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Two-port versus four-port laparoscopic cholecystectomy
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Three-port vs standard four-port laparoscopic cholecystectomy
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Context : To assess the analgesic efficacy of the combination of bupivacaine and buprenorphine in alleviating postoperative pain following laparoscopic cholecystectomy . Aims : Laparoscopic cholecystectomy is comparatively advantageous as it offers less pain in the postoperative period and requires a shorter hospital stay . There are only a few studies performed to evaluate the analgesic efficacy of intraperitoneal instillation of buprenorphine and bupivacaine during laparoscopic cholecystectomy . Setting s and Design : The present research is a r and omized , double-blind controlled study conducted in the Department of Anaesthesiology , Dayan and Medical College and Hospital Ludhiana , Punjab after formal ethical approval from Hospital 's Ethics Committee . Subjects and Methods : This study analyzed 90 adults admitted for elective laparoscopic cholecystectomy . After the procedure , subjects were divided into three equal groups to conduct the study . Three Groups A , B , and C had intraperitoneal instillation of the 25 ml of physiological saline ( 0.9 % normal saline ) , 0.25 % of bupivacaine , 0.25 % bupivacaine , and 0.3 mg buprenorphine , respectively . Necessary vitals were monitored and recorded . Visual analog scale ( VAS ) and verbal rating scale ( VRS ) scores were recorded and analyzed systematic ally . Statistical Analysis Used : All observations were analyzed using analysis of variance and Student 's t-test . Results : The mean pain scores were highest in Group A compared to Group B and Group C. Mean VAS and VRS scores were highest in Group C comparatively and lowest in Group A. Conclusion : Combination of buprenorphine and bupivacaine intraperitoneally is comparatively more effective in relieving postoperative pain in comparison to intraperitoneal instillation of bupivacaine alone for postoperative pain management after laparoscopic cholecystectomy Background : Significant pain can be experienced after laparoscopic cholecystectomy . This systematic review aims to formulate PROSPECT ( PROcedure SPECific Postoperative Pain ManagemenT ) recommendations to reduce postoperative pain after laparoscopic cholecystectomy . Methods : R and omised controlled trials published in the English language from January 2006 ( date of last PROSPECT review ) to December 2017 , assessing analgesic , anaesthetic , or operative interventions for laparoscopic cholecystectomy in adults , and reporting pain scores , were retrieved from MEDLINE and Cochrane data bases using PRISMA ( Preferred Reporting Items for Systematic Review s and Meta‐Analyses ) search protocol s. PROSPECT methodology was used , and recommendations were formulated after review and discussion by the PROSPECT group ( an international group of leading pain specialists and surgeons ) . Results : Of 1988 r and omised controlled trials identified , 258 met the inclusion criteria and were included in this review . The studies were of mixed method ological quality , and quantitative analysis was not performed because of heterogeneous study design and how outcomes were reported . Conclusions : We recommend basic analgesic techniques : paracetamol + NSAID or cyclooxygenase‐2 specific inhibitor + surgical site local anaesthetic infiltration . Paracetamol and NSAID should be started before or during operation with dexamethasone ( GRADE A ) . Opioid should be reserved for rescue analgesia only ( GRADE B ) . Gabapentanoids , intraperitoneal local anaesthetic  , and  transversus abdominis plane blocks  are not recommended ( GRADE D ) unless basic analgesia is not possible . Surgically , we recommend low‐pressure pneumoperitoneum , postprocedure saline lavage , and aspiration of pneumoperitoneum ( GRADE A ) . Single‐port incision techniques are not recommended to reduce pain ( GRADE A ) Background Minimizing the number and scope of ports used to perform laparoscopic cholecystectomy attempts to build on the improvements in postoperative pain control , rapid return to activity and work , patient satisfaction , and cosmetic result achieved by the laparoscopic method . Methods We studied 141 patients in two sequential studies : the first a prospect i ve r and omized trial with 41 patients , and the second an examination of the more minimal procedure in 100 patients . In the r and omized trial , patients underwent laparoscopic cholecystectomy with three ports : three 5-mm ports or two 10-mm ports and one 5-mm port .  The 100 patients underwent the three 5-mm port procedure .  Results In the r and omized trial , differences were not statistically significant . However , on the average , the group with three 5-mm ports required less medication over less time , had less postoperative pain , and took less time to return to activity than the second group with larger ports . A statistically significant difference was found in incisional pain between the smaller group ( 21 patients ) with two 10-mm ports and one 5-mm port and the larger group ( 100 patients ) with three 5-mm ports , whether the measure was overall incisional pain ( p=0.014 ) or a comparison based on specific ports ( p=0.001 ) . The percentage of cases requiring port enlargement to remove the gallbladder was not significantly different between the groups . There were no conversions to an open procedure , no fourth trocars added , and no complications . No patient required overnight hospitalization . Conclusions Reducing the number and size of ports in laparoscopic cholecystectomy sustains or enhances the improvements initiated by performing laparoscopic rather than open cholecystectomy . In a comparison of microlaparoscopic procedures , patients undergoing the procedure with the shorter incisions experienced significantly less pain Although laparoscopic cholecystectomy has rapidly become routine practice in the UK , there has been no rigorous comparison of it with open cholecystectomy . In our trial , 302 patients were r and omised to laparoscopic or minilaparotomy cholecystectomy .  Recovery after surgery was assessed by length of hospital stay , outpatient review at 10 days and 4 weeks , and patient question naires 1 , 4 , and 12 weeks after surgery . The mean operation time was 14 min shorter for minilaparotomy , while median post-operative hospital stay was 2 days shorter after laparoscopic cholecystectomy . The hospital costs were about 400 pounds greater for the laparoscopic procedure . Laparoscopic patients returned to work in the home sooner ; at 1 week , they had better physical and social functioning , were less limited by physical problems , and had less pain and depression . At 4 weeks , only physical functioning and depression scores were better in the laparoscopic group , and by 3 months there were no differences . Laparoscopic patients were more satisfied with the appearance of their scars . The incidence of complications after both procedures was 20 % . Compared to minilaparotomy cholecystectomy , laparoscopic cholecystectomy results in shorter hospital stay , less postoperative dysfunction , and quicker return to normal activities , but is more costly Abstract Background R and omized studies could not demonstrate significant outcome benefit after single-incision laparoscopic cholecystectomy compared to classic four-port laparoscopic cholecystectomy ( CLC ) . The new robotic single-site platform might offer potential benefits on local inflammation and postoperative pain due to its technological advantages . This prospect i ve r and omized double-blind trial compared the short-term outcomes between single-incision robotic cholecystectomy ( SIRC ) and CLC . Methods Two groups of 30 eligible patients were r and omized for SIRC or CLC .  During the first postoperative week , patients and study monitors were blinded to the type of procedure performed by four dressing tapes applied on the abdomen . Pain was assessed at 6 h and on day 1 , 7 and 30 after surgery , along with a 1–10 cosmetic score . Results No significant difference in postoperative pain occurred in the two groups at any time point nor for any of the abdominal sites . Nineteen ( 63 % ) SIRC patients reported early postoperative pain in extra-umbilical sites . Intraoperative complications which might influence postoperative pain , such as minor bleeding and bile spillage , were similar in both groups and no conversions occurred . The cosmetic score 1 month postoperatively was higher for SIRC ( p < 0.001 ) . Two SIRC patients had wound infection , one of which developed an incisional hernia . Conclusions SIRC does not offer any significant reduction of postoperative pain compared to CLC . SIRC patients unaware of their type of operation still report pain in extra-umbilical sites like after CLC . The cosmetic advantage of SIRC should be balanced against an increased risk of incisional hernias and higher costs . Trial registration numberACTRN12614000119695 ( http://www.anzctr.org.au ) Laparoscopic cholecystectomy has rapidly become established as the treatment of choice for cholecystolithiasis . There is very little evidence , however , to support the cl aim ed benefit to patients . In the present study 30 consecutive patients below the age of 65 years without acute cholecystitis and with no signs of common bile duct stones were r and omized to laparoscopic or conventional open eholecystectomy .  Median ( interquartile range ) intravenous consumption of pethidine with a patientcontrolled injection device between 13 and 24 h after surgery was 125 ( 62–175 ) mg in patients who underwent the laparoscopic procedure and 200 ( 150–250 ) mg in those who had open operation . Urinary adrenaline and cortisol levels as well as those of plasma glucose , C‐reactive protein and interleukin 6 were increased after surgery in both groups of patients , but without any significant difference between them . The mean(s.d . ) duration of postoperative hospital stay ( 2·8(0·8 ) versus 1·8(0·6 ) days ) and sick leave ( 24·0(4·4 ) versus 11·7(4·1 ) days ) was significantly longer with open than laparoscopic cholecystectomy . The findings demonstrate obvious advantages of laparoscopic surgery  as regards postoperative pain and convalescence , although factors reflecting the magnitude of trauma did not differ Inappropriate therapy of postoperative pain in laparoscopic cholecystectomy may lead to late mobilization , patient dissatisfaction , delayed hospital discharge , and chronic pain development . Our objective was to identify the best therapeutic strategy available to the anesthesiologist for the acute postoperative pain of patients su bmi tted to elective laparoscopic cholecystectomy . This is a systematic review that included 36 complete articles indexed in the Medline , Scopus , Web of Science and LILACS data bases , with a five-year time cut ( 2012 to 2016 ) , result ing from controlled and r and omized studies that were su bmi tted to qualitative analysis . In a proposal for multimodal analgesia , it is important to consider the contraindications , adverse effects , dose and optimal timing of interventions . Non-opioid drugs , such as non-steroidal anti-inflammatory drugs (NSAIDs)/cyclooxygenase-2 ( COX-2 ) inhibitors , gabapentin/pregabalin , N-methyl-D-aspartate ( NMDA ) receptor antagonists , and others . Opioids may be used at low doses associated with multimodal therapy or are restricted to cases where non-opioid multimodal analgesia is insufficient . We conclude that there is no consensus as to the best analgesic strategy to be implemented in the acute postoperative pain of laparoscopic cholecystectomy , which requires its applicability in an individualized way , based on the scientific evidence found in the literature . As contribution to medical learning and practice , we point out the theoretical enrichment of the analgesic drug options available for the therapy of postoperative pain in patients su bmi tted to elective laparoscopic cholecystectomy , and alert the team to consider the adverse effects of the interventions implemented BACKGROUND Laparoscopic cholecystectomy ( LC ) is the gold-st and ard for the treatment of gallbladder stone disease . In recent years laparoendoscopic single site surgery ( LESS ) has gained greater interest and diffusion for the treatment of gallstones and also in bariatric and colonic surgery . However , no r and omized controlled trials are present in the literature that confirm the clinical advantages of LESS compared with the classic laparoscopic procedures . For this reason , we present the preliminary results of this r and omized prospect i ve study regarding the feasibility and safety of LESS cholecystectomy versus classic laparoscopic technique . METHODS Between October 2009 and April 2010 , 50 patients were r and omly assigned to three-port classic laparoscopic cholecystectomy ( n = 25 ) or LESS procedure ( n = 25 ) . Exclusion criteria were : ( 1 ) previous abdominal surgery , ( 2 ) signs of acute cholecystitis , choledocholithiasis , or acute pancreatitis , ( 3 ) ASA grade III or more , ( 4 ) lack of written informed consent , and ( 5 ) BMI ≥ 30 Kg/m(2).All the patients ' details were recorded : age , weight , height , body mass index , operative time , length of hospital stay , patients ' pain and wound satisfaction score . Abdominal pain was registered at 6 , 12 , and 24 h postoperatively . Wound satisfaction score ( very unsatisfied = 1 , unsatisfied = 2 , acceptable = 3 , satisfied = 4 , very satisfied = 5 ) was registered for each patient at the seventh postoperative day . RESULTS No differences were registered between the two groups about gender , age , weight , height , and BMI . Also postoperative hospital stay was similar ( P = 0.71 ) . In three patients ( 1 in group A and 2 in group B ) a 5-mm trocar was added . Intraoperative cholangiography was performed in five patients ( 2 in group A and 3 in group B ) . Mean operative time was significantly longer in LESS procedures ( 41.3 ± 12.0 versus 35.6 ± 5.8 ; P = 0.04 ) . Abdominal postoperative pain was similar in LC and LESS cholecystectomy . Wound satisfaction score showed statistically significant differences between the two groups : in LESS group , patients were more satisfied with the presence of a small umbilical medication ( P < 0.05 ) . CONCLUSION In this r and omized prospect i ve study , we conclude that LESS cholecystectomy is an excellent alternative to traditional three-port cholecystectomy for patients with uncomplicated disease , and no previous abdominal surgery . Although no differences are present about hospital stay and postoperative pain compared with classic laparoscopic cholecystectomy , in our experience LESS has had a significant impact on patients ' wound satisfaction 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 Inpatient low-pressure pneumoperitoneum laparoscopic cholecystectomy ( LPLC ) has been shown to have less postoperative pain ( especially shoulder-tip pain ) . No report so far has documented the use of lower-pressure pneumoperitoneum in outpatient laparoscopic cholecystectomy ( LC ) .  