Lidocaine’s Role in Laparoscopic Cholecystectomy
Various studies show that Intraperitoneal (IP) and intravenous (IV) lidocaine administration of lidocaine markedly alleviates postoperative pain and reduces need for opioid medication in patients who have undergone Laparoscopic cholecystectomy (LC).
Even Though laparoscopic cholecystectomy is much better than traditional open surgeries still patients who have undergone LC experience postoperative pain due to either super?cial incisional wound pain, deep visceral pain or post laparoscopy shoulder pain.
3 types of pain can be experienced after Laparoscopic cholecystectomy.
They are as follows:
- Parietal (somatic) pain: It is caused due to the holes made in the abdominal wall for the trocars.
- Visceral pain: It is caused by surgical handling and by diaphragmatic irritation due to dissolved CO2. Visceral pain is predominant during the first 24 hours after the procedure. It is short-lived and is unaffected by mobilization .However it is increased by coughing.
- Shoulder tip pain: It is caused by rapid distension of the peritoneum (leading to the tearing of blood vessels & traumatic traction of the nerves and the release of inflammatory mediators) and excitation of the phrenic nerve. It is associated with persistent pneumoperitoneum and can sometimes last for 3 days.
Management of this postoperative pain will require administration of systemic opioid analgesia and hence can result in longer hospital stay of the patients. Various methods have been tried to relieve this postoperative pain like administration of NSAIDS (nonsteroidal anti-inflammatory drugs), opioids & local anaesthetic agents but none has shown to provide effective relief.
Administration of local anaesthesia via the Intraperitoneal (IP) route has been shown to reduce postoperative pain and the need for use of analgesics post laparoscopic surgery. But spraying lidocaine during a laparoscopic surgery to reduce postoperative pain is burdensome for the surgeon especially if the surgery is complicated.
Intravenous (IV) lidocaine is better suited for such complex cases which also has analgesic, anti-inflammatory and antihyperalgesic properties. Post operation of Laparoscopic cholecystectomy pain which is experienced cannot be attributed to any single cause or factor making its management complex. Hence management of such multifactorial postoperative pain will require a multimodal approach. IV lidocaine is indicated for giving regional blocks and in cases of antiarrhythmia, for providing analgesia for neuropathic and central pain and postoperative pain.
Mechanism of action of Lidocaine:
IV administration of Lidocaine results in a suppression of the excitability of dorsal horn neurons and it depresses the spike activity, amplitude and conduction time in myelinated A-D and also the unmyelinated C fibres.
Hence IV administration of Lidocaine is useful in management of pain post operation of Laparoscopic cholecystectomy as it decreases the neural response to postoperative pain by blocking or inhibiting nerve conduction, suppressing central sensitization, inhibiting spinal visceromotor neurons, and reducing inflammation.
The patient therefore experiences less pain with IV lidocaine. However the mechanism of action for systemic analgesia due to lidocaine is still poorly understood and cannot be explained solely on the basis of the sodium channel blockade effect of lidocaine.
Other possible factors of postoperative pain can be the direct or indirect interaction with different receptors and nociceptive transmission pathways (like muscarinic antagonists, glycine inhibitors, reduced production of excitatory amino acids, thromboxane A2, release of endogenous opioids, reduced neurokinin levels).
Even though there is lack of proper understanding of the mechanism of systemic action of lidocaine there is growing evidence showing the effectiveness of perioperative lidocaine infusions as part of a multimodal analgesic regimen for the management of postoperative pain.
However there are some advantages of the use of IV technique for administration of Lidocaine over IP technique.
These advantages are as follows:
- Less preparation needed for the surgeon and less complex equipments are required.
- Clinical advantages are that the patients experience fewer opioid-related side effects when prescribed opioids.
- IV lidocaine is a convenient technique and has a better safety profile than IP Lidocaine .Hence it is preferable to use IV Lidocaine in cases of serious intra-abdominal inflammatory conditions and other complex cases.
For more information:
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