LAPAROSKOPİK KOLESİSTEKTOMİ SONRASI POSTOPERATİF AĞRI NASIL YÖNETİLİR? ÜÇ FARKLI YAKLAŞIMIN KARŞILAŞTIRILMASI: PROSPEKTİF RANDOMİZE KONTROLLÜ BİR ÇALIŞMA

Yıl 2025, Cilt: 5 Sayı: 12, 12 - 18

Zafer Şenol , Tuna Ertürk , Taygun Gülşen , Muhammed Kadir Yıldırak , Dilek Metin Yamaç , Nurhilal Kızıltoprak , Mahmut Salih Genç , Bora İşçeviren Sümeyra Emine Bölük , Merve Karadağ , Elif Didem Terzi Bülent Güleç

https://doi.org/10.54270/atljm.2025.77

Öz

Amaç: Laparoskopik Kolesisektomi (LC), günlük genel cerrahi pratiğinde en çok yapılan ameliyatlardan biridir ve ameliyat sonrası ağrının giderilmesinin yetersiz olması, hastanede kalış süresinin uzamasıyla ilişkilidir. Transvers abdominis düzlem bloğu (TAPB), port bölgesi lokal anestezik enjeksiyonu (PSLAI) ve safra kesesi yatağı lokal anestezik püskürtme (GBLAS), çok sayıda ağrı yönetimi stratejisinin bir parçasını oluşturur. Bu çalışmada, transvers abdominis düzlem bloğu (TAPB), port bölgesi lokal anestezik enjeksiyonu (PSLAI) ve safra kesesi yatağı lokal anestezik püskürtme (GBLAS) yaklaşımlarında laparoskopik kolesisektomi sonrası postoperatif ağrıyı karşılaştırmayı amaçladık.
Gereç ve Yöntem: 99 hasta 3 gruba randomize edildi. Hasta Kontrollü Analjezi (PCA) kullanıldı ve toplam analjezik talebi ve dozu, postoperatif (p.o) 2, 6, 12 ve 24 saatlerde Sayısal Derecelendirme Ölçeği (NRS) değerleri ile birlikte kaydedildi.
Bulgular: Postoperatif 24. saatte gruplar arasında PCA açısından istatistiksel olarak anlamlı bir fark yoktu. Bununla birlikte, NRS değerleri PSLAI grubunda TAPB ve GBLAS gruplarına kıyasla anlamlı olarak daha yüksekti.
Sonuç: Bu çalışma, tek bir denemedeki üç yöntemi karşılaştırdığı için benzersizdir. GBLAS, daha kısa bir prosedürle ilişkili olduğu için biraz daha fazla dikkat çekerken, her üç yöntem de uygulanabilir ve hatta birleştirilebilir. Bu çalışmanın, bu konuda gelecekteki randomize kontrollü çalışmaların (RCT) önünü açacağına inanıyoruz.

Anahtar Kelimeler

Laparoskopik kolesistektomi, Transvers abdominis düzlem bloğu, Port bölgesi lokal anestezik enjeksiyonu, Safra kesesi yatağı lokal anestezik püskürtme, Ağrı yönetimi

HOW TO MANAGE POST-OPERATIVE PAIN AFTER LAPAROSCOPIC CHOLESYSTECTOMY? COMPARISON OF THREE DISTINCT APPROACHES: A PROSPECTIVE RANDOMIZED CONTROLLED STUDY

Öz

Aim: Laparoscopic Cholecystectomy (LC) is one of the most performed surgeries in daily general surgery practice and inadequate pain relief following surgery is associated with prolonged hospital stay. Transverse abdominis plane block (TAPB), port site local anesthetic injection (PSLAI) and gallbladder bed local anesthetic spraying (GBLAS) account for a part of numerous pain management strategies. In this study, we aimed to compare post-operative pain after laparoscopic cholecystectomy in transverse abdominis plane block (TAPB), port site local anesthetic injection (PSLAI) and gallbladder bed local anesthetic spraying (GBLAS) approaches.
Materials and Methods: 99 patients were randomized into 3 groups. Patient-Controlled Analgesia (PCA) was utilized, and total analgesic demand and dosage were recorded along with Numerical Rating Scale (NRS) values at post-operative (p.o) 2, 6, 12 and 24 hours.
Results: At p.o 24 hours, there was no statistically significant difference between groups in terms of PCA readings. However, NRS values were significantly higher in PSLAI group compared to TAPB and GBLAS groups.
Conclusion: This study is unique as it compares the three methods in a single trial. While GBLAS gains slightly more attention as it is associated with a shorter procedure, all three methods are viable and might even be combined. We believe this study will pave way for future randomized controlled trials (RCT) in this regard.