A prospect i ve r and omized trial was conducted in Tung Wah Hospital , Day Surgery Centre from January 2004 to December 2004 . A total of 40 patients were recruited and 20 of whom were allocated to each arm . Outcome measures included operation time , treatment-related morbidity , mortality , postoperative pain ( eg , shoulder-tip pain ) , consumption of analgesics , and level of satisfaction . All patients in both groups could be discharged on the same day . Patients ' demographics and operation time were comparable in both groups . There were no treatment-related morbidity and mortality , nor was there any significant difference in postoperative pain . Less shoulder-tip pain was observed in the LPLC group though without significant difference ( 5 % vs. 20 % ; P=0.151 ) . Three patients in the LPLC group needed higher insufflation pressure ( 12 mm Hg ) because of inadequate exposure and adhesions , and the operations were successful in all of them . Otherwise , no conversion to open procedure was noted in both groups . The consumption of analgesics was minimal and a high level of satisfaction was achieved in both groups of patients . The present study demonstrated no difference in LPLC and st and ard-pressure pneumoperitoneum laparoscopic cholecystectomy in the outcomes of outpatient LC . Routine use of lower-pressure pneumoperitoneum in outpatient LC would not be recommended unless in selected straightforward cases Background The attempt to further reduce operative trauma in laparoscopic cholecystectomy has led to new techniques such as natural orifice transluminal endoscopic surgery ( NOTES ) and single-incision laparoscopic surgery ( SILS ) . These new techniques are considered to be painless procedures , but no published studies investigate the possibility of different pain scores in these new techniques versus classic laparoscopic cholecystectomy . In this r and omized control study , we investigated pain scores in SILS cholecystectomy versus classic laparoscopic cholecystectomy . Patients and methods Forty patients ( 34 women and 6 men ) were r and omly assigned to two groups . In group A ( n = 20 ) four-port classic laparoscopic cholecystectomy was performed . Patients in group B ( n = 20 ) underwent SILS cholecystectomy .  In all patients , preincisional local infiltration of ropivacaine around the trocar wounds was performed . Infusion of ropivacaine solution in the right subdiaphragmatic area at the beginning of the procedure plus normal saline infusion in the same area at the end of the procedure was performed in all patients as well . Shoulder tip and abdominal pain were registered at 2 , 6 , 12 , 24 , 48 , and 72 h postoperatively using visual analog scale ( VAS ) . Results Significantly lower pain scores were observed in the SILS group versus the classic laparoscopic cholecystectomy group after the first 12 h for abdominal pain , and after the first 6 h for shoulder pain . Total pain after the first 24 h was nonexistent in the SILS group . Also , requests for analgesics were significantly less in the SILS group , while no difference was observed in incidence of nausea and vomiting between the two groups . ConclusionS ILS cholecystectomy , as well as the invisible scar , has significantly lower abdominal and shoulder pain scores , especially after the first 24 h postoperatively , when this pain is nonexistent . ( Registration Clinical Trial number : NTC00872287 , www . clinical trials.gov ) Objective To investigate to what effect active subdiaphragmatic gas aspiration reduces pain after a laparoscopic cholecystectomy . Material s and Methods A total of 104 patients undergoing laparoscopic cholecystectomy were r and omly placed into 2 groups . Group I included active subdiaphragmatic gas aspiration ( n=52 ) while group II included simple evacuation ( n=52 ) without any additional procedures . Postoperative analgesic requirements were recorded and the level of postoperative abdominal and shoulder pain was assessed using a numeric scale after 24 postoperative hours . Data were analyzed using the & khgr;2 test for nonparametric data and Student t test for parametric data . Results Age , volume of CO2 used during surgery , and operation duration were similar in the 2 groups . The simple evacuation group ( group II ) experienced more shoulder and abdominal pain postoperatively when compared with the active subdiaphragmatic aspiration group ( group I ) and had a higher use of analgesics during the postoperative period . Conclusions Active subdiaphragmatic gas aspiration after a laparoscopic cholecystectomy is a simple procedure that can effectively reduce postoperative abdominal and shoulder pain and as a result the need for analgesics Laparoscopy using carbon dioxide insufflation induces adverse effects in both the cardiovascular and the respiratory function . The use of low pressure pneumoperitoneum has been shown to reduce adverse hemodynamic effects . However , its effect on tissue trauma and postoperative pain and recovery remains controversial . The aim of this study was to compare tissue trauma , postoperative pain , and recovery in two groups of patients undergoing laparoscopic cholecystectomy , one at insufflation pressure of 8 ( LC8 ) and the other at 15 mm Hg ( LC15 ) . Forty patients were r and omized , 20 in each group . The characteristics of the patients were similar in the two groups . The procedure was completed in all patients in the LC15 group , but in 2 patients in the LC8 group the pressure was increased to 15 mm Hg to complete the operation . There were no significant differences in postoperative pain scores , analgesic consumption , and the incidence of nausea , vomiting , and shoulder pain between the two groups . C-reactive protein concentrations and white blood cell count rose significantly after surgery , but the increase was similar in the two groups . The median duration of surgery was similar , 23 minutes ( range 15–65 ) in the LC8 group and 25 minutes ( range 15–80 ) in the LC15 group . Using our technique of laparoscopic cholecystectomy , there were no advantages to tissue damage , postoperative pain , and recovery when a low pressure pneumoperitoneum was used BACKGROUND : Studies evaluating intraperitoneal local anesthetic instillation for pain relief after laparoscopic procedures have reported conflicting results . In this r and omized , double-blind study we assessed the effects of intraperitoneal local anesthetic nebulization on  pain relief  after laparoscopic cholecystectomy . METHODS : Patients undergoing elective laparoscopic cholecystectomy were r and omly assigned to receive either instillation of ropivacaine 0.5 % , 20 mL after induction of the pneumoperitoneum , or nebulization of ropivacaine 1 % , 3 mL before and after surgery . Anesthetic and surgical techniques were st and ardized . Degree of pain at rest and on deep breathing , incidence of shoulder pain , morphine consumption , unassisted walking time , and postoperative nausea and vomiting were evaluated at 6 , 24 , and 48 hours after surgery . RESULTS : Of the 60 patients included , 3 exclusions occurred for conversion to open surgery . There were no differences between groups in pain scores or in morphine consumption . No patients in the nebulization group presented significant shoulder pain in comparison with 83 % of patients in the instillation group ( absolute risk reduction −83 , 95 % CI −97 to −70 , P < 0.001 ) . Nineteen ( 70 % ) patients receiving nebulization walked without assistance within 12 hours after surgery in comparison with 14 ( 47 % ) patients receiving instillation ( absolute risk reduction −24 , 95 % CI −48 to 1 , P = 0.04 ) . One ( 3 % ) patient in the instillation group vomited in comparison with 6 ( 22 % ) patients in the nebulization group ( absolute risk reduction −19 % , 95 % CI −36 to −2 , P = 0.03 ) . CONCLUSIONS : Intraperitoneal ropivacaine nebulization was associated with reduced shoulder pain and unassisted walking time but with an increased incidence of postoperative vomiting after laparoscopic cholecystectomy Background This study aim ed to compare the short-term outcomes of single-access laparoscopic cholecystectomy ( SALC ) and conventional laparoscopic cholecystectomy ( CLC ) . Methods In a prospect i ve study , patients with symptomatic cholelithiasis were r and omized to SALC or CLC with follow-up at 1 week , 1 and 6 months . The primary end point of this study was to assess the total outcomes of quality of life using the EuroQoL EQ-5D question naire . The secondary end points were postoperative pain , analgesia requirement and duration of use , operative time , perioperative complications , estimated blood loss , hospital stay , cosmesis outcome , and number of days required to return to normal activities . Results A total of 269 patients were prospect ively r and omized into two groups ( 125 in each group after excluding 19 patients for various reasons ) . The SALC procedure was done safely without intraoperative or major postoperative complications . In four SALC patients , an extra epigastric port was inserted to enhance exposure . There was no open conversion in either group . SALC patients reported better results among four of the EuroQoL EQ-5D dimensions ( mobility , self-care , activity , and pain/discomfort ) at 1 week after surgery , an improved pain profile at 4 , 12 , and 24 h , better cosmetic outcome at 1 and 6 months ( P ≤ 0.01 ) , shorter duration of need for analgesia ( P ≤ 0.02 ) , and earlier return to normal activities ( P ≤ 0.026 ) . Operative times , hospital stay , QOL at 1 and 6 months postoperatively , and estimated blood loss were similar for both procedures . Conclusion This study supports other studies that show that SALC is a feasible and promising alternative to traditional laparoscopic cholecystectomy in selected patients with better cosmesis , QOL , and improved postoperative pain results , and it can be performed with the existing laparoscopic instruments Background : We set out to assess the safety and efficacy of mini-laparoscopic cholecystectomy ( MLC ) in uncomplicated situations . Methods : MLC was performed on 30 consecutive selected patients ( < 60 years old , ASA I-II , uncomplicated cholecystectomy ) with one 12-mm and three 3-mm ports . The total operating time , conversion rate , degree of postoperative pain , duration of postoperative hospital stay , complications , and cosmetic results were all review ed and compared with 30 cases of consecutive conventional laparoscopic cholecystectomy ( LC ) . Results : None of the patients in either group required conversion to open cholecystectomy . No complications were observed . The operating time and duration of hospital stay were similar in both groups . The level of postoperative pain was lower in the MLC group ( p < 0.001 ) . More patients in the MLC group expressed satisfaction with the cosmetic result ( p < 0.05 ) . Conclusions : MLC was shown to be feasible in uncomplicated situations . Furthermore , it was associated with less pain and produced better cosmetic results than conventional LC . R and omized studies are still needed to confirm these findings UNLABELLED Abstract Background : Postoperative abdominal and shoulder pains after laparoscopic cholecystectomy ( LC ) are the most frequent complaints and are related to delayed recovery . There is a strong correlation between the residual gas volume and the severity of pain following various laparoscopic procedures . We aim ed to investigate the effects of aspiration of residual gas on postoperative outcomes and pain following LC . SUBJECTS AND METHODS Patients were r and omly assigned to either the active gas reduction group ( Group 1 , n=105 ) or the control group ( Group 2 , n=95 ) . After completion of the operative procedures , residual gas was aspirated with a flexible cannula in Group 1 . In Group 2 , gas release from the abdomen was performed using the port site by opening the gas tap only . The demographic data , operation time , insufflated CO2 volume during the operation , hospitalization period , and time to return to daily activities were recorded . Postoperative shoulder and abdominal pain assessment was performed using a numerical pain intensity scale ( NPIS ) at 1 hour , 24 hours , 3 days , and 7 days postoperatively . RESULTS There was no statistically significant difference between the groups in terms of demographic data , operative findings , and clinical outcomes . NPIS scores for shoulder pain at 1 hour and 24 hours were significantly lower in Group 1 ( P=.001 and P=.021 , respectively ) . However , there were no significant differences in the NPIS scores for shoulder and abdominal pain following 24 hours . No differences were found in the hospitalization duration and time to return to daily activities data ( P>.05 ) . CONCLUSIONS Active aspiration of the residual gas just before the removal of the trochars is a simple procedure and leads to a more comfortable hospital stay for patients 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 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 BACKGROUND The management of postoperative pain is paramount to facilitate the delivery of day case surgical programs . In recent years , the complexity of procedures carried out has increased to include laparoscopic cholecystectomy . The aim of this study was to evaluate the impact of laparoscopic-assisted 4-quadrant transversus abdominis plane ( TAP ) block vs periportal local anesthetic wound infiltration in managing postoperative pain . STUDY DESIGN A prospect i ve , r and omized , double-blinded trial was conducted with patients undergoing elective laparoscopic cholecystectomy . Patients were r and omized using computerized " r and om number table " into a test group that received laparoscopic-assisted TAP block with bupivacaine with periportal saline injection and a control group that received a laparoscopic-assisted TAP block with saline and periportal bupivacaine .  All patients received intraperitoneal instillation of bupivacaine in the gallbladder bed . Postoperative pain scores were recorded using numerical rating scores at rest and coughing at dedicated time points . Statistical analysis was carried out using GraphPad Prism software , version 5 ( GraphPad Software ) and p < 0.05 was considered significant . RESULTS Eighty patients ( 70 female and 10 male ) were enrolled ; 40 patients were r and omized to each group .  