title: Desflurane versus propofol maintenance for outpatient laparoscopic cholecystectomy Oral clonidine premedication preserves heart rate variability for patients undergoing larparoscopic cholecystectomy Interpleural catheter for analgesia after cholecystectomy: the surgical perspective. Intraperitoneal Normal Saline Infusion for Postoperative Pain after Laparoscopic Cholecystectomy "Patient demand" postoperative analgesia with buprenorphine. Comparison between sublingual and i.m. administration. Conventional pneumoperitoneum compared with abdominal wall lift for laparoscopic cholecystectomy. Effect of timing of morphine administration during remifentanil-based anaesthesia on early recovery from anaesthesia and postoperative pain. Pain after laparoscopic cholecystectomy A new method of preemptive analgesia in laparoscopic cholecystectomy Intraperitoneal pethidine versus Intramuscular pethidine for the relief of pain after laparoscopic cholecystectomy: Randomized trial Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy Inhalation Versus Total Intravenous Anesthesia for Lumbar Disc Herniation: Comparison of Hemodynamic Effects, Recovery Characteristics, and Cost Gasless laparoscopic cholecystectomy: comparison of postoperative recovery with conventional technique. Post-operative nausea and vomiting in out-patient gynecologic laparoscopy: a comparison of thiopental-nitrous oxide, propofol-nitrous oxide and total intravenous anesthesia using propofol. Analgesic effect of low‐dose intrathecal morphine and bupivacaine in laparoscopic cholecystectomy Propofol Maintenance to Reduce Postoperative Emesis in Thyroidectomy Patients: A Group Sequential Comparison with Isoflurane/Nitrous Oxide An intervention study to enhance postoperative pain management. Is minisite cholecystectomy less traumatic? Prospective randomized study comparing minisite and conventional laparoscopic cholecystectomies Bupivacaine instillation into gallbladder bed after laparoscopic cholecystectomy: does it decrease shoulder pain? Prospective randomized trial of low‐pressure pneumoperitoneum for reduction of shoulder‐tip pain following laparoscopy Recovery following laparoscopic cholecystectomy in either a 23 hour or an 8 hour facility. Microlaparoscopic vs conventional laparoscopic cholecystectomy: a prospective randomized double-blind trial. Preoperative Multimodal Analgesia Facilitates Recovery After Ambulatory Laparoscopic Cholecystectomy The Value of Pre-Emptive Analgesia in the Treatment of Postoperative Pain after Laparoscopic Cholecystectomy The clinical impact of warmed insufflation carbon dioxide gas for laparoscopic cholecystectomy Pain and analgesic response after third molar extraction and other postsurgical pain Effect of Short-Term Ketorolac Infusion on Recovery following Laparoscopic Day Surgery Effect of oral clonidine premedication on perioperative hemodynamic response and postoperative analgesic requirement for patients undergoing laparoscopic cholecystectomy. Physician variability in the management of acute postoperative and cancer pain: a quantitative analysis of the Michigan experience. Intraperitoneal normal saline and bupivacaine infusion for reduction of postoperative pain after laparoscopic cholecystectomy. Interpleural analgesia improves pulmonary function after cholecystectomy Analgesia after upper abdominal surgery with extradural buprenorphine with lidocaine A Comparison of the Efficacy of Ketorolac and Indomethacin for Postoperative Analgesia following Laparoscopic Surgery in Day Patients Efficacy of thoracic epidural analgesia following laparoscopic cholecystectomy. Epidural Morphine by the Thoracic or Lumbar Routes in Cholecystectomy. Effect on Postoperative Pain and Respiratory Variables Continuous Infusion of Interpleural Bupivacaine Maintains Effective Analgesia After Cholecystectomy Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Dextromethorphan attenuation of postoperative pain and primary and secondary thermal hyperalgesia The effects of intraperitoneal local anesthetic on analgesic requirements and endocrine response after laparoscopic cholecystectomy: a randomized double-blind controlled study. Wound closure tramadol administration has a short-lived analgesic effect Interpleural Bupivacaine for Postoperative Analgesia Following Cholecystectomy: A Randomized Prospective Study A Single Small Dose of Postoperative Ketamine Provides Rapid and Sustained Improvement in Morphine Analgesia in the Presence of Morphine-Resistant Pain Intraperitoneal Application of Bupivacaine During Laparoscopic Cholecystectomy--Risk or Benefit? The use of intraperitoneal bupivacaine to decrease the length of stay in elective laparoscopic cholecystectomy patients. Randomized, controlled trial of bupivacaine injection to decrease pain after laparoscopic cholecystectomy. A simple and effective way to reduce postoperative pain after laparoscopic cholecystectomy. Comparison of continuous epidural infusion of fentanyl and fentanyl-bupivacaine for post cholecystectomy pain control. Preemptive Analgesia: Intraperitoneal Local Anesthetic in Laparoscopic Cholecystectomy A Randomized, Double-blind, Placebo-controlled Study Post-operative pain in needlescopic versus conventional laparoscopic cholecystectomy: a prospective randomised trial. A randomized controlled trial assessing the benefit of humidified insufflation gas during laparoscopic surgery Comparison of immunologic and physiologic effects of CO2 pneumoperitoneum at room and body temperatures Comparison of Three Morphine Regimens in Postsurgical Patients Using Patient-Controlled Analgesia Clonidine premedication prevents sympathetic hyperactivity but does not prevent hypothalamo-pituitary-adrenocortical responses in patients undergoing laparoscopic cholecystectomy Randomized comparison of conventional and gasless laparoscopic cholecystectomy: Operative technique, postoperative course, and recovery Comparison of nalbuphine and buprenorphine in total intravenous anaesthesia A prospective randomized trial of intraoperative bupivacaine irrigation for management of shoulder-tip pain following laparoscopy. Intravenous Tenoxicam for Analgesia following Laparoscopic Cholecystectomy Lack of pre‐emptive analgesic effect of (R)‐ketamine in laparoscopic cholecystectomy A comparative study of ketorolac and diclofenac on post-laparoscopic cholecystectomy pain. Postoperative recovery after cholecystectomy by minilaparotomy: a randomized double-blind comparison between alpha-trinositol and placebo. Intercostal nerve blockade with a mixture of bupivacaine and phenol enhance the efficacy of intravenous patient-controlled analgesia in the control of post-cholecystectomy pain. A randomized prospective study of radially expanding trocars in laparoscopic surgery Preoperative Parenteral Parecoxib and Follow-Up Oral Valdecoxib Reduce Length of Stay and Improve Quality of Patient Recovery After Laparoscopic Cholecystectomy Surgery Effects of intraperitoneal lidocaine combined with intravenous or intraperitoneal tenoxicam on pain relief and bowel recovery after laparoscopic cholecystectomy Comparison of N2O and CO2 pneumoperitoneums during laparoscopic cholecystectomy with special reference to postoperative pain. Sympathetic suppression attenuates anomalous responses to morphine in unexplained pain after cholecystectomy The effect of drains in laparoscopic cholecystectomy. Incidence and severity of postoperative nausea and vomiting are similar after metoclopramide 20 mg and ondansetron 8 mg given by the end of laparoscopic cholecystectomies Pain After Laparoscopic Cholecystectomy: Characteristics and Effect of Intraperitoneal Bupivacaine Effect of intramuscular intraoperative pain medication on narcotic usage after laparoscopic cholecystectomy. Analgesic effect of intraperitoneal instillation of bupivacaine for postoperative laparoscopic cholecystectomy. Comparison of 40 milliliters of 0.25% intrapleural bupivacaine with epinephrine with 20 milliliters of 0.5% intrapleural bupivacaine with epinephrine after cholecystectomy. A prospective randomized trial on comparison of low-pressure (LP) and standard-pressure (SP) pneumoperitoneum for laparoscopic cholecystectomy Effect of fluid instillation on postlaparoscopy pain. Dexamethasone 8 mg in combination with ondansetron 4 mg appears to be the optimal dose for the prevention of nausea and vomiting after laparoscopic cholecystectomy The Effects of Small-Dose Ketamine on Morphine Consumption in Surgical Intensive Care Unit Patients After Major Abdominal Surgery Prospective randomized blinded trial of pulmonary function, pain, and cosmetic results after laparoscopic vs microlaparoscopic cholecystectomy Elective transumbilical compared with standard laparoscopic cholecystectomy. Helium vs carbon dioxide gas insufflation with or without saline lavage during laparoscopy Effectiveness and Safety of Combined Epidural and General Anesthesia for Laparoscopic Cholecystectomy Recovery after uncomplicated laparoscopic cholecystectomy. Effect of different therapeutic suggestions presented during anaesthesia on post-operative course. Postoperative pain treatment after cholecystectomy with epidural sufentanil at lumbar or thoracic level. Randomized controlled trial of total intravenous anesthesia with propofol versus inhalation anesthesia with isoflurane-nitrous oxide: postoperative nausea with vomiting and economic analysis. Post-cholecystectomy pulmonary function following interpleural bupivacaine and intramuscular pethidine. Intercostal blockade and pulmonary function after cholecystectomy. Pain after laparoscopic cholecystectomy: the effect and timing of incisional and intraperitoneal bupivacaine Epidural bupivacaine and morphine plus systemic indomethacin eliminates pain but not systemic response and convalescence after cholecystectomy. Effect of intraperitoneal bupivacaine on pain after laparoscopic cholecystectomy Muscle pain after outpatient laparoscopy--influence of propofol versus thiopental and enflurane. Intraperitoneal bupivacaine for analgesia after laparoscopic cholecystectomy Intraperitoneal Bupivacaine Does Not Attenuate Pain Following Laparoscopic Cholecystectomy Perioperative antinociceptive effects of tramadol. A prospective, randomized, double-blind comparison with morphine Ibuprofen provides longer lasting analgesia than fentanyl after laparoscopic surgery. The effect of CO2 insufflation rate on the postlaparoscopic shoulder pain. Suprascapular nerve block or a piroxicam patch for shoulder tip pain after day case laparoscopic surgery Effects of Ketorolac on Postoperative Analgesia and Ventilatory Function After Laparoscopic Cholecystectomy Pain after microlaparoscopic cholecystectomy. A randomized double-blind controlled study. Intraperitoneal Versus Interpleural Morphine or Bupivacaine for Pain after Laparoscopic Cholecystectomy Influence of intraperitoneal anesthesia on pain and the sympathoadrenal response to abdominal surgery Dexamethasone reduces nausea and vomiting after laparoscopic cholecystectomy. Preoperative diclofenac sodium reduces postlaparoscopy pain [Gasless versus conventional laparoscopic cholecystectomy. A randomized trial with regard to technical problems, postoperative course and convalescence]. Postoperative Analgesia by D-myo-Inositol-1,2,6-Trisphosphate in Patients Undergoing Cholecystectomy Postoperative Effects of Fentanyl, Ketorolac, and Piroxicam as Analgesics for Outpatient Laparoscopic Procedures Dexamethasone in Combination with Dolasetron for Prophylaxis in the Ambulatory Setting: Effect on Outcome after Laparoscopic Cholecystectomy The effect and timing of local anesthesia in laparoscopic cholecystectomy. Small-Dose Dexamethasone Reduces Nausea and Vomiting After Laparoscopic Cholecystectomy: A Comparison of Tropisetron with Saline The Effect of Anaesthetic Technique on Postoperative Nausea and Vomiting after Day-case Gynaecological Laparoscopy Antiemetic efficacy of prophylactic ondansetron in laparoscopic cholecystectomy The Clinical Efficacy and Pharmacokinetics of Intraperitoneal Ropivacaine for Laparoscopic Cholecystectomy A randomised double‐blind study of interpleural analgesia after cholecystectomy Indomethacin and ketorolac given preoperatively are equally effective in reducing early postoperative pain after laparoscopic cholecystectomy. Comparison of fentanyl and nalbuphine in total intravenous anaesthesia (TIVA). Intraperitoneal bupivacaine for effective pain relief after laparoscopic cholecystectomy. Intravenous clonidine fails to reduce postoperative meperidine requirements. Application of sublingual buprenorphine in combination with naproxen or paracetamol for post‐operative pain relief in cholecystectomy patients in a double‐blind study Use of subdiaphragmatic bupivacaine instillation to control postoperative pain after laparoscopic surgery. Randomized trial of different insufflation pressures for laparoscopic cholecystectomy Randomized trial of periportal peritoneal bupivacaine for pain relief after laparoscopic cholecystectomy Influence of intravenous clonidine pretreatment on anesthetic requirements during bispectral EEG-guided sevoflurane anesthesia. A randomized comparison of patient-controlled versus standard analgesic requirements in patients undergoing cholecystectomy. Intraoperative wound infiltration with bupivacaine in patients undergoing elective cholecystectomy. Emetic effects of morphine and piritramide. Randomized trial of needlescopic versus laparoscopic cholecystectomy Preoperative Dexamethasone Improves Surgical Outcome After Laparoscopic Cholecystectomy: A Randomized Double-Blind Placebo-Controlled Trial Intramuscular diclofenac sodium for postoperative analgesia after laparoscopic cholecystectomy: a randomised, controlled trial. Anesthesia for laparoscopic cholecystectomy. Is nitrous oxide contraindicated?
abstract: Background : The aims of the study were to evaluate costs and clinical characteristics of desflurane‐based anaesthetic maintenance versus propofol for outpatient cholecystectomy Background : Clonidine has been shown to reduce perioperative circulatory instability . This postoperative analgesic effect of clonidine was also known in previous studies . The aim of the study was to investigate the clinical efficiency of oral clonidine premedication in anesthesia and analgesia in patients undergoing laparoscopic cholecystectomy Sixteen otherwise healthy women undergoing cholecystectomy were r and omized to receive postoperative analgesia either by continuous infusion of papaveretum  ( n = 8) , or by continuous interpleural infusion of bupivacaine  ( n = 8) . Postoperative pain was assessed by linear analogue and ventilatory capacity . Changes in body protein were measured by in vivo neutron activation analysis . Clinical course was also noted . Pain scores were significantly lower in the interpleural group over the first 48 h ( P less than 0.02 ) . Ventilatory capacity was also significantly better for the first 24 h ( P less than 0.025 ) . There was no evidence of shortened postoperative ileus ; hospital stay and postoperative fatigue were similar for the two groups . Weight and protein losses over a 2 week period were similar in the two groups . It is concluded that the apparent advantages in patient comfort and mobility offered by interpleural infusion are most marked in the first 48 h postoperatively , with an advantage in ventilatory capacity over the first 24 Abstract . After laparoscopic surgery carbon dioxide remains within the peritoneal cavity for a few days , commonly causing pain . This prospect i ve r and omized study was performed to determine the efficacy of intraperitoneal infusion of normal saline on  postoperative pain after laparoscopic cholecystectomy . Altogether 300 patients were r and omly assigned to one of five groups of 60 patients each . Group A : control group , no peritoneal infusion , no subhepatic drain . Group B : no peritoneal infusion but a subhepatic closed drain was left for 24 hours . Group C : normal saline 25 to 30 ml/kg body weight at a temperature of 37 ° C was infused under the right hemidiaphragm and left in the peritoneal cavity . Group D : normal saline in a room temperature was infused under the right hemidiaphragm and suctioned after the pneumoperitoneum was deflated . Group E : normal saline was infused and suctioned as in group D , but a subhepatic closed drain was left for 24 hours . Postoperatively , analgesic medication usage , nausea , vomiting , and pain scores were determined at 2 , 6 , 12 , 24 , 48 , and 72 hours ( during hospitalization and at home ) . Postoperative pain was reduced significantly ( p < 0.001 ) in the patients of groups C , D , and E versus controls , whereas no difference was observed between groups A and B. Among groups C , D , and E , group E ( p < 0.01 ) had the best results followed by group D and then group C. Intraperitoneal normal saline offered a detectable benefit to patients undergoing laparoscopic cholecystectomy . The beneficial effect was better when the fluid was suctioned after deflation of the pneumoperitoneum and even better when a subhepatic closed drain continued fluid suction during the first postoperative hours A r and omized , double-blind , placebo-controlled study of buprenorphine was carried out in 20 patients after cholecystectomy . The drug was given on " patient dem and " either i.m . ( 0.15 mg ) or sublingually ( 0.2 mg ) with a minimum dose interval of 30 min . Over the 24-h study period the mean dem and by the sublingual route was 0.8 mg ( range 0.6 - 1.2 mg ) and by the i.m . route 0.66 mg ( range 0.45 - 0.9 mg ) . Pain relief , by visual analogue scales and grading , was similar . Plasma buprenorphine concentrations varied more after sublingual administration . Either route was effective for the treatment of pain when administered by " patient dem and " We have compared , in a r and omized study , conventional carbon dioxide pneumoperitoneum with abdominal wall lift in 25 patients undergoing laparoscopic cholecystectomy .  Intra-abdominal pressure ( IAP ) ( 11 ( SD 2 ) mm Hg vs 2.7 ( 9 ) mm Hg ) ( P < 0.01 ) and total amount of carbon dioxide used ( 40 ( 23 ) litre vs 9 ( 7 ) litre ) ( P < 0.001 ) were significantly less with abdominal wall lift . Pulmonary compliance was significantly greater ( P < 0.01 ) in the abdominal wall lift group throughout operation . During the first 15 min of insufflation , arterial pressures were lower with abdominal wall lift ( P < 0.05 ) . In the conventional pneumoperitoneum group , femoral vein pressure increased ( P < 0.01 ) and remained elevated for 3 h in the recovery room . Postoperative drowsiness was of significantly longer duration in the conventional pneumoperitoneum group than in the abdominal wall lift group ( 98 ( 46 ) min vs 13 ( 34 ) min ) ( P < 0.01 ) . Postoperative nausea and vomiting and right shoulder pain occurred more often in patients with conventional pneumoperitoneum ( P < 0.05 ) . We conclude that the benefits of abdominal wall lift may be attributed to avoiding excessive carbon dioxide and high IAP BACKGROUND Since the time to peak analgesic effect of intravenous morphine can be longer than 40 - 60 min in volunteers , the goal of this study was to evaluate the effect of the timing of intraoperative morphine administration on  early postoperative pain .  METHODS A total of 120 adult patients undergoing laparoscopic cholecystectomy were studied .  Anaesthesia was induced with remifentanil and etomi date and maintained with remifentanil and sevoflurane/nitrous oxide . Morphine 150 micrograms kg-1 was given r and omly at three different times during surgery , and a fourth group received placebo .  Times to eyes opening and extubation were measured , and pain was evaluated in the post-anaesthesia care unit ( PACU ) using a visual analogue scale ( VAS ) . Morphine 2 - 3 mg was given when the VAS score was > or = 50 mm . The four groups were , according to the time elapsed from morphine administration to the end of surgery , group 1 ( n = 30 ) : placebo ; group 2 ( n = 33 ) : < 20 min ; group 3 ( n = 30 ) : 20 - 40 min ; group 4 ( n = 27 ) : > 40 min . RESULTS Recovery from anaesthesia and pain scores were similar in all groups . However , mean ( SD ) morphine consumption was 5.7 ( 4.7 ) mg in group 1 , 4.4 ( 4.2 ) mg in group 2 , 4.7 ( 4.7 ) mg in group 3 , and 2.2 ( 4.0 ) mg in group 4 ( P < 0.05 , group 1 vs 4 ) .  Morphine  was required in only 38 % of patients in group 4 compared with 83 % , 67 % and 69 % in groups 1 , 2 , and 3 , respectively ( P < 0.01 , group 1 vs 4 ) . CONCLUSIONS The timing of intraoperative morphine administration did not affect the early recovery from anaesthesia . However , the reduction in the number of patients requiring morphine  in the PACU when morphine had been given more than 40 min before the end of surgery supports this practice , rather than administration closer to the end of surgery It is postulated that laparoscopic cholecystectomy as “ patient-friendly surgery ” leads to more comfort and in particular to less pain . A prospect i ve study on pain was performed on all patients undergoing the operation over the period of 1 year ( n=382 ) out of a series of more than 1,000 patients who have undergone the operation in our clinic .  Pain was measured by a 100-point visual analogue scale ( VAS ) , by a five-point verbal rating scale , and by the  consumption of analgesics . Pain was the most frequent symptom , both before and after the operation . The mean level of pain was 37 VAS points 5 h after the operation and declined to 16 points on the third day . In 106 patients ( 27.8 % ) the intensity of pain was higher than 50 VAS points . Analgesics  were used by 282 patients ( 73.8 % ) , opioids by 112 ( 29.3 % ) . Pain was significantly higher in female than male patients ( P<0.05 ) , but consumption of analgesics was similar in both groups . The most severe pain was localized to the abdominal wall wounds by 157 ( 41.1 % ) and to the right upper abdomen by 138 patients ( 36.1 % ) on the first postoperative day . Patients who needed  opioids  and /or had a pain level of > 50 VAS points ( n=138 ) had higher preoperative pain levels ( P=0.018 ) and preoperatively complained more frequently about nausea , vomiting , bloating , and a feeling of abdominal pressure ( P=0.003–0.031 ) . However , predictive values of these variables were too small to be of clinical benefit . The duration of operation , intraoperative events ( loss of bile , blood , or gallstones ) , and additional laparoscopic procedures ( adhesiolysis , lavage , extension of an incision , suture of fascia ) did not influence the intensity of postoperative pain . We conclude that laparoscopic cholecystectomy did cause significant postoperative pain in one-third of our patients only up to the first postoperative day . As predictors for high intensity of pain were not identified , pain should be monitored and analgesics should be delivered liberally Background Although laparoscopic cholecystectomy ( LC ) results in less pain then open cholecystectomy , it is not a pain-free procedure . The aim of this study was to test a new method of preemptive analgesia . Methods By simple r and omization 60 patients were assigned to two groups ( 30 in each group ) . Group A , the placebo group , received 200 ml of 0.9 % saline , and group B received 5 mg/kg of a local anesthetic solution ( ropivacaine ) in 200 ml of 0.9 % saline . Local anesthetic or place solution were administer before creation of the pneumoperitoneum . Results Pain intensity , as rated by visual analog and verbal rating scales , and stress response data were significantly less in the group receiving ropivacaine than in the placebo group . No patients in treatment group received an additional dose of analgesic , whereas two patients in placebo group needed an additional analgesic . Conclusions Our results support the clinical validity of preemptive analgesia , but the timing of intraperitoneal administration of local anesthetic is very important . Only application before creation of the pneumoperitoneum may preempt every neuronal central sensitization Laparoscopic cholecystectomy is widely used and may be performed as an ambulatory procedure . We undertook a r and omized comparison of the benefits of intraperitoneal pethidine compared with intramuscular pethidine for postoperative analgesia following laparoscopic cholecystectomy . A series of 100 consecutive American Society of Anesthesiologists ( ASA ) I or II patients were r and omly assigned to intramuscular pethidine ( 54 patients ) or intraperitoneal pethidine ( 46 patients ) . Each was combined with intraperitoneal bupivacaine . The primary end-points were the pain and nausea scores at intervals after operation . All recruited patients completed the study . Pain scores at rest and upon movement were significantly lower in the group receiving the intraperitoneal pethidine at each of the time periods examined ( pain at rest at 4 hours : 1.6±0.8 vs. 2.4±0.9 cm ; p<0.001 ; pain upon movement at 4 hours : 2.1±0.9 vs. 3.1±1.2 cm ; p<0.001 ) . The total dose of pethidine administered via patient-controlled analgesia ( PCA ) during the first 24 hours after surgery was also significantly lower in this group ( total dose 50.9±3.9 vs. 55.9±4.4 mg ; p<0.001 ) . There were no significant differences in the respiratory rate at any of the time periods . Intraperitoneal pethidine  analgesia was superior to an equivalent dose of intramuscular pethidine for the relief of postoperative pain in patients undergoing laparoscopic cholecystectomy . This was achieved at the expense of increased nausea but no significant increase in vomiting . The accessibility of this route of analgesia administration has implication s for patients undergoing laparoscopic procedures , particularly with the recent trend toward increased use of ambulatory techniques . RésuméLa cholécystectomie laparoscopique est réalisée dans le monde entier et peut être réalisée en ambulatoire . Nous avons comparé par une étude r and omisée les bénéfices de la pethidine en intraperitoneal comparée à la pethidine en intramusculaire pour l’analgésie postcholecystectomic laparoscopique . Cent patients consécutifs , ASA I ou II , ont été r and omisés pour recevoir soit de la pethidine en intra-musculaire ( 54 patients ) ou en intrapéritonéale ( 46 patients ) . De la bupivacaïne a été administrée en intrapéritonéale chez tous les patients . Les critères de jugement principaux et secondaires ont été les scores de la douleur et de la nausée à des intervalles successifs post-opératoires . Tous les patients inclus ont complété l’étude . La douleur au repos et lors des mouvements a été significativement moindre dans le groupe recevant de la pethidine en intrapéritonéale à chaque intervalle étudié [ douleur au repos à 4 heures : 1.6 ( 0.8 ) cm vs. 2.4 ( 0.9 ) cm ; p=0.001 ; douleur lors des mouvements à 4 heures : 2.1 ( 0.9 ) cm vs. 3.1 ( 1.2 ) cm ; p=0.001 ] . La dose totale de pethidine administrée via la PCA pendant les 24 premières heures après chirurgie a également été plus basse dans ce groupe [ dose totale 50.9 ( 3.9 ) mg vs. 55.9 ( 4.4 ) mg ; p=0.001 ] . Il n’y avait aucune différence statistiquement significative en ce qui concernait la fréquence respiratoire quel que soit le moment de l’étude . La pethidine en intrapéritonéale est supérieure à la pethidine en intramusculaire pour l’analgésie de la douleur post-cholécystectomie laparoscopique . Cette amélioration a été accomplie au prix de plus de nausées mais sans augmentation significative des vomissements . L’utilisation de cette route d’administration a des implication s importantes chez le patient opéré sous laparoscopic , en particulier , vu la tendance actuelle à élargir les indications de la chirurgie ambulatoire . ResumenLa colecistectomía laparoscópica es el procedimiento más empleado en cirugía ambulatoria . Efectuamos un estudio comparative aleatorio sobre los efectos , de la petidina intraperitoneal vs intramuscular , en la analgesia postcolecistectomía laparoscópica .  