respectively), but not at 1 and 2 h Cengiz et al 2005
  • One out of two studies found that postoperative nausea scores (VAS) were significantly reduced in the ultrasonic shears group compared with the electrocautery group at 2, 4 and 24 h (p=0.023; p=0.002; p<0.001, respectively), but not at 1 h Cengiz et al 2005
  • In one study Tsimoyiannis et al 1998c
  • The length of sick leave was significantly shorter in the ultrasonic shears group compared with the electrocautery group (p<0.001) Cengiz et al 2005

Arguments against…

  • There were no significant differences between the laser dissection and the diathermy dissection groups for VAS pain scores at 24 h postoperatively (only time assessed) Scott et al 1992
  • Postoperative analgesia use was similar in both the ultrasonic shears and electrocautery groups (postoperative analgesia was rofecoxib 50 mg tablets and oral paracetamol 1 g tablets as required) Cengiz et al 2005
  • Postoperative analgesia use was similar in both laser dissection and diathermy dissection groups (type, dose and route not specified) Scott et al 1992
  • There were no significant differences between the laser dissection and the diathermy dissection groups for the duration of hospital stay Scott et al 1992
  • Study details Scott et al 1992 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • PCA opioid demands (1 mg/ml bolus doses of morphine were given, to a maximum of 6 mg/h) were significantly lower in the active aspiration group compared with the control group (p<0.05); but there was no significant difference between groups for total morphine use Fredman 1994
  • Abdominal and shoulder VAS pain scores were significantly lower in the saline lavage group compared with the control group at 2–48 h  (p<0.05, in all cases), but not at 72 h Tsimoyiannis et al 1998
  • The proportion of patients not requiring analgesia was significantly greater in the saline lavage group compared with the control group (p<0.05) Tsimoyiannis et al 1998
  • The number of suppositories required (400 mg 4-acetylamino-phenol with 20 mg codeine phosphate + 50 mg caffeine was given rectally, as required), and the proportion of patients requiring parenteral pethidine (one 50 mg dose was given if the suppositories failed) were significantly lower in the saline lavage group compared with the control group (p<0.05, in both cases) Tsimoyiannis et al 1998
  • The incidence of vomiting was similar in both groups but the incidence of nausea was significantly lower in the saline lavage group compared with the control group in one study (p<0.05) Tsimoyiannis et al 1998
  • Saline + suction was associated with significantly reduced postoperative pain scores compared with control Barczynski and Herman 2004 Click here for more information
  • Saline + suction was associated with significantly reduced supplemental analgesic requirements compared with control Barczynski and Herman 2004 Click here for more information
  • Saline lavage + suction significantly decreased abdominal and shoulder VAS pain scores at rest in the first 48 h postoperatively (both arms) (p<0.05, in all cases) Tsimoyiannis et al 1998 Click here for more information
  • The proportion of patients not requiring analgesia was significantly higher in the saline lavage + suction group compared with the control group (with or without subhepatic drain in both groups) (p<0.05, in both cases) Tsimoyiannis et al 1998Click here for more information
  • One study Tsimoyiannis et al 1998 Click here for more information
  • Two studies found that drain + saline lavage + saline suction was associated with significantly reduced supplemental analgesic use compared with control Tsimoyiannis et al 1998 Click here for more information
  • The incidence of nausea was significantly lower in the drainage + saline lavage + suction group compared with the control group in both studies (p<0.05, in both cases) Tsimoyiannis et al 1998 Click here for more information

Arguments against…

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments against…

  • There were no significant differences between the restrictive fluid administration and liberal fluid administration groups for reducing VAS pain scores in the early (i.e 0–4 h after surgery) or late (from the evening on the day of surgery to the evening on the third postoperative day) postoperative periods Holte et al 2004
  • In one study Holte et al 2004
  • In one study Holte et al 2004
  • FVC and FEV1 were significantly reduced in the restrictive fluid administration group compared with the liberal fluid administration group at 2 h postoperatively for FVC, and 2 and 4 h postoperatively for FEV1 (p<0.05, in all cases); PEF was similar in both groups Holte et al 2004
  • Study details Holte et al 2004 Click here for more information