Age , American Society of Anesthesiologists score , operative time , and BMI were comparable between the groups . No adverse events were encountered with the administration of TAP blocks . Numerical rating scores were significantly reduced in the test group at 1 , 3 , and 6 hours at rest ( p = 0.025 , p = 0.03 , and p = 0.007 , respectively ) . Numerical rating score was significantly reduced at 1 , 3 , and 6 hours during coughing ( p = 0.026 , p = 0.02 , and p = 0.03 , respectively ) . Difference in postoperative analgesic requirements between both groups was statistically insignificant ( p = 0.17 ) . CONCLUSIONS This analysis has confirmed the therapeutic benefit of laparoscopically delivered TAP blocks in elective laparoscopic cholecystectomy Background : Two-port laparoscopic cholecystectomy has been reported to be safe and feasible . However , whether it offers any additional advantages remains controversial . This study reports a r and omized trial that compared the clinical outcomes of two-port laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy . Methods : One hundred and twenty consecutive patients who underwent elective laparoscopic cholecystectomy were r and omized to receive either the two-port or the four-port technique . All patients were blinded to the type of operation they underwent . Four surgical tapes were applied to st and ard four-port sites in both groups at the end of the operation . All dressings were kept intact until the first follow-up 1 week after surgery . Postoperative pain at the four sites was assessed on the first day after surgery using a 10-cm unscaled visual analog scale ( VAS ) . Other outcome measures included analgesia requirements , length and difficulty of the operation , postoperative stay , and patient satisfaction score on surgery and scars . Results : Demographic data were comparable for both groups . Patients in the two-port group had shorter mean operative time ( 54.6 ± 24.7 min vs 66.9 ± 33.1 min for the four-post group ; p = 0.03 ) and less pain at individual subcostal port sites [ mean score using 10-cm unscaled VAS : 1.5 vs 2.8 ( p = 0.01 ) at the midsubcostal port site and 1.3 vs 2.3 ( p = 0.02 ) at the lateral subcostal port site ] . Overall pain score , analgesia requirements , hospital stay , and patient satisfaction score on surgery and scars were similar between the two groups . Conclusion : Two-port laparoscopic cholecystectomy result ed in less individual port-site pain and similar clinical outcomes but fewer surgical scars compared to four-port laparoscopic cholecystectomy . Thus , it can be recommended as a routine procedure in elective laparoscopic cholecystectomy Background . Laparoscopic cholecystectomy is the st and ard treatment for symptomatic gallbladder disease .  Single‐incision laparoscopic surgery was developed with the aim of decreasing the invasiveness of conventional laparoscopy . The aim of this study was to compare the clinical outcome of single‐incision laparoscopic cholecystectomy with 3‐port laparoscopic cholecystectomy . Methods . From February 2014 to September 2016 , 187 patients with symptomatic cholecystolithiasis were r and omized to a single‐incision laparoscopic cholecystectomy group ( 89 patients ) or a 3‐port laparoscopic cholecystectomy group ( 98 patients ) . The primary outcomes were a postoperative pain score ( at 6 hours and 1 day ) and patients of complications , while the secondary outcomes were operative time , estimated blood loss , opioid requirements , duration of hospital stay , and patient satisfaction with aesthetic effects . Results . When comparing 3‐port laparoscopic cholecystectomy and single‐incision laparoscopic cholecystectomy , there were differences in the ( mean ± st and ard deviation ) operative time ( 58.9 ± 18.6 minutes vs 45.2 ± 11.8 minutes ; P < .001 ) , success rate ( 93 % vs 99 % ; P < .01 ) , conversion rate ( 7 % vs 1 % ; P < .001 ) , and aesthetic score ( 7.9 ± 1.6 vs 6.7 ± 1.4 ; P = .008 ) . There were no statistically significant differences in estimated blood loss , postoperative pain , opioid requirement , complications , and hospital stay between both groups . Conclusion . Single‐incision laparoscopic cholecystectomy is a safe and feasible procedure in selected patients . The main advantage is the superior aesthetic results , while the main disadvantage is a greater operative time with some technical difficulties Objective : To compare short-term surgical outcomes and quality of life ( QOL ) between single-port laparoscopic cholecystectomy ( SPLC ) and classic 4-port laparoscopic cholecystectomy ( CLC ) . Background : There is significant interest in further reducing the trauma associated with surgical procedures . Although a number of observational studies have suggested that SPLC is a feasible alternative to CLC , there is a lack of data from r and omized studies validating any benefit over CLC . Methods : Eligible patients were r and omized to receive SPLC or CLC .  Operative and perioperative outcomes , including cosmesis and QOL were analyzed . Results : Forty-three patients were r and omized to SPLC ( n = 21 ) or CLC ( n = 22 ) . There were no significant differences between groups for most preoperative demographics , American Society of Anesthesiology score , gallstone characteristics , local inflammation , blood loss , or length of stay .  Patients undergoing SPLC were older than those receiving CLC  ( 57.3 years vs. 45.8 years , P < 0.05 ) . Operative times for SPLC were greater than CLC ( 88.5 minutes vs. 44.8 minutes , P < 0.05 ) . Overall and cosmetic satisfaction , QOL as determined by the SF-36 survey , postoperative complications , and post-operative pain scores between discharge and 2-week postoperative visit were not significantly different between groups . Wound infection rates were similar in both groups . The SPLC group contained 1 retained bile duct stone , 1-port site hernia , and 1 postoperative port site hemorrhage . Conclusions : SPLC procedure time was longer and incurred more complications than CLC without significant benefits in patient satisfaction , postoperative pain and QOL .  SPLC may be offered in carefully selected patients . Larger r and omized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another Purpose  Laparoscopic cholecystectomy ( LC ) is usually performed under the general anesthesia ( GA ) . Aim of the study is to investigate the availability , safety and side effects of combined spinal/epidural anesthesia ( CSEA ) and comparison it with GA for LC . Methods Forty-nine patients who have a LC plan were included into the study . The patients were r and omly divided into GA ( n = 25 ) and CSEA ( n = 24 ) groups . Intraoperative and postoperative adverse events , postoperative pain levels were compared between groups . Results Anesthesia procedures and surgeries for all patients were successfully completed . After the organization of pneumoperitoneum in CSEA group , 3 patients suffered from shoulder pain ( 12.5 % ) and 4 patients suffered from abdominal discomfort ( 16.6 % ) . All these complaints were recovered with IV fentanyl administration . Only 1 patient developed hypotension which is recovered with fluid replacement and no need to use vasopressor treatment . Postoperative shoulder pain was significantly less observed in CSEA group ( 25 % vs. 60 % ) . Incidence of postoperative nausea and vomiting ( PONV ) was less observed in CSEA group but not statistically significant ( 4.2 % vs. 20 % ) . In the group of CSEA , 3 patients suffered from urinary retention ( 12.5 % ) and 2 patients suffered from spinal headache ( 8.3 % ) . All postoperative pain parameters except 6th hour , were less observed in CSEA group , less VAS scores and less need to analgesic treatment in CSEA group comparing with GA group . Conclusion CSEA can be used safely for laparoscopic cholecystectomies . Less postoperative surgical field pain , shoulder pain and PONV are the advantages of CSEA compared to GA Since its introduction in 1987 , the technique of cholecystectomy has continued to undergo evolution . Surgeons have reduced the port size and number or both to achieve improvement in postoperative pain control , rapid return to activity and better cosmetic results . Therefore , this study was done to compare the st and ard 4 port laparoscopic cholecystectomy ( LC ) with the 3 port laparoscopic cholecystectomy using a 5 mm telescope instead of 10 mm telescope ( mini laparoscopic cholecystectomy - MLC ) .  Forty patients were r and omised to each group .  Mean operating time , intraoperative and postoperative complications , mean period to resume walking , eating and return to normal activities and mean hospital stay were similar in the two groups . The level of postoperative pain was significantly lower in the MLC group . Patients who underwent MLC required a significantly lower dose of analgesics . In conclusion mini laparoscopic cholecystectomy is a feasible and safe procedure with less postoperative pain and better cosmesis and without increased complications 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 Background Postoperative pain is the dominant complaint and the most common cause of delayed discharge after laparoscopic cholecystectomy . The aim of this study is to evaluate the potential of preoperative administration of pregabalin to reduce postoperative pain and opioid consumption . Methods Fifty American Society of Anesthesiologists ( ASA ) I and II adult patients with symptomatic gallstone disease scheduled for elective laparoscopic cholecystectomy were r and omized into two groups : group I patients ( n = 25 ) were given 600 mg pregabalin per os divided in two doses , the night before surgery and 1 h preoperatively , respectively , while group II patients ( n = 25 ) received a matching to pregabalin placebo at the same scheme . Postoperative pain , morphine consumption , and complications were compared between the two groups . Results Postoperative pain ( static and dynamic assessment ) was significantly less at 0 , 1 , 8 , 16 , and 24 h ( p < 0.001 ) after the procedure for group I ( pregabalin ) compared with the placebo group . Postoperative patient-controlled morphine consumption during hospital stay was also significantly less in the pregabalin group compared with the placebo group . Side-effects were similar in both groups expect for dizziness , which was significantly higher ( p < 0.0001 ) in the pregabalin group . Conclusions Administration of 600 mg pregabalin per os , divided in two preoperative doses , significantly reduces postoperative pain as well as opioid consumption in patients undergoing laparoscopic cholecystectomy , at the cost of increased incidence of dizziness 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 BACKGROUND Intraperitoneal local anesthesia ( IPLA ) during elective laparoscopic cholecystectomy ( el-LC ) decreases post-operative pain . None of the studies have explored the efficacy of IPLA at emergency laparoscopic cholecystectomy ( em-LC ) . A longer operative duration , the greater frequency of washing , and the inflammation associated with cholecystitis or pancreatitis are a few reasons why it can not be assumed that a benefit in pain scores will be seen in em-LC with IPLA . This study was undertaken to assess the efficacy of IPLA in patients undergoing em-LC . METHODS Double-blind r and omized sham controlled trial was conducted of 41 consecutive subjects undergoing em-LC . IPLA was delivered by a combination of injection to the diaphragmatic and topical wash over the liver and gallbladder with bupivacaine or saline . The primary outcome was visual analogue scale pain scores until discharge . Secondary outcomes included pain scores in theatre recovery and analgesic consumption . RESULTS One patient had a procedure converted to open and was excluded . There was no significant difference in pain scores in the ward or theatre recovery . Analgesic use , respiratory rate , oxygen saturation , duration to ambulation , eating , satisfaction scores , and time to discharge were comparable between the two groups . CONCLUSIONS IPLA during em-LC does not influence postoperative pain . Other modalities of analgesia should be explored for decreasing the interval between diagnosis of acute admission and em-LC 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 OBJECTIVES In surgery clinics , postoperative pain is a common occurrence and care is needed in its treatment . One form of treatment is various acupuncture techniques . This study investigated the effect of acupuncture on postoperative analgesia in patients undergoing laparoscopic cholecystectomy . METHODS A total of 59 patients undergoing laparoscopic cholecystectomy were included in the study ; 31 comprised the acupuncture group ( Group A ) , and 29 constituted the  control group ( group C ) . All patients underwent st and ard anesthesia procedures . Patient-controlled analgesia with tramadol was administered postoperatively . Patients ' postoperative pain scores , results of the satisfaction question naire and amounts of tramadol used were recorded . Postoperative 0 , 1st , 2nd , 6th , 12th and 18th hour controls were performed . RESULTS A comparison of the groups showed Group A pain scores to be significantly lower statistically than those of Group C at all postoperative controls . There was no statistically significant difference for postoperative analgesic consumption and satisfaction level between the groups . CONCLUSION Despite detection of a reduction in postoperative pain scores , the application of acupuncture did not cause any change in the consumption of tramadol Anterior lumbar interbody fusion ( ALIF ) is a widely accepted tool for management of painful degenerative disc disease .  