Laparoscopic cholecystectomy is increasingly becoming a procedure carried out in an ambulatory surgical setting. Optimal management of postoperative pain is an important factor as moderate to severe pain can delay a patient from being discharged from hospital and influences the patient’s well being at home. ANZCA chapter 9.1.4, p 239.

Pain after laparoscopic cholecystectomy is an outcome of tissue injury, abdominal distension, local trauma secondary to gallbladder removal, chemical irritation of the peritoneum and the pneumoperitoneum.

Evidence-based recommendations specific to the condition

For overall recommendations see PROSEPCT PROSPECT/ laparoscopic cholecystectomy update/OVERALL Prospect recommendations

For overview of treatments NOT recommended see: PROSPECT/laparoscopic cholecystectomy update /OVERALL Prospect recommendations

Preoperative

See: PROSPECT / laparoscopic cholecystectomy update / Summary recommendations / preoperative

• COX 2 selective inhibitors.
• Dexamethasone, for its antiemetic effects and potential analgesic effects
• Gabapentin.
• For ROUTINE surgery: Infiltration of the wound with a long acting local anaesthetic AND general anaesthesia. Infiltration of the wound after day surgeryreduced requirements for opioids and PONV. ANZCA chapter 9.1.4., p 239.

• For HIGH RISK PULMONARY PATIENTS: consider combined epidural analgesia with general anaesthesia.

Intraoperative

See: PROSPECT / laparoscopic cholecystectomy update / Summary recommendations / intraoperative

Systemic-based options

• Conventional NSAIDs or COX 2 selective at the end of surgery.

Regional analgesia-based techniques

• Long acting LA to infiltrate wound (infiltration of trocar orifices): reduces wound pain, does not affect shoulder pain French section 9.1. p 407.
• Intraperitoneal LA after the removal of gallbladder. Monitor dose to prevent toxicity. French section 9.1. p 407.

Postoperative

See: PROSPECT / laparoscopic cholecystectomy update / Summary recommendations / postoperative

Systemic-based options

• Whenever possible, patients should be given multimodal pain management.
  • COX-2 selective NSAIDs, nonselective NSAIDs, and calcium channel α-2-δ antagonists (gabapentin and pregabalin) should be considered as part of a postoperative multimodal pain management regimen.
  • Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen. ASA section V Multimodal techniques for Pain Management, p 253-254.
• Opioids for moderate to severe pain.
• For HIGH RISK PULMONARY PATIENTS. Continue with epidural LA and opioid combination.

Summary

Laparoscopic cholecystectomy is increasingly becoming a procedure carried out in an ambulatory surgical setting. Postoperative analgesia should include wound infiltration as part of a multi-modal regimen, including paracetamol, NSAIDs and perhaps gabapentin.

Supplementary reading

1. Ross S, Rosemurgy A, Albrink M, et al Consensus statement of the consortium for LESS cholecystectomy. Surg Endosc 2012 Oct;26(10):2711-6.