100 pacientes ASA I o II fueron aleatoriamente distribuidos en 2 grupos : petidina intramuscular ( n=54 ) y petidina intraperitoneal ( n=46 ) ; a este último grupo se le asoció bupivacaina intraperitoneal . Se investigaron el dolor y las nauseas durante el postoperatorio . Todos los pacientes completaron el estudio . El dolor postoperatorio tanto en reposo como con la movilización fue significativamente menor en el grupo de petidina intraperitoneal [ dolor en reposo a las 4 horas 1.6 ( 0.8 ) cm vs 2.4 ( 0.9 ) cm ; p<0.001 ; dolor a la movilización a las 4 horas 2.1 ( 0.9 ) cm vs 3.1 ( 1.2 ) cm ; p<0.001 ] . Además , en este grupo la dosis total de petidina  administrada en las primeras 24 horas del periodo postoperatorio fue menor [ dosis total 50.9 ( 3.9 ) mg vs 55.9 ( 4.4 ) mg , p<0.001 ] . No se observaron diferencias significativas en la frecuencia respiratoria a lo largo del periodo postoperatorio . La analgesia proporcionada por la administración intraperitoneal de petidina es superior a la obtenida por inyección intramuscular , aunque se produzcan más nauseas pero sin que se incremente la frecuencia de vómitos . Dada la accesibilidad de esta vía para la administración de analgésicos este proceder debe tenerse muy en cuenta en las técnicas laparoscópicas , especialmente si se quiere incrementar la realización de las mismas de manera ambulatoria Abstract Background : Laparoscopic cholecystectomy using low-pressure pneumoperitoneum ( 8 mmHg ) minimizes adverse hemodynamic effects , reduces postoperative pain , and accelerates recovery . Similar cl aims are made for gasless laparoscopy using abdominal wall lifting . The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery . Methods : Thirty-six patients were r and omized to low-pressure or gasless laparoscopic cholecystectomy using a subcutaneous lifting system ( Laparotenser ) .  Results : The characteristics of the patients were similar in the two groups . The procedure was completed in all patients in the low-pressure group , but two patients in the gasless group were converted to pneumoperitoneum . There were no significant differences in postoperative pain and analgesic consumption , but patients in the gasless group developed shoulder pain more frequently ( 50 % vs 11 % , p < 0.05 ) . Gasless operation took longer to perform ( 95 vs 72.5 min , p= 0.01 ) . Conclusions : Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery . The gasless technique provided inferior exposure and the operation took longer , but the technique may still have value in high-risk patients with cardiorespiratory disease The clinical effects , recovery characteristics , and costs of total intravenous anesthesia ( TIVA ) , sevoflurane , and isoflurane anesthesia have been measured in various out-patient operations , but have not been evaluated in patients undergoing laminectomy or discectomy . In the current study , the authors assessed the hemodynamic characteristics , recovery , and cost analyzes after laminectomy and discectomy operations , comparing TIVA , sevoflurane , and isoflurane anesthesia .  Sixty American Society of Anesthesiologists I and II patients were r and omly divided into three groups , each consisting of 20 patients . Group I received propofol-alfentanil , Group 2 received sevoflurane-N2O , and Group 3 received isoflurane-N2O . At the end of surgery , the anesthetics were discontinued , and recovery from anesthesia was assessed by measuring the time until spontaneous eye opening and the time until response to verbal comm and s. The drug and delivery costs were calculated in United States dollars . No significant differences were found in the demographic data . Heart rate and mean arterial pressure decreased significantly after induction of anesthesia in the TIVA group , compared to the two other groups ( P < .05 for both comparisons ) . The fastest recovery was seen in the TIVA group . Incidences of postoperative nausea , vomiting , and pain were significantly reduced after TIVA ( P < .05 for both comparisons ) . Thus , TIVA patients required fewer additional drugs and showed the lowest additional costs in the post-anesthesia care unit . However , the total cost was significantly higher in the TIVA group than in the sevoflurane and isoflurane groups ( $ 52.73 , $ 29.99 , and $ 24.14 , respectively ) ( P < .05 ) . Total intravenous anesthesia was associated with the highest intraoperative cost but provided the most rapid recovery from anesthesia , and the least frequent postoperative side effects We have compared , in a r and omized study in 26 patients , immediate and late postoperative recovery after elective laparoscopic cholecystectomy using the gasless , mechanical abdominal wall lift method with conventional carbon dioxide pneumoperitoneum .  After the gasless method , tracheal extubation was performed significantly earlier than after the conventional method ( P < 0.01 ) . End-tidal carbon dioxide concentrations were significantly higher after pneumoperitoneum for 30 min after operation ( P < 0.01 ) . In the conventional group , deviation in Maddox-Wing recordings from preoperative values remained at a significantly higher level during the 3-h recovery room period ( P < 0.01 ) . There was a positive correlation between the total amount of carbon dioxide used and duration of drowsiness ( r = 0.61 , P < 0.001 ) and the Maddox-Wing deviation ( r = 0.62 , P < 0.001 ) . Postoperative nausea and vomiting , and right shoulder pain occurred less often after the gasless method ( P < 0.05 ) . Late recovery criteria ( ability to drink , void and walk ) in patients in the gasless group were fulfilled approximately 7 h earlier than in those in the pneumoperitoneum group ( P < 0.01 ) . Gasless laparoscopic cholecystectomy result ed in more uneventful and faster immediate and late postoperative recovery than conventional carbon dioxide pneumoperitoneum An intravenous anesthetic drug , propofol was considered to pose antiemetic action . A r and omized controlled trial was conducted to evaluate whether propofol could effectively reduce  post-operative nausea and vomiting ( PONV )  compared to thiopental-nitrous oxide ( N2O ) .  One-hundred and eight patients undergoing outpatient gynecologic laparoscopy were assigned to receive 3 techniques of anesthesia ; thiopental-N2O ( T/N ) , propofol-N2O ( P/N ) and total intravenous anesthesia ( TIVA ) using propofol ( P/P ) . The results showed that in the early period ( 0 - 5 hours ) , post-operative nausea in T/N , P/N and P/P groups was 72 per cent , 44 per cent and 31 per cent , respectively ( P = 0.002 ) , and post-operative vomiting was 58 per cent , 36 per cent and 11 per cent respectively ( P = 0.00014 ) . Patients in the P/N and P/P groups experienced nausea less frequently than the T/N group [ relative risk ( RR ) = 0.62 , ( 95 % CI 0.41 - 0.93 ) and RR = 0.42 ( 0.25 - 0.72 ) respectively ] . Patients in the P/N and P/P groups experienced vomiting less frequently than the T/N group [ RR = 0.62 ( 0.37 - 1.04 ) and RR = 0.19 ( 0.07 - 0.5 ) respectively ] . Two patients in the T/N group were admitted because of severe nausea and vomiting . In conclusion , TIVA using propofol and propofol-N2O anesthesia can significantly reduce the incidence of PONV in the early period . Concerning the economic crisis of the country as well as the quality of care , propofol-N2O would be the most appropriate anesthetic of choice We assessed the peri‐operative analgesic efficiency of low‐dose intrathecal morphine combined with a low dose of bupivacaine  after elective laparoscopic cholecystectomy since postoperative pain in such procedures , although less than after a conventional open technique , may be significant , particularly during the first 12–24 h. After informed consent , 34 ASA I or II patients were r and omly allocated to one of two groups to receive either a lumbar intrathecal injection of morphine ( 75 or 100 μg ) combined with 5 mg of isobaric bupivacaine ( spinal group ) or a subcutaneous injection of a saline solution ( control group ) . Intra‐operatively , opioid requirements , blood pressure response and heart rate changes after insufflation were recorded . Postoperatively , morphine requirements , pain scores and opioid‐related side‐effects were assessed by a physician blinded to the r and omisation . Intra‐operative opioid requirements did not differ significantly between groups . Mean ( SD ) postoperative morphine requirements were significantly lower in the spinal group [ 13 ( 10 ) vs. 23 ( 10 ) mg ; p = 0.04 ] as were postoperative pain scores ( p < 0.001 ) . Side‐effects were of comparable incidence and severity between groups . Low‐dose intrathecal morphine combined with low‐dose bupivacaine provided effective postoperative analgesia for elective laparoscopic cholecystectomy The clinical benefit of propofol anaesthesia in the prevention of postoperative nausea and vomiting ( PONV ) is still being eluci date d despite many studies to date . In this study 64 adult female patients scheduled for thyroidectomy received , in a r and omized double-blind fashion , propofol with air or isoflurane with nitrous oxide for maintenance of anaesthesia . The primary response variable was the presence or absence of vomiting in the first six hours . A group sequential design was used to allow interim analysis . After 64 patients , the fourth analysis showed that fewer patients receiving propofol  vomited or required an anti-emetic during the first six hours ( P<0.05 ) . There was no significant difference detected in the 6 to 24 hour interval . In this group of female patients , total intravenous anaesthesia ( TIVA ) with propofol is associated with an early reduction in early postoperative vomiting compared with st and ard inhalational techniques . This reduction in vomiting does not appear to persist beyond the first six hours UNLABELLED This study , conducted before and after the implementation of an  acute pain service ( APS ) in a 1000-bed hospital , describes the process of the implementation of an APS . The nursing , anesthesia , and surgery departments were involved . In this study we sought to evaluate the results of a continuous quality improvement program by defining quality indicators and using quality tools . A quality program in accordance with current st and ards of acute pain treatment ( multimodal ) was worked out to enhance pain relief for all surgical in patients . A survey of nurses ' knowledge with regard to postoperative pain was conducted , and a  visual analog scale ( VAS ) was introduced to assess pain intensity . Both nurses and physicians became familiar with evidence -based guidelines concerning postoperative pain . The entire process was monitored in three consecutive surveys and enrolled 2383 surgical in patients .  Pain indicators based on VAS and analgesic consumption were recorded during the first 72 postoperative hours . After a baseline survey about current practice s of pain treatment , a nurse-based , anesthesiologist-supervised APS was implemented . The improvement in pain relief , expressed as VAS scores , was assessed in two further surveys . A quality manual was written and implemented . A major improvement in pain scores was observed after the APS inception ( P < 0.001 ) . IMPLICATION S The implementation of an acute pain service , including pain assessment by a visual analog scale , st and ard multimodal pain treatment , and continuous quality evaluation , improved postoperative pain relief . Establishing teams of surgeons , anesthesiologists , and nurses is the prerequisite for this improvement The main objectives of minisite cholecystectomy ( MC ) are to have smaller incisions , better cosmetic results , less trauma , and a lower morbidity rate . This prospect i ve r and omized study compares MC with conventional laparoscopic cholecystectomy ( CLC ) in terms of surgical trauma and cosmetic results in 44 patients . Conversion from MC to CLC was required in five patients . No conversion to open surgery was needed in the CLC group . The average operating time was slightly longer in the MC group , but the difference was not statistically significant ( 81 minutes versus 72 minutes , p=0.22 ) . The population characteristics , postoperative respiratory function measurements , pain scores , and analgesic requirements were similar in the two groups . The average score for scar tissue was significantly lower in the MC group ( 0.73 versus 1.93 , p=0.0045 ) . Only the cosmetic results of MC were superior to CLC . This technique could be a feasible alternative procedure in patients seeking better cosmetic results . However , further studies with larger sample sizes are needed to evaluate the postoperative morbidity of MC.RésuméLes objectifs principaux de la cholécystectomie laparoscopique minime ( CM ) ( par mini-trocars ) sont de réaliser de plus petites incisions , d’obtenir un meilleur résultat esthétique , de provoquer moins de trauma et d’avoir un taux plus bas de morbidité que la cholécystectomie par laparoscopic classique . Cette étude prospect i ve r and omisée a comparé la CM à la cholécystectomie par laparoscopic ( CL ) traditionnelle en termes de traumatisme chirurgical et de résultat esthétique chez 44 patients . On a du convertir la CM en CL chez cinq patients . Aucune conversion vers la chirurgie ouverte n’a été nécessaire dans le groupe de CL traditionnelle . Le temps moyen d’intervention a été plus long dans le groupe CM mais cette différence n’était pas statistiquement significative ( 81 min vs. 72 min , p=0.22 ) . Les caractéristiques de la population , les fonctions respiratoires , les scores de la douleur et les besoins en analgésiques étaient similaires dans les deux groupes . Les scores moyens d’évaluation de la cicatrice ont été significativement plus bas dans le groupe CM ( 0.73 vs. 1.93 , p=0.0045 ) . Seuls les résultats esthétiques de la CM étaient supérieurs à la CL . Cette technique pourrait être une alternative valable chez les patients cherchant une amélioration des résultats esthétiques . Cependant , d’autres études avec des échantillons plus larges sont nécessaires pour évaluer la morbidité postopératoire de la CM.ResumenEl propósito principal de la colecistectomía de invasión mínima ( CIM ) es lograr una cicatriz pequeña , mejor apariencia estética , menos trauma y morbilidad reducida . El présente estudio prospect i ve y aleatorizado compara la CIM con la colecistectomía laparoscópica convencional ( CLC ) en cuanto a trauma operatorio y result ado estético en 44 pacientes . Se requirió conversión de CIM a CLC en cinco pacientes , pero ninguna CLC tuvo que ser convertida a cirugía abierta . El promedio del tiempo operatorio fue ligeramente más prolongado en la CIM , pero la diferencia no es estadísticamente significativa ( 81 min versus 72 min , p=0.22 ) . Las características demográficas de los dos grupos eran similares y las determinaciones postoperatorias de función respiratoria , grado de dolor y requerimiento analgésico fueron sensiblemente iguales . El grado de tejido cicatricial fue significatamente menor en el grupo de la CIM ( 0.73 versus 1.93 , p=0.0045 ) . Sólo el result ado estético de la CIM fue superior al de la CLC . Esta técnica podría ser una alternativa factible en pacientes que busquen un mejor result ado estético . Sin embargo , se requieren estudios adicionales y grupos de pacientes más numerosos para evaluar la morbilidad postoperatoria de la CIM BACKGROUND Shoulder pain is common after  laparoscopic cholecystectomy  ( 60.5 % ) and can delay return to normal activities . The cause is unclear but may involve referral of pain from the traumatized area . PATIENTS AND METHODS A total of 75 patients with chronic cholecystitis who underwent laparoscopic cholecystectomy  were r and omized into two groups . Group I ( 37 patients ) had 10 mL of 0.25 % bupivacaine instilled into the gallbladder bed and Calot 's triangle area at the end of cholecystectomy . Group II ( 38 patients ) served as controls and had no bupivacaine instillation .  Postoperative shoulder pain was evaluated . RESULTS Six patients in Group I developed shoulder pain ( 16 % ) compared with 23 patients in Group II ( 60.5 % ) . The difference was statistically significant ( P = 0.0002 ) . CONCLUSION The raw area of the removed organ is at least partially responsible for shoulder pain after laparoscopic cholecystectomy . Local bupivacaine is effective in reducing such pain Postoperative shoulder‐tip pain occurs frequently following laparoscopic cholecystectomy . The aim of this r and omized clinical trial was to evaluate the efficacy of a low‐pressure carbon dioxide pneumoperitoneum during laparoscopic surgery in reducing the incidence of postoperative shoulder‐tip pain Research confirms that  laparoscopic cholecystectomy ( LC )  results in shorter lengths of hospital stay and earlier return to usual activity than the traditional cholecystectomy procedure . Research in this area , however , focuses more on the medical aspects of patient recovery , but very few studies have evaluated how these patients manage their recovery at home or what types of problems they encounter . A total of 28 LC patients were r and omly assigned to two groups : ( 1 )  23 h stay ( overnight ) in a general surgical ward or ( 2 ) day procedure unit ( DPU ) stay .  Data was collected by a self-administered Postoperative Symptoms Diary and telephone interview . Results showed no significant difference between the two groups of patients recovery symptoms scores . Problems with mobility , pain and elimination recorded the highest mean scores for both groups of patients . Overnight patients also experienced problems with tiredness and eating . All DPU patients were able to manage their postoperative symptoms , compared to only 44 % of patients who had stayed in overnight . Carer assistance was needed with regard to activities of daily living , child care and reassurance . Results showed that with careful selection of patients , LC cases performed as day procedures did not impact at all on the patients ' recovery trajectory BACKGROUND Downsizing the port incisions may reduce pain after laparoscopic cholecystectomy . METHODS In a double-blind controlled study , 60 patients were r and omized to undergo either microlaparoscopic cholecystectomy using one 10-mm and three 3.5-mm trocars ( 3.5-mm LC ) or traditional laparoscopic cholecystectomy using two 10-mm and two 5-mm trocars ( LC ) .  Incisional pain at each port incision and overall pain were recorded for 1 week after the operation . Fatigue , nausea and vomiting , pulmonary function , and cosmetic results were also measured . RESULTS Data from 52 patients were analyzed ; eight patients were excluded from the study for various reasons . One patient was converted from 3.5-mm LC to LC due to technical problems with the 3.5-mm optic . In the 3.5-mm LC group ( n = 25 ) , incisional pain was significantly decreased in the 1st postoperative week as compared with the LC group ( n = 27 ) ( p < 0.01 ) . In both groups , pain scores at the supraumbilical 10-mm port were significantly higher compared with other port sites ( p < 0.05 ) . The cosmetic results were significantly better in the 3.5-mm LC group ( p < 0.01 ) . There were no significant differences in any of the other variables . CONCLUSION The use of 3.5-mm trocars is feasible in LC , and it both reduces incisional pain and improves the cosmetic result Laparoscopy approach to cholecystectomy has shortened the recovery period , reducing discharge times from 1 to 3 days to same-day discharge . We hypothesize that the use of more than one modality to prevent postoperative pain may be more efficacious than single modality . Patients were r and omized to a treatment ( n = 24 ) or control ( n = 25 ) group and studied using a prospect i ve , double-blind design . Preoperatively , at 45 min before induction of anesthesia , the treatment group received an intramuscular ( IM ) bolus injection of meperidine 0.6 mg/kg and ketorolac 0.5 mg/kg . The control group received two bolus IM injections of placebo ( normal saline ) . Ten minutes before incision , local anesthesia ( treatment group ) or saline ( control group ) was infiltrated into the skin of each patient . Anesthetic management , postoperative pain , and nausea treatment were st and ardized . Pain and nausea assessment were done 1 h preoperatively , 0 , 0.5 , 1 , 2 , 3 , and 4 h postoperatively , at discharge , and 10 , 24 , and 48 h postoperatively . Patients were discharged by scoring criteria . Postoperatively , significantly more patients in the treatment group were without pain on arrival in the postanesthesia care unit ( PACU ) , 12/21 ( 57.1 % ) vs 1/24 ( 4.2 % ) in the control group ( P < 0.001 ) . Similarly , the severity of pain was sixfold less in the treatment group than in the control group . The incidence of nausea in the PACU was significantly less in the treatment group ; 4.7 % vs 29.5 % in the control group ( P < 0.05 ) . Patients from the treatment group satisfied Postanesthesia Discharge Score significantly earlier than those in the control group ( 281 + /- 12 min vs 375 + /- 19 min ; P < 005 ) . The concomitant use of local anesthetic and nonsteroidal antiinflammatory and opioid drugs proved to be highly effective in our patients , result ing in faster recovery and discharge . ( Anesth Analg 1996;82:44 - 51 Background and Aim : Postoperative pain is an important surgical problem . Recent studies in pain pathophysiology have led to the hypothesis that with pre-operative administration of analgesics ( pre-emptive analgesia ) it may be possible to prevent or reduce postoperative pain . This study was planned to investigate the efficacy of pre-emptive analgesia on postoperative pain after laparoscopic cholecystectomy . Methods : 45 patients undergoing laparoscopic cholecystectomy were r and omized into three groups . Bupivacaine was injected into the area of skin incision before trocar entry and after trocar removal in group 1 and 2 , respectively ; however , this procedure was not applied to the control group . The pain score of the patients was evaluated by the visual analogue scale ( VAS ) at 1 , 4 , 12 and 24 h after surgery . The daily analgesic requirement was evaluated in terms of diclophenac sodium ( Diclomec , Abdi Ibrahim , 75 mg ) intake/day . Analgesics were given to the patients whose VAS was 5 or higher . Results : While there was no significant difference in VAS scores between group 1 and 2 , the mean pain scores of these two groups were found to be significantly lower than of the control group although the analgesic requirement of the patients in each group was not statistically significant . Conclusion : Pre-emptive analgesia is as effective as postsurgical local anaesthesia in reducing postoperative pain Abstract Background : Reports suggest that the insufflation of cold gas to produce a pneumoperitoneum for laparoscopic surgery can lead to an intraoperative decrease in core body temperature and increased postoperative pain . Methods : In a r and omized controlled trial with 20 patients undergoing laparoscopic cholecystectomy , the effect of insufflation using carbon dioxide gas warmed to 37 ° C ( group W ) was compared with insufflation using room-temperature cold ( 21 ° C ) gas ( group C ) . Intraoperative body core and intra-abdominal temperatures were determined at the beginning and end of surgery . Postoperative pain intensity was evaluated using a visual analog scale and recording the consumption of analgesics . Results : There were no significant group-specific differences during the operation , neither in body temperature ( group W : 36.1 ± 0.4 ° C vs group C : 35.7 ± 0.6 ° C ) nor in intra-abdominal temperature ( group W : 35.9 ± 0.3 ° C vs group C : 35.6 ± 0.6 ° C ) . Postoperatively , the two groups did not differ in pain susceptibility and need of analgesics . Conclusion : The use of carbon dioxide gas warmed to body temperature to produce a pneumoperitoneum during short-term laparoscopic surgery has no clinical ly important effect & NA ; There is uncertainty over whether the patient group in which acute pain studies are conducted ( pain model ) has any influence on the estimate of analgesic efficacy . Data from four recently up date d systematic review s of aspirin 600/650 mg , paracetamol 600/650 mg , paracetamol 1000 mg and ibuprofen 400 mg were used to investigate the influence of pain model . Area under the pain relief versus time curve equivalent to at least 50 % maximum pain relief over 6 h was used as the outcome measure . Event rates with treatment and placebo , and relative benefit ( RB ) and number needed to treat ( NNT ) were used as outputs from the meta‐analyses . The event rate with  placebo was systematic ally statistically lower for dental than postsurgical pain for all four treatments . Event rates with analgesics , RB and NNT were infrequently different between the pain models . Systematic difference in the estimate of analgesic efficacy between dental and postsurgical pain models remains unproven , and , on balance , no major difference is likely This study tested the hypothesis that , by the addition of parenteral ketorolac to an oral analgesic regimen for one day following laparoscopic surgery , analgesia would be improved and thus the return of normal function hastened . Seventy-two female patients were r and omly assigned to receive ketorolac 10.5 mg subcutaneously at the end of surgery followed by a subcutaneous infusion of 1.75 mg/h for 24 to 36 hours , or an equivalent volume of saline . All patients were provided with codeine tablets ( 30 mg ) for analgesia if required . For the first four postoperative days patients recorded details of pain , side-effects and discomfort on performing everyday activities . Patients who received ketorolac received significantly less  fentanyl  in the Recovery Ward and significantly less codeine  prior to discharge than the saline group . They also took significantly fewer codeine tablets over the four-day postoperative period . Pain scores in the ketorolac group were not significantly lower than in the saline group on the first postoperative day ( P=0.052 ) and subsequently remained similar . Levels of discomfort on performing six common activities were similar in the two groups over the four-day postoperative period . We conclude that , despite beneficial effects during the period of ketorolac administration , there was no continuing benefit after this time other than reduced analgesic use , and no improvement in the patients ’ ability to perform common activities BACKGROUND To investigate the clinical efficacy of oral clonidine premedication in anesthesia and analgesia in patients undergoing laparoscopic cholecystectomy ( LC ) . METHODS One hundred and ten patients , scheduled for elective laparoscopic cholecystectomy , were recruited for the prospect i ve , r and omized , single-blind , comparative study . They were r and omly allotted to either of the placebo or clonidine group . Patients of the  placebo group ( n = 65 ) were premedicated with oral antacid ( alugel hydroxide 300 mg ) , while those in the clonidine  group ( n = 45 ) were premedicated with oral clonidine 150 micrograms prior to anesthesia . The premedication was given 60 to 90 min before the anticipated time of induction of anesthesia . Normocapnia was maintained throughout the perioperative period . Mass spectrometer was used to assess the inspired and expiratory concentrations of isoflurane , the anesthetic used for maintenance of anesthesia . Postoperative pain intensity , sedation scores , adverse events , time to the first dose of postoperative analgesic and cumulative analgesic requirement in 24 hours were recorded . Data were expressed as mean + /- SD . RESULTS Patients in the clonidine group displayed greater hemodynamic stability perioperatively and the isoflurane requirement was also reduced ( 30 % less ) . The postoperative analgesic requirement was less ( 1.5 + /- 1.3 vs. 2.2 + /- 1.3 dose , P < 0.05 ) and the time for the first dose of analgesic was prolonged ( 411 + /- 565 vs. 264 + /- 441 min ) in comparison with the placebo group but no statistic difference was found . CONCLUSIONS Oral clonidine premedication helped to provide perioperative hemodynamic stability , spared the use of isoflurane and reduced the requirement of postoperative analgesia so as to smoother the way to recovery in patients undergoing LC BACKGROUND Little is known about physician attitudes , goals , or satisfaction regarding acute postoperative and cancer pain management . OBJECTIVES To provide quantitative data regarding the status of acute postoperative and cancer pain management by Michigan physicians . To measure physician confidence , preference , and satisfaction as well as identify their pain care goals for acute postoperative and cancer pain management . To evaluate variability in acute postoperative and cancer pain decision making based upon physician demographic characteristics , knowledge , and attitudes . RESEARCH DESIGN A cross-sectional survey , which included two cancer and three acute postoperative pain vignettes . SUBJECTS A r and omly-selected sample of three hundred sixty-eight licensed Michigan physicians who provide clinical care for acute postoperative and cancer pain patients . RESULTS The majority of respondents ( > 50 % ) reported providing acute postoperative pain care frequently , while a minority ( < 20 % ) reported doing so for cancer pain . The majority of the physicians ( > 75 % ) reported goals of at least adequate pain relief without distress for both acute postoperative and cancer pain . Physicians more frequently chose the optimal pain management response for men following prostatectomy ( 56.2 % ) than for women following myomectomy ( 42 % ) . They also chose the optimal response for metastatic prostate cancer more frequently ( 16.3 % ) than for metastatic breast cancer pain management ( 10.7 % ) . CONCLUSION These data highlight physician variability in acute postoperative and cancer pain management decision making . Further study of the physician variable is necessary to improve the management of acute postoperative and cancer pain After laparoscopic cholecystectomy , CO2 remains within the peritoneal cavity , commonly causing pain . This prospect i ve r and omized study was performed to determine the efficacy of intraperitoneal normal saline and bupivacaine infusion on  postoperative pain after laparoscopic cholecystectomy . Three hundred patients were r and omly assigned to one of six groups of 50 patients each . Group A patients served as controls . In group B patients , normal saline was infused under the right hemidiaphragm and suctioned after the pneumoperitoneum was deflated . After suction , a subhepatic closed drain was left for 24 h. In group C patients , bupivacaine 1.5 mg/kg in solution 2.5 mg/ml , minus 15 ml of this solution , which was infiltrated in the trocar wounds , was infused under the right hemidiaphragm at the end of the cholecystectomy . In group D patients , bupivacaine was given as in group C , but a subhepatic drain was left for 24 h. In group E patients , normal saline was used as in group B plus bupivacaine as in group C. Group F patients were treated as in group E , but a subhepatic drain was left for 24 h. In all groups , 15 ml of a 2.5 mg/ml bupivacaine solution was infiltrated in the trocar wounds . Postoperatively , analgesic medication usage , nausea , vomiting , and pain scores were recorded at 2 , 6 , 12 , 24 , 36 , 48 , and 72 h. Postoperative pain was reduced significantly in the patients of the treatment groups vs. the controls . Between treatment groups , patients in groups B , E , and F had the best results , while those in groups C and D had significantly greater pain than those in groups B , E , and F. It is concluded that postoperative pain after laparoscopic cholecystectomy can be significantly reduced by intraperitoneal normal saline infusion subdiaphragmatically and after its postdeflation suction , bupivacaine infusion in the same area , or without bupivacaine in case a subhepatic drainage has been needed The purpose of this study was to examine the effects of interpleural bupivacaine on analgesia and ventilatory capacity after cholecystectomy . Forty-two patients undergoing elective cholecystectomy were r and omly assigned to two groups : one to receive interpleural administration of bupivacaine-adrenaline mixture ( Croup 1 = 22 patients ) and the other st and ard administration of intramuscular meperidine ( Group 2 = 20 patients ) for postoperative pain relief . The intensity of pain was evaluated by a visual analogue scale ( VAS ) preoperatively as well as at 2 , 8 , 24 and 48 hr postoperatively . At the same time , FVC and FEV1.0 measurements were obtained for all patients . The group given interpleural bupivacaine had better pain relief withmean VAS of 0.6 ± 0.9 ( mean ± SD ) 1.1 ± 1.4 , 0.6 ± 0.9 and 0.8 ± 1.2 compared with 5.2 ± 2.2 . 5.8 ± 2.7 . 5.5 ± 2.2 and 4.5 ± 1.8 for patients receiving meperidine ( P < 0.001 ) . The patients in Group 1 also had larger FVC and FEV than those in Group 2 : FVC 22 ± 14.5 per cent vs 32 ± 15.2 per cent ( P < 0.005 ) , FEV1.025 ± 15.5 vs 38 ± 14.8 per cent ( P < 0.001 ) ( mean ± SD ) . We conclude that the interpleural analgesia can achieve better pain relief with greater ventilatory capacity than a st and ard analgesic regimen in the first two days after cholecystectomy . RésuméLe but de cet étude clinique était d’examiner les effets de l’administration interpleurale de bupivacaine sur l’analgésie et les fonctions ventilatoires chez des patients opérés de cholécystectomie . Quarante-deux patients admis pour une cholécystectomie élective ont été distribués au hasard en deux groupes . Le Groupe 1 a reçu de la bupivacaine interpleurale ( 22 patients ) et le Groupe 2 a reçu du démérol IM ( 20 patients ) . La qualité de l’analgésie était mesurée à l’aide d’une échelle visuelle analogue ( VAS ) et des tests de fonctions pulmonaires ( CV et VEMS ) étaient faits aux temps suivants : avant l’intervention et 2 , 8 , 24 et 48 hre après l’intervention . Une radiographie pulmonaire était faite à la salle de réveil pour tous les patients du Groupe 1 . Le Groupe 1 était mieux soulagé tel qu’en témoigne la VAS en post-opératoire : Groupe 1:0,6 ± 0,9(± SD ) , 1,1 ± 1,4 , 0,6 ±0,9 et 0,8 ± 1,2 ; Groupe 2:5,2 ± 2,2 , 5,8 ± 2,7 , 5.5 ± 2,2 et 4 , 5 ± 1.8(P < 0.001 ) . Les fonctions ventilatoires ont été mieux préservées chez les patients recevant la bupivacaine interpleurale tel que démontré par les réductions de la CV ( 22 ± 14.5 pour cent ) et du VEMS ( 25 ± 15,5 pour cent ) observés dans ce groupe comparé au Groupe 2 ( diminution de la CV de 32 ± 15.2 pour cent et VEMS de 38 ± 14,8 pour cent ) ( P < 0,005 et P < 0.001 ) ( ± SD ) . Aucun patient du Groupe 1 n’a présenté de pneumothorax . Nous concluons que la bupivacaine interpleurale est une technique puissante d’analgésie , qu’elle préserve mieux la fonction pulmonaire que la mépéridine IM et que le cathéter peut être installé par voie percutanée en toute sécurité Purpose To determine whetherthe continuous low thoracic extradural administration of the same dose of lidocaine at low concentration with a high infusion rate or at high concentration with a low infusion rate in combination with a fixed dose of buprenorphine ( 0.4 ing·day−1 ) modifies postoperative pain relief . Methods Twenty-eight patients undergoing elective upper abdominal surgery were r and omly allocated to one of two groups to receive lidocaine 2 % — buprenorphine at a rate of 6.3 ml · hr−1 ( 2 % group , n = 13 ) or lidocaine 6 % — buprenorphine at a rate of 2.1 ml · hr−1 ( 6 % group , n = 15 ) . During suture of the peritoneum , mepivacaine 2 % ( 8 ml ) with 0.1 mg ( 0.5 ml ) buprenorphine was infused extradurally . After extubation , the continuous extradural infusion was initiated . Patients were assessed for the level of analgesia with the 10 cm VAS score at rest and with the Prince Henry Pain Scale ( PHPS ) at 3 , 6 , 9 , 12 , 18 , and 24 hr postoperatively . Results The visual analogue scale ( VAS ) scores at rest did not differ between the two groups except at 18 hr after surgery . The Prince Henry Pain Scale ( PHPS ) scores were not different between the two groups post-operatively . Conclusion There was no difference in analgesia produced by the continuous extradural infusion of lidocaine 2 % — buprenorphine at a rate of 6.3 ml · hr−1 and that of lidocaine 6 % — buprenorphine at a rate of 2.1 ml · hr−1 following upper abdominal surgery . RésuméObjectifDéterminer si la perfusion épidurale thoracique basse d’une même dose de lidocaïne à basse concentration avec un débit élevé de perfusion ou une haute concentration avec un débit faible de perfusion en association avec une dose fixe de buprénorphine ( 0,4 mg · j−1 ) modifie le soulagement de la douleur . MéthodesVingt-huit patients programmés pour une chirurgie non urgente de l’étage supérieur de l’abdomen participaient à l’étude . Ils étaient répartis aléatoirement en deux groupes do nt l’un recevait lidocaïne 2 % —buprénorphine à la vitesse de 6,3 ml · h−1 ( groupe 2 % = 13 ) l’autre lidocaïne 6 % — buprénorphine ( groupe 6 % = 15 ) à la vitesse de 2,1 ml · h−1 . Au moment de la fermeture du péritoine , on injectait en épidural de la mépivacaïne à 2 % ( 8 ml ) avec 0,1 mg ( 0,5 ) de buprénorphine . Après l’extubation , on débutait la perfusion épidurale continue . Le niveau d’analgésie des patients était évalué à 3 , 6 , 9 , 12 , 18 et 24 heures en post-opératoire au moyen de l’EVA de 10 cm pour la douleur au repos et avec le Prince Henry Pain Scale (PHPS).RésultatsLes scores sur l’ÉVA au repos ne différaient pas entre les groupes excepté 18 hres après l’intervention . Le PHPS n’était différent en aucun moment de la période postopératoire Conclusion Après une chirurgie abdominale , l’analgésie produite par la perfusion épidurale de lidocaïne 2 % — buprénorphine au débit de 6,3 ml·h−1 était la même que celle produite par la lidocaïne 6 % — buprénorphine au débit de 2,1 ml·h−1 The analgesia provided in the postoperative period by three regimens commonly used in our private anaesthetic practice were compared in a double-blind study of one hundred and thirty-seven women presenting for day-case laparoscopic procedures . After r and om allocation into three groups , all patients were similarly anaesthetized and then received both a rectal suppository and an IM injection . Group P received two placebos , Group I had an indomethacin suppository 100 mg , and Group K an IM injection of ketorolac 30 mg . The trial showed a statistically significant reduction in pain at 180 minutes postoperatively in the group receiving ketorolac ( visual analog pain score of 13.8 v 21.7 ) . The parenterally administered ketorolac may be a useful analgesic supplement in these patients . However the trial was aborted following the appearance in the literature of case reports of postoperative renal failure . Further investigation of the efficacy and side-effect profile of reduced doses may be warranted This study was undertaken to determine whether epidural analgesia has any benefit for post-operative pain relief in patients undergoing laparoscopic cholecystectomy . Patients were r and omly assigned to receive post-operative epidural analgesia with a morphine-bupivacaine combination  ( Group A , n = 22 ) or placebo ( saline ) ( Group B , n = 22 ) . The same st and ard general anaesthetic technique , which consists of nitrous oxide and isoflurane in oxygen was used . Analgesia was assessed using visual analogue pain scores ( 0 - 10 cm ) . The evaluation was carried out 24 and 48 h post-operatively . At 24 h after anaesthesia , pain scores in Group A ( 2.3 + /- 1.2 ) were lower than those in Group B ( 4.4 + /- 1.5 ) ( P < 0.05 ) . However , at 48 h post-operatively , no difference in scores was observed between the two groups . In conclusion , epidural analgesia with a morphine-bupivacaine combination improves pain relief during the first 24 h following laparoscopic cholecystectomy Thirty-seven women undergoing elective cholecystectomy were r and omised into two groups , receiving either lumbar epidural morphine ( group L ) or epidural morphine via the thoracic route ( group T ) . The effect on pain relief was assessed by a visual analogue scale and included both resting pain and ‘ provoked ’ pain . Respiratory parameters ( PEF , FEVI and FVC ) were also studied . The patients were investigated preoperatively , and 4 , 6 , 12 and 24 hours after the start of surgery . No significant difference was observed between the groups concerning pain relief or respiratory performance . We conclude that after cholecystectomy lumbar epidural morphine is as effective as thoracic epidural morphine in relieving postoperative pain Twenty‐five patients who had undergone elective cholecystectomy were prospect ively r and omized to receive via an interpleural catheter either a continuous infusion of 0.25 % bupivacaine at 0.125 mL·kg−1·h−1 ( n = 13 ) or repeated bolus injections ( n = 22 ) of 0.5 % bupivacaine with epinephrine 1:200,000 at 0.4 mL/kg every sixth hour . Adequacy of pain relief was measured by the amount of patient‐controlled analgesia morphine  required postoperatively and by patient scores on a visual analog scale obtained every sixth hour . Two venous blood sample s for measurements of serum bupivacaine levels were obtained from patients in the continuous group at hours 6 and 24 ; four blood sample s were obtained from patients in the bolus group , both immediately before and 30 min after injections at hours 6 and 24 . Among the patients receiving the bolus injections , morphine was required 62 ± 15 ( SEM ) times over the 24-h study period with total morphine dosage averaging 30 ± 15 mg . Corresponding values for patients in the continuous group were 35 ± 10 times and 23 ± 5 mg of morphine . The difference was not , however , statistically significant , but when activity during the 2-h time periods immediately before reinjection ere examined , patients in the bolus group required and received significantly more morphine  than did those in the continuous group ( P<0.05 ) . Patients in the continuous group had visual analog scale scores that averaged 2.9 ± 0.6 over the 24-h study period . Patients within the bolus group had visual analog scale scores before and again 30 min after injection that averaged 5.8 ± 0.8 arid 1.8 ± 0.5 , respectively ( P<0.05 ) . Serum bupivacaine levels increased in both groups between the sixth and 24th hour measurements ; the average postinjection bupivacaine levels were significantly higher ( P<0.05 ) with intermittent injection than corresponding levels in the continuous infusion group . The bupivacaine level rose to 3.2 ± 0.4 μg/mL 30 min after the bolus injection at hour 24 . In summary , continuous interpleural infusion of 0.25 % bupivacaine  provides safer and more effective postoperative pain relief after cholecystectomy than does intermittent interpleural injection of 0.5 % bupivacaine with epinephrine every 6 BACKGROUND In a l and mark hypothesis-generating study , Todd et al found that a difference of approximately 13 mm ( 95 % confidence interval [ CI ] 10 to 17 mm ) on a visual analog scale ( VAS ) represented the minimum change in acute pain that was clinical ly significant in a cohort of trauma patients . STUDY OBJECTIVE We test the hypothesis that the minimum clinical ly significant change in pain as measured by the VAS in an independent , more heterogeneous validation cohort is approximately 13 mm . METHODS This was a prospect i ve , observational cohort study of adults presenting to 2 urban emergency departments with pain . At 30-minute intervals during a 2-hour period , patients marked a VAS and were asked if their pain was " much less , " " a little less , " " about the same , " " a little more , " or " much more . " All data were obtained without reference to prior VAS scores . The minimum clinical ly significant change in pain was defined a priori as the difference in millimeters between the current and immediately preceding VAS scores when " a little more " or " a little less pain " was reported . RESULTS Ninety-six patients enrolled in the study , providing 332 paired pain measurements . There were 141 paired measurements design ated by patients as " a little less " or " a little more " pain . The mean clinical ly significant difference between consecutive ratings of pain in the combined " little less " or " little more " groups was 13 mm ( 95 % CI 10 to 16 mm ) . The difference between this finding and that of Todd et al was 0 mm ( 95 % CI -4 to 4 mm ) . CONCLUSION These data are virtually identical to previous findings indicating that a difference of 13 mm on a VAS represents , on average , the minimum change in acute pain that is clinical ly significant Purpose : To determine the effect of 90 mg dextromethorphan (DM)po vs placebo 90 min preoperatively , on the immediate and delayed postoperative course . Methods : Thirty patients undergoing laparoscopic cholecystectomy or inguinal hernioplasty under general anesthesia were studied . Half ( DM ) received 90 mg dextromethorphan and half received placebo 90 min before anesthesia . Intravenous Patient Controlled Aanalgesia with morphine was available for two hours within a six-hour observation period ; 75 mg diclofenacim prn was given later in PACU and on-ward ( 24 hr ) . Pain was assessed using the visual analogue scales . Thermal thresholds for cold and hot sensation and for pain ( by limit method ) were evaluated at the site of skin incision ( primary - ) and distantly ( secondary hyperalgesia ) . Von Frey filaments were applied testing touch sensation . Sedation level and morphine consumption were also assessed in PACU . Results : Demographic , surgical and perioperative parameters were similar ; no untoward effects were encountered . Pain intensity and sedation were lower , and the feeling of well-being was greater , in the DM patients : onevs five ( median ) , twovs five , fivevs two , respectively , P<0.01 ( 90 min time-point ) . Thermal application revealed absence of primary and secondary hyperalgesia only in the DM patients ; von Frey filaments induced similar pain sensation in both groups . Mean morphine/group , morphine/weight and diclofenac injection rates were ∼55 % lower in the DM group : 2.1±1.2 (SD)vs 4.7±2.3 , 0.03±0.02vs 0.07±0.03 , 1.0±0.3vs 2.4±0.2 , respectively , P<0.01 . Conclusions : Compared with placebo , DM enabled reduction of postoperative analgesics consumption , improved well-being , and reduced sedation , pain intensity and primary and secondary thermal hyperalgesia . RésuméObjectif : Déterminer l’effet de 90 mg de dextrométhorphane (DM)po vs un placebo , administrés 90 min avant l’opération , sur l’évolution postopératoire immédiate et tardive . Méthode : L’étude a porté sur 30 patients devant subir une cholécystectomie laparoscopique ou un hernioplastie inguinale . La moitié a reçu 90 mg de dextrométhorphane et l’autre moitié , un placebo , 90 min avant le début de l’anesthésie générale . La morphine , en qualité d’analgésie intraveineuse autocontrôlée , a été disponible pendant deux heures sur une période d’observation de six heures ; 75 mg de diclofénacim prn ont été administrés plus tard à la salle de réveil et à la chambre ( 24 h ) . La douleur a été évalué grâce à l’échelle visuelle analogique . Les seuils thermiques de sensation au froid et à la chaleur ainsi qu’à la douleur ( selon une méthode du seuil différentiel ) ont été évalués au site de l’incision cutanée ( hyperalgésie primaire ) et à distance ( hyperalgésie secondaire ) . Des filaments von Frey ont été appliqués pour tester le toucher . On a aussi évalué , à la salle de réveil , le niveau de sédation et la consommation de morphine . Résultats : Les paramètres démographiques , chirurgicaux et périopératoires ont été similaires : aucun effet indésirable n’a été noté . L’intensité de la douleur et de la sédation a été plus faible , et le confort meilleur , chez les patients du groupe DM : unvs cinq ( médiane ) , deuxvs cinq , cinqvs deux , respectivement , P<0,01 ( 90 min après le début de l’analgésie ) . L’épreuve de sensibilité thermique a révélé l’absence d’hyperalgésie primaire et secondaire chez les patients du groupe DM seulement ; les filaments von Frey ont induit une sensation de douleur similaire chez les patients des deux groupes . La consommation moyenne de morphine selon le groupe et selon le poids des patients ainsi que les taux d’injection de diclofénac ont été de ∼55 % plus bas dans le groupe DM : 2,1±1,2 ( écart type)vs 4,7±2,3 ; 0,03±0,02vs 0,07±0,03 ; 1,0±0,3vs 2,4±0,2 , respectivement , P<0,01 . Conclusion : Comparé à un placebo , le DM a permis de réduire la consommation d’analgésiques postopératoires , a amélioré le confort et a réduit la sédation , l’intensité de la douleur et l’hyperalgésie thermique primaire et secondaire This r and omized double-blind placebo-controlled study was design ed to evaluate the effects on  postoperative pain of the local anesthetic , 0.5 % bupivacaine with epinephrine , sprayed hepatodiaphragmatically under the surgeon 's direct view during laparoscopic cholecystectomy . Metabolic endocrine responses to surgery ( glucose and cortisol ) and nonsteroidal anti-inflammatory drug requirements were investigated , as well as the presence of nausea , vomiting , and sweating . Local anesthetics or placebo solutions were given as follows . Immediately following the creation of a pneumoperitoneum , surgeons sprayed the first 20 mL of solution ( S1 ) , and an additional 20 mL of solution ( S2 ) was sprayed at the end of the operation . Patients were classified into three groups ( 14 patients per group ) . Group A received 20 mL of saline during both S1 and S2 , group B received 20 mL of saline during S1 and 20 mL of bupivacaine during S2 , and group C received 20 mL of bupivacaine during both S1 and S2 . The degree of postoperative pain was assessed using the visual analogue scale ( VAS ) and the verbal rating scale ( VRS ) on arrival in the recovery room and subsequently at time intervals of 4 h , 8 h , 12 h , and 24 h. The results of this study indicate a significant decrease of postoperative pain in patients treated with local anesthetic .  