Recently , the modern laparoscopic surgical technique has been combined with ALIF procedure , with good early postoperative results being reported . However , the benefit of laparoscopic fusion is poorly defined compared with its open counterpart . This study aim ed to compare perioperative parameters and minimum 2-year follow-up outcome for laparoscopic and open anterior surgical approach for L5–S1 fusion . The data of 54 consecutive patients who underwent anterior lumbar interbody fusion ( ALIF ) of L5–S1 from 1997 to 1999 were collected prospect ively . More than 2-years ’ follow-up data were available for 47 of these patients . In all cases , carbon cage and autologous bone graft were used for fusion . Twenty-five patients underwent a laparoscopic procedure  and 22 an  open mini-ALIF . Three laparoscopic procedures were converted to open ones . For perioperative parameters only , the operative time was statistically different ( P=0.001 ) , while length of postoperative hospital stay and blood loss were not . The incidence of operative complications was three in the laparoscopic group and two in the open mini-ALIF group . After a follow-up period of at least 2 years , the two groups showed no statistical difference in pain , measured by visual analog scale , in the Oswestry Disability Index or in the Patient Satisfaction Index . The fusion rate was 91 % in both groups . The laparoscopic ALIF for L5–S1 showed similar clinical and radiological outcome when compared with open mini-ALIF , but significant advantages were not identified , despite its technical difficulty Background : Although  laparoscopic hernia repair  has been shown to be associated with less postoperative pain and an earlier recovery , there is still controversy about its role in hernia surgery . In general , laparoscopy produces less trauma to tissues than open surgery . This has been reflected by the reduced acute phase inflammatory response observed after laparoscopic surgery compared to open surgery in various setting s , such as cholecystectomy or hysterectomy . The aim of this study was to evaluate the acute phase response after bilateral hernia repair by comparing the open Stoppa procedure with the laparoscopic totally extraperitoneal prosthetic repair ( TEPP ) . Methods : Patients were r and omly allocated to either technique after written informed consent was obtained . Measurements were made of complete blood count , erythrocyte sedimentation rate ( ESR ) , C-reactive protein ( CRP ) , interleukin-1b ( IL-1b ) , IL-6 , and tumor necrosis factor-a ( TNF-a ) preoperatively and 4 , 24 , and 48 h postoperatively . VAS pain scores , consumption of analgesics , and delay before resumption of normal activities were also recorded . All the procedures were performed under general anesthesia by or in the presence of the same surgeon . Results : Thirty-nine patients were included : 19 underwent the Stoppa procedure and 20 had a laparoscopic repair .  The two groups were well matched for age , sex , ASA score , and preoperative values . The operation took longer ( p < 0.001 ) in the group undergoing TEPP . Patients resumed their normal activities earlier ( p < 0.05 ) after laparoscopy . In the open group , there was a larger decrease of the lymphocyte count after 4 ( p < 0.01 ) and 24 h ( p = 0.04 ) ; an increased elevation of ESR after 48 h ( p = 0.02 ) ; a larger increase of IL-6 after 4 ( p = 0.05 ) , 24 ( p = 0.003 ) , and 48 h ( p < 0.001 ) ; and a larger increase in CRP after 24 ( p = 0.05 ) and 48 h ( p = 0.01 ) . There was no morbidity . There was no difference in postoperative IL-1b , TNF-a , total white blood cell count , polymorphonuclear count , VAS for pain , or need for analgesics between the two groups , except on the operative day . Conclusions : The acute phase inflammatory response in clearly more active after the open Stoppa procedure than after TEPP , indicating that the former is associated with increased tissue trauma . This may play a role in the earlier recovery seen after the TEPP procedure Background The purpose of this study was to compare the postoperative inflammatory response and severity of pain between single-incision laparoscopic surgery ( SILS ) cholecystectomy and conventional laparoscopic cholecystectomy ( LC ) . Methods Two groups of 20 patients were prospect ively r and omized to either conventional LC or SILS cholecystectomy .  Serum interleukin-6 ( IL-6 ) levels were assayed before surgery , at 4–6 h , and at 18–24 h after the procedure . Serum C-reactive protein ( CRP ) levels also were assayed at 18–24 h after surgery . Pain was measured at each of three time points after surgery using the visual analogue scale ( VAS ) . The number of analgesia doses administered in the first 24 h after the procedure also was recorded and 30-day surgical outcomes were documented . Results The groups had equivalent body mass index ( BMI ) , age , and comorbidity distribution  . Peak IL-6 levels occurred 4–6 h after surgery , and the median level was 12.8 pg/ml in the LC and 8.9 pg/ml in the SILS group ( p = 0.5 ) . The median CRP level before discharge was 1.6 mg/dl in the LC and 1.9 mg/dl in the SILS group ( p = 0.38 ) . There was no difference in either analgesic use or pain intensity as measured by the VAS between the two groups ( p = 0.72 ) . The length of the surgical procedure was significantly longer in the SILS group ( p < 0.001 ) . No intraoperative complications occurred in either group . Conclusions Single-incision laparoscopic surgery does not significantly reduce systemic inflammatory response , postoperative pain , or analgesic use compared with LC BACKGROUND We report a prospect i ve r and omised comparison between laparoscopic and small-incision cholecystectomy in 200 patients which was design ed to eliminate bias for or against either technique . METHODS Patients were r and omised in the operating theatre and anaesthetic technique and pain-control methods were st and ardised . Four experienced surgeons did both types of procedure . Identical wound dressings were applied in both groups so that carers could be kept blind to the type of operation . FINDINGS There was no significant difference between the groups for age , sex , body mass index , and American Society of Anaesthesiologists grade . Laparoscopic cholecystectomy took significantly longer than small-incision cholecystectomy ( median 65 [ range 27 - 140 ] min vs 40 [ 18 - 142 ] min , p<0.001 ) . The operating time included operative cholangiography which was attempted in all patients . We found no significant difference between the groups for hospital stay ( postoperative nights in hospital , median 3 - 0 [ 1 - 17 ] nights for laparoscopic vs 3 - 0 [ 1 - 14 ] nights for small-incision , p=0.74 ) , time back to work for employed persons ( median 5 - 0 weeks vs 4.0 weeks ; p=0.39 ) , and time to full activity ( median 3 - 0 weeks vs 3.0 weeks ; p=0.15 ) . INTERPRETATION Laparoscopic cholecystectomy takes longer to do than small-incision cholecystectomy and does not have any significant advantages in terms of hospital stay or postoperative recovery 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 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 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 Objectives : With increasing surgeon experience , laparoscopic cholecystectomy has undergone many refinements including reduction in port number and size . Three-port laparoscopic cholecystectomy has been reported to be safe and feasible in various clinical trials . However , whether it offers any additional advantages remains controversial . This study reports a r and omized trial that compared the clinical outcomes of 3-port laparoscopic cholecystectomy versus conventional 4-port laparoscopic cholecystectomy . Methods : Seventy-five consecutive patients who underwent elective laparoscopic cholecystectomy were r and omized to undergo either the 3-port or the 4-port technique . Four surgical tapes were applied to st and ard 4-port sites in both groups at the end of the operation . All dressings were kept intact until the first follow-up 1 week after surgery . Postoperative pain at the 4 sites was assessed on the first day after surgery by using a 10-cm unscaled visual analog scale ( VAS ) . Other outcome measures included analgesia requirements , length of the operation , postoperative stay , and patient satisfaction score on surgery and scars . Results : Demographic data were comparable for both groups . Patients in the 3-port group had shorter mean operative time ( 47.3±29.8 min vs 60.8±32.3 min ) for the 4-port group ( P=0.04 ) and less pain at port sites ( mean score using 10-cm unscaled VAS : 2.19±1.06 vs 2.91±1.20 ( P=0.02 ) . Overall pain score , analgesia requirements , hospital stay , and patient satisfaction score ( mean score using 10-cm unscaled VAS : 8.2±1.7 vs 7.8±1.7 , P=0.24 ) on surgery and scars were similar between the 2 groups . Conclusion : Three-port laparoscopic cholecystectomy result ed in less individual port-site pain and similar clinical outcomes with fewer surgical scars and without any increased risk of bile duct injury compared with 4-port laparoscopic cholecystectomy . Thus , it can be recommended as a safe alternative procedure in elective laparoscopic cholecystectomy INTRODUCTION Up to 75 % of the patients undergoing laparoscopic cholecystectomy develop postoperative nausea and vomiting ( PONV ) . Both ramosetron , a serotonin subtype 3 ( 5-HT3 ) antagonist , and dexamethasone are effective for PONV prophylaxis following laparoscopic cholecystectomy but their combined effect has not been investigated . We investigated the efficacy and tolerance of ramosetron alone and ramosetron with dexamethasone for PONV prophylaxis after laparoscopic cholecystectomy . METHODS Seventy six patients scheduled for laparoscopic cholecystectomy were r and omized to receive either intravenous ( i.v . ) 0.3 mg ramosetron ( group R ) , or 8 mg dexamethasone plus 0.3 mg ramosetron ( group D ) . St and ardized anesthesia with desflurane and remifentanil was used in all patients . Postoperative nausea , retching , vomiting , rescue antiemetics , pain scores , rescue analgesics and side effects were assessed at 0 - 2 , 2 - 24 and 24 - 48 h postoperatively . RESULTS Seventy two patients were r and omized . The overall incidence of PONV did not differ ( p = 0.31 ) but fewer patients needed rescue antiemetics in group D than in groups R ( 3 vs. 13 patients , respectively ; p = 0.01 ) during 0 - 48 h postoperatively . Additionally , pain scores were significantly lower in group D during the study period ( p < 0.01 ) and rescue analgesics were required less often in group D during 2 - 48 h postoperatively ( p < 0.01 ) . CONCLUSIONS In patients undergoing laparoscopic cholecystectomy , the combined use of ramosetron and dexamethasone was more effective than ramosetron alone for reducing the need for rescue antiemetics and pain control following the procedure BACKGROUND The observation of hemodynamic and metabolic impairment related to CO2 pneumoperitoneum and postoperative mesenteric ischemia reports following laparoscopic procedures have raised concern about local and systemic effects of increase intraabdominal pressure during laparoscopic procedures . The present study aims to evaluate the metabolic and acid base responses of using high pressure versus low pressure pneumoperitonium in patients undergoing laparoscopic cholecystectomy in a prospect i ve r and omized clinical trial . PATIENTS AND METHOD 20 ASA I-II patients scheduled for elective laparoscopic cholecystectomy were r and omly allocated to one of two study groups ; high pressure pneumoperitoneum 12 - 14mmHg ( HPP  , n=10 ) versus low pressure pneumoperitoneum 6 - 8mmHg ( LPP , n=10 ) undergoing laparoscopic cholecystectomy .  Arterial blood gases and lactate levels were determined after induction of anesthesia ( before pneumoperitonium ) , then after 10 min , then 30 min after insufflations and at the end of surgery and 1 hour postoperatively . Nurses in recovery unit reported pain assessment starting postoperatively until 3 hours on a 10 mm VAS ( 0 - 10 ) . Statistical significant was established at P<0.05 . RESULT Bicarbonate was significantly ( P>0.0412 ) lower in high pressure group at 30 min and 60 min after insufflations . In high pressure group lactate levels increased significantly as compared to low pressure group , ( at 30 minutes after the establishment of abdominal pneumatic inflation P<0.006 and remained significantly increased ( P<0.001 ) until the end of surgery and one hour thereafter ) ( P<0.001 ) . The mean postoperative pain score during second hour ( VAS ) at HPP group was 7.4 + /- 1.17 which is significantly ( P < or = 0.006 ) higher than pain score in LPP group 5.0 + /- 1.886 . Shoulder tip pain was reported in 3 patients in the high pressure group and only one patient in the lower pressure group . CONCLUSION High-pressure pneumoperitonium causes statistically significant elevation in the arterial lactate level intraoperatively until one hour post operatively . It also causes higher pain score and shoulder tip pain Background : Two alternative surgical techniques for elective laparoscopic cholecystectomy ( LC ) , low‐pressure insufflation of the peritoneal cavity and abdominal wall lifting ( AWL ) , have been developed over time to minimize the disadvantages associated with CO2‐elicited pneumoperitoneum . To the best of our knowledge , the 2 methods have seldom been compared as regards their relative advantages and disadvantages . Methods : Eighty patients scheduled for elective LC were r and omized into either a low‐pressure ( 8 mmHg ) CO2 insufflation method ( LPLC ) group , or a gasless technique using a subcutaneous abdominal wall lifting device ( GLC group ) . The duration of the surgical procedure , the surgical results including level of postoperative pain , and perioperative cardiopulmonary function changes experienced by the members of both groups were compared . Results : Laparoscopic surgery was completed for all but 1 patient from each group due to an inadequate surgical‐site exposure . There was no mortality for study participants , and no major complications were noted for members of either group . The LPLC group evidence d a shorter surgical duration as compared to the GLC group ( 77 ± 28 minutes vs. 98 ± 27 minutes , respectively ; p < 0.01 ) and a lower incidence of postoperative shoulder pain ( 2/38 vs. 8/39 , respectively ; p < 0.05 ) , although significant differences in intraoperative pulmonary function were noted ( an increased PaCO2 , PetCO2 and peak‐airway pressure and decreased arterial blood pH ; p < 0.01 ) for the LPLC group compared to the GLC group . Conclusion : Both alternative methods for this type of surgery appeared feasible and safe for LC . Low‐pressure CO2 pneumoperitoneum had a shorter surgical duration and less postoperative shoulder pain compared to the GLC technique , but did not feature any other advantage over the AWL technique with regard to impact on cardiopulmonary function Background The objective of this study was to evaluate the interest of using ropivacaine for  outpatient laparoscopic cholecystectomy .  The use of local anesthesia by instillation and infiltration could reduce pain and increase the number of outpatient cholecystectomies . Methods A one-center r and omized prospect i ve clinical trial compared the use of ropivacaine during outpatient laparoscopic cholecystectomy to the control group of out patients for laparoscopic cholecystectomy between April 2014 and May 2015 . One hundred twenty-four were eligible , and 100 patients were r and omized . Patients with outpatient cholecystectomy were r and omized into 2 groups : ropivacaine group ( Rop group ) and control group ( control group ) . We performed a ropivacaine intraperitoneal instillation and wound infiltration for the ropivacaine group at the end of the procedure . The primary observation was authorization for home discharge . The patient was evaluated by the surgeon using the Chung score . Secondary observations included postoperative pain at 2 h post-surgery , at 6 h post-surgery and the day following surgery . Results Ninety-eight were able to leave on the evening of surgery . At 6 h post-surgery , the Chung score was identical for both groups ( p = 0.73 ) . At 2 and 6 h post-surgery and the day following surgery , there was no significant difference in pain levels ( p = 0.63 ; p = 0.61 ; p = 0.98 ) . Analgesic consumption was no significant difference in the groups . Conclusions The use of ropivacaine does not increase the rate of home discharge and does not change the postoperative pain of outpatient cholecystectomy INTRODUCTION Cholelithiasis is one of the most common disorders of the digestive tract encountered by general surgeons worldwide . Conventional or open cholecystectomy was the mainstay of treatment for a long time for this disease . In the 1980s laparoscopic surgery revolutionized the management of biliary tract diseases . It brought about a revolutionary change in the basic concepts of surgical principles and minimal access surgery gradually started to be acknowledged as a safe means of carrying out surgeries . AIM To investigate the technical feasibility , safety and benefit of Single Incision Laparoscopic Cholecystectomy ( SILC ) versus Conventional Four Port Laparoscopic Cholecystectomy ( C4PLC ) . MATERIAL S AND METHODS This prospect i ve r and omized control trial was conducted to compare the advantages if any between the SILC and C4PLC .  