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Acute Pain | Chronic Pain | General

Incisional local anaesthesia for pain after abdominal surgery

Clinical bottom line:

Incisional local anaesthetic is effective in relieving postoperative pain after inguinal herniotomy up to about seven hours. For hysterectomy, cholecystectomy and other major/minor surgical procedures, there was a lack of evidence for effectiveness. This may be due in part to inadequate trial design, and further trials are needed before recommendations can be made.


Incisional local anaesthesia

Wound infiltration with local anaesthesia is used widely for postoperative pain: it is simple, safe and low cost. However, it is unclear whether differences in surgical procedure or whether visceral components influence efficacy.

Systematic review

Moiniche S, Mikkelsen S, Wetterslev J, Dahl JB. A qualitative systematic review of incisional local anaesthesia for postoperative pain relief after abdominal operations. British Journal of Anaesthesia 1998; 81:377-383

Inclusion criteria were randomised, double blind, placebo-controlled trials of wound infiltration with local anaesthesia; incisional delivery; adult patients; postoperative pain; placebo (saline) or no treatment comparisons; surgical intervention with abdominal incisions; pain outcomes.

For this review, incisional anaesthesia was defined as infiltration, topical administration or instillation of local anaesthesia at the following sites only: skin, subcutaneous tissue, fascia, muscle and/or the parietal peritoneum.

Reviewers assessed the efficacy of incisional anaesthesia by using the original authors conclusions on pain relief (using pain scores), time to first request for supplementary analgesia and supplementary analgesic consumption.

Findings

Inguinal herniotomy

Five trials of 242 patients were included. Trials used bupivacaine 0.25% 40 ml and 0.5% 15 ml; lidocaine 200 mg; ropivacaine 0.25% and 0.5% 40 ml. Five of five trials showed significant pain relief compared with placebo. In three of these trials this was for one to seven hours after surgery, in one trial for 24 hours and one for 48 hours.

Abdominal hysterectomy

Four trials of 167 patients were included.

Two trials showed significant pain relief with incisional local anaesthetic. One trial with lidocaine 500 mg (aerosol subcutaneous) showed significant pain relief for 24 hours only, and bupivacaine 0.25% 45 ml (subfascial and subcutaneous) showed significant reduction on analgesic consumption, but not pain. The remaining two trials looked at subcutaneous bupivacaine 0.5% 40 ml (before and after surgery) and 20 ml, and showed no benefit. However, a power analysis of both trials revealed 20% likelihood of error.

Open cholecystectomy

Eight trials of 376 patients were included. Seven of these looked at 0.25% to 0.5% bupivacaine 40 to 55 ml as a single dose, or infusion of 10 to 16 ml every 4 to 12 hours. One trial looked at 0.125% and 0.25% ropivacaine.

Five trials looked at pain relief. Two of five trials found significant pain relief - one at 24 and 48 hours with bupivacaine bolus dose followed by continuous subfascial infusion of 0.5% 4 ml per hour, and the second trial with 0.25% (but not 0.125%) ropivacaine 70 ml at six hours. The remaining three trials found no benefit of incisional local anaesthetic.

Three trials looked at analgesic consumption only, and although three of three found a significant reduction, two of these findings were questionable.

Other surgical procedures (major and minor)

Nine trials of 426 patients were included.

Four of nine trials showed significant pain relief (ranging from about two hours to 12 hours), and two further trials showed significant reduction in analgesic consumption. Reviewers did not state all doses and methods of delivery.

Adverse effects

No adverse effects attributable to incisional local anaesthesia were reported.

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