VAS and VRS pain scores , as well as respiratory rate and analgesic requirements , were significantly lower in group C. The postoperative plasma cortisol level in group C was significantly lower than in groups A and 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 prospect i ve , r and omized , double-blind study 80 patients were allocated into two groups ( n=40 in each ) to receive either 200 mg tramadol or placeboiv at the time of wound closure . Prostoperatively , 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 . RésuméObjectif : Évaluer les effects de l’administration de tramadol , lors de la suture de la plaie chirurgicale , sur la douleur postopératoire et les besoins analgésiques chez des patients qui subissent une cholécystectomie laparoscopique . Méthode : Il s’agit d’une étude prospect i ve , r and omisée et en double aveugle auprès de 80 patients , répartis en deux groupes de 40 , qui ont reçu 200 mg de tramadol ou un placebo iv au moment de la suture de la plaie . Après l’opération , tous les patients ont reçu du tramadol sous forme d’analgésie contrôlée par le patient ( ACP ) . La douleur , la consommation d’analésique , les signes vitaux et les effects secondaires ont été enregistrés pendent 24 h après l’intervention . Résultats : L’administration de 200 mg de tramadol , comparé au placebo , lors de la fermeture cutanée , a été associée à une brève ( 60 min ) diminution des scores de douleur et de la consommation d’ACP . Même si le temps écoulé avant la première dem and e d’analgésie postopératoire a été plus long chez les patients qui ont reçu du tramadol au moment de la suture de la plaie , il n’y a pas eu de différence intergroupe quant aux seuils de douleur ou aux besoins d’analgésie postopératoire pendant les 23 h suivantes . La consommation totale de tramadol en ACP pendant 24 h a été de 139,4±108 et 102,4±106 mg dans les groupes placebo et tramadol , respectivement ( P=0,06 ) . Conclusion : L’administration de 200 mg de tramadol lors de la suture de la plaie chirurgicale a un effect analgésique de courte durée ( 60 min ) , mais ne modifie pas les scores de douleur ou les besoins analgésiques à long terme qui suivent la cholécystectomie laparoscopique The effect of interpleural analgesia on postoperative hospital course was analyzed in a prospect i ve r and omized study of patients undergoing cholecystectomy . Control patients were treated in the st and ard manner with systemic narcotics alone ; catheter patients had an interpleural catheter placed at the end of surgery and , in addition , could receive systemic narcotics if necessary . The catheter group received interpleural 0.5 % bupivacaine with epinephrine every six hours for a total of four injections . Thirteen patients were in each group . Pain score , pulmonary function and narcotic requirement were measured over the first postoperative day . Catheter patients had a lower average pain score ( visual analog scale ( VAS ) , 3.6 versus 5.2 ) , decreased narcotic requirement in the recovery room and improved oxygen saturation ( 96 % versus 93 % ) . However , there was no statistical difference in amount of morphine ( catheter , 25 ± 14 mg ; control , 31 ± 15 mg ) , number of narcotic injections ( catheter , 3.8 ± 1.5 ; control , 3.5 ± 1.5 ) , forced vital capacity ( catheter , 44 % preoperative control , 41 % preoperative ) , recovery room time ( catheter , 129 ± 54 minutes , control , 117 ± 39 minutes ) or total hospital stay ( catheter , 4.1 ± 0.9 days ; control , 3.7 ± 0.8 days ) . Analysis of hourly VAS scores following a bolus indicated that the analgesia disappeared within approximately four hours . The mean time to a request for narcotic following a bolus was 4.2 hours ( excluding 17 of a potential total of 52 instances when narcotic was not requested at all ) . Therefore , the duration of pain relief for subcostal incisions using interpleural 0.5 % bupivacaine is approximately four hours . In conclusion , while there are some advantages conferred to patients treated with the intrapleural catheter , it would appear that a bolus regimen more frequent than every six hours would be necessary to maximize any benefit It is a common clinical observation that  postoperative  pain may be resistant to morphine . The analgesic potentials of ketamine have also been well documented . In this study , we evaluated the effects of postoperative coadministration of small doses of ketamine and morphine on pain intensity , Spo2 , and subjectively rated variables in surgical patients who underwent st and ardized general anesthesia and complained of pain ( ≥6 of 10 on a visual analog scale [ VAS ] ) despite > 0.1 mg/kg of IV morphine administration within 30 min . Patients r and omly received up to three boluses of 30 & mgr;g/kg of morphine plus saline ( MS;n = 114 ) or 15 & mgr;g/kg of morphine plus 250 & mgr;g/kg of ketamine ( MK;n = 131 ) within 10 min in a double-blinded manner . The MS group ’s pain VAS scores were 5.5 ± 1.18 and 3.8 ± 0.9 after 10 and 120 min , respectively , after 2.52 ± 0.56 injections , versus the MK group ’s VAS scores of 2.94 ± 1.28 and 1.47 ± 0.65 , respectively ( P < 0.001 ) , after 1.35 ± 0.56 injections ( P < 0.001 ) . The 10-min level of wakefulness ( 1–10 VAS ) in the MS group was significantly ( P < 0.001 ) less ( 6.1 ± 1.5 ) than the MK group ’s ( 8.37 ± 1.19 ) . Spo2 decreased by 0.26 % in the MS group but increased by 1.71 % in the MK patients at the 10-min time point ( P < 0.001 ) . Thirty MS versus nine MK patients ( P < 0.001 ) experienced nausea/vomiting ; nine MK patients sustained a 2-min light-headed sensation , and one patient had a weird dream after the second drug injection We investigated , in a double-blind study , the effects of intraperitoneal local anesthetics during laparoscopic cholecystectomy . In Part A of the study 30 patients received 50 mL saline 0.9 % ( A 0 ) , bupivacaine 0.125 % ( A 125 ) , or bupivacaine 0.25 % ( A 25 ) intraperitoneally at the end of surgery .  Mean maximum plasma concentrations of bupivacaine reached 0.48 mg/L ( range 0.15 - 0.90 mg/L ) in Group A 125 and 1.0 mg/L ( 0.35 - 2.10 mg/L ) in Group A 25 within 15 min ( range , 5 - 30 min ) . There was no significant difference in pain scores or opioid consumption ( patient-controlled analgesia with piritramid ) : 24 , 28 , and 13 mg/24 h among the study groups , respectively ( not significant ) . Postoperative respiratory function deteriorated in comparison to preoperative values in all study groups , but the forced vital capacity was significantly more impaired in Group A.25 . In Part B , 24 patients received placebo ( B 0 ) or bupivacaine 0.25 % ( B 25 ) . Postoperative hypoxemic periods ( oxygen saturation < 92 % ) were significantly more frequent in Group B 25 . Considering the question able benefits and the potential risks , we would not recommend the application of intraperitoneal bupivacaine during laparoscopic cholecystectomy . ( Anesth Analg 1995;81:967 - 72 This prospect i ve , double-blind , r and omized , and placebo-controlled study evaluates the effectiveness of intraperitoneal bupivacaine in decreasing the length of stay for elective laparoscopic cholecystectomy patients . Seventy-seven patients undergoing elective laparoscopic cholecystectomy before noon at a single institution and by a single group of surgeons were entered into the study . The pharmacy r and omly assigned each patient to one of four study groups ( control , predissection , postdissection , and both ) . Two syringes ( A and B ) containing 15 cm3 of either normal saline or 0.5 per cent bupivacaine were sent with the patient to surgery . Syringe A was sprayed over the perihepatic area before any dissection , and B was sprayed over the perihepatic area just before port removal . Preoperative , intraoperative , and postoperative data were collected . Sixty-six patients completed the study : control , 14 ; predissection , 18 ; postdissection , 15 ; and both , 19 . There was no statistical difference between the predissection , postdissection , and both groups regarding same-day discharge . Therefore , these groups were combined for comparison against the control group . The study found that patients receiving bupivacaine at any time during the surgery were more likely to go home the same day as their procedure ( 79 % vs 43 % , respectively : P < 0.02 ) OBJECTIVES To determine if intraoperative instillation of bupivacaine would decrease early postoperative pain  after laparoscopic cholecystectomy , if the patients would consequently require less narcotic postoperatively and if such patients would elect to be discharged on the day of operation if given the choice . DESIGN Double-blind , r and omized , controlled trial . SETTING A tertiary care hospital in Hamilton , Ont . PATIENTS Fifty patients underwent laparoscopic cholecystectomy . Day-surgery patients had the choice of staying overnight for discharge the following day . They were compared with a control group of 47 patients who had laparoscopic cholecystectomy but did not receive bupivacaine .  INTERVENTION Instillation of 20 mL of 0.5 % bupivacaine with epinephrine into laparoscopic cholecystectomy port sites intraoperatively before closure . MAIN OUTCOME MEASURES Visual analogue scale ( VAS ) pain scores assessed 4 times postoperatively , the choice of patients to leave hospital the same day or to remain in the hospital overnight ; the level of postoperative narcotic usage . MAIN RESULTS Mean VAS pain scores ( range 0 [ no pain ] to 5 [ severe pain ] ) at less than 2 hours and at 6 hours after surgery were 2.9 and 2.9 , respectively , in the bupivacaine group compared with 4.5 and 4.0 , respectively , in the control group ( p = 0.001 and 0.025 ) . VAS scores at 10 hours postoperatively and the next morning did not differ between the groups . More patients in the bupivacaine group elected to go home on the day of surgery ( p = 0.034 ) . Narcotic usage was not significantly different . CONCLUSION Instillation of bupivacaine into port sites should be st and ard practice for elective laparoscopic cholecystectomy The aims of this study were to see if laparoscopic cholecystectomy is associated with a similar postoperative pain pattern to gynaecological laparoscopy and to see whether the use of a suprahepatic suction drain makes recovery from laparoscopic cholecystectomy more comfortable . After routine laparoscopic cholecystectomy and insertion of a suprahepatic suction drain , patients were r and omized to suction or no suction on the drain . The time course of the severity of wound , abdominal and shoulder tip pain was assessed by visual analogue scales administered in the morning and afternoon of the first 3 postoperative days . The control group had a high incidence of shoulder tip pain similar to that after gynaecological laparoscopy . Patients in the treatment group reported significantly less shoulder tip pain than the control group ( O.R. 0.16 , 95 % CI , 0.06 - 0.40 ) . There was a tendency for the treatment group to report reduced abdominal and , to a lesser extent , wound pain . The authors recommend suprahepatic suction as a simple and more effective way to improve patient comfort after laparoscopic cholecystectomy Epidural narcotics has been shown to produce profound and long-lasting analgesia . It has been suggested that lipid-soluble narcotics such as fentanyl , because of their short transit time in the CSF , are less likely to be associated with delayed respiratory depression and side effects . We tried to combine low concentrations of fentanyl with bupivacaine to minimize side effects and to see if synergistic effect existed . Forty ASA physical status I or II patients who present for cholecystectomy were included in the trial . Before surgery a thoracic epidural catheter was inserted and pain control began when patients became fully awake and complained of pain in the recovery room after surgery . Patients were r and omized in a double-blind fashion to one of four groups . Patients in group I were given epidural infusions of fentanyl 0.001 % ; patients in group 2 received fentanyl 0.001 % mixed with bupivacaine 0.1 % ; patients in group 3 received fentanyl 0.0005 % ; patients in group 4 received fentanyl 0.0005 % mixed with bupivacaine 0.1 % . A continuous epidural infusion of these drugs began at a rate of 10 mL/h after a 5-mL bolus of the solution . Pain relief was assessed with visual analogue pain scale . Respiratory rates , vital signs , and mental status were assessed hourly . Except the group 3 , the degree of analgesia achieved was similarly satisfactory in all other groups . There was no respiratory depression developed in either group . Motor block was minimal or absent in all groups . The incidence of nausea and pruritus was significant less in group 3 and group 4 . In conclusion , the continuous infusion of dilute bupivacaine with fentanyl provides synergistic analgesia with minimal side effects Background A controversy exists over the effectiveness and clinical value of preemptive analgesia . Additional studies are needed to define the optimum intensity , duration , and timing of analgesia relative to incision and surgery . Methods One hundred twenty patients undergoing laparoscopic cholecystectomy under general anesthesia plus topical peritoneal local anesthetic or saline were studied .  Local anesthetic ( 0.5 % bupivacaine with epinephrine ) or placebo solutions were given as follows : immediately after the creation of a pneumoperitoneum ( blocking before surgery ) , and at the end of the operation ( blocking after surgery ) . Patients were r and omly assigned to one of four groups of 30 patients each . Group A ( placebo ) received 20 ml 0.9 % saline both before and after surgery , group B received 20 ml 0.9 % saline before surgery and 20 ml local anesthetic after surgery , group C received 20 ml local anesthetic both before and after surgery , group P received 20 ml local anesthetic before and 20 ml 0.9 % saline after surgery .  Pain was assessed using a visual analog scale and a verbal rating scale at 0 , 4 , 8 , 12 , and 24 h after surgery . Metabolic endocrine responses ( blood glucose and cortisol concentrations ) and analgesic requirements also were investigated . Results Pain intensity ( visual analog and verbal rating scales ) and analgesic requirements were significantly less in the group receiving bupivacaine after surgery compared to placebo . However , in the groups receiving bupivacaine before surgery , both pain intensity and analgesic consumption were less than in the group receiving bupivacaine only after surgery . Blood glucose and cortisol concentrations 3 h after surgery were significantly less in groups receiving bupivacaine before surgery . Conclusions The results indicate that intraperitoneal local anesthetic blockade administered before or after surgery preempts postoperative pain relative to an untreated placebo-control condition . However , the timing of administration is also important in that postoperative pain intensity and analgesic consumption are both lower among patients treated with local anesthetic before versus after surgery BACKGROUND Needlescopic cholecystectomy ( NC ) utilises instruments and ports smaller than 3 mm in diameter compared with the 5 mm ones used in conventional laparoscopic cholecystectomy ( LC ) . Post-operative pain control and recovery has been thought to be superior in NC , when compared with historical controls with LC , but has not been proven in a prospect i ve fashion . PATIENTS AND METHODS A prospect i ve r and omised trial of NC versus LC for patients with symptomatic gallstone disease , with st and ardisation of post-operative analgesia and daily assessment of post-operative pain , using a 5-point visual analogue scale . RESULTS There were 64 eligible patients r and omised into NC ( 28 ) and LC ( 36 ) . Four patients who had NC were converted to LC due to technical problems . Another three and six patients from the NC and LC groups , respectively , had conversion to open surgery . Post-operative pain scores were low in both groups . Mean pain scores for those with successful NC and LC were : 1.24 versus 1.43 for the day of operation ( P = 0.49 ) , 0.86 versus 0.83 for the first day post-operatively ( P = 0.92 ) and 0.75 versus 0.81 for the second post-operative day ( P = 0.87 ) . The mean number of intra-muscular analgesic injections required were 0.76 versus 0.83 after NC and LC , respectively ( P = 0.93 ) . There were no significant differences between the two groups in the time taken to return to feeding , eating a normal diet and discharge from hospital . CONCLUSION There is no advantage of NC over LC in terms of post-operative pain or recovery . Nevertheless , NC can be performed safely and expediently and has an excellent cosmetic outcome and high patient acceptability Abstract Background : We conducted a r and omized controlled trial during laparoscopic cholecystectomy to determine the extent of heat preservation and postoperative pain reduction using humidified carbon dioxide ( CO2 ) gas insufflation instead of st and ard dry insufflation gas . Methods : Forty consecutive patients were r and omized . Twenty patients received humidified CO2 , and 20 control patients received st and ard CO2 insufflation .  A sample of 16 patients from each group was evaluated for postoperative pain levels . Results : No adverse effects from the humidification of insufflated gas were observed . There was no significant difference in core body temperature between the two groups for this brief operation . Pain , as assessed by the Analogue Pain Score ( APS ) was significantly less for the group with humidified gas insufflation than for the control group at 6 h postoperatively as well as on the 1st , 2nd , and 3rd postoperative day and at follow-up 10 days after the operation . In the humidified group , the mean time to return to normal activities was significantly less—5.9 days , as compared to 10.9 days in the control group . Conclusions : The use of humidified insufflation gas reduces postoperative pain following laparoscopic cholecystectomy , but except for these relatively brief procedures , the heat-preserving effect of humidified gas insufflation is not significant Abstract Background : Prolonged and complex laparoscopic procedures expose patients to large volumes of cool insufflation gas . The aim of this study was to compare the effects of a conventional room temperature carbon dioxide ( CO2 ) pneumoperitoneum with those of a body temperature pneumoperitoneum . Methods : Patients were r and omized to undergo laparoscopic cholecystectomy with a CO2 pneumoperitoneum  warmed to either body temperature ( n= 15 ) or room temperature ( n= 15 ) . The physiologic and immunologic effects of warming the gas were examined by measuring peroperative core and intraperitoneal temperatures , peritoneal fluid cytokine concentrations , and postoperative pain . Results : The mean duration of surgery was 32 min in both groups . Core temperature was reduced in the room temperature group ( mean , 0.42 ° C ; p < 0.05 ) . No reduction in temperature occurred when the gas was warmed . Greater levels of cytokines were detected in peritoneal fluid from the room temperature insufflation group tumor necrosis factor alpha ( TNF-α ) : mean , 10.9 pg/ml vs. 0.42 , p < 0.05 ; interleukin 1 beta ( IL-1β ) : mean , 44.8 pg/ml vs. 15.5 , p < 0.05 ; and IL-6 : mean , 60.4 ng/ml vs. 47.2 . There was no difference in postoperative pain scores or analgesia consumption between the two groups . Conclusions : The authors conclude that intraoperative cooling can be prevented by warming the insufflation gas , even in short laparoscopic procedures . In addition , warming the insufflation gas leads to a reduced postoperative intraperitoneal cytokine response OBJECTIVE : To compare the efficacy and toxicity of three  patient-controlled analgesia ( PCA ) morphine regimens . DESIGN : A prospect i ve , r and omized , pilot study of three PCA morphine regimens : ( 1 ) 1 mg with 6-minute lockout ( n=10 ) , ( 2 ) 2 mg with 12-minute lockout ( n=12 ) , and ( 3 ) 2 mg with 20-minute lockout ( n=12 ) . SETTING : Large teaching institution . PARTICIPANTS : Thirty-four patients undergoing cholecystectomy or hysterectomy . MAIN OUTCOME MEASURES : Pain scores ( 0 = no pain , 1 = mild pain , 2 = moderate pain , 3 = severe pain ) , sedation scores , analgesic consumption , and patient attempts ( patient activation of PCA device ) and injections ( doses actually delivered ) were evaluated using analysis of covariance . Distribution of pain and sedation scores and adverse effects were assessed using Fisher 's exact test . RESULTS : Data on 24 patients were evaluable . Six patients withdrew for poor pain control  ( 2 in group 1 , 1 in group 2 , and 3 in group 3 ) . Three other patients withdrew because of adverse effects and 1 withdrew because of pump problems . Mean morphine consumption did not differ significantly among the groups . Distribution of pain and sedation scores and the number of patients with nausea were similar across treatment groups . The mean injection to attempt ratio was significantly smaller in group 3 ( 0.71 ± 0.11 ) compared with groups 1 and 2 ( 0.9 ± 0.06 and 0.83 ± 0.09 , respectively ; p=0.001 ) . Adverse events occurred similarly among treatment groups . CONCLUSIONS : No significant differences in the efficacy or toxicity of the three morphine PCA regimens were identified Abstract Purpose . The effects of oral administration of clonidine on sympathetic and endocrinological responses were investigated in patients undergoing elective laparoscopic cholecystectomy . Methods . Twenty adult patients were allocated r and omly to the clonidine group ( n = 10 ) or the control group ( n = 10 ) . The control and clonidine groups received placebo on clonidine 4μg·kg−1 orally 2 h before the induction of anesthesia . All patients underwent laparoscopic cholecystectomy under isoflurane anesthesia . The hemodynamic variables were observed perioperatively . Plasma concentrations of cortisol , ACTH , noradrenaline , adrenaline , and dopamine were determined before administration of clonidine or placebo , 2 h after the beginning of the operation , and 3 h after the end of the operation . Results . Systolic and diastolic blood pressures were lower in the clonidine group than in the control group immediately after endotracheal intubation and extubation ( P < 0.05 ) . Patients in the clonidine group showed lower plasma concentrations of noradrenaline 2 h after the beginning of the operation than patients in the control group ( P < 0.01 ) . However , the plasma concentrations of the other hormones did not differ between groups . Conclusion . Clonidine premedication prevents sympathetic hyperactivity but does not suppress hypothalamo-pituitary-adrenocortical responses in patients undergoing laparoscopic cholecystectomy The positive CO2 pneumoperitoneum needed to create the working space for laparoscopic surgery induces cardiovascular , neuroendocrine , and renal changes . Concern about these pathophysiologic changes has led to the introduction of a gasless technique .  Fifty consecutive patients with symptomatic gallstones were r and omized to conventional ( CLC ) or gasless laparoscopic cholecystectomy ( GLC ) , with special reference to overall patient satisfaction , technical difficulties , duration of surgery , postoperative pain , and recovery . The overall exposure of the operative field was extremely poor in the GLC group , whereas the duration of surgery , steps involved in the cholecystectomy technique , length of hospital stay , and postoperative pain score did not differ significantly . After discharge , the median time to complete relief of pain tended to be shorter in the gasless group ( 5 days [ range 1 to 15 ] ) vs. the conventional group ( 8 days [ range 1 to 15 ] ) . The period to return to normal activity was shorter in the GLC group ( 6 days [ range 1 to 1.5 ] ) compared to the CLC group ( 8.5 days [ range 1 to 15 ] ) ( P = 0.031 ) . No differences were found in terms of fatigue , dizziness and nausea , and overall satisfaction with the outcome . This study demonstrates a significantly shorter convalescence after laparoscopic cholecystectomy by means of the gasless technique compared to the conventional CO2 technique . Exposure of the operative field was less than optimal using the gasless technique Nalbuphine ( 0.3 mgkg−1 ) and buprenorphine ( 2.5 μgkg−1 ) were compared as part of a total intravenous anaesthesia regimen using a propofol infusion in 60 patients undergoing laparoscopic cholecystectomy in a r and omised double‐blind study . Changes in haemodynamic variables greater than 20 % from the baseline were noted . No difference was observed in blood pressure but the heart rate was significantly lower in the buprenorphine group . Intra‐operative bradycardia ( heart rate < 60 beatmin−1 ) occurred more often in the buprenorphine group . Recovery was fast and comparable with both drugs and no patient reported awareness . Quality of analgesia was similar in both groups . Both drugs provide suitable analgesic supplementation to total intravenous anaesthesia BACKGROUND Postoperative shoulder-tip pain ( STP ) frequently occurs following laparoscopic surgery .  