Thirty two patients underwent SILC procedure and C4PLC , each . The age of the patients ranged from 16 - 60years . Other demographic data and indications for cholecystectomy were comparable in both the groups . Simple comparative statistical analysis was carried out in the present study . Results on continuous variables are shown in Mean ± SD ; whereas results on categorical variables are shown in percentage ( % ) by keeping the level of significance at 5 % . Intergroup analysis of the various study parameters was done by using Fisher exact test . SPSS version 22 was used for statistical analysis . RESULTS The mean operating time was higher in the SILC group ( 69 ± 4.00 mins vs. 38.53 ± 4.00 mins ) which was of statistical significance ( p=<0.05 ) . Furthermore , the patients of the SILC group had less post-operative pain , with lesser analgesic requirements ( p=<0.05 ) , shorter hospital stay and earlier return to normal activity . CONCLUSION SILC is feasible and safe in trained h and s. It did not compromise the procedural safety , or lead to any complication . The operating time was longer otherwise it has almost similar clinical outcomes to those of C4PLC OBJECTIVE To determine whether intraoperative local injection of 0.5 % bupivacaine around port sites would decrease early postoperative pain after laparoscopic cholecystectomy , and the use of intravenous opioid analgesics postoperatively . STUDY DESIGN R and omised controlled trial . PLACE AND DURATION OF STUDY Department of Surgery , Khyber Teaching Hospital , Peshawar , from July 2016 to June 2017 . METHODOLOGY Patients who underwent laparoscopic cholecystectomy were divided into two groups . Group A had instillation of 20 ml of 0.5 % Inj . bupivacaine at the end of procedure into port sites and group B had no bupivacaine injection at trocar sites . Both groups had postoperative intravenous ketorolac 30 mg three times daily and intravenous opioid analgesics on dem and . Pain was assessed 2 hours after recovery from general anesthesia , and at 6 , 12 and 24 hours through visual analog scale 0 - 10 . RESULTS One hundred and twenty patients completed this study with 60 patients in each group . A significant difference in mean postoperative pain scores was observed at 2 and 6 hours after surgery between the groups . Pain scores at 2 and 6 hours after surgery were 3.97 + 1.327 and 3.02 ±1.08 in group A , while it was 4.65 + 1.448 and 4.72 ±1.277 in group B with p-values of 0.008 and 0.005 , respectively . There was no significant difference in mean postoperative pain scores at 12 and 24 hours between the groups , with pain scores of 3.72 ±0.78 and 3.75 ±0.95 ( p=0.488 and 0.744 , respectively ) . However , there was a significant difference in opioid analgesics use in first 24 hours with less analgesics use in bupivacaine injected group . CONCLUSION Injecting 0.5 % bupivacaine at trocar sites during laparoscopic cholecystectomy offers significant reduction in early postoperative pain Abstract Background Laparoscopic cholecystectomy ( LC ) is increasingly being performed as a day-care surgery . Intraperitoneal ( IP ) instillation of lignocaine has been proved to provide pain relief following LC . Of late , there is an increased interest in using intravenous ( IV ) lignocaine to provide pain relief following LC . There are no studies in the existing literature as to which form of administration is more effective for pain relief . Hence , this study has been undertaken . Methods Patients ( n = 50 ) undergoing LC for symptomatic cholelithiasis were r and omized into two groups ( n = 25 each ) to receive IV 2 % lignocaine from induction until 1 h after surgery or IP instillation of 0.2 % lignocaine in the gallbladder fossa after removal of gallbladder . Postoperative analgesic requirement , pain scores , time to return of bowel activity , and stress response were assessed . Results The mean total morphine requirement ( p = 0.001 ) , median VAS , first analgesic requirement time ( p < 0.001 ) , and total PCA dem and s ( p < 0.001 ) during the 24-h period were statistically significantly less in the IV group compared with the IP group . Return of bowel activity was earlier in the IV group , and it was statistically significant ( p < 0.001 ) . However , stress response , respiratory function , and postoperative nausea and vomiting were not significant statistically among the two groups . Conclusions IV lignocaine is superior to IP lignocaine in providing pain relief following LC . IV lignocaine has an added advantage of bringing about the early return of bowel activity , which will further facilitate surgeons to perform LC as a day-care procedure OBJECTIVE To compare the effects of laparoscopic inguinal hernia repair ( LIHR ) and Lichtenstein tension-free inguinal hernia repair and to explore the safety and feasibility of LIHR as well as the advantages and disadvantages of these procedures . SUBJECTS AND METHODS In total , 252 patients with inguinal hernia were equally r and omized into the  transabdominal preperitoneal ( TAPP ) repair , totally extraperitoneal ( TEP ) repair , and Lichtenstein tension-free hernia repair groups  ( n=84 each ) . Operating time , postoperative pain scores , postoperative scrotal seroma , postoperative local esthesiodermia , postoperative chronic pains , postoperative long-term hernia relapse , and costs of hospitalization were compared among the three groups . RESULTS All laparoscopic operations were performed smoothly without intraoperative conversion to open surgery . The LIHR groups showed significantly better effects on postoperative pains and hernia recurrence than the Lichtenstein tension-free herniorrhaphy group ( P<.05 ) , but with a significantly higher hospitalization cost ( P<.05 ) . The occurrence rate of postoperative scrotal seroma or hydrops in the TAPP , TEP , and Lichtenstein groups was 11 ( 13.10 % ) , 13 ( 15.48 % ) , and 6 ( 7.14 % ) , respectively . No significant differences among the operating time , postoperative local esthesiodermia , or postoperative chronic pains of the groups were observed ( P>.05 ) . CONCLUSIONS LIHR is a safe and feasible procedure . It has significantly better effects on postoperative pains and hernia relapse than Lichtenstein tension-free hernia repair Background and objective : Non‐steroidal anti‐inflammatory drugs are considered as an effective treatment of  postoperative pain after laparoscopic cholecystectomy . COX‐2 inhibitors are newer drugs having less adverse effects . Data supporting their efficacy postoperatively in comparison to older non‐steroidal anti‐inflammatory drugs are scarce . Our study is a prospect i ve , r and omized , double‐blinded , placebo‐controlled trial comparing the efficacy of lornoxicam vs. parecoxib for the management of pain after laparoscopic cholecystectomy . Material s and methods : We enrolled 76 patients , ASA I and II , scheduled for elective laparoscopic cholecystectomy . The patients were r and omized to receive before induction parecoxib 40 mg i.v . , lornoxicam 8 mg i.v . or placebo .  Pain at rest and on movement was assessed using a visual analogue scale at 0 , 6 , 12 h postoperatively . Total meperidine consumption and adverse effects were also recorded . Results : At 12 h , visual analogue scale scores at rest and on movement were significantly lower with parecoxib and lornoxicam compared with control ( P = 0.047 ) . The percentage of patients needing meperidine and the average dose of meperidine administered was significantly lower with parecoxib and lornoxicam compared with control ( P < 0.001 and P = 0.018 ) . There was no difference between parecoxib and lornoxicam . One patient receiving lornoxicam vomited . Conclusions : Parecoxib 40 mg i.v . and lornoxicam 8 mg i.v . were equianalgesic and both were more efficacious than placebo for the management of pain after laparoscopic cholecystectomy In this study , we aim ed to investigate the postoperative pain relief effect of preoperative tenoxicam usage in patients who undergo elective laparoscopic cholecystectomy or groin hernia repair . Eighty patients undergoing laparoscopic cholecystectomy or groin hernia repair procedures were r and omized to receive either physiologic serum at 100 mL ( group I , n = 40 ) or 20 mg iv tenoxicam ( group II , n = 40 ) immediately before induction . Postoperative analgesic requirement , peroperative side effects and complications of drugs , operating time , postoperative mobilization time and pain score , hospitalization time , and patient pleasure were recorded . Postoperative pain was assessed by the visual analogue scale ( VAS ) on the recovery unit ( RU ) , at 4 , 8 , and 24 h and every day at the same times in the morning . The RU median VAS score was also not different when Group 1 was compared with Group 2 ( p = . 97 ) . However , the postoperative 4-h and 8-h median VAS score was significantly less ( p = . 01 and p = . 03 , respectively ) ; first postoperative mobilization time was earlier in group 2 ( p = . 32 ) . The median pain score and intramuscular analgesic requirement of patients were also reduced in Group 2 in postoperative day 1 ( p = . 015 ) . The median duration of intramuscular analgesic requirement and total amount of intramuscular analgesic used in patients were also significantly less in Group 2 ( p = . 0001 and p = . 0001 , respectively ) . Thus , this study showed that preoperative use of iv tenoxicam is safe , simple , and effective for postoperative pain relief after laparoscopic cholecystectomy or inguinal hernia repair The objective demonstration of improved postoperative recovery suggests that surgical injury induced by the laparoscopic approach is less intense than that after open surgery .  Forty-two patients diagnosed as having noncomplicated gallstones were studied prospect ively . They were operated on by laparoscopy ( LC , n = 21 ) or open surgery ( OC , n = 21 ) . Both surgical procedures induced significant changes of investigated parameters ( acute-phase response , free radical mediated reactions , neutrophil functions ) . Comparison of the results of the two cholecystectomy techniques showed that laparoscopic cholecystectomy induced a significantly less intense acute-phase response , a more attenuated oxidative stress characterising by free radical mediated reactions and that is less disruptive to neutrophil function . The results and the data from the literature suggest that surgical injury causing by the laparoscopic cholecystectomy is less intense than that after open cholecystectomy , which can explain partially the better clinical outcome following laparoscopic versus open procedure Background Post-laparoscopic pain syndrome is well recognized and characterized by abdominal and particularly shoulder tip pain ; it occurs frequently following laparoscopic cholecystectomy . The etiology of post-laparoscopic pain can be classified into three aspects : visceral , incision , and shoulder . The origin of shoulder pain is only partly understood , but it is commonly assumed that the cause is overstretching of the diaphragmatic muscle fibers owing to a high rate of insufflations . This study aim ed to compare the frequency and intensity of shoulder tip pain between  low-pressure ( 7 mmHg ) and st and ard-pressure  ( 14 mmHg ) in a prospect i ve r and omized clinical trial . Methods One hundred and forty consecutive patients undergoing elective laparoscopic cholecystectomy  were r and omized prospect ively to either high- or low-pressure pneumoperitoneum and blinded by research nurses who assessed the patients during the postoperative period . The statistical analysis included sex , mean age , weight , American Society of Anesthesiologists ( ASA ) grade , operative time , complication rate , duration of surgery , conversion rate , postoperative pain by using visual analogue scale , number of analgesic injections , incidence and severity of shoulder tip pain , and postoperative hospital stay . p < 0.05 was considered indicative of significance . Results The characteristics of the patients were similar in the two groups except for the predominance of males in the st and ard-pressure group ( controls ) . The procedure was successful in 68 of 70 patients in the low-pressure group compared with in 70 patients in the st and ard group . Operative time , number of analgesic injections , visual analogue score , and length of postoperative days were similar in both groups . Incidence of shoulder tip pain was higher in the st and ard-pressure group , but not statistically significantly so ( 27.9 % versus 44.3 % ) ( p = 0.100 ) . Conclusions Low-pressure pneumoperitoneum tended to be better than st and ard-pressure pneumoperitoneum in terms of lower incidence of shoulder tip pain , but this difference did not reach statistical significance following elective laparoscopic cholecystectomy Abstract Background : The aim of this r and omized controlled study was to compare the postoperative analgesic efficacy of intraperitoneal bupivacaine versus levobupivacaine in patients undergoing laparoscopic cholecystectomy . Methods : We r and omly divided 90 patients undergoing elective laparoscopic cholecystectomy into 3 groups . A dose of 0.125 % bupivacaine ( Group B ) 80 ml or 0.125 % levobupivacaine ( Group L ) 80 ml or 0.09 % NaCl ( Group P ) 80 ml was instilled intraperitoneally at the end of the procedure , before removal of the trocars . All patients had a st and ard anesthetic .  