Laparoscopic Sleeve Gastrectomy 2018

Recommended: Pre- and 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-operatively) to provide sufficient analgesia in the early recovery period

• Peri-operative pain management for LSG is recommended to include paracetamol (Grade A) and, unless contraindicated, an NSAID/COX-2-selective inhibitor (Grade A), administered pre-operatively or intra-operatively and continued into the postoperative period
• Although there was limited procedure-specific evidence to support the use of paracetamol and NSAIDs/COX-2-selective inhibitors, the analgesic benefits of these non-opioids are well described. They are considered “basic analgesics”

• A single, low dose of IV dexamethasone is recommended (Grade A) for its ability to decrease analgesic use and act as an anti-emetic (LoE 1)
• Although only one procedure-specific study reported on the analgesic effects (LoE 1), the anti-emetic effects of dexamethasone are well established, and it is likely to be of benefit in LSG

• Gabapentinoids may be considered with caution when a ‘‘basic’’ analgesic regimen such as paracetamol and NSAID/COX-2-selective inhibitor is not possible (Grade A)
• The recommendation is based on evidence of analgesic benefit in procedure-specific studies (LoE 1), but caution is advised as doses in these studies varied substantially and there are concerns that gabapentinoids may increase opioid-induced respiratory depression (Cavalcante 2017), especially in the obese or obstructive sleep apnoea populations (Joshi 2012)

• Even though there is limited procedure-specific evidence, port-site infiltration may be considered (Grade D). Port-site infiltration is favoured over TAP blocks as it is a simple and inexpensive approach that provides adequate somatic blockade

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-operatively) to provide sufficient analgesia in the early recovery period

• Peri-operative pain management for LSG is recommended to include paracetamol (Grade A) and, unless contraindicated, an NSAID/COX-2-selective inhibitor (Grade A), administered pre-operatively or intra-operatively and continued into the postoperative period
• Although there was limited procedure-specific evidence to support the use of paracetamol and NSAIDs/COX-2-selective inhibitors, the analgesic benefits of these non-opioids are well described. They are considered “basic analgesics”

• Opioids are recommended as rescue analgesia, postoperatively (Grade A) after continuation of paracetamol and unless contraindicated, an NSAID/COX-2-selective inhibitor

Interventions that are NOT recommended

• TAP blocks are not recommended (Grade D) despite the reported analgesic benefits, as the optimal technique is unclear and their use in laparoscopic procedures has been questioned (Kehlet 2015)

• Alpha-2 adrenergic agonists such as dexmedetomidine are not recommended (Grade D) due to limited and inconsistent procedure-specific evidence of analgesic benefit (LoE 4) as well as concerns regarding potential sedative and hypotensive effects

• Magnesium sulphate is not recommended (Grade D) because in the one procedure-specific study, its analgesic efficacy was not evaluated in the context of optimal multimodal analgesia including paracetamol and NSAIDs, and due to concerns of potentiation of muscle paralysis and increased incidence of residual paralysis (Thevathasan 2017)

• Intraperitoneal local anaesthetic instillation is not recommended (Grade D) as the one procedure-specific study found no analgesic benefit

• The single-port approach is not recommended (Grade B) due to limited evidence with inconsistent results

• Paracetamol (Grade A)
• NSAID OR COX-2 selective inhibitor (Grade A)
• Single, low dose of IV dexamethasone (Grade A)
• Gabapentinoids, when paracetamol and/or NSAID/COX-2 selective inhibitor are not possible (Grade A)

• Paracetamol (Grade A)
• NSAID or COX-2 selective inhibitor (Grade A)
• Rescue opioid (Grade A)