In an attempt to abrogate this complication we prospect ively evaluated the efficacy of intraoperative irrigation of the diaphragm with bupivacaine . METHODS One hundred and five consecutive patients undergoing laparoscopic surgery  were prospect ively r and omized to treatment or control groups . Treatment group ( B , n = 55 ) received irrigation with 10 mL 0.5 % bupivacaine in 500 mL saline and control group ( A , n = 50 ) received an equal volume of normal saline . Each dome of the diaphragm was irrigated with 250 mL of either solution at the end of surgery . Laparoscopic procedures performed included cholecystectomy ( n = 63 ) , Nissen fundoplication ( n = 21 ) , appendicectomy ( n = 7 ) , hernia repair ( n = 4 ) , and diagnostic laparoscopy ( n = 10 ) . Patients ' anesthesia and perioperative analgesia were st and ardized . STP was recorded on a visual analogue pain scale ( VAPS ) in the recovery room immediately following surgery and at 4 , 10 , and 24 hours thereafter . RESULTS The overall incidence of STP in patients undergoing laparoscopic procedures was approximately 24 % . Twenty-one patients ( 42 % ) in the control group and 4 patients ( 7 % ) in the treatment group complained of shoulder pain during the recording period ( P = 0.003 ) . Mean STP scores as recorded on VAPS were significantly lower in the bupivacaine group than in the control group from 4 to 24 hours after surgery ( P < 0.01 ) . Postoperative analgesia requirements were also significantly reduced in those patients receiving bupivacaine irrigation ( P < 0.04 ) . CONCLUSION Intraperitoneal irrigation with bupivacaine to both hemidiaphragms at the end of surgery significantly reduces both frequency and intensity of STP following laparoscopic procedures thus reducing patient morbidity In a double-blind , placebo-controlled clinical trial ( power of 80 % to detect a 30 % reduction in morphine consumption , P<0.05 ) we have determined that intraoperative intravenous administration of tenoxicam 40 mg during laparoscopic cholecystectomy , when compared with placebo , was associated with a significant reduction in consumption of morphine at 6 hours and 12 hours ( P<0.05 ) but not at 24 hours , when assessed by patient-controlled analgesia . Furthermore there was a significantly greater requirement for “ rescue ” analgesia with intramuscular morphine in the placebo group during the period of the study . There was no difference between the groups in pain scores , either at rest or on movement , nor in the incidence of nausea and vomiting . No patient in either group suffered a respiratory rate less than 8/min or oversedation at any time , and there were no other adverse effects Aim : This study evaluated the pre‐emptive analgesic effect of intravenous  ( i.v . ) (R)‐ketamine  in laparoscopic cholecystectomy .  (R)‐ketamine was used due to the lower incidence of side‐effects In a r and omized , double-blind , placebo-controlled study design ed to assess the post-operative analgesic efficacy and cost-effectiveness of ketorolac and diclofenac 60  ASA I and II patients undergoing laparoscopic cholecystectomy were studied . Prior to concluding the operative procedure , an injection ( i.m . ) of an equal volume of either saline 3 mL , ketorolac 60 mg , or diclofenac 75 mg was administered . All patients received intravenous morphine via a patient-controlled analgesia device ( PCA ) . Post-operative pain intensity was assessed hourly for 4 h , by recording visual analogue score ( VAS ) for pain , PCA dem and s and actual  morphine administered . PCA dem and s ( mean + /- SD ) were greater in the saline treatment group ( 115 + /- 90 ) when compared with both the ketorolac ( 42 + /- 44 ) and diclofenac groups ( 74 + /- 77 ) . Furthermore , the saline treatment group received significantly ( P < 0.05 ) more PCA morphine  compared with both the ketorolac and diclofenac groups ( 12.2 mg + /- 5.0 vs. 8.6 mg + /- 5.2 vs. 8.9 mg + /- 4.8 ) . Improved pain scores were demonstrated in both the ketorolac and diclofenac groups compared with the saline group . PCA dem and s and post-operative morphine requirements were similar in the ketorolac and diclofenac groups . Diclofenac has the added advantage , in our institution , of being 60 % less expensive than ketorolac . We conclude that both ketorolac and diclofenac are effective post-operative analgesic drugs . However , economic considerations may favour diclofenac administration An opioid-sparing effect of alpha-trinositol ( D-myo-inositol 1,2,6-trisphosphate ) following cholecystectomy in otherwise healthy patients was suggested by a pilot study . In order to verify this result , pain , pain relief and nausea were studied in patients undergoing elective cholecystectomy by minilaparotomy .  The patients were r and omized using double-blind design to receive an intravenous infusion of either alpha-trinositol or sodium chloride ( placebo ) for eight hr after the operation . Pain , pain relief and nausea were evaluated up to 72 hr after surgery using visual analogue scales ( VAS ) . Rescue analgesic medication was registered . As a further measure of pain and /or restrictions caused by pain , peak expiratory flow , walking distance and pressure pain thresholds were assessed . There was no difference between the groups in ratings of pain , pain relief , nausea or amount of analgesic medication given . The mean ratings of pain were significantly higher in the sitting position compared to lying down . Neither pressure pain thresholds , nor the walking distance differed between the patients given alpha-trinositol and placebo , respectively . There were significant reductions of peak expiratory flow and of pressure pain thresholds under both costal margins up to 72 hr after surgery compared to presurgery values . As a conclusion , no analgesic effect of alpha-trinositol at the dosage used was observed in the postoperative patients studied Prolonged nerve conduction blockade has been proposed to result from the summed effects of charged and neutral local anaesthetics . Thirty-seven patients were r and omly allocated to receive intravenous patient-controlled analgesia alone or combined with intercostal blockade ( T7-T11 ) with a mixture of 0.45 % bupivacaine and 0.6 % phenol for post-cholecystectomy analgesia .  Adequacy of pain relief was measured by patient scores on a 10-cm visual analogue scale and by dose-dem and ratio , amounts of loading dose and total consumption of morphine  and also the duration of patient-controlled analgesia in each group . No differences were found between groups in post-operative scores , dose-dem and ratios and loading doses of morphine .  However , in the combined treatment group , a significantly lower total consumption of morphine ( P < 0.05 ) , associated with a shorter duration of patient-controlled analgesia ( P < 0.02 ) and a decreased mean number of unsuccessful dem and s ( P < 0.001 ) were recorded . Intercostal blockade with bupivacaine-phenol supplements intravenous patient-controlled analgesia for post-cholecystectomy pain relief Trocar injury is one of the most serious and potentially preventable complications of laparoscopic surgery . Use of a blunt rather than a cutting trocar could be expected to lessen the likelihood of this injury . Therefore complications related to laparoscopic port design were studied by comparing conventional cutting trocars with radially exp and ing ( blunt ) trocars . A multicenter , prospect i ve , r and omized clinical trial was conducted in 250 adult patients undergoing elective laparoscopic procedures at tertiary care centers and community hospitals . The patients were r and omly assigned to one of two groups : group C , conventional cutting trocars ; or group S , radially exp and ing trocars .  Sixteen surgeons performed 244 elective laparoscopic procedures ; six patients were removed from the study . One hundred nineteen patients were assigned to group S and 125 to group C. The groups were similar with regard to age , sex , and type of procedure . The following data were collected : intraoperative complications related to the trocars , abdominal wall bleeding , visceral or vascular injury , other complications , fascial closure , procedure time , trocar site assessment at 4 and 24 hours postoperatively , and visual analog pain scores at 4 , 8 , 12 , and 24 hours postoperatively . Fascial defects from 10 mm or larger trocars in group C were closed ; the fascial defects in group S were not closed . The trocar sites were checked for incisional hernias at late follow-up . Mean operating time was not different between the two groups ( group S , 92 + -73 minutes ; group C , 100 + -74 minutes ) . There were no episodes of intraoperative cannula site bleeding in group S compared with 16 episodes in 13 patients ( P < 0.001 ) in group C. Postoperative wound complications were fewer in group S ( 13 vs. 23 ; P < 0.05 ) . Although the pain scores were generally lower in group S , the differences were not significant . Only 3 % of the patients in group S had fascial defects of 10 mm or greater that had to be closed . Within a follow-up period of 6 to 18 months , there have been no incisional hernias in either group . This study shows that radially exp and ing trocars are safe and effective , and less likely than conventional trocars to result in intraoperative or postoperative complications . The defects created by the radially exp and ing trocars do not have to be routinely closed In this r and omized , double-blinded , placebo-controlled study , we evaluated the effects of preoperative IV parecoxib sodium ( parecoxib ) followed by postoperative oral valdecoxib on length of stay , re source utilization , opioid-related side effects , and patient recovery after elective laparoscopic cholecystectomy . Patients were r and omized to receive a single IV dose of parecoxib 40 mg ( n = 134 )  or placebo  ( n = 129 ) 30–45 min before the induction of anesthesia . Six to 12 h after the IV dose , the parecoxib group received a single oral dose of valdecoxib 40 mg , followed by valdecoxib 40 mg once daily on postoperative Days 1–4 and then 40 mg once daily as needed on Days 5–7 . Patients in the parecoxib/valdecoxib group had a shorter length of stay in the postanesthesia care unit ( 78 ± 47 min ) compared with those taking placebo ( 90 ± 49 min ; P < 0.05 ) . Patients in the parecoxib/valdecoxib group also had reduced pain intensity and , after discharge , experienced a significant reduction in vomiting in the first 24 h , slept better , returned to normal activity earlier , and expressed greater satisfaction than placebo patients ( P < 0.05 ) . Preoperative parecoxib followed by postoperative valdecoxib is a valuable adjunct for treating pain and improving patient outcome after laparoscopic cholecystectomy Background : Previous work has demonstrated that intraperitoneal ( i.p . ) lidocaine may provide analgesia  after laparoscopic cholecystectomy . The aim of this prospect i ve , r and omized , double‐blind study was to compare pain relief , recovery variables , and side effects after i.p . instillation of lidocaine plus tenoxicam given either i.v . or i.p . after laparoscopic cholecystectomy To study the possible benefits of N2O pneumoperitoneum , 40 patients scheduled for laparoscopic cholecystectomy for symptomatic cholelithiasis were r and omized into either CO2-induced ( n = 20 ) or N2O-induced ( n = 20 ) pneumoperitoneum groups . The intensity of postoperative pain was assessed by the patients themselves using an visual analogue pain score scale .  CO2 insufflation caused respiratory acidosis . The total amount of anesthetic enflurane needed was lower in the N2O than in the CO2 group ( p < 0.041 ) . The N2O group experienced less pain 1 hour ( p < 0.040 ) and 6 hours ( p < 0.017 ) postoperatively and the next morning . Serum cortisol and plasma adrenaline concentrations in the N2O group did not differ from those in the CO2 group . Patients with N2O pneumoperitoneum seem to have less pain without the side effects caused by CO2 . The N2O pneumoperitoneum is a good alternative to the CO2 pneumoperitoneum , especially for prolonged laparoscopic operations in patients with chronic cardiopulmonary diseases Anomalous responses to morphine are common in patients with unexplained pain in the upper abdomen after cholecystectomy and may be linked to activation of the sympathetic nervous system . The hypothesis that sympathetic suppression would attenuate anomalous responses to morphine was tested by a r and omized , cross-over trial using a st and ard challenge with morphine , with and without pretreatment with clonidine ( 300 µg orally , 1 h prior to the administration of morphine ) . In 13 of the 15 patients who completed the study , pre-treatment with clonidine decreased plasma concentrations of noradrenaline , dopamine and adrenaline by 56 , 15 and 25 % respectively . This was associated with a significant reduction in morphine-induced pain ( p = 0.02 ) and nausea ( p = 0.04 ) and attenuated increases in plasma aspartate aminotransferase ( AST ) activity ( p = 0.03 ) . Clonidine attenuates anomalous responses to morphine , perhaps through effects on sympathetic nervous activity or plasma concentrations of catecholamines A prospect i ve controlled r and omized study was performed on 100 patients undergoing elective laparoscopic cholecystectomy to evaluate the benefit of routine drainage in simple uncomplicated procedures . The 100 patients were r and omized into two groups . Group 1 patients ( n = 50 ) had a drain placed through the epigastric trocar site . The drain was removed before their discharge unless bile or blood was present . Group 2 patients ( n = 50 ) did not have a drain placed . Eleven patients in group 2 ( no drain ) ( 22 % ) were discharged on the same day of surgery ( within 8 h ) , and the remaining 89 patients in both groups were discharged the day after surgery ( within 23 h ) . There were no wound infections or postoperative fever in either group . There were minor but not statistically significant differences between the two groups in postoperative severity and duration of abdominal pain , shoulder pain , and nausea . Furthermore , the two groups were similar in respect to postoperative recovery time and return to work Background : Ondansetron has a well documented antiemetic prophylactic effect , whereas in most studies of postoperative nausea and vomiting ( PONV ) , metoclopramide is less efficacious . This can be attributed to the short‐lasting effect of metoclopramide when a low dose is given at the beginning of surgery . We wanted to test a 20‐mg dose of metoclopramide given at the end of surgery , using ondansetron 8 mg as a reference Although pain after laparoscopic cholecystectomy is less intense than after open cholecystectomy , some patients still experience considerable discomfort . Furthermore , the characteristics of post-laparoscopy pain differ considerably from those seen after laparotomy . Therefore , we investigated the time course of different pain components after  laparoscopic cholecystectomy  and the effects of intraperitoneal bupivacaine on these different components . Forty ASA physical status grade I-II patients were r and omly assigned to receive either 80 mL of bupivacaine 0.125 % with epinephrine 1/200,000 ( n = 20 ) or the same volume of saline ( n = 20 ) instilled under the right hemidiaphragm at the end of surgery . Intensity of total pain , visceral pain , parietal pain , and shoulder pain was assessed 1 , 2 , 4 , 6 , 8 , 24 , and 48 h after surgery . Analgesic consumption was also recorded . Patient data were similar in the two groups . In the saline group , visceral pain was significantly more intense than parietal pain at each time point ; visceral and parietal pain were greater than shoulder pain during the first 8 h postoperatively . Intraperitoneal bupivacaine did not significantly affect any of the different components of postoperative pain . Analgesic consumption was similar in the two groups . This study demonstrates that visceral pain accounts for most of the pain experienced after laparoscopic cholecystectomy . Intraperitoneal bupivacaine is not effective for treating any type of pain after laparoscopic cholecystectomy . ( Anesth Analg 1995;81:379 - 84 The purpose of this r and omized , double-blind , clinical trial was to determine whether intraoperative , intramuscular ( IM ) injections of meperidine or ketorolac would improve postoperative pain relief in patients undergoing elective laparoscopic cholecystectomy . A total of 125 patients were entered into five study groups : 1 ) ( N = 23 ) control placebo ; 2 ) ( N = 31 ) meperidine 100 mg IM intraoperative preprocedure ; 3 ) ( N = 20 ) meperidine 100 mg IM intraoperative postprocedure ; 4 ) ( N = 25 ) ketorolac tromethamine 60 mg IM intraoperative preprocedure ; 5 ) ( N = 26 ) ketorolac tromethamine 60 mg IM postprocedure . All groups were analyzed by comparing the amount of pain medication received in the recovery room , the time until first oral pain medication was requested , the overall amount of pain medication used in the first 24 hours , the percent requiring IM medication , and the pain score ratings from each group . There was decreased pain medication usage in the recovery room in all groups compared to control ( P < 0.05 ) . Group 4 had a longer painfree interval than meperidine groups or control . Both Groups 4 and 5 had decreased postoperative narcotic usage . Finally , the analogue pain scores showed that both ketorolac groups had significantly less postoperative pain compared to control , whereas the meperidine groups showed no improvement in postoperative pain relief . Intraoperative ketorolac given preprocedure or postprocedure significantly improved postoperative pain management and facilitated the transition to oral pain medication OBJECTIVE To study the effectiveness of intraperitoneal instillation of bupivacaine for postoperative laparoscopic cholecystectomy pain relief , especially specific pain ( visceral pain , shoulder pain and epigastric pain ) . PATIENTS AND METHOD Eighty ASA ( American Society of Anesthesiologists ) 1 and 2 patients were r and omly assigned to receive either 20 ml of 0.5 per cent bupivacaine ( n=39 ) or the same volume of saline ( n=41 ) instilled under direct vision into the hepatodiaphragmatic space , near and above the hepatoduodenal ligament and above the gall bladder bed at the end of surgery . The intensity of visceral pain , shoulder pain and epigastric pain was assessed at 1 , 6 , 24 and 48 h after surgery using a visual analogue scale ( 100 mm VAS ) and verbal rating " Prince Henry " pain scale ( VRS ) . The time when analgesia was first required and total analgesic consumption were also recorded . t-test , Chi-square , Mann-Whitney U test and Kaplan-Meier survival analysis were used for statistical analysis . RESULTS Patient data were similar in the two groups except for body weight . There were no statistical differences between the two groups for the time when analgesia was first ' required , VAS , VRS and total analgesic consumption . CONCLUSION In this study , intraperitoneal instillation of bupivacaine does not show any advantage for postoperative analgesia after laparoscopic cholecystectomy To determine the influence of the volume of local anesthetic injected for intrapleural analgesia , 40 patients undergoing cholecystectomy were r and omly allocated to two groups of 20 patients each . One group received 40 mL of 0.25 % bupivacaine with epinephrine injected intrapleurally postoperatively . The other group received 20 mL of 0.5 % bupivacaine with epinephrine . The onset time of analgesia was nearly the same in both groups and within 25 min all patients were nearly pain free . Our data demonstrate that 100 mg of bupivacaine with epinephrine elicits effective analgesia after cholecystectomy . There are only minor differences between 20 and 40 mL with regard to pain relief . The authors conclude that the volume of local anesthetic within the range of 20 - 40 mL in an adult has little influence on the extent or duration of intrapleural analgesia Aim : This study aim ed to investigate the advantages and disadvantages of LP ( 7 mmHg ) in comparison to SP ( 12 mm Hg ) pneumoperitoneum in a prospect i ve r and omized clinical trial . Material s and Methods : 148 consecutive patients qualified for laparoscopic cholecystectomy ( LC ) due to uncomplicated symptomatic gallstones were r and omized to either SPLC or LPLC .  All the procedures were performed by the same experienced team of surgeons . The statistical analysis included sex , mean age , body mass index , ASA grade , operative time , complication rate , conversion rate , postoperative pain assessed by the Visual Analogue Scale of Pain ( VAS ) including the incidence of shoulder-tip pain , postoperative hospital stay , recovery time , and the quality of life ( QOL ) within 7 days following the operation . p < 0.05 was considered as indicative of significance . Results : Neither conversion to an open procedure nor major complications occurred in either group . The operative time was similar in both groups ( LP 55.7 ± 8.6 min vs SP 51.9 ± 8.3 min ) . The mean postoperative pain score was 6.18 ± 3.48 lower after LP than SPLC and the difference amounted to 22.2 % ( p < 0.005 ) . The incidence of shoulder-tip pain was 2.1 times lower after LP than SPLC ( p < 0.05 ) . QOL within 7 days following the operation was remarkably better after LPLC than after SPLC ( p < 0.01 ) . Conclusions : LP pneumoperitoneum is superior to SP pneumoperitoneum in terms of lower postoperative pain , a lower incidence of shoulder-tip pain , and a better QOL within 5 days following the operation . LP should be used for LC in cases of uncomplicated symptomatic gallstones as a recommended procedure as long as an adequate exposure is obtained with this technique One hundred thirty-seven patients participated in a r and omized , double-blind study to determine what effect instillation of fluid at the conclusion of  operative laparoscopy  has on postoperative postural pain . The first phase examined pain intensity as related to closing pH , operative time and the surgeon . The second phase focused on the absence or presence of postural pain in the fluid and control groups . In phase 1 , there was no significant relationship between pain and duration of surgery , closing pH or surgeon . In phase 2 , 6 of 27 ( 22 % ) patients receiving postoperative fluid instillation experienced postural pain as compared to 19 of 25 ( 76 % ) in the control group ( P < .001 ) . Displacing the pneumoperitoneum by the instillation of 1 - 2 L of fluid at the conclusion of laparoscopy significantly decreased the frequency of subdiaphragmatic and shoulder pain on sitting or st and ing . This pain is probably produced by traction on the triangular or coronary ligaments of the liver due to loss of the suction effect by the diaphragm Purpose The combination of antiemetic drugs could be a solution to prevent severe postoperative nausea and vomiting ( PONV ) . The aim of this r and omized double blind , dose-ranging study was to determine the minimum single effective dose of dexamethasone combined with ondansetron for the prevention of PONV in patients undergoing laparoscopic cholecystectomy . Methods One hundred eighty patients were allocated r and omly to one of six groups to receive saline ( P group ) , ondansetron 4 mg ( O group ) , or ondansetron 4 mg and dexamethasone at doses of 2 mg ( OD2 group ) , 4 mg ( OD4 group ) , 8 mg ( OD8 group ) , and 16 mg ( OD16 group ) . A st and ardized general anesthetic was used . All episodes of PONV during the intervals of zero to six hours , 6–12 hr and 12–24 hr after surgery were evaluated using a numeric scoring system . Mean visual analogue scale pain scores at rest and on movement , the time to first dem and of analgesia , total analgesic consumption in 12 hr epochs , duration of hospital stay , and side effects were recorded . Results The incidence of PONV in the OD8 ( 16 % ) and OD 16 ( 16 % ) groups was lower than in the P 83 % ( P < 0.001 ) and O groups ( 50 % ) at the 12–24 hr epoch ( P < 0.05 ) . There were no differences in antiemetic effect between the O , OD2 and OD4 groups and between the OD8 and OD 16 groups . Pain scores , total analgesic consumption , duration of hospital stay and side effects were similar among groups . Conclusion Our results suggest that 8 mg is the minimum dose of dexamethasone that , combined with ondansetron 4 mg will effectively prevent PONV in patients undergoing laparoscopic cholecystectomy . RésuméObjectifLa combinaison de médicaments antiémétiques pourrait être ia solution de ia prévention des nausées et vomissements postopératoires sévères ( NVPO ) . Le but de notre étude de dosage r and omisée et à double insu était de déterminer la dose minimale efficace unique de dexaméthasone qui , combinée à l’ondansétron , puisse prévenir les NVPO chez des patients qui subissent une cholécystectomie laparoscopique . MéthodeCent quatrevingt patients ont été répartis au hasard en six groupes et ont reçu une solution saline ( groupe P ) , 4 mg d’ondansétron ( groupe O ) ou 4 mg d’ondansétron et de la dexaméthasone en doses de 2 mg ( groupe OD2 ) , 4 mg ( groupe OD4 ) , 8 mg ( groupe OD8 ) ou 16 mg ( groupe OD16 ) . Une anesthésie générale normalisée a été utilisée . Tous les épisodes de NVPO survenus entre zéro et six heures , 6–12 h et 12–24 h après l’opération ont été évalués au moyen d’un système de cotation numérique . Les scores de douleur ont été enregistrés avec l’échelle visuelle analogique au repos et lors de mouvement , de même que le moment de la première dem and e d’analgésie , la consommation totale d’analgésique pour la période de 12 h , la durée du séjour hospitalier et les effets secondaires . RésultatsL’incidence de NVPO dans les groupes OD8 ( 16 % ) et OD 16 ( 16 % ) a été plus faible que dans les groupes P ( 83 % , P < 0,001 ) et O ( 50 % ) pendant la période de 12–24 h ( P < 0,05 ) . L’effet antiémétique n’a pas présenté de différence entre les groupes O , OD2 et OD4 et entre les groupes OD8 et OD16 . Les scores de douleur , la consommation totale d’analgésique , la durée du séjour hospitalier et les effets secondaires ont été similaires d’un groupe à l’autre . Conclusion Nos résultats permettent de dire que 8 mg constituent la dose minimale de dexaméthasone qui , combinée à 4 mg d’ondansétron , pourra efficacement prévenir les NVPO chez des patients qui subissent une cholécystectomie laparoscopique In a r and omized , double-blinded study , we evaluated the analgesic effect of ketamine in the management of pain in a surgical intensive care unit after major abdominal surgery . Patients received morphine patient-controlled analgesia with either placebo ( Group M ) or ketamine ( Group K ) . Morphine was administered with initial loading doses of 2 mg until the visual analog scale ( VAS ) score was < 30 and thereafter with bolus doses of 1 mg and a lockout time of 7 min . Ketamine was administered with an initial bolus of 0.5 mg/kg followed by a perfusion of 2 & mgr;g · kg−1 · min−1 during the first 24 h and 1 & mgr;g · kg−1 · min−1 during the following 24 h. The 4-h cumulative morphine doses were measured over 48 h. The VAS scores at rest and at mobilization were measured every 4 h during 48 h. A total of 101 patients were enrolled , and 93 were analyzed ( 41 in Group K and 52 in Group M ) . VAS scores at rest and at mobilization were similar . The cumulative consumption of morphine was significantly smaller in Group K ( P < 0.05 ) . We concluded that small doses of ketamine were a valuable adjunct to opioids in surgical intensive care unit patients after major abdominal surgery Abstract Background : The size of laparoscopic instruments has been reduced for use in abdominal video endoscopic surgery . However , it has yet to be proven that microlaparoscopic surgery will actually result in clinical ly relevant benefits for patients . Methods : Fifty patients were r and omized in a blinded fashion to receive either elective laparoscopic ( MINI ) , ( n= 25 ) or microlaparoscopic ( MICRO ) ( n= 25 ) cholecystectomy .  