Tramadol was administered intravenously via a patient controlled analgesia pump as a rescue analgesic in all patients . Postoperative pain scores were assessed at 30 minutes , 1 , 2 , 4 , 6,12 and 24 hours after surgery by using a visual analog scale . The primary end point of this study was to compare tramadol consumption of the three groups at the postoperative 24 h. Total tramadol consumption , first analgesic requirement time and adverse effects were recorded . Results : Group B experienced significantly less pain ( P < 0.01 ) than the placebo group at 6 h , 12 h and 24 h postoperatively during rest . Group L registered significantly lower visual analog scale scores ( p < 0.01 ) than the placebo group at 12 h during rest . During movement , visual analog scale pain scores were lower in group B than Group P ( P < 0.01 ) . Additionally , total tramadol consumption was significantly lower in Group B than the other groups . First analgesic requirement time was shorter in the placebo group compared with group B and group L ( P < 0.05 ) . There was no significant difference between the groups with respect to right shoulder pain , total nausea and vomiting . Conclusion : Intraperitoneal instillation of bupivacaine 0.125 % 80 ml ( 100 mg ) is more effective than levobupivacaine 0.125 % 80 ml ( 100 mg ) in reducing the postoperative pain after laparoscopic cholecystectomy BACKGROUND The management of  bile leaks  has evolved in the laparoscopic era . This study characterizes risk factors for their developmental and their clinical course and management . METHODS Data on a cohort of patients who developed bile leaks after cholecystectomy in the laparoscopic era  were gathered prospect ively and retrospectively from an ongoing surgical data base and following a review of hospital charts . RESULTS Sixty-four patients ( mean age 56 + /- 17.1 years , 72 % women ) were included over a 5-year study period . The incidence of leaks was 1.1 % among patients entered in a  laparoscopic cholecystectomy data base . Intraoperative complications were encountered in 36 % . Rates of intraoperative complication and conversion to open surgery were greater among patients who developed leaks ( 5.2 % vs 0.6 % and 33 % vs 6.3 % , respectively , p < 0.00001 ) . Patients presented 5.3 + /- 4.2 days following surgery with abdominal pain ( 89 % ) , fever ( 74 % ) , and tenderness ( 81 % ) . Ultrasound diagnosed a suspected leak in 73 % , which ERCP showed as originating from the cystic duct stump in 77 % . Biliary obstruction was noted in 20 ( 31 % ) patients ( 14 with stones ) . Treatments included percutaneous ( 13 % ) , endoscopic ( 28 % ) , primary or secondary operative procedures ( 14 % ) , or a combination thereof ( 45 % ) . CONCLUSION A complication at laparoscopic cholecystectomy increases the likelihood of a subsequent bile leak . Most patients present early with a patent cystic duct stump in the absence of biliary obstruction . Endoscopic therapy is successful in the majority of cases , but otherwise percutaneous or operative procedures may be needed Purpose Early postoperative pain is a common complaint after elective laparoscopic cholecystectomy . The use of non-opioid medications as a part of multimodal analgesia has been increasingly advocated in the management of acute post-surgical pain . This r and omized , double-blinded , placebo-controlled study evaluated the efficacy of pregabalin , celecoxib , and their combination in the management of acute postoperative pain in patients undergoing elective laparoscopic cholecystectomy . Methods One hundred ASA I/II patients scheduled to undergo elective laparoscopic cholecystectomy were assigned to receive two perioperative doses , 12 h apart , of either pregabalin alone , celecoxib alone , their combination , or a placebo . St and ard anesthetic protocol was followed . The primary outcomes were postoperative pain at rest and with movement . Secondary outcomes were fentanyl requirements and side effects , which were assessed at 1 , 2 , 4 , 8 , 12 , and 24 h following surgery . Patient satisfaction with pain relief was recorded at discharge . Differences in main outcomes were analyzed using an intention-to-treat approach . Results There was no statistically significant difference ( p > 0.05 ) between the four groups in terms of outcomes such as rest pain , movement pain , postoperative fentanyl requirements , or changes in anxiety scores . Patients who had only celecoxib had significantly higher satisfaction with pain management ( p = 0.013 ) . Patients who had only pregabalin were at three-times-higher odds of having drowsiness ( p = 0.040 ) and four-times-higher odds of having lightheadedness ( p = 0.019 ) when compared with the placebo group . Conclusions Pregabalin , celecoxib alone , or in combination offers no analgesic superiority over st and ard opioid care in the treatment of postoperative pain following laparoscopic cholecystectomy ABSTRACT Background s : Despite increasing trend in single incision laparoscopic cholecystectomy ( SILC ) , there is still controversy regarding its global acceptance as a routine practice . Our study aim ed to compare surgical events , early in-hospital and later outcomes of SILC with conventional multiport laparoscopic cholecystectomy ( LC ) . Methods : Through a r and omized controlled trial ( RCT ) between June and December 2011 , 90 consecutive patients with documented biliary diseases waiting for LC were equally allocated to 3-port , 4-port , and single incision LC group . Operative time , surgical adverse events , postoperative pain according to visual analogue scale ( VAS ) , total morphine administration , length of hospital stay , and cosmetic outcomes were compared between these three groups . Results : A total of 27 males ( 30 % ) and 63 females ( 70 % ) were enrolled in this study . The average patients ’ age and BMI were 42.6 ± 12.1 years and 26.2 ± 2.7 kg/m2 , respectively  . Operative time  in SILC group was significantly longer than other groups . Total intraoperative adverse events and postoperative complications did not differ significantly between the three groups . Mean ± SD VAS score at rest was significantly lower ( p < 0.05 ) in SILC group . The average VAS at coughing was significantly lower in SILC group in all time intervals except the first 6 hr ( p < 0.05 ) . In addition , total morphine dose showed significantly lower amount in SILC group ( p = 0.02 ) . 12-month follow-up did not reveal significant difference between the study groups ( p > 0.05 ) . Conclusion : SILC is associated with less postoperative pain in later hours , reduces in-hospital analgesic dosages , has longer procedure time , but does not increase intraoperative and postoperative adverse events It seems that SILC has no obvious advantages in terms of later outcomes Background Stress response after laparoscopic cholecystectomy ( LC ) is less compared with open cholecystectomy , but is still responsible for significant postoperative morbidity . Though preoperative glucocorticoids were found to be effective in reducing the response in open surgical procedures , their role in minimal access surgery is not clear . Aims and Objectives To evaluate the efficacy of single-dose preoperative dexamethasone in reducing the stress response and postoperative morbidity after LC . Material s and Methods In a prospect i ve r and omized , double-blind , placebo-controlled trial , 70 patients undergoing elective LC were r and omized to receive either dexamethasone ( 8 mg intravenously ) , or placebo . The change in C-reactive protein levels after LC , pain scores at rest , and on exertion and narcotic requirements , the incidence and severity of postoperative nausea and vomiting ( PONV ) , anti-emetic requirement , peak expiratory flow rate in both groups were compared . Results Dexamethasone was more effective in controlling late PONV ( P=0.05 ) . The antiemetic requirement was significantly less in the dexamethasone group ( 0.56 mg vs. 2.24 mg ; P=0.02 ) . Median pain scores were significantly less in the dexamethasone group at 24 hours at rest ( P=0.002 ) and on exertion at 24 and 48 hours ( P=0.03 and 0.001 ) . Analgesic requirement was less in the test group ( 22.9 mg vs. 29.9 mg ; P=0.054 ) . The peak expiratory flow rate at 48 hours was higher in the dexamethasone group ( 315.28 vs. 285.8 l/min ; P=0.04 ) . The dexamethasone group showed significantly less elevation of C-reactive protein levels at 24 hours ( 7.17 μg/mL vs. 17.53 μg/mL ; P=0.003 ) and 48 hours ( 10.65 μg/mL vs. 23.18 μg/mL ; P=0.02 ) postoperatively . Conclusions Preoperative single-dose dexamethasone significantly reduces the pain scores , PONV , and antiemetic requirements while improving the respiratory function in the postoperative period after LC Background : Since the first  laparoscopic cholecystectomy ( LC ) was reported in 1990 , it has met with widespread acceptance as a st and ard procedure using four trocars . The fourth ( lateral ) trocar is used to grasp the fundus of the gallbladder so as to expose Calot ’s triangle . It has been argued that the fourth trocar is not necessary in most cases . Therefore , the aim of this study was to compare the three-port vs the four-port technique . Methods : Between 1998 and 2000 , 200 consecutive patients undergoing elective LC for gallstone disease were r and omized to be treated via either the three- or four-port technique .  Results : There was no difference between the two groups in age , sex , or weight . In terms of outcome , there was no difference between the two groups in success rate , operating time , number of oral analgesic tablets ( paracetamol ) , visual analogue score , or postoperative hospital stay ; however , the three-port group required fewer analgesic injections ( nalbuphine ) ( 0.4 vs 0.77 , p = 0.024 ) . Conclusion : The three-port technique is as safe as the st and ard four-port one for LC . The main advantages of the three-port technique are that it causes less pain , is less expensive , and leaves fewer scars 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 Objective To compare laparoscopic hernioplasty with two open tension-free hernia repairs . Summary Background Data Laparoscopic hernioplasty is associated with a short rehabilitation , but it is a technically difficult procedure . It is unclear if it has advantages over the technically easier open tension-free herniorrhaphy . Methods Two hundred ninety-nine men 30 to 75 years old were r and omized to undergo laparoscopic totally extraperitoneal hernioplasty ( TEP ) , open operation with mesh-plug and patch , or Lichtenstein ’s operation .  Results Two hundred ninety-four ( 98 % ) patients were followed for 19.8 ± 8.6 months . Over 90 % of the patients in all groups were operated in day surgery ; the rest of the patients were all discharged within 24 hours . Postoperative pain ( visual analog score ) was lower in the patients undergoing TEP than in those undergoing Lichtenstein and mesh-plug procedures . The median sick-leave period was 5 days in the TEP group , 7 days in the mesh-plug group , and 7 days in the Lichtenstein group . The median time to full recovery was significantly shorter in the TEP group compared to the other two groups . There were no major complications . Two recurrences were found in the TEP group and two in the mesh-plug group . Conclusions Laparoscopic hernioplasty is superior to tension-free open herniorrhaphy in terms of postoperative pain and rehabilitation Laparoscopic cholecystectomy ( LC ) is the gold-st and ard surgical method used to treat gallbladder diseases . Recently Laparoendoscopic single site surgery ( LESS ) has gained greater interest and diffusion for the surgical treatment of several pathologies . In elderly patients , just few r and omized controlled trials are present in the literature that confirm the clinical advantages of LESS compared with the classic laparoscopic procedures . We present in this paper the preliminary results of this r and omized prospect i ve study regarding the feasibility and safety of LESS cholecystectomy versus classic laparoscopic technique . We demonstrated that LESS technique compared with traditional technique show some advantages like : acceptable operative times , lower post-operative discomfort and sometimes reduction added complications . In addition we also demonstrate that fewer incisions and less scarring which mean less pain , and fewer parietal complications are related to this surgical procedure . In conclusion in the elderly  LESS cholecystectomy technique is to be considered a suitable alternative to traditional three-port cholecystectomy INTRODUCTION As Laparoscopic Cholecystectomy ( LC ) is not a totally pain free procedure , with the pain being most intense on the day of surgery and on the following day . Various techniques are available for postoperative pain relief like intraperitoneal instillation of local anaesthetics and rectus sheath block (RSB)which may provide effective pain relief . AIM To compare the efficacy of preemptive administration ( initiated before the surgical procedure ) of intraperitoneal instillation and rectus sheath block using ropivacaine for postoperative analgesia after laparoscopic cholecystectomy . MATERIAL S AND METHODS A total of 75 selected patients were r and omly assigned to three equal groups as Group R , who received bilateral RSB with 0.25 % ropivacaine 15 ml on either side ; Group I , who received intraperitoneal instillation of 0.25 % ropivacaine 50 ml and Group C ( Control group ) , who received only rescue analgesic on pain . These were compared regarding postoperative analgesia in terms of Visual Analog Scale ( 0 - 10 cm ) , Prince Henry Hospital Pain Score ( 0 - 3 ) , time to first dose of rescue analgesic ( tramadol ) , total rescue analgesic consumption in 48 hours , patient satisfaction scores ( 1 - 7 ) and adverse effects . RESULTS The time to first rescue analgesic was significantly longer in Group R ( 16.16±4.73h ) and Group I ( 7.84±1.34h ) as compared to Group C ( 1.72±0.67h ) , p<0.001 . Mean tramadol consumption in 48h for each patient was significantly less in Group R ( 148±54.92 mg ) and Group I ( 202±33.78 mg ) as compared to Group C ( 298±22.73 mg ) p<0.001 . Postoperative pain scores were also significantly less in Group R and Group I as compared to Group C during first 6 hours , p<0.05 . The difference in above parameters was also significant between Group R and Group I , p<0.05 . Thus order of postoperative analgesia effect was : Group R > Group I > Group C. Rescue analgesic requirement showed a 32.21 % reduction in Group I and 50.33 % reduction in Group R as compared to Group C. Patient Satisfaction Scores ( PSS ) showed a significant difference among groups with acceptable PSS scores as : Group R ( 92 % ) v/s Group I ( 40 % ) v/s Group C ( 20 % ) p<0.001 . CONCLUSION Pre-emptive administration of rectus sheath block or intraperitoneal instillation of 0.25 % ropivacaine was found effective in providing better postoperative analgesia as compared to control group after laparoscopic cholecystectomy . Among these two techniques , rectus sheath block was found to be superior over intraperitoneal instillation 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 : Gabapentinoids have been used as preemptive analgesics for pain management following laparoscopic