Anahtar Kelimeler

Laparoscopic cholecystectomy, Transverse abdominis plane block, Port site local anesthetic injection, Gallbladder bed local anesthetic spraying, Pain management

Kaynakça

• Hassler KR, Collins JT, Philip K, Jones MW. Laparoscopic Cholecystectomy, 2022.
• Ergenç M, Uprak TK. Laparoscopic treatment of a rare cause of acute abdomen; primary omental torsion. Laparoscopic Endoscopic Surgical Science 2021; 28:125–127. DOI: 10.14744/less.2021.82653.
• Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The Analgesic Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block in Adult Patients. Anesth Analg 2015; 121:1640–1654. DOI: 10.1213/ANE.0000000000000967
• Bisgaard T, Schulze S, Hjortsø NC, et al. Randomized clinical trial comparing oral prednisone (50 mg) with placebo before laparoscopic cholecystectomy. Surg Endosc 2008; 22: 566–72. DOI: 10.1007/s00464-007-9713-y
• Mitra S, Khandelwal P, Roberts K, et al. Pain relief in laparoscopic cholecystectomy-A review of the current options. Pain Pract. 2012, 12, 485–96. DOI: 10.1111/j.1533-2500.2011.00513.x
• Kadam V, Howell S, Kadam V. Evaluation of postoperative pain scores following ultrasound guided transversus abdominis plane block versus local infiltration following day surgery laparoscopic cholecystectomy-retrospective study. J Anaesthesiol Clin Pharmacol 2016; 32:80. DOI: 10.4103/0970-9185.168195
• Gurusamy KS, Nagendran M, Toon CD, Guerrini GP, Zinnuroglu M, Davidson BR. Methods of intraperitoneal local anaesthetic instillation for laparoscopic cholecystectomy. Cochrane Database of Systematic Reviews 2014. DOI: 10.1002/14651858.CD009060.pub2
• Peng K, Ji F, Liu H, Wu S. Ultrasound-Guided Transversus Abdominis Plane Block for Analgesia in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis. Medical Principles and Practice 2016; 25:237–246. DOI: 10.1159/000444688
• Loizides S, Gurusamy KS, Nagendran M, Rossi M, Guerrini GP, Davidson BR. Wound infiltration with local anaesthetic agents for laparoscopic cholecystectomy. Cochrane Database of Systematic Reviews 2014. DOI: 10.1002/14651858.CD007049.pub2
• Gupta A. Local anaesthesia for pain relief after laparoscopic cholecystectomy—a systematic review. Best Pract Res Clin Anaesthesiol 2005; 19:275–292. DOI: 10.1016/j.bpa.2004.12.007
• Rutherford D, Massie EM, Worsley C, Wilson MS. Intraperitoneal local anaesthetic instillation versus no intraperitoneal local anaesthetic instillation for laparoscopic cholecystectomy. Cochrane Database of Systematic Reviews 2021. DOI: 10.1002/14651858.CD007337.pub4
• Elamin G, Waters PS, Hamid H, O’Keeffe HM, Waldron RM, Duggan M, Khan W, Barry MK, Khan IZ. Efficacy of a Laparoscopically Delivered Transversus Abdominis Plane Block Technique during Elective Laparoscopic Cholecystectomy: A Prospective, Double-Blind Randomized Trial. J Am Coll Surg 2015; 221:335–344. DOI: 10.1016/j.jamcollsurg.2015.03.030
• Vijayaraghavalu S, Bharthi Sekar E. A Comparative Study on the Postoperative Analgesic Effects of the Intraperitoneal Instillation of Bupivacaine Versus Normal Saline Following Laparoscopic Cholecystectomy. Cureus 2021. DOI: 10.7759/cureus.14151
• Liang M, Chen Y, Zhu W, Zhou D. Efficacy and safety of different doses of ropivacaine for laparoscopy-assisted infiltration analgesia in patients undergoing laparoscopic cholecystectomy. Medicine 2020; 99:e22540. DOI: 10.1097/MD.0000000000022540
• Kaushal-Deep SM, Lodhi M, Anees A, Khan S, Khan MA. Evolution of Various Components of Pain After Laparoscopic Cholecystectomy: Importance of Its Prognostication for Effective Pain Control Using a Local Anesthetic and for Making a Valid Practical “Discharge Criteria” Model Predicting Early Discharge of Patients. Journal of Laparoendoscopic & Advanced Surgical Techniques 2018; 28:389–401. DOI: 10.1089/lap.2017.0530
• Grape S, Kirkham KR, Akiki L, Albrecht E. Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis. J Clin Anesth 2021; 75:110450. DOI: 10.1016/j.jclinane.2021.110450
• Mishra PK, Mani S, Singh RB. Evaluating the Efficacy of Pre-incisional Infiltration and Intraperitoneal Instillation of a Local Anesthetic Agent on Postoperative Analgesia and Hemodynamics in Patients Undergoing Laparoscopic Cholecystectomy Under General Anesthesia. Cureus 2022. DOI: 10.7759/cureus.22977
• Kaushal-Deep SM, Anees A, Khan S, Khan MA, Lodhi M. Randomized controlled study of intraincisional infiltration versus intraperitoneal instillation of standardized dose of ropivacaine 0.2% in post-laparoscopic cholecystectomy pain: Do we really need high doses of local anesthetics—time to rethink! Surg Endosc 2018; 32: 3321–3341. DOI: 10.1007/s00464-018-6053-z