Pulmonary function ( FVC , FEV 1 ) , analgesic consumption during patient-controlled analgesia ( PCA ) , pain perception by visual analogue score ( VAS ) , and the cosmetic result ( by the patient 's self- assessment ) were evaluated postoperatively as clinical ly relevant end points . Results : Age , sex , body mass index ( BMI ) , preoperative pulmonary function , pain perception , and operative time were similar for the two groups . At 8:00 PM on the day of surgery , FVC ( MINI : 1.96 L [ range , 1.48–2.48 ] ; MICRO : 2.13 L ) [ ( range , 1.61.–2.50 ) ] and FEV 1 ( MINI : 1.17 L/sec ) [ range , 0.87–1.48 ] ; MICRO : 1.34 L/sec [ range , 1.05.–2.14 ] were also similar ( each p= 0.5 ) . From surgery to the 3rd postoperative day , cumulative PCA morphine doses were comparable ( MINI : 0.15 mg/kg bw [ range , 0.09–0.23 ] ; MICRO : 0.21 mg/kg bw [ range , 0.10–0.42 ] ; p= 0.4 ) , but overall VAS scores for pain while coughing were higher in the laparoscopic group ( 406 [ range , 358–514 ] ) than in the microlaparoscopic group ( 365 [ range , 215–427 ] ; p= 0.02 ) . The cosmetic result was judged to be slightly superior by the microlaparoscopic patients ( 10 [ range , 9–10 ] ) , as compared to those in the laparoscopic ( 9 [ range , 8–10 ] ) group ( p= 0.04 ) . Conclusion : Because microlaparoscopic cholecystectomy has some minor advantages over laparoscopic surgery , it should be considered for use in selected patients OBJECTIVE To compare the transumbilical technique of laparoscopic cholecystectomy with st and ard laparoscopic cholecystectomy . DESIGN R and omised open study . SETTING Teaching hospital , Italy . SUBJECTS 90 patients who required elective cholecystectomy under general anaesthesia . INTERVENTIONS St and ard laparoscopic cholecystectomy through 4 ports or transumbilical cholecystectomy through 2 ports . MAIN OUTCOME MEASURES Amount of pain and analgesia , cost , side effects , and cosmesis . RESULTS 25 patients were excluded from analysis ( 8 in the st and ard group because relevant data were not recorded ; and 17 in the transumbilical group in 4 of whom relevant data were not recorded , and 13 for technical reasons ) . 32 patients who had st and ard  , and 25 who had transumbilical cholecystectomy had operative cholangiograms . There were no complications , no side effects , and no conversions to open cholecystectomy . Those who had transumbilical cholecystectomy had significantly lower pain scores ( p<0.05 ) and required significantly less analgesia during the first 24 hours ( p<0.05 ) than those who had st and ard laparoscopic cholecystectomy . CONCLUSION Once the learning curve has been completed , transumbilical cholecystectomy is possible without some of difficulties associated with st and ard laparoscopic cholecystectomy 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 prospect i ve r and omized 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 r and omized to undergo laparoscopy with either CO2 or helium insufflation .  Within each group , patients were further r and omized 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 r and omization , and post-operative assessment was also performed by a blinded investigator , who applied a st and ardized 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 Background and Objectives The aim of this study was to compare the efficacy and safety of two anesthesia techniques , combined epidural/general anesthesia ( CEGA ) versus total intravenous anesthesia ( TIVA ) , for laparoscopic cholecystectomy . Methods Forty patients were r and omly assigned to one of two different groups : group A received TIVA and group B received CEGA . At preset times during the operation , systolic and diastolic arterial pressure , heart rate , oxygen saturation ( SaO2 ) and end-tidal carbon dioxide ( Etco2 ) were monitored . Postoperatively , recovery ( Steward 's test ) and analgesia ( visual analog scale [ VAS ] pain scores ) were assessed , as well as the incidence of adverse effects . Results The groups were comparable as to demographic data and duration of surgery and of anesthesia . Intraoperative parameters also showed no statistical differences . Both groups had a rapid recovery ( Steward score of 6 within 12 minutes ) , but group B showed better recovery scores at 4 minutes . Postoperative pain was well controlled in both groups , but group B exhibited better scores at postoperative hour 2 . The incidence of postoperative side effects was low in both groups . Conclusions The use of CEGA for laparoscopic cholecystectomy seems to be effective and safe and to offer some advantages as compared to TIVA alone . CEGA can control pain due to CO2-induced peritoneal irritation , providing excellent intra- and postoperative analgesia . CEGA does not require the use of intraoperative intravenous opioids and shortens recovery time , without increasing the incidence of side effects BACKGROUND After laparoscopic cholecystectomy , the duration of convalescence is 2 to 3 weeks with an unclear pathogenesis . This study was undertaken to analyze postoperative recovery after uncomplicated elective laparoscopic cholecystectomy . METHODS Twenty-four consecutive unselected employed patients were followed up prospect ively from 1 week before to 1 week after outpatient laparoscopic cholecystectomy . Daily computerized monitoring of physical motor activity and sleep duration and night sleep fragmentation ( actigraphy ) , subjective sleep quality , pulmonary function , pain , and fatigue were registered . Treadmill exercise performance ( preoperatively and at postoperative days 2 and 8) and nocturnal pulse oximetry  at the patients ' homes ( preoperatively and postoperative nights 1 - 3 ) were completed . RESULTS Median age was 41 years ( range , 21 - 56 ) . Compared with preoperatively , levels of physical motor activity , fatigue , and pain scores were normalized 2 days after operation . Subjective sleep quality was significantly worsened on the first postoperative night , and sleep duration was significantly increased on the first 2 postoperative nights . There were no significant perioperative changes in actigraphy night sleep fragmentation , incidence of self-reported awakenings or nightmares/distressing dreams , exercise performance , or nocturnal oxygenation . Pulmonary peak flow measurements were normalized the day after operation . CONCLUSION After uncomplicated outpatient laparoscopic cholecystectomy , there is no pathophysiologic basis for recommending a postoperative convalescence of more than 2 to 3 days in otherwise healthy younger patients A double-blind , r and omized study was conducted to examine the effect of different types of therapeutic suggestions , administered during general anaesthesia , on post-operative course . Eighty-two patients undergoing cholecystectomy were intra-operatively exposed to either affirmative and non-affirmative suggestions , affirmative or non-affirmative suggestions separately , or some irrelevant text . Patients who had received both affirmative and non-affirmative suggestions  spent less time in hospital than patients in the other three groups . No significant differences were demonstrated for subjective well-being measured on the third and sixth days The difference in analgesic activity following lumbar ( group I ) or thoracic ( group II ) epidural administration of 50 micrograms sufentanil was studied after cholecystectomy . Fifteen patients in each group were evaluated for pain relief using a linear analog scale ( LAS ) , heart rate ( HR ) , mean arterial pressure ( MAP ) , respiratory rate ( RR ) , peak expiratory flow ( PEF ) , forced vital capacity ( FVC ) , forced expiratory volume ( FEV1 ) and arterial CO2 tension ( PaCO2 ) . In five additional patients in each group 75 micrograms sufentanil was injected for determination of serum levels . Pain scores were lower than three in both groups after 10 min , while mean pain scores remained below one from 20 min until 2 h following injection in both groups . Satisfactory pain relief lasted for 4 h. RR was significantly decreased from two until 360 min . in the lumbar group and from five until 120 min in the thoracic group . PaCO2 was raised in both groups only during the first hour . PEF and FVC were significantly improved compared to control 1 , 2 and 4 h following injection . Serum sufentanil levels reached a maximum of 0.299 + /- 0.052 ng.ml-1 in the lumbar group and 0.377 + /- 0.076 ng.ml-1 in the thoracic group after 5 min . There were no significant differences between the two groups in the variables studied BACKGROUND To assess the incidence of postoperative nausea and vomiting after  total intravenous anesthesia ( TIVA ) with propofol versus inhalational anesthesia with isoflurane-nitrous oxide , the authors performed a r and omized trial in 2,010 unselected surgical patients in a Dutch academic institution . An economic evaluation was also performed . METHODS Elective in patients ( 1,447 ) and out patients ( 563 ) were r and omly assigned to inhalational anesthesia with isoflurane-nitrous oxide or TIVA with propofol-air . Cumulative incidence of postoperative nausea and vomiting was recorded for 72 h by blinded observers . Cost data of anesthetics , antiemetics , disposables , and equipment were collected . Cost differences caused by duration of postanesthesia care unit stay and hospitalization were analyzed . RESULTS Total intravenous anesthesia reduced the absolute risk of postoperative nausea and vomiting up to 72 h by 15 % among in patients ( from 61 % to 46 % , P < 0.001 ) and by 18 % among out patients ( from 46 % to 28 % , P < 0.001 ) . This effect was most pronounced in the early postoperative period . The cost of anesthesia was more than three times greater for propofol TIVA .  Median duration of stay in the postanesthesia care unit was 135 min after isoflurane versus 115 min after TIVA for in patients ( P < 0.001 ) and 160 min after isoflurane versus 150 min after TIVA for out patients ( P = 0.039 ) . Duration of hospitalization was equal in both arms . CONCLUSION Propofol TIVA results in a clinical ly relevant reduction of postoperative nausea and vomiting compared with isoflurane-nitrous oxide anesthesia ( number needed to treat = 6 ) . Both anesthetic techniques were otherwise similar . Anesthesia costs were more than three times greater for propofol TIVA , without economic gains from shorter stay in the postanesthesia care Twenty-four patients who were to undergo cholecystectomy were r and omised into two groups , one to receive postoperative analgesia with interpleural bupivacaine , 20 ml of a 0.5 % solution with adrenaline 5 micrograms/ml , and the other to receive intramuscular pethidine , 1 mg/kg . Preoperative and postoperative pulmonary function , postoperative pain scores , and days from operation to hospital discharge were recorded and statistically compared . There was no significant difference in pain scores , nor in days to discharge ; however , postoperative pulmonary mechanics were significantly poorer in the interpleural group . A hypothesis to explain the differences is offered Sixty-six patients undergoing cholecystectomy were r and omly allocated to receive either intercostal blockade with bupivacaine supplemented with papaveretum or papaveretum alone for postoperative analgesia . Both groups were similar regarding distribution of sex , age , and weight . These two groups were compared . Patients who did not have intercostal blockade required postoperative analgesia sooner . There was no significant difference , however , in the total consumption of papaveretum . Both groups experienced similar degrees of pain , and there were no differences in postoperative pulmonary function . We conclude that although single intercostal blockade is an effective analgesic , it does not improve pain relief and does not improve pulmonary function after cholecystectomy when compared with a regimen of on-dem and , intramuscularly administered papaveretum Purpose To examine the combined preemptive effects of somatovisceral blockade during laparoscopic cholecystectomy ( LC ) . Methods One hundred fifty-seven patients under general anesthesia receiving local infiltration and /or topical peritoneal local anesthesia  were studied . Patients were r and omized to receive a total of 150 mg ( 0.25 % 60 mL ) bupivacaine via periportal ( 20 mL ) and intraperitoneal ( 40 mL with 1:200,000 epinephrine ) administration of each . Group A received preoperative periportal bupivacaine before incision and intraperitoneal bupivacaine immediately after the pneumoperitoneum . Group B received periportal and intraperitoneal bupivacaine at the end of the operation . Group C ( preoperative ) and Group D ( postoperative ) received only periportal bupivacaine and Group E ( preoperative ) and Group F ( postoperative ) received only intraperitoneal bupivacaine . The control group received no treatment .  Pain and nausea were recorded at one , two , three , six , nine , 12 , 24 , 36 , and 48 hr postoperatively . Results Throughout the postoperative 48 hr , incisional somatic pain dominated over other pain localizations in the control group ( P < 0.05 ) . The incisional pain of groups A , B , C and D was significantly lower than that of the control group in the first and second hours . The incisional pain of groups A and C was significantly lower than that of the control group in the first three hours . Conclusion Incisional pain dominated during the first two postoperative days after LC . Preoperative somato-visceral or somatic local anesthesia reduced incisional pain during the first three postoperative hours . A combination of somato-visceral local anesthetic treatment did not reduce intraabdominal pain , shoulder pain or nausea more than somatic treatment alone . Preoperative incisional infiltration of local anesthetics is recommended . RésuméObjectifVérifier les effets préventifs d’un blocage somato-viscéral combiné , réalisé pendant la cholécystectomie laparoscopique (CL).MéthodeCent cinquante-sept patients sous anesthésie générale ont reçu une infiltration locale et/ou une anesthésie locale péritonéale topique . Les patients , répartis de façon aléatoire , ont reçu au total 150 mg ( 0,25 % 60 mL ) de bupivacaïne administrée par la voie périportale ( 20 mL ) et intrapéritonéale ( 40 mL avec I : 200 000 d’épinéphrine ) . Les modalités intergroupes sont les suivantes : dans le groupe A , une dose préopératoire périportale avant l’incision et une dose intrapéritonéale immédiatement après le pneumopéritoine ; dans le groupe B , une dose périportale et une intrapéritonéale à la fin de l’opération ; dans les groupes C ( préopératoire ) et D ( postopératoire ) , seulement une périportale et dans les groupes E ( préopératoire ) et F ( postopératoire ) , seulement intrapéritonéale . Le groupe témoin n’a reçu aucun médicament . La douleur et les nausées ont été notées à une , deux , trois , six , neuf , 12 , 24 , 36 et 48 h après l’intervention . RésultatsPendant les 48 h d’observation postopératoire , la douleur somatique de l’incision a dominé toute autre douleur chez les patients témoins ( P < 0,05 ) . La douleur incisionnelle a été significativement plus faible dans les groupes A , B , C et D que dans le groupe témoin pendant les deux premières heures . Elle a aussi été significativement plus faible dans les groupes AetC que dans le groupe témoin pendant les trois premières heures . Conclusion La douleur incisionnelle a dominé pendant les deux premiers jours qui ont suivi la CL . L’anesthésie préopératoire somatoviscérale ou somatique locale ont réduit la douleur incisionnelle pendant les trois premières heures postopératoires . Une combinaison d’anesthésiques locaux somatoviscéraux n’a pas réduit la douleur intra-abdominale , la douleur à l’épaule ou les nausées davantage que l’anesthésie somatique employée seule . L’Infiltration préopératoire d’anesthéslque local au site d’Incision est recomm and ée We studied 24 patients undergoing elective cholecystectomy and r and omized to either conventional postoperative pain treatment , with intermittent nicomorphine ( 10 to 15 mg ) and  acetaminophen ( 1 gm ) on request , or thoracic epidural analgesia with plain bupivacaine  for 48 hours and epidural morphine 4 mg every 8 hours for 96 hours plus systemic indomethacin 100 mg every 8 hours for 96 hours . Epidural analgesia for pin prick extended from the fourth thoracic to the first lumbar nerve for 48 hours . Assessment s of pain , various injury response parameters , peak flow , and subjective feeling of fatigue were performed preoperatively , 3 and 6 hours after skin incision , and 1 , 2 , 4 , and 8 days postoperatively . The epidural analgesia-systemic indomethacin treatment eliminated postoperative pain during rest and coughing . In contrast , only a minor and clinical ly unimportant modulation of the conventional perioperative and postoperative changes in plasma cortisol , glucose , transferrin , orosomucoid , leukocyte and differential counts , rectal temperature , peak flow , and fatigue was observed . Our results suggest that factors other than pain per se must be controlled in order to reduce postoperative morbidity The effect of intraperitoneal bupivacaine on postoperative pain was studied in 60 ASA 1–2 patients undergoing elective laparoscopic cholecystectomy . The patients were r and omly selected ( 20 patients in each group ) to receive in double‐blind fashion 100 ml of either plain 0.15 % bupivacaine { 150 mg · 100 ml‐1 ) or the same solution with adrenaline ( 1.5 μg ml‐l ) , or the same volume of saline into the right subdiaphragmatic space at the end of surgery . The patients were kept in the Trendelenburg 's position for 20 min after the instillation . Venous blood sample s for the determination of bupivacaine plasma concentrations were drawn up to 180 min . Plasma bupivacaine concentrations peaked at 30 min ( highest individual value 2.6 μg ml‐1 ) after instillation . Bupivacaine concentrations were significantly lower in the bupivacaine‐adrenaline group . During the follow‐up no difference between the groups occurred as to the time to first dem and of analgesia , severity of postoperative pain , amount of consumed analgesics during 7 days , and length of hospitalization . In all groups , 30–45 % of the patients complained of right shoulder pain . After the first 24 hours , pain at rest and during moving was reported as mild and was managed with oral ketoprofen The incidence and pattern of postoperative muscle pains was studied in 155 healthy women undergoing outpatient laparoscopic surgery who were assigned r and omly to one of five treatment groups . Group 1 ( control ) received thiopental and succinylcholine , 1 mg/kg , followed by enflurane and nitrous oxide . Group 2 received d-tubocurarine , 3 mg , followed by succinylcholine , 1.5 mg/kg , but was otherwise similar to Group 1 . Groups 3 and 4 were similar to Group 1 , but received propofol instead of thiopental , and Group 4 also received a variable-rate propofol infusion instead of enflurane . Finally , Group 5 was similar to Group 3 , but received atracurium instead of succinylcholine .  Muscle fasciculations were often observed in Groups 1 , 3 , and 4 , but were attenuated in Group 2 and absent in Group 5 . Overall , postoperative shoulder pain occurred in 81 % , 72 % , and 29 % of patients on the first , second , and third postoperative days , respectively . The incidence of this symptom did not differ among the five groups . Neck pain occurred less frequently than shoulder pain in each group , and also occurred less often in Group 5 than in Group 1 . Muscle stiffness occurred less often than muscle pain , and also occurred less frequently in Group 5 than in Group 1 . In conclusion , succinylcholine contributes to neck pain and muscle stiffness after laparoscopic procedures . Compared to thiopental and enflurane , the use of propofol for induction and /or maintenance of anesthesia failed to alter the incidence of postlaparoscopic muscle pain or stiffness Background The effects of intraperitoneal administration of bupivacaine on  pain after laparoscopic cholecystectomy were studied in a prospect i ve , double‐blind , r and omised trial . Methods : Eighty ASA 1 and 2 patients were r and omly assigned to one of two groups . Immediately after pneumoperi‐toneum was obtained patients in group 1 were given 15 ml of 0.5 % bupivacaine injected under direct vision into the hepato‐diaphragmatic space , near and above the hepato‐duodenal ligament and above the gallbladder . At the end of operation another 15 ml of bupivacaine was injected . Patients in group 2 were given 15 ml of 0.9 % saline solution in a similar fashion . Postoperative pain was assessed using a visual analogue scale ( VAS 100 mm ) at 0.5,4 , 8,12 and 24 h after surgery . Analgesic consumption was also recorded Background : Laparoscopic cholecystectomy is characterized by a short hospital stay . Hence , pain control on the day of surgery is increasingly important . The aim of this study was to evaluate the effect of intraperitoneal bupivacaine on pain relief following laparoscopic cholecystectomy . Methods : Sixty patients undergoing elective laparoscopic cholecystectomy were prospect ively r and omized into 2 groups . Following removal of the gallbladder , group A received 100 mg of bupivacaine in 50 cc of saline , installed into the gallbladder bed and right subphrenic space . Group B received saline without bupivacaine .  Pain was assessed using a visual/analog scale at fixed-time intervals . Results : No significant difference occurred in the average pain levels between the groups at 1 , 2 , 4 , and 14 hours postsurgery . The average analgesic requirement was lower in the bupivacaine group , but this did not reach statistical significance . Conclusion : Application of intraperitoneal bupivacaine did not attenuate pain following laparoscopic cholecystectomy , and no role exists for its routine use Purpose To compare the efficacy of tramadol and morphine for intra- and postoperative analgesia in patients undergoing laparoscopic cholecystectomy . Methods In a prospect i ve , r and omized , double-blind study 100 patients were allocated r and omly into two groups . Ten minutes before induction of anaesthesia , patients in group I received 100 mg tramadol and those in group 2 received 10 mg morphineiv . Anaesthesia was induced with 5 mg·kg−1 thiopental and was maintained with O2 , N2O plus isoflurane with additional doses of tramadol or morphine as decided by the attending anaesthetist . Postoperatively , patients in group I and group 2 received tramadol and morphine , respectively , from a patient-controlled analgesia ( PCA ) device . Pain , analgesic consumption , vital signs and side effects were recorded postoperatively for 24 hr . Results Intraoperative consumption of tramadol and morphine were 137 ± 37 and 12.2 ± 3 mg , respectively . Compared with morphine , patients receiving tramadol had higher blood pressures and required greater mean ETiso to control haemodynamic variables ( P < 0.05 ) . Postoperatively , there were no differences in observer pain score or visual analogue pain score during the first 24 hr between groups except at 30 , 45 , and 90 min where patients in the tramadol group reported higher pain scores ( P < 0.05 ) . The cumulative , 24 hr PCA consumption was III ± 93 and 7.5 ± 6.6 mg of tramadol and morphine , respectively . Conclusions There was no difference between the use of tramadol and morphine to treat pain after laparoscopic cholecystectomy from 90 min after the end of surgery . Morphine was more effective than tramadol as an intraoperative analgesic . RésuméObjectifComparer l’efficacité du tramadol et de la morphine pour l’analgésie peropératoire et postopératoire de patients devant subir une cholécystectomie laparoscopique . MéthodeLors d’une étude prospect i ve , r and omisée et en double aveugle , 100 patients ont été répartis au hasard en deux groupes . Dix minutes avant l’induction de l’anesthésie , les patients du groupe I ont reçu 100 mg de tramadol et ceux du groupe 2 , 10 mg de morphineiv . Lanesthésie a été induite avec 5 mg·kg−1 de thiopental et a été maintenue avec un mélange d’O2 et de N2O plus de l’isoflurane et des doses supplémentaires de tramadol ou de morphine selon la décision de l’anesthésiste traitant . Après l’intervention , les patients des groupes 1 et 2 ont reçu respectivement du tramadol et de la morphine à l’aide d’un dispositif d’analgésie contrôlée par le patient ( ACP ) . En période postopératoire également , on a enregistré pendant 24 heures la douleur , la consommation d’analgésiques , les signes vitaux et les effets secondaires . RésultatsLa consommation peropératoire de tramadol et de morphine a été de 137 ± 37 et de 12,2 ± 3 mg , respectivement . Comparativement , les patients qui ont reçu du tramadol ont présenté une tension artérielle plus élevée et ont eu besoin d’isofluraneTE ( télé-expiratoire ) de moyenne plus élevée pour contrôler les variables hémo-dynamiquesP < 0,05 ) . Il n’y a pas eu de différence de douleur postopératoire entre les groupes d’après les niveaux enregistrés par un observateur ou par l’échelle visuelle analogique , pendant les 24 premières heures , sauf à 30 , 45 et 90 min alors que les patients du groupe ayant reçu du tramadol ont éprouvé des douleurs plus intenses ( P < 0,05 ) . La consommation totale des 24 h d’ACP a été de 111 ±93 et de 7,5 ± 6,6 mg de tramadol et de morphine , respectivement . Conclusion À partir de 90 min après la chirurgie , il n’y a pas de différence entre l’usage de tramadol ou de morphine pour traiter la douleur consécutive à la cholécystectomie laparoscopique . La morphine a été plus efficace que le tramadol en tant qu’analgésique peropératoire The authors compared the analgesic efficacy of one dose of oral ibuprofen with that of intravenously administered fentanyl for relief of pain after outpatient laparoscopic surgery . Thirty healthy female patients received either 800 mg of oral ibuprofen preoperatively or 75 micrograms of intravenous fentanyl intraoperatively plus respective intravenous or oral placebos in a r and omized , double-blind manner . Patients recorded their degree of pain and nausea  in the recovery room , in the same-day surgery stepdown unit , during the ride home , and upon arrival at home . The postanesthesia care nurse recorded the amount of fentanyl and droperidol needed to treat pain and nausea in the recovery room . Patients who received ibuprofen were more comfortable in the stepdown unit ( P less than 0.05 ) and after arrival home ( P less than 0.05 ) than those in the fentanyl group . Additionally , patients who received ibuprofen had lower nausea scores in the step-down unit ( P less than 0.05 ) ; this may have been related to the lower total fentanyl dose in these patients . The authors conclude that ibuprofen may be a useful alternative to fentanyl for providing postoperative analgesia for outpatient surgery Shoulder pain ( SP ) is frequently mentioned in recent literature following laparoscopic operations . In the literature , many causes have been declared to explain shoulder pain after CO2 insufflation , such as direct peritoneal irritation of the CO2 gas , excessive traction of the triangular ligament , and overstretching of the diaphragmatic muscle fibers due to the high rate of insufflation . This study was planned as multicentric , and 76 patients , aged between 35 to 45 , were entered into the study . They were all selected by a r and omized sampling method , with equal numbers of men and women , to achieve true evaluation . The low flow-rate ( LFR ) group was insufflated with 2.5 L/min and the high flow-rate ( HFR ) group with 7.5 L/min . All cases were evaluated by subjective pain classification on postoperative day 3 . According to the subjective pain scale method , shoulder pain average was 23.9+/-3.1 in the LFR group and 55.4+/-6.5 in the HFR group . The difference between these groups was significant ( p > 0.01 ) . There is no significant difference for the operation time ( LFR% : 64+/-15 minutes , HFR : 61+/-20 minutes , p > 0.05 ) . Our results suggest that there is a significant statistical relation between the postoperative shoulder pain levels and increased insufflation rates . For this reason , low insufflation rate significantly reduces the shoulder pain but does not increase the operation time . Therefore , a low insufflation rate should be applied in all cases for patients ' comfort and safety Background and objective : The reported incidence of shoulder tip pain following laparoscopic surgery varies from 35 to 63 % . This study evaluated the analgesic efficacy of either performing a prophylactic suprascapular nerve block with bupivacaine or applying a piroxicam patch to the skin over both shoulders for the relief of shoulder tip pain after laparoscopy . Methods : Sixty healthy informed female patients were r and omly assigned to one of three groups : ( a ) a control group ( n = 20 ) , no treatment ; ( b ) a suprascapular nerve block group ( n = 20 ) in which a bilateral suprascapular nerve block was performed before induction of anaesthesia with 5 mL 0.5 % bupivacaine with epinephrine ; and ( c ) a piroxicam patch group ( n = 20 ) in which a 48 mg piroxicam patch on the skin of each shoulder was applied before induction of anaesthesia . All patients received a total intravenous anaesthesia technique with propofol , fentanyl and vecuronium .  Shoulder tip and wound pain were recorded on a visual analogue pain scale at five time intervals for 24 h after surgery . Results : A total of 80 % of patients in the control group , 75 % in the suprascapular nerve block group and 45 % in the piroxicam patch group complained of shoulder tip pain during the recording period ( P < 0.05 ) . The scores for shoulder tip pain in the piroxicam patch group were significantly lower compared with the control group at 3 , 6 and 12 h , and compared with the suprascapular nerve block group at 6 and 12 h. The need for analgesics was also significantly lower in the piroxicam patch group compared with the other two groups . Conclusions : Prophylactic piroxicam patches are effective and safe for the relief of shoulder tip pain after laparoscopy . Bilateral suprascapular nerve block is not effective in this setting Ketorolac , a nonsteroidal anti-inflammatory drug , is alleged to produce postoperative analgesia without opioid-related side effects . Patients undergoing laparoscopic cholecystectomy were assigned r and omly to receive either ketorolac or a placebo ( saline ) according to a double-blind protocol . Preoperative ( baseline ) pulmonary function was evaluated using a Respiradyne II monitor . Patients received midazolam , 2 mg , and 2 mL of either ketorolac , 60 mg ( n = 311 , or saline ( n = 29 ) , 20–40 min before surgery . Anesthesia consisted of thiopental , 4–5 mg/kg , and vecuronium , 0.1 mg/kg , for induction , and isoflurane , 0.5%–2.0 % , with 67 % nitrous oxide in oxygen for maintenance . A second 2-mL dose of the same study medication ( ketorolac , 60 mg , or saline ) was administered 4 h after the initial dose . Post-operatively , 66 % of patients in the saline group complained of pain requiring treatment with fentanyl compared to 32 % in the ketorolac group ( P < 0.05 ) . There were no significant differences between the two groups with respect to postoperative sedation , anxiety , pain , or nausea visual analog scores . Compared to the preoperative values , significant decreases in pulmonary function tests were noted in both groups at 4 h after the operation and the following morning ( P < 0.01 ) . In the ketorolac group , only values of forced expiratory volume at 1 s and forced expiratory flow at 25%–75 % of the forced vital capacity at 4 h after the operation were significantly higher than those in the saline group ( P < 0.05 ) . Incidences of nausea ( 45 % vs 52 % ) and vomiting ( 10 % vs 10 % ) were similar in both groups . In conclusion , ketorolac decreased the postoperative requirement for opioid analgesic medication . However , the use of ketorolac failed to decrease postoperative emesis or ventilatory impairment after laparoscopic cholecystectomy BACKGROUND Laparoscopic cholecystectomy ( LC ) is traditionally performed with two 10-mm and two 5-mm trocars . The effect of smaller port incisions on pain has not been established in controlled studies . METHODS In a double-blind controlled study , patients were r and omized to LC or cholecystectomy with three 2-mm trocars and one 10-mm trocar ( micro-LC ) .  All patients received a multimodal analgesic regimen , including incisional local anesthetics at the beginning of surgery , NSAID , and paracetamol .  Pain was registered preoperatively , for the first 3 h postoperatively , and daily for the 1st week . RESULTS The study was discontinued after inclusion of 26 patients because five of the 13 patients ( 38 % ) r and omized to micro-LC were converted to LC . In the remaining 21 patients , overall pain and incisional pain intensity during the first 3 h postoperatively increased in the LC group ( n = 13 ) compared with preoperative pain levels ( p<0.01 ) , whereas pain did not increase in the micro-LC group ( n = 8) . CONCLUSIONS Micro-LC in combination with a prophylactic multimodal analgesic regimen reduced postoperative pain for the first 3 h postoperatively . However , the micro-LC led to an unacceptable rate of conversion to LC ( 38 % ) . The micro-LC instruments therefore need further technical development before this surgical technique can be used on a routine basis for laparoscopic cholecystectomy Background Opioids can produce peripheral analgesic effects by activation of opioid receptors on sensory nerves . This study was design ed ( 1 ) to examine a novel route of opioid administration , the intraperitoneal injection ; ( 2 ) to compare this to interpleural application , and ( 3 ) to compare opioid with local anesthetic effects under both conditions . Methods At the end of laparoscopic cholecystectomy , 110 patients received the following injections in a double‐blind , r and omized manner : Group 1 ( n = 18 ) was given intraperitoneal morphine ( 1 mg in 20 ml saline ) and 20 ml intravenous saline . Group 2 ( n = 17 ) received intraperitoneal saline and 1 mg intravenous morphine . Group 3 ( n = 15 ) received 20 ml 0.25 % intraperitoneal bupivacaine and intravenous saline . Group 4 ( n = 20 ) received interpleural morphine ( 1.5 mg in 30 ml saline ) and 30 ml intravenous saline . Group 5 ( n = 20 ) received interpleural saline and 1.5 mg intravenous morphine . Group 6 ( n = 20 ) received 30 ml 0.25 % interpleural bupivacaine and intravenous saline .  Postoperative pain was assessed using a visual analog scale , a numeric rating scale , and the McGill pain question naire . Pain localization , supplemental analgesic consumption , vital signs , and side effects were recorded for 24 h. Results Neither intraperitoneal nor interpleural morphine produced significant analgesia after laparoscopic cholecystectomy ( P > 0.05 , Kruskal‐Wallis test ) , whereas interpleural bupivacaine was effective ( P < 0.05 , Kruskal‐Wallis test , up to 6 h postoperatively ) but not intraperitoneal bupivacaine ( P > 0.05 , Kruskal‐Wallis test ) . Shoulder pain was not prevalent in the majority of patients during the first 6 h. By 24 h , about half of the patients complained of shoulder pain , which was rated “ low ” by about one‐third of all patients . No significant side effects occurred . Conclusions Interpleural bupivacaine ( 0.25 % ) produces analgesia after laparoscopic cholecystectomy . We attribute the lack of effect of intraperitoneal injections to the small dose and to a rapid dilution within the peritoneal cavity . The fact that interpleural morphine ( 0.005 % ) is ineffective may be due to an intact perineurial barrier in the noninflamed pleural cavity , which restricts the transperineurial passage of morphine to opioid receptors on intercostal nerves The effects of intraperitoneal administration of bupivacaine on pain and the sympathoadrenal response to surgery were studied in a double‐blind r and omized trial in 19 patients undergoing cholecystectomy .  Bupivacaine ( 2 mg/kg ) was dissolved in 300 ml isotonic saline and administered into the peritoneal cavity 10 min before the operation ( n = 9 ) . Saline was administered in a comparable group of patients ( n = 10 ) . There were no significant differences in pain scores between the groups during the first day after surgery ( P>0.05 ) . Postoperative requirements of pethidine during the first 2 days after surgery did not differ significantly between the groups . Blood glucose levels were significantly lower in the bupivacaine‐treated group 1 h ( P<0.05 ) and 4 h ( P<0.05 ) after skin incision . No significant differences were observed between the groups regarding plasma catecholamine and serum cortisol levels during and after surgery . Differences between the groups regarding urine output of catecholamines during the first and second postoperative days were not significant . Our results suggest that single administration of a local anesthetic intraperitoneally does not reduce pain or the sympathoadrenal response to upper abdominal surgery We have evaluated the antiemetic effect of i.v . dexamethasone compared with saline in the prevention of nausea and vomiting after laparoscopic cholecystectomy . We studied 90 patients requiring general anaesthesia for laparoscopic cholecystectomy , in a r and omized , double-blind , placebo-controlled study . The  dexamethasone group ( n = 45 ) received dexamethasone 8 mg i.v . and the saline group received saline 2 ml i.v . at induction of anaesthesia . Anaesthesia was maintained with isoflurane in oxygen . We found that 10 % of patients in the dexamethasone group compared with 34 % in the saline group reported vomiting ( P < 0.05 ) . Of note , the total incidence of nausea and vomiting was 23 % in the dexamethasone group and 63 % in the saline group ( P < 0.001 ) . We conclude that dexamethasone 8 mg significantly decreased the incidence of nausea and vomiting after laparoscopic cholecystectomy Post-laparoscopy pain can increase recovery time and delay patient discharge . While previous studies have focused on the problems of nausea and vomiting , the purpose of this study was to assess the effect of diclofenac ( a non-steroidal antiinflammatory drug ) in the treatment of post-laparoscopy pain .  Diclofenac ( 50 mg ) or placebo was administered pr r and omly and double-blind , prior to induction of anaesthesia , to 46 women .  Pain intensity was assessed by the patient using a visual analogue scale 1 , 12 and 24 hr after surgery . Postoperative analgesic requirements and side effects were also studied . Diclofenac result ed in better pain relief at 24 hr ( 1.0 vs 2.5 , P < 0.05 ) and reduced the number of patients who needed additional postoperative analgesics ( 7 vs 15 , P < 0.05 ) . There was no difference in the incidence of side effects . These data suggest that diclofenac reduces post-laparoscopy pain and postoperative analgesic requirements . RésuméLa douleur postlaparoscopique ralentit la récupération et retarde le congé . Alors que des études antérieures portaient sur les phénomènes de nausées et de vomissements , l’objectif de cette étude est d’évaluer les effets du diclofénac ( un antiinflammatoire non-stéroïdien ) sur la douleur postlaparascopie . Le diclofénac 50 mg ou un placébo sont administrés à 46 femmes au hasard et à double insu par la voie rectale avant l’induction de l’anesthésie . L’intensité de la douleur est évaluée par la patiente à l’aide d’une échelle visuelle analogique 1 hre , 12 et 24 hres après la chirurgie . Les besoins analgésiques postopératoires et les effets secondaires sont aussi étudiés . Le diclofénac produit un meilleur soulagement à 24 hres ( 1,0 vs 2,5 , P < 0,05 ) et diminue le nombre de patientes qui ont besoin d’analgésiques additionnels ( 7 vs 15 , P < 0,05 ) . Il n’y a pas de différence dans l’incidence des effets secondaires . Ces données suggèrent que le diclofénac diminue la douleur postlaparoscopie et les besoins postopératoires d’analgésiques INTRODUCTION The positive CO2 pneumoperitoneum needed to create the working space for laparoscopic surgery may induce pathophysiological changes . Concern about these changes has led to the introduction of a gasless technique . The aim of the present study was to compare the gasless CLC and GLC with regard to exposure , technical problems , operation time , postoperative pain , clinical course , and convalescence . MATERIAL AND METHODS Fifty consecutive patients with symptomatic gallstones were r and omised to  conventional ( CLC ) or gasless laparoscopic cholecystectomy ( GLC ) , with special reference to overall patient satisfaction , technical difficulties , duration of surgery , postoperative pain , and recovery . RESULTS The overall exposure of the operative field was poorer in the GLC group , whereas the duration of surgery , steps involved in the cholecystectomy technique , length of hospital stay , and postoperative pain score did not differ significantly . The period to return to normal activity was significantly shorter in the GLC group , six days compared to 8.5 days in the CLC group ( p < 0.05 ) . No differences were found in terms of fatigue , dizziness and nausea , and overall satisfaction with the outcome . DISCUSSION This study shows that convalescence is significantly shorter after laparoscopic cholecystectomy by the gasless technique than by the conventional CO2 technique . However , exposure of the operative field was less than optimal with the gasless technique D-myo-inositol-1,2,6-trisphosphate ( 1,2,6-IP3 ) possesses antiinflammatory properties , such as reduced eicosanoid synthesis and inhibition of inflammationinduced edema . These properties suggest possible analgesic effects . The analgesic effect of 1,2,6-IP3 was evaluated in a double-blind , r and omized study in 24 patients undergoing cholecystectomy . Ten patients received 1,2,6-IP3 as an intravenous ( IV ) bolus dose of 240 mg , followed by a continuous IV infusion at 90 mg/h for 24 h. The placebo  group ( n = 14 ) received corresponding volumes of isotonic saline .  Postoperative pain ( visual analog pain scale ; VAS ) and opiate analgesic requirements ( ketobemidon )  were evaluated during five postoperative days . Results showed significantly reduced pain during the first five postoperative days in patients treated with 1,2,6-IP ( 3 ) , as measured by using a VAS ( P < 0.05 ) . The requirements of opioid analgesics were significantly reduced during the first three postoperative days ( P < 0.05 ) . No drug-related side effects were observed . Results of the present study demonstrate a potent and long-lasting analgesic effect of 1,2,6-IP3 , possibly related to its antiinflammatory properties . Implication s : A new antiinflammatory drug under investigation , inositol-1,2,6-trisphosphate , was evaluated as a possible analgesic in a pilot study during the postoperative period in cholecystectomized patients . Results showed significantly lower pain assessment and opioid consumption , which should encourage further studies Objective : To compare blood volumes and hematologic indices between nine aerobically trained , physically active pregnant women who continued to exercise throughout gestation and five healthy yet sedentary gravidas . Methods : Subjects were tested on three occasions : 25 and 36 weeks of pregnancy and 12 weeks postpartum . Plasma volumes were estimated by dye dilution with Evans blue . Blood sample s were taken from the antecubital vein with the subjects resting in a seated , semirecumbent position . In addition to plasma volume estimations , blood sample s were analyzed for hematocrit ratio , hemoglobin concentration , red cell count , and plasma protein concentration . Blood volumes and red cell volumes were calculated from plasma volume estimates and hematocrit ratios . Results : Average birth weight and length of gestation did not differ between the subject groups . Analysis of variance indicated that absolute blood volume measures were significantly greater ( P < .01 ) in the physically active compared to sedentary subjects at all three test times . Similar results were found for plasma and red cell volumes ( P < .01 ) . Blood volumes relative to body weight were significantly higher in physically active subjects ( P < .01 ) than in their sedentary counterparts at 25 weeks ( 88.5 versus 75.5 mL/ kg ) and at 36 weeks ( 88.4 versus 70.9 mL/ kg ) , as well as at 12 weeks postpartum ( 72.2 versus 57.6 mL/ kg ) . All vascular volumes were significantly ( P < 001 ) lower at 12 weeks postpartum compared to those seen during pregnancy in both subject groups . Hematologic indices of hematocrit ratio , hemoglobin concentration , red cell count , and plasma protein concentration were all greater ( P < 001 ) at 12 weeks postpartum than during pregnancy Background Postoperative nausea and vomiting after laparoscopic cholecystectomy remains a common problem despite routine antiemetic prophylaxis . Therefore , the authors investigated the effect of administering 4 mg intravenous dexamethasone as an adjunct to a 5-HT3 antagonist ( 12.5 mg intravenous dolasetron ) with respect to patient outcome . Methods Out patients ( N = 140 ) were enrolled in this prospect i ve , r and omized , placebo-controlled , double-blind , institutional review board – approved protocol involving two antiemetic treatment groups . After induction of anesthesia , the control group received 1 ml intravenous saline , whereas the dexamethasone group received 4 mg intravenous dexamethasone . Both groups received 12.5 mg intravenous dolasetron at the time of gallbladder removal . A blinded observer recorded the recovery times , emetic episodes , rescue antiemetics , maximum nausea score , and time to achieve discharge criteria . Postdischarge side effects , as well as patient satisfaction and quality of recovery scores were assessed at 24 h after surgery . Results Although there was no difference in the incidence of postoperative nausea and vomiting in the early recovery period , the dexamethasone group had a shorter stay in the day-surgery unit ( 136 ± 57 vs. 179 ± 62 min ) and more rapidly achieved discharge criteria ( 161 ± 32 vs. 209 ± 39 min ) . In addition , fewer patients in the dexamethasone group experienced nausea at home within 24 h after discharge ( 13 vs. 28 % , P < 0.05 ) . Finally , the dexamethasone group reported higher quality of recovery and patient satisfaction scores ( P < 0.05 ) . Conclusions The authors conclude that the adjunctive use of 4 mg intravenous dexamethasone shortened the time to achieve discharge criteria and improved the quality of recovery and patient satisfaction scores after laparoscopic cholecystectomy procedures in out patients receiving prophylaxis with 12.5 mg intravenous dolasetron Although postoperative pain following  laparoscopic cholecystectomy ( LC ) is less intense than that after open surgery , postoperative morbidity nonetheless increases with LC . The aim of this study was to investigate whether local anesthetic infiltration of trocar sites during LC decreased postoperative pain and , if so , to find the optimum timing for local anesthesia ( LA ) .  Seventy patients undergoing LC  were r and omized into three groups . In the first ( control group , n = 25 ) 3 ml of 0.9 % NaCl was subcutaneously infiltrated around each 5-mm trocar site , 4 ml around each 10-mm site . In the second group ( n = 20 ) , the same volume of local anesthetic was administered in the same manner prior to surgery , and in the third group ( n = 25 ) an identical dose of local anesthetic was infiltrated at the end of surgery . A visual analog scale was given to all patients , who were asked to record their pain intensity at 1 , 3 , 5 , 7 , and 12 h postoperatively . Pethidine HCl 1 mg/kg i.m . was given to those whose pain intensities were greater than 5 . The mean pain intensities were 7.6 , 5.9 , and 5.1 in the control , preoperative , and postoperative LA groups , respectively . In the preoperative LA group , 50 % of patients and in the postoperative LA group 28 % of patients required analgesics compared with 76 % in the control group . The main pain intensities and analgesic requirements were significantly lower in the postoperative LA group compared with other groups . We conclude that local anesthesia during LC reduces postoperative pain and that infiltration of trocar sites following surgery offers better pain relief than local anesthetic given just before the incision Dexamethasone is an effective antiemetic drug , but the efficacy of small-dose dexamethasone 5 mg on the prophylaxis of postoperative nausea and vomiting ( PONV ) in patients undergoing laparoscopic chole-cystectomy has not been evaluated . We , therefore , evaluated the prophylactic effect of small-dose dexamethasone ( 5 mg ) on PONV in patients undergoing laparoscopic cholecystectomy .  Tropisetron and saline served as controls . One-hundred-twenty patients scheduled for laparoscopic cholecystectomy were enrolled in a r and omized , double-blinded , placebo-controlled study . At the induction of anesthesia , the Dexamethasone group received IV dexamethasone 5 mg , the Tropisetron group received IV tropisetron 2 mg , and the Pla- cebo group received IV saline . We found that both dexamethasone and tropisetron significantly decreased the following variables : the total incidence of PONV ( P < 0.01 ) , more than four vomiting episodes ( P < 0.05 ) , and the proportions of patients requiring rescue antiemetics ( P < 0.05 ) . The differences between the Dexamethasone and Tropisetron groups were not significant . We conclude that prophylactic IV dexamethasone 5 mg significantly reduces the incidence of PONV in patients undergoing laparoscopic cholecystectomy . At this dose , dexamethasone is as effective as tropisetron 2 mg and is more effective than placebo Gynaecological surgery is of high emetogenic potential and both total intravenous anaesthesia ( TIVA ) and prophylactic antiemetic therapy may reduce the incidence of postoperative nausea and vomiting ( PONV ) . We studied 144 patients scheduled for day-case gynaecological laparoscopy in a r and omized trial comparing balanced inhalational anaesthesia and prophylactic dolasetron ( group I+D ) with propofol TIVA and dolasetron ( group T+D ) or TIVA alone ( group T ) . The primary outcome of “ complete response ” ( no vomiting , no treatment for PONV ) was not significantly different among groups ( 34 % , 51 % , 32 % ; groups I+D vs T+D vs T , P=0.12 ) . During the first hour after surgery , group I+D had nausea of greater severity ( P<0.03 ) . During hospital admission , group T had more vomiting ( P<0.03 ) . From discharge until 24 hours postoperatively , 55 % of group I+D experience nausea and 38 % vomited . The incidence and severity of nausea were significantly lower in the TIVA groups ( P<0.04 and < 0.05 respectively ) . There were no significant differences between groups T+D and T , although comparing all groups the complete response rate was highest and the post-discharge incidence and severity of nausea lowest in group T+D. In conclusion , propofol TIVA , with or without dolasetron , reduced postoperative nausea , but not perioperative vomiting or antiemetic requirement , when compared with inhalational anaesthesia plus dolasetron The antiemetic efficacy of ondansetron given prophylactically was investigated in a r and omised , double‐blind , placebo‐controlled trial of 63 patients undergoing laparoscopic cholecystectomy . The patients received intravenously prior to anaesthesia either ondansetron 4 mg or placebo . The same st and ardised general anaesthetic technique was used . Nausea , emetic episodes and the need for rescue medication were recorded for 24 h postoperatively . Nausea was experienced by 64 % of the patients in the ondansetron group and 56 % in the placebo group , and emetic episodes occurred in 45 % and 50 % of the patients in the two groups , respectively . The proportions of patients given rescue antiemetic medication were 45 % and 44 % , respectively . No clinical ly important adverse events were observed . In conclusion , ondansetron given prior to anaesthesia in a dosage of 4 mg did not prevent postoperative nausea and vomiting after laparoscopic cholecystectomy Postoperative pain after laparoscopic surgery is less than after laparotomy , and patients may benefit from an intraperitoneal injection of local anesthetic .  Thirty-seven ASA physical status I or II patients received in double-blinded fashion 20 mL of 0.9 % saline solution ( placebo ) , ropivacaine 0.25 % ( Rop 0.25 % ) , or ropivacaine 0.75 % ( Rop 0.75 % ) immediately after trocar placement and at the end of surgery . We measured pain and morphine consumption until 20 h after surgery . Plasma ropivacaine concentrations were measured . The three groups were comparable for shoulder pain , parietal pain , and incidence of side effects . Visceral pain at rest , during cough , and on movement and total consumption of morphine were significantly smaller in Groups Rop 0.25 % and Rop 0.75 % when compared with Placebo . Although no adverse effect occurred in any patient , the largest dose led to large plasma concentrations of ropivacaine  ( 2.93 ± 2.46 & mgr;g/mL and 3.76 ± 3.01 & mgr;g/mL after the first and second injection , respectively ) . We conclude that intraperitoneal administration of ropivacaine before and after surgery significantly decreases postoperative pain . Because the smaller dosage ( 2 × 50 mg ) provided similar analgesia and was associated with significantly smaller plasma concentrations than the larger dosage ( 2 × 150 mg ) , this smaller dosage seems more appropriate Continuous interpleural analgesia provided by 4 hourly injections of 20 ml bupivacaine 0.5 % with adrenaline 5 μg/ml was compared with placebo in a r and omised , double‐blind study after cholecystectomy . All patients self‐administered intravenous morphine using a patient‐controlled analgesia device . There was a highly significant difference in mean morphine consumption between the groups ( 72 mg as compared with 22 mg ) . Visual analogue pain scores tended to be lower in the bupivacaine group throughout and this was significant at 2 hours . Respiratory function measurements were not significantly different between the groups . The mean peak venous plasma bupivacaine concentration after the sixth dose was 3.03 μg/ml and no symptoms suggestive of local anaesthetic toxicity occurred . It is concluded that this regimen can provide effective and continuous analgesia after cholecystectomy and that combined administration of interpleural bupivacaine and systemic morphine is more effective than morphine alone in the immediate postoperative period . The doses of bupivacaine required for optimal use of the technique lead to significant total plasma bupivacaine concentrations within 24 hours OBJECTIVE To evaluate the efficacy of nonsteroidal anti-inflammatory drugs ( NSAIDs ) on pain after laparoscopic cholecystectomy . DESIGN A prospect i ve , r and omized , placebo-controlled , double-blind study . SETTING A university hospital . PATIENTS Fifty-two patients with cholelithiasis but without known allergy to one of the study drugs , history of bleeding , peptic ulcer disease , known cardiac , lung or renal disease , abnormal liver function or use of opiates or NSAIDs within 2 weeks before operation . Patients were assigned to one of three groups and treatment was r and omized by placing the drugs in sealed , numbered envelopes . INTERVENTION Administration of the NSAIDs ketorolac , intramuscularly , or indomethacin , rectally , before laparoscopic cholecystectomy . MAIN OUTCOME MEASURES Postoperative pain scored on a a visual analogue scale and by nurse assessment , total dose of fentanyl citrate given , and nausea or emesis . RESULTS Patients in the placebo group reported significantly more pain than either NSAID group ( p<0.05 ) and were reported as having significantly more pain by the nurses ( P<0.05 ) . These patients were subsequently treated with a higher mean postoperative dose of fentanyl citrate than either NSAID group ( p<0.05 ) . Furthermore , the placebo group reported more nausea and emesis ( p<0.05 ) . There was no significant difference in any of the parameters measured between the ketorolac or indomethacin group . CONCLUSIONS The data demonstrate that the NSAIDs ketorolac and indomethacin , administered preoperatively , decrease early postoperative pain and nausea after laparoscopic cholecystectomy and are equally efficacious in producing these results OBJECTIVE To compare Nalbuphine and fentanyl as total intravenous anaesthesia with propofol infusion in laproscopic cholecystectomy cases . STUDY DESIGN Double blind r and omised . METHODS Changes in haemodynamic variables greater than twenty percent above or below the baseline and recovery profile were observed . RESULTS Blood pressure remained within 20 % of baseline in either group . Nine patients in fentanyl and fifteen in nalbuphine group required an additional bolus of propofol intraoperatively . Heart rate response after tracheal intubation was significantly higher in the nalbuphine group ( 25 % ) . No difference was observed in the incidence of nausea and vomiting in the recovery room . Twenty-seven percent patients in the nalbuphine group required analgesia in the recovery in comparison to 87 % in the fentanyl group . Patients in the fentanyl group required analgesia earlier ( 37 minutes vs. 62 minutes ) . CONCLUSION Fentanyl provided better intraoperative haemodynamic stability in comparison to nalbuphine when used as the analgesic component in total intravenous anaesthesia with propofol . The recovery profile with both drugs was similar . Lesser number of patients required analgesia in the recovery in the nalbuphine group Laparoscopic cholecystectomy is now widely practised . There are various methods of pain relief used but none has been assessed or compared following this procedure . We have assessed the analgesic effect of intraperitoneal bupivacaine in laparoscopic cholecystectomy . Sixty consecutive patients were r and omly assigned to one of two groups . Patients in group 1 were given 20 ml of saline injected under vision into the region of the gallbladder bed . Patients in group 2 were given 20 ml of 0.25 % bupivacaine in a similar fashion . Postoperative pain was assessed with a visual analogue pain scale and the site of pain was recorded . Patients in the bupivacaine group had less pain in the early postoperative period and a lower incidence of pain in the right hypochondrium . Intraperitoneal bupivacaine is a simple and effective treatment for postoperative pain after laparoscopic cholecystectomy STUDY OBJECTIVE To investigate the effect of an additional postoperative intravenous ( IV ) clonidine infusion on meperidine requirements in the early postoperative period . DESIGN Prospect i ve , r and omized , double-blind , placebo-controlled study . SETTING Postoperative recovery room at a university medical center . PATIENTS Sixty female patients who had undergone a cholecystectomy . INTERVENTIONS On first complaining of postoperative pain , 30 patients ( clonidine group ) received clonidine 150 micrograms IV over 30 minutes and an additional 150 micrograms of clonidine during the following 90 minutes . The other 30 patients ( control group ) were given identical volumes of 0.9 % sodium chloride IV at identical time intervals . All patients received a patient-controlled analgesia device ( initial dose , meperidine 16 mg ; subsequent doses , meperidine 8 mg on dem and ; lockout time , 5 minutes ; background infusion , meperidine 2.5 mg/hr ) . MEASUREMENTS AND MAIN RESULTS Pain intensity was evaluated with a 101-point numerical rating scale . Blood pressure , heart rate ( HR ) , respiratory rate , arterial hemoglobin oxygen saturation , and any side effects were recorded . There were no significant differences between the clonidine and control groups with respect to postoperative pain . The patients in the clonidine group required a total meperidine dose of 62.7 + /- 4.9 mg , compared with 70.4 + /- 3.9 mg in the control group ( mean + /- SEM ; not a significant difference ) . Systolic blood pressure and HR were significantly lower from 20 to 120 minutes and from 30 to 120 minutes , respectively after the start of the clonidine infusion compared with the placebo . No patient had to be treated for hypotension or bradycardia . Serious side effects were not observed . CONCLUSIONS During the first 2 postoperative hours following cholecystectomy , postoperative meperidine intake could not be reduced by IV administration of clonidine 300 micrograms In a double‐blind , placebo‐controlled study in 125 patients undergoing a cholecystectomy , a comparison was made of the quality of post‐operative pain relief during ‘ patient‐controlled ’ intake of sublingual buprenorphine in combination with either rectally administered naproxen 1000 mg/24 h , paracetamol 4000 mg/24 h or a placebo . Results obtained in 97 patients were analysed . Five of these patients needed a rescue medication with morphine hydrochloride intramuscularly because of insufficient pain relief or because of nausea and vomiting . The quality of pain relief , as measured on a four‐point scale , was comparable in all three groups throughout the study period and no significant differences became apparent . Only on the day of surgery ( day 0 ) was intake of buprenorphine  significantly greater in the placebo group ( 2.3 tablets/24 h ) than in the naproxen and paracetamol groups ( 1.8 and 1.5 tablets/24 h , respectively ) . It is concluded that after cholecystectomy ‘ patient‐controlled ’ intake of sublingual buprenorphine as a sole agent provides acceptable pain relief in about 80 % of patients . More elaborate methods , such as intravenous patient‐controlled analgesia , might be necessary to achieve good pain relief in the remainder of these patients Although postoperative pain has been reduced significantly since the advent of laparoscopic surgery , many patients still complain of moderate abdominal and shoulder pain during the first 48 to 72 h after surgery . In this study , the effect of subdiaphragmatic instillation of bupivacaine after laparoscopic cholecystectomy was investigated . The evaluation of postoperative pain was done according to a numerical verbal scale and the dose of analgesia required . The results showed a considerable reduction of postoperative pain during the first 48 h after surgery in patients who received  bupivacaine instillation . Although the literature shows certain controversy as to the effects of similar methods , our study concludes that instillation of a long-acting anesthetic , such as bupivacaine , into the subdiaphragmatic space after laparoscopic procedures is effective in postoperative pain reduction Background The factors affecting cardiorespiratory changes and postoperative pain after laparoscopic cholecystectomy are poorly understood . The aim of this study was to assess these changes in patients undergoing laparoscopic cholecystectomy at an insufflation pressure of 7.5 or 15 mmHg The aim of this study was to determine whether injection of a long‐acting local anaesthetic , in relation to the port sites at the level of the parietal peritoneum , would reduce postoperative pain following laparoscopic cholecystectomy . Patients were entered into a r and omized , prospect i ve , double‐blind study comparing the effects of a st and ard technique , in which bupivacaine ( total of 20 ml , 0–5 per cent ) was injected into the subcutaneous periportal tissue around the four port sites , and a technique in which bupivacaine ( total of 20 ml , 0.25 per cent ) was injected into the subcutaneous periportal tissue as above with the addition of periportal parietal peritoneal injection of bupivacaine ( total of 20 ml , 0–25 per cent ) . Two scores for pain , with the patient at rest , and on movement , were assessed 6 and 18 h after surgery using a visual analogue pain scale . Median pain score was significantly higher in patients who received st and ard technique ( n = 40 ) than in those given peritoneal injection ( n = 40 ) at both 6 ( rest = 3.0 versus 1.0 , movement = 5.0 versus 2.9 ) and 18 h ( rest = 1.9 versus 0 , movement = 3.2 versus 1.2 ) . Both opiate and oral analgesic requirements were reduced in patients administered peritoneal injection , although this was not statistically significant . The addition of periportal injection of bupivacaine at the level of the parietal peritoneum , performed under direct vision , reduces pain after laparoscopic cholecystectomy STUDY OBJECTIVE To assess the anesthetic effects of clonidine during sevoflurane anesthesia guided by the bispectral index ( BIS ) , which is a processed EEG variable correlated with anesthetic-hypnotic depth . DESIGN Placebo-controlled , double-blind clinical trial . SETTING S Elective laparoscopic surgery . PATIENTS 60 ASA physical status I patients scheduled for laparoscopic surgery . INTERVENTIONS Patients received either clonidine ( 3 micrograms/kg , 15 min before induction ) or placebo premedication for a sevoflurane-induced and sevoflurane-maintained anesthesia . Sevoflurane was titrated against a BIS held between 40 and 50 . Analgesia was provided by local infiltration with bupivacaine . Need for postoperative analgesia was recorded . RESULTS AND CONCLUSION Mean sevoflurane requirements were not lower with clonidine pretreatment . There was statistically better perioperative hemodynamic stability ( i.e. , fewer episodes of hypertension and tachycardia ) without clinical relevance . A decreased need for postoperative analgesia was observed In the current study , 55 patients undergoing elective cholecystectomy were r and omly allocated to receive postoperative analgesia ( morphine sulfate ) administered through either  patient-controlled intravenous ( PCA ) or st and ard intramuscular ( IM ) routes . There were no significant differences in length of hospitalization or required dose of morphine sulfate . Patients r and omized to PCA reported significantly improved subjective relief from pain and a smaller percentage of time in pain during each of the first two postoperative days . In addition , they reported less sedation and less interference with both postoperative breathing and pulmonary recovery than patients who received IM morphine . Theoretically , PCA regimens can deliver narcotic analgesia at a higher and more varied rate ( with fewer side effects ) compared with st and ard IM narcotic delivery , which is more limited by considerations of clinical doses . In PCA dosing , patients should experience less time in pain and sedation . The results of the current study support this premise In a double-blind r and omized trial , 50 patients scheduled for elective cholecystectomy received 50 mL of either 0.25 % bupivacaine hydrochloride or physiologic saline by wound perfusion at the end of the operation before wound closure . The duration of incisional infiltration , total amount of postoperative analgesics administered , and total hospital stay were recorded . Pulmonary function tests were performed the day before surgery and 1 day after surgery . There was no difference between the two groups with regard to duration of analgesia , the amount of analgesics administered , or the total hospital stay . Both groups also had similar decrements in forced vital capacity and forced expiratory volume on the first postoperative day . We conclude that wound infiltration with 0.25 % bupivacaine after elective cholecystectomy is not effective in reducing postoperative pain . Lung function disturbances can not be prevented BACKGROUND Successful management of postoperative pain requires that adequate analgesia is achieved without excessive adverse effects . Opioid-induced nausea and vomiting is known to impair patients ' satisfaction , but there are no studies providing sufficient power to test the hypothesis that the incidence of opioid-induced nausea and vomiting differs between micro -opioid receptor agonists . Thus , we tested the hypothesis that the incidence of vomiting and nausea differs between morphine and piritramide . METHODS In a prospect i ve , r and omized , double-blind fashion , we administered either morphine ( n=250 ) or piritramide ( n=250 ) by patient-controlled analgesia ( PCA ) for postoperative pain relief . We used a bolus dose of 1.5 mg with a lockout time of 10 min . Incidence and intensity ( numerical rating scale ) of postoperative nausea , vomiting , pain , patient satisfaction ( score 0 - 10 ) , side-effects ( score 0 - 3 ) and drug consumption were measured . RESULTS Mean drug consumption did not differ between the piritramide and morphine groups ( 30.8 ( SD 22.4 ) mg day(-1 ) vs 28.4 ( 21.8 ) mg day(-1 ) ) during the first postoperative day and there were no significant differences in the overall incidence of nausea ( 30 % vs 27 % ) and vomiting ( 19 % vs 15 % ) . Intensity of nausea correlated inversely ( P=0.01 ) with morphine consumption but not with piritramide consumption . Pain scores both at rest ( 2.2 ( 1.9 ) vs 2.6 ( 2 ) ) and during movement ( 4.4 ( 2.2 ) vs 4.9 ( 2.3 ) ) were slightly but significantly less with morphine . CONCLUSIONS Opioid-induced emesis was observed in about one-third of the patients using morphine  and  piritramide for PCA and the incidence of vomiting was one-half of that . Potential differences in the incidence of vomiting during PCA therapy between these micro-opioid receptor agonists can be excluded Several studies have reported the feasibility of using ‘ needlescopic ’ instruments with a diameter less than 3 mm in minimally invasive surgery . This study reports a comparison of needlescopic cholecystectomy and laparoscopic cholecystectomy Objective : To determine the effects of preoperative dexamethasone on surgical outcome after laparoscopic cholecystectomy ( LC ) . Summary Background Data : Pain and fatigue are dominating symptoms after LC and may prolong convalescence . Methods : In a double-blind , placebo-controlled study , 88 patients were r and omized to intravenous dexamethasone ( 8  mg ) or placebo  90 minutes before LC . Patients received a similar st and ardized anesthetic , surgical , and multimodal analgesic treatment . All patients were recommended 2 days postoperative duration of convalescence . The primary endpoints were fatigue and pain . Preoperatively and at several times during the first 24 postoperative hours , we measured C-reactive protein ( CRP ) and pulmonary function , pain scores , nausea , and number of vomiting episodes were registered . Analgesic and antiemetic requirements were recorded . Also , on a daily basis , patients reported scores of fatigue and pain before and during the first postoperative week and the date s for resumption of work and recreational activities . Results : Eight patients were excluded from the study , leaving 40 patients in each study group for analysis . There were no apparent side effects of the study drug . Dexamethasone significantly reduced postoperative levels of CRP ( P = 0.01 ) , fatigue ( P = 0.01 ) , overall pain , and incisional pain during the first 24 postoperative hours ( P < 0.05 ) and total requirements of opioids ( P < 0.05 ) . In addition , cumulated overall and visceral pain scores during the first postoperative week were significantly reduced ( P < 0.05 ) . Dexamethasone also reduced nausea and vomiting on the day of operation ( P < 0.05 ) . Resumption of recreational activities was significantly faster in the dexamethasone group versus placebo group ( median 1 day versus 2 days ) ( P < 0.05 ) . Conclusion : Preoperative dexamethasone ( 8 mg ) reduced pain , fatigue , nausea and vomiting , and duration of convalescence in patients undergoing noncomplicated LC , when compared with placebo , and is recommended for routine use Laparoscopic cholecystectomy is the surgical treatment of choice for symptomatic gallstones . Nonsteroidal antiinflammatory drugs offer effective analgesia , avoiding the central side effects of opiate drugs . To assess intramuscular diclofenac sodium ( Voltarol ; Ciba-Geigy ) after laparoscopic cholecystectomy , 55 consecutive patients ( 41 female ; 14 male ; mean age : 50 years ) were r and omised to receive either diclofenac or placebo in double-blind fashion . Six patients were withdrawn from study ( three conversions to open cholecystectomy ; three incomplete documentation ) . Pain scores were assessed at 4 , 24 , and 48 h using a linear analogue scale ; opiate consumption and time to first oral fluid and food were recorded . In 26 patients receiving diclofenac , median scores at 4 h were 1.6 ( range 0 - 7.6 ) as compared with 4.1 ( range 0 - 7.6 ) in 23 control patients ( p = 0.05 , 95 % confidence limits 3.2 , 0 ; Mann-Whitney U test ) . Nausea scores , return to diet , and time to discharge did not differ significantly between the groups . Intramuscular diclofenac significantly reduces early postoperative pain after laparoscopic cholecystectomy and is worthy of consideration if the procedure were ever undertaken as day case surgery Since it has been suggested that the use of nitrous oxide ( N2O ) may contribute to bowel distention , we evaluated the effects of N2O on operating conditions during laparoscopic cholecystectomy in 50 healthy patients using a double-blind protocol design . All patients received the same preanesthetic medication ( midazolam , 2 mg intravenously ) and induction of anesthesia consisted of intravenously administered fentanyl 1.5 micrograms.kg-1 , thiopental 4 - 6 mg.kg-1 , and a nondepolarizing muscle relaxant . For maintenance of anesthesia , patients were r and omly assigned to one of two treatment groups : group 1 ( n = 26 ) received isoflurane with 70 % N2O in oxygen ( O2 ) , whereas group 2 ( n = 24 ) received isoflurane in an air/O2 mixture . The surgeon ( blinded to the anesthetic technique ) estimated the degree of technical difficulty before beginning the operation using a five-point scale . At 15-min intervals throughout the operation , the surgeon was asked to evaluate both " overall operating conditions " and degree of " bowel distension " using independent five-point scales . At the end of the operation , the surgeon was asked whether or not N2O had been used as part of the anesthetic technique . There were no significant intraoperative differences between the two groups with respect to operating conditions or bowel distension . More importantly , there was no time-related change in either variable during the course of the operation . Finally , the incidence of postoperative nausea and vomiting was similar in both treatment groups . The surgeon was able to correctly determine that N2O had been administered only 44 % of the time . Thus , N2O had no clinical ly apparent deleterious effects during laparoscopic cholecystectomy
target: This approach has been design ed to provide adequate analgesia while minimizing exposure to adverse events
background: Background : Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain .
  However , a systematic review of postoperative pain management in this procedure has not been conducted .