cholecystectomy . Recently , multimodal analgesic techniques have been found superior to preemptive analgesia alone . Aim : The aim of this study is to evaluate and compare a single preoperative dose of pregabalin 150 mg and gabapentin 300 mg for pain relief following laparoscopic cholecystectomy as a part of multimodal drug regime . Setting s and Design : This r and omized , single-blind study was conducted after Ethical Committee approval and written informed consent from the patients . Material s and Methods : Fifty patients undergoing laparoscopic cholecystectomy under general anesthesia were r and omly allocated to receive either 150 mg pregabalin ( Group PG ) , or 300 mg gabapentin ( Group GB ) orally , 2 h before surgery . St and ard anesthesia induction and maintenance were done . For intraoperative pain management , injection fentanyl 2 μg.kg-1 intravenous ( IV ) along with injection voveran 75 mg IV and port site infiltration was used . Postoperatively , injection diclofenac 75 mg intramuscular TDS was continued . Severity of postoperative pain ( visual analog scale [ VAS ] ) , postoperative fentanyl requirement and incidence , and severity of side effects were assessed . When VAS > 40 mm or on patient 's request , a Fentanyl bolus at an increment of 25–50 μg IV was given as rescue analgesia . Results : Intraoperative fentanyl requirement was 135 ± 14 μg in Group PG and 140 ± 14 μg in Group GB ( P = 0.21 ) . Postoperative , fentanyl requirement was 123 ± 18 μg in Group PG and 131 ± 23 μg in Group GB ( P = 0.17 ) There was no statistically significant difference in the VAS score for static and dynamic pain . Time to the first requirement of analgesic was 5.4 ± 1.1 h in Group PG and 4.6 ± 1.6 h in Group GB ( P = 0.015 ) . No side effects were observed . Conclusion : We conclude that a single preoperative dose of pregabalin ( 150 mg ) or gabapentin ( 300 mg ) are equally efficacious in providing pain relief following laparoscopic cholecystectomy as a part of multimodal regime without any side effects BACKGROUND Surgical injury is associated with oxidative stress , often due to ischemia/reperfusion injury . During laparoscopy , increased intra-abdominal pressure caused by pneumoperitoneum may cause splanchnic ischemia followed by reperfusion due to deflation . We measured several markers of oxidative stress in patients undergoing laparoscopic cholecystectomy ( LC ) versus open cholecystectomy ( OC )  to find if these surgical procedures result in different patterns of oxidative stress . METHODS This prospect i ve study enrolled 43 patients with symptomatic cholelithiasis , of whom 21 underwent open , and 22 laparoscopic , cholecystectomy . Twenty healthy adults comprised the control group .  Total antioxidant status ( TAS ) , superoxide dismutase ( SOD ) , endogenous peroxide level ( POX ) , oxidized low density lipoprotein ( oLDL ) autoantibodies ( oLAb ) , and neopterin were measured preoperatively and on postoperative days 1 , 3 , and 7 . RESULTS POX values decreased significantly on postoperative day 1 in the OC ( P<0.01 ) , but not in the LC , group . On postoperative day 7 , POX values were higher than preoperatively in both groups ( P<0.01 ) with no difference between the LC and OC groups . Significant postoperative elevations of oLAb and neopterin levels were observed only on postoperative day 7 in the OC group . There were no changes of oLAb and neopterin levels in the LC group . TAS and SOD levels did not change after either LC or OC . CONCLUSION Cholecystectomy , either open or laparoscopic , caused only moderate oxidative stress . Open cholecystectomy caused changes of oLAb and neopterin , suggesting more severe oxidative stress , and a possible role of reactive oxygen species in the healing of the laparotomic wound 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 The aim of this study was to test the use of preincisional and intraperitoneal levobupivacaine ( L-B ) 0.25 % in laparoscopic cholecystectomies for postoperative analgesia . Methods A total of 108 patients under general anesthesia were r and omly assigned to receive preincisional local infiltration of 20 ml solution and intraperitoneal instillation of another 20 ml solution . Group A received for local infiltration and intraperitoneal instillation normal saline ( NS ) . Group B received for local infiltration L-B 0.25 % and for intraperitoneal instillation NS . Group C received for local infiltration NS and for intraperitoneal instillation L-B 0.25 % . Group D received both for local infiltration and intraperitoneal instillation L-B 0.25 % . Abdominal and right shoulder pain were recorded for 24 h postoperatively . Results The pain scores were lower in group D than in the other groups during rest , cough , and movement ( p < 0.05 ) . Rescue analgesic treatment was significantly lower in patients of group D ( 35 % ) as compared with that of group A ( 84 % ) ( p < 0.05 ) . The incidence of right shoulder pain was significantly lower in groups C ( 22 % ) and D ( 18 % ) than in any of the other groups ( p < 0.05 ) . Conclusions The combination of preincisional local infiltration and intraperitoneal instillation of L-B 0.25 % shows an advantage for postoperative analgesia after laparoscopic cholecystectomy 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 Background : We undertook a r and omized controlled trial to ascertain if single-incision laparoscopic cholecystectomy ( SILC ) was more beneficial for reducing postoperative pain than traditional laparoscopic cholecystectomy ( TLC ) . Moreover , the influencing factors of SILC were analyzed . Methods : A total of 552 patients with symptomatic gallstones or polyps were allocated r and omly to undergo SILC ( n = 138 ) or TLC ( n = 414 ) . Data on postoperative pain score , operative time , complications , procedure conversion , and hospital costs were collected . After a 6-month follow-up , all data were analyzed using the intention-to-treat principle . Results : Among SILC group , 4 ( 2.9 % ) cases required conversion to TLC . Mean operative time  of SILC was significantly longer than that of TLC ( 58.97 ± 21.56 vs. 43.38 ± 19.02 min , P < 0.001 ) . The two groups showed no significant differences in analgesic dose , duration of hospital stay , or cost . Median pain scores were similar between the two groups 7 days after surgery , but SILC-treated patients had a significantly lower median pain score 6 h after surgery ( 10-point scale : 3 [ 2 , 4 ] vs. 4 [ 3 , 5 ] , P = 0.009 ) . Importantly , subgroup analyses of operative time for SILC showed that a longer operative time was associated with greater prevalence of pain score > 5 ( ≥100 min : 5/7 patients vs. < 40 min , 3/16 patients , P = 0.015 ) . Conclusions : The primary benefit of SILC appears to be slightly less pain immediately after surgery . Surgeon training seems to be important because the shorter operative time for SILC may elicit less pain immediately after surgery Background : The comparison of laparoscopic to open appendectomy has been review ed in many retrospective and prospect i ve studies . Some report shorter hospital stays , less postoperative pain , and earlier return to work while others fail to demonstrate such differences . We performed a prospect i ve , r and omized double-blinded trial to evaluate this ongoing debate . Methods : Fifty-two consecutive men presenting with signs and symptoms suggestive of acute appendicitis were r and omized to undergo either laparoscopic appendectomy or open appendectomy .  Length of operative times , hospital stay , lost work days , visual analog pain scores , and operative costs were compared . Results : Length of stay averaged 21.5 h for the laparoscopic group and was not statistically different when compared to the open group . Perceived postoperative pain on postoperative days 1 and 7 were not statistically different between the two groups . Mean time to return to work was 11 days , and there was no statistical difference between groups . Operative costs were > $ 600 greater for the laparoscopic approach . Conclusions : In this prospect i ve r and omized double-blinded trial , laparoscopic appendectomy appears to confer no significant advantage over open appendectomy for postoperative pain or lost work days . It does carry an increase in operating room costs and , contrary to other reports , hospital stay is not shortened . Further studies are needed to determine if specific population s , such as the obese or women , may benefit from a minimally invasive approach to appendicitis Background Intraperitoneal local anesthesia has been reported to reduce postoperative pain after laparoscopy for gynecologic procedures that do not require a great deal of dissection or manipulation of viscera . This study was performed to determine the efficacy of intraperitoneal bupivacaine in laparoscopic cholecystectomy ( LC ) . Methods Fifty-five patients were evaluable in this r and omized , double-blind , placebo-controlled study . Twenty-six patients received bupivacaine ( 0.1 % ) and 29 patients received placebo ( saline ) . Prior to any dissection of the gallbladder , the surgeon irrigated 100 ml of experimental solution under the right hemidiaphragm , over Glisson ’s capsule , over the gallbladder serosa , and into the subhepatic space . The operation was then performed as usual . Postoperatively , analgesic medication usage , nausea , vomiting , and pain scores were determined during hospitalization . A question naire was given to each patient upon discharge from the hospital in order to continue monitoring medications and pain for the first 48 h at home . Results Postoperative pain was reduced significantly ( P < 0.05 ) in the patients who received bupivacaine , but the effect was modest and observable only during the first 6 h after surgery . Despite this difference , there was no significant reduction in the amount of analgesic medication used by the patients who received bupivacaine , nor was there any reduction in nausea , vomiting , or shoulder pain when queried specifically . Conclusions Intraperitoneal bupivacaine offered a detectable , albeit subtle benefit to patients undergoing LC . However , the effect was transient and had little impact upon the patient ’s convalescence BACKGROUND Pain is the most common complaint of patients on the first day after laparoscopic cholecystectomy ( LC ) . The aim of this study was to compare the efficacy of local anesthesia with bupivacaine and intravenous parecoxib on postoperative abdominal pain relief up to 24 h after surgery . METHODS One hundred and eighty patients who underwent LC were r and omized to one of three groups with sixty patients each : Group A received 50 mg 0.5 % bupivacaine subcutaneously at trocar sites before incision closure ; Group B received intravenous parecoxib ( 40 mg ) after entering the recovery room ; Group C did not receive postoperative analgesia unless needed and was served as control . The postoperative pain at 1 , 2 , 4 , 8 , 12 , and 24 h after the operation was assessed using a visual analog scale ( VAS ) . Secondary outcomes , including intraoperative and postoperative complications , the incidence of shoulder pain , pethidine requirements , postoperative nausea and vomiting , and hospital stay were also recorded . RESULTS At 1 , 2 , and 4 hours after surgery , VAS pain scores were significantly lower in group A and B compared with group C ( P < 0.05 for all ) . There was no significant difference among the three groups at 8 , 12 , and 24 hours after the procedure ( P > 0.05 for all ) . A repeated- measures ANOVA analysis revealed that VAS pain scores over the first 24 hours after LC were significantly lower in group A and B compared with group C ( P = 0.014 and P = 0.029 for between-group comparison , respectively ) . Furthermore , the percentage of patients requiring postoperative rescue analgesics was significantly higher in group C as compared with group A and group B ( P = 0.018 ) . CONCLUSION Local anesthesia with bupivacaine and intravenous parecoxib are both effective at decreasing postoperative pain and pethidine requirements after LC Abstract . After cholecystectomy a certain number of patients continue to suffer from abdominal symptoms or develop such symptoms postoperatively . The aim of this study was to compare the prevalence of postcholecystectomy symptoms with open cholecystectomy during the prelaparoscopic era and those with laparoscopic cholecystectomy 4 years after introduction of the laparoscopic technique .  Between July 1988 and June 1989 a total of 163 consecutive patients with elective open cholecystectomy and between September 1994 and August 1995 a total of 234 consecutive patients with elective laparoscopic cholecystectomy  were prospect ively evaluated using a st and ard question naire about preoperative symptoms , diagnostic modalities , and intraoperative findings . After a minimum of 12 months the patients were interviewed by telephone . Since the introduction of the minimal invasive technique the number of cholecystectomies performed at our institution increased . There was no significant difference in the prevalence of postcholecystectomy symptoms found after the open procedure compared with laparoscopic cholecystectomy : 90 % of patients after open and 94 % after laparoscopic cholecystectomy had no or only minor symptoms Background Dexamethasone has been reported to reduce postoperative nausea and vomiting ( PONV ) after laparoscopic cholecystectomy ( LC ) . However , its effects on other surgical outcomes , such as pain and fatigue , have been unclear . We evaluated the efficacy of preoperative dexamethasone for ameliorating postoperative symptoms after LC . Methods In this prospect i ve , double-blind , placebo-controlled study , 210 patients scheduled for elective LC were analyzed after r and omization to  intravenous dexamethasone ( 8 mg ) or a placebo .  All patients underwent st and ardized procedures for general anesthesia and surgery . Episodes of PONV and the pain and fatigue scores were recorded on a visual analog scale . Analgesic and antiemetic requirements were also recorded . Results There were no significant differences between groups with regard to medical or demographic variables . Significantly fewer patients experienced PONV in the dexamethasone group immediately after LC and at 6 and 12 h. The need for ondansetron to relieve PONV was higher in the placebo group ( P = 0.001 ) . Patients in the study group reported less postoperative pain during the first 24 h and less fatigue after 6 , 12 , and 24 h. The need for buprenorphine to relieve intolerable pain was also less in this group ( P = 0.009 ) . There were no side effects , and the morbidity was similar in the two groups ( 6.7 vs. 7.6 % ) . Conclusions The regimen we employed is safe and without apparent side effects . Thus , preoperative dexamethasone can significantly reduce the incidence of PONV , pain and fatigue after elective LC Background The increase in intra-abdominal pressure by insufflation of carbon dioxide during laparoscopy brings certain changes in function of organ systems and also leads to postoperative pain . Degree of intra-abdominal pressure is directly related with such change . Laparoscopic cholecystectomy can be performed at low pressure pneumoperitoneum . However , available space for dissection is less than the high pressure pneumoperitoneum . Methods Twenty-six patients for elective laparoscopic cholecystectomy  were studied in a prospect i ve , r and omized , patient , and surgeon blinded manner . The intra-abdominal pressure was kept either in low pressure ( 8 mm Hg ) or in high pressure ( 12 mm Hg ) . All patients underwent two dimensional echocardiography , pulmonary function test and color Doppler examination of lower limb vessels preoperatively and postoperatively . Arterial blood gas analysis and End Tidal CO2 monitored before insufflation , during surgery and after deflation . Pain score was measured by visual analog scale and surgeon 's comfort level was recorded . Postoperative analgesia requirement , complications , and hospital stay were recorded . Student t test used for the statistical analysis . Results Both groups match for the demographic parameters . Four patients required conversion to high pressure . Intraoperative pO2 level , postoperative pain , analgesic requirement , pulmonary function , and hospital stay were favoring low pressure pneumoperitoneum in a statistically significant manner . There was no difference between 2 groups for duration of surgery , intraoperative , and postoperative complications . However , the technical difficulties were grade d more ( statistically nonsignificant ) with low pressure pneumoperitoneum . Conclusions An uncomplicated gall stone disease can be treated by low pressure laparoscopic cholecystectomy with reasonable safety by an experienced surgeon . Though surgeons experience more difficulty in dissection during low pressure pneumoperitoneum , it is significantly advantageous in terms of postoperative pain , use of analgesics , preservation of pulmonary function , and hospital stay Purpose Laparoscopic techniques have allowed surgeons to perform complicated intra-abdominal surgery with minimal trauma . Single incision laparoscopic surgery ( SILS ) was developed with the aim of reducing the invasiveness of conventional laparoscopy . In this study we aim ed to compare results of SILS cholecystectomy and three port conventional laparoscopic ( TPCL ) cholecystectomy prospect ively . Methods In this prospect i ve study , 100 patients who underwent laparoscopic cholecystectomy for gallbladder disease were r and omly allocated to  SILS cholecystectomy ( group 1 ) or  TPCL cholecystectomy  ( group 2 ) . Demographics , pathologic diagnosis , operating time , blood loss , length of hospital stay , complications , pain score , conversion rate , and satisfaction of cosmetic outcome were recorded . Results Forty-four SILS cholesystectomies ( 88 % ) and 42 TPCL cholecystectomies ( 84 % ) were completed successfully . Conversion to open surgery was required for 4 cases in group 1 and 6 cases in group 2 . Operating time was significantly longer in group 1 compared with group 2 ( 73 minutes vs. 48 minutes ; P < 0.05 ) . Higher pain scores were observed in group 1 versus group 2 in postoperative day 1 ( P < 0.05 ) . There was higher cosmetic satisfaction in group 1 ( P < 0.05 ) . Conclusion SILS cholecystectomy performed by experienced surgeons is at least as successful , feasible , effective and safe as a TPCL cholecystectomy . Surgeons performing SILS should have a firm foundation of advanced minimal access surgical skills and a cautious , gra date d approach to attempt the various procedures . Prospect i ve r and omized studies comparing single access versus conventional multiport laparoscopic cholecystectomy , with large volumes and long-term follow-up , are needed to confirm our initial experience . ( Clinical Trials.gov Identifier : NCT01772745 . 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 This work aims to compare the curative effect of transumbilical single-port laparoscopic cholecystectomy ( TUSPLC ) and four-port laparoscopic cholecystectomy ( FPLC ) .  200 patients with cholecystolithiasis were enrolled in this study . They were r and omly divided into TUSPLC group and FPLC group , 100 cases in each group , and the TUSPLC and FPLC was performed , respectively . The surgical time , intraoperative complication , conversions rate , postoperative pain , postoperative analgesic drug use , incision infection , postoperative hospitalization time and postoperative cosmetic results in two groups were compared . The total conversion rate , conversion rate with Nassar grade II , and conversion rate with Nassar grade III in TUSPLC group were significantly higher than FPLC group ( P < 0.01 ) , and the incision cosmetic result after 1 month in TUSPLC group was obviously better than FPLC group ( P < 0.01 ) , but the surgical time in TUSPLC group was significantly longer than FPLC group ( P < 0.01 ) . There was no significant difference of incision infection , intraoperative complication , and postoperative hospitalization time , incision pain in postoperative first and second day , postoperative use of analgesia drug and incision cosmetic result on discharge day between two groups ( P > 0.05 ) . TUSPLC has obvious advantage in treatment of Nassar grade I patients with cholecystolithiasis . It can be used as a supplement for st and ard laparoscopic gallbladder surgery . It is safe and feasible , without abdominal scar , thus achieving to excellent cosmetic result and high satisfaction in patients Live  donor renal transplantation  provides significant advantages when compared with cadaveric donor renal transplantation in terms of improved patient and graft survival , a lower incidence of delayed function , and a shorter waiting time . Yet despite these advantages , live donors continue to be an under utilized source of kidneys for transplantation . Disincentives to live donation include the length of hospitalization , postoperative pain , cosmetic concerns , and the prolonged convalescence associated with the donor operation . In many instances minimally invasive video-assisted techniques have proven more efficacious than st and ard open procedures in terms of patient discomfort , length of hospital stay , cost , and length of time until the patient can return to full activity .  Laparoscopic live donor nephrectomies  are being performed at our institution in an attempt to make live donation more attractive to the potential donor . The purpose of this study was to retrospectively review the results of  laparoscopic live donor nephrectomy ( LapNx )  and to compare them with those obtained using the st and ard open approach ( OpenNx ) .  Ten consecutive LapNx were performed from February 1995 through April 1996 . The control group consisted of the 20 consecutive OpenNx performed at the same institution from January 1991 through January 1995 immediately before the initiation of the LapNx program . Live donors were considered c and i date s for LapNx if they possessed at least one kidney with normal renal anatomy with single renal vessels and a single ureter .  LapNx was safely performed in all cases . No patients required open conversion or blood transfusions . The allograft warm ischemic time for the laparoscopic cases was 4.2+/-1.3 min . All kidneys harvested laparoscopically produced urine on the table immediately upon revascularization . Presently nine of the ten recipients have functioning allografts . At three months posttransplant the calculated recipient creatinine clearances were 67.0+/-11.5 ml/min and 64.8+/-21.4 ml/min for the LapNx and OpenNx groups , respectively ( P = NS ) . The LapNx donors had a significantly decreased estimated blood loss , shorter time until resumption of oral intake , decreased postoperative pain ( in terms of decreased analgesic requirements ) , shorter hospitalization , and a shorter interval until the resumption of full activities ( P<0.05 for all ) . In addition , the LapNx group donors returned to work sooner than the OpenNx group ( 3.9+/-1.6 wk vs. 6.4+/-3.1 wk , respectively ) ( P=0.024 ) . Four individuals agreed to donate a kidney only after learning of the availability of the laparoscopic approach . We conclude that laparoscopic live donor nephrectomy is technically feasible . In addition , it may offer significant advantages over the st and ard open approach in terms of patient comfort and convenience . These advantages may make live donor renal transplantation more attractive to prospect i ve donors . The potential decrease in hospitalization and convalescence may also prove to be financially advantageous . We believe that further careful study of this procedure is warranted 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 Postoperative pain is the dominating complaint and the primary reason for prolonged convalescence after laparoscopic cholecystectomy . We have evaluated the efficacy of a single preoperative dose of pregabalin for attenuating postoperative pain and fentanyl consumption after laparoscopic cholecystectomy . METHODS Sixty adults ( 16 - 60 yr ) , ASA physical status I and II , of either sex undergoing elective laparoscopic cholecystectomy were included in this prospect i ve , r and omized placebo controlled , double-blind study . Subjects were divided into two groups of 30 each to receive either a matching placebo or pregabalin 150 mg , administered orally 1 h before surgery . Postoperative pain ( static and dynamic ) was assessed by a 100 mm visual analogue scale , where 0 , no pain ; 100 , worst imaginable pain . Subjects received patient-controlled i.v . fentanyl analgesia during the postoperative period . Results were analysed by Student 's t-test , chi(2 ) test , Mann-Whitney U-test , and Fisher 's exact test . RESULTS Postoperative pain ( static and dynamic ) and postoperative patient-controlled fentanyl consumption were reduced in the pregabalin group compared with the placebo group ( P<0.05 ) . Side-effects were similar in both groups . CONCLUSIONS A single preoperative oral dose of pregabalin 150 mg is an effective method for reducing postoperative pain and fentanyl consumption in patients undergoing laparoscopic cholecystectomy BACKGROUND Intraperitoneal local anaesthetic nebulization is a relatively novel approach to pain management after laparoscopic surgery . This r and omized , double-blind , placebo-controlled trial evaluated the effects of intraperitoneal ropivacaine nebulization on pain control after laparoscopic cholecystectomy . METHODS Patients undergoing laparoscopic cholecystectomy were r and omized to receive intraperitoneal nebulization of ropivacaine 1 % ( 3 ml ) before surgical dissection and normal saline 3 ml at the end of surgery ( preoperative nebulization group ) ; intraperitoneal nebulization of normal saline 3 ml before surgical dissection and ropivacaine 1 % ( 3 ml ) at the end of surgery ( postoperative nebulization group ) ; or intraperitoneal nebulization of normal saline 3 ml before surgical dissection and at the end of surgery ( placebo group ) . Intraperitoneal nebulization of ropivacaine or saline was performed using the Aeroneb Pro ( ® ) device . Anaesthetic and surgical techniques were st and ardized . The degree of pain on deep breath or movement , incidence of shoulder pain , morphine consumption , and postoperative nausea and vomiting were collected in the post-anaesthesia care unit and at 6 , 24 , and 48 h after surgery . RESULTS Compared with placebo , ropivacaine nebulization significantly reduced postoperative pain ( -33 % ; Cohen 's d 0.64 ) , referred shoulder pain ( absolute reduction -98 % ) , morphine requirements ( -41 % to -56 % Cohen 's d 1.16 ) , and time to unassisted walking ( up to -44 % Cohen 's d 0.9 ) ( P<0.01 ) . There were no differences in pain scores  between ropivacaine nebulization groups . CONCLUSIONS Ropivacaine nebulization before or after surgery reduced postoperative pain and referred shoulder pain after laparoscopic cholecystectomy . Furthermore , ropivacaine nebulization reduced morphine requirements and allowed earlier mobility Background : Postoperative abdominal and shoulder pain are the most common complaints after elective laparoscopic cholecystectomy . Postoperative pain is multifactorial in origin , and therefore multimodal therapy may be needed to optimize pain relief . Methods : We conducted a double-blind study where patients were r and omly allocated to 1 of 5 groups of 20 patients each . Statistical significance was considered P<0.05 . Group 1 received 40mL bupivacaine 0.25 % intraperitoneal spray . Group 2 received 40 mL bupivacaine 0.25 % intraperitoneal spray mixed with 200 mg ketoprofen . Group 3 received 40 mL bupivacaine 0.25 % intraperitoneal spray and intravenous 200 mg ketoprofen . Group 4 received 200 mg ketoprofen intravenously . Group 5 was the control group . Results : Demographic data were similar in the 5 groups . As compared with the control group , group 1 had significantly lower abdominal pain scores at 6 hours ; group 2 at 0 , 1 , 2 , and 6 hours ; group 3 at 0 , 1 , 2 , 6 , 12 , and 24 hours ; and group 4 at 2 hours . Group 1 had significantly lower shoulder pain scores at 1 and 6 hours ; group 2 at 0 and 6 hours ; and groups 3 and 4 at 0 , 1 , and 6 hours . The number of patients requiring postoperative rescue analgesics and the incidence of postoperative vomiting were significantly lower in group 3 only . Conclusions : A multimodal approach to pain management following elective laparoscopic cholecystectomy is best achieved with a combination of 40 mL bupivacaine 0.25 % intraperitoneal spray and 200 mg intravenous ketoprofen , achieving the least incidence of postoperative vomiting Background : Postoperative pain is a major complaint following laparoscopic cholecystectomy . Objectives : The aim of this study was to compare the impact of intraperitoneal hydrocortisone with intraperitoneal bupivacaine on pain relief after laparoscopic cholecystectomy Patients and Methods : In a double blind clinical trial , 63 c and i date s for laparoscopic cholecystectomy were r and omly allocated to receive intraperitoneal instillation of either 100 mg bupivacaine in 250 mL normal saline ( n = 32 ) or 100 mg hydrocortisone in 250 mL normal saline ( n = 31 ) before insufflation of CO2 into the peritoneum for postoperative pain relief . Patients were investigated regarding abdominal and shoulder pain using ( visual analog scale ) VAS in recovery room and at 6 , 12 and 24 hours postoperatively . Patients were also followed regarding postoperative analgesic requirements , nausea and vomiting , and return of bowel function . Results : Sixty patients completed the study . Patients in the hydrocortisone group had no statistically significant abdominal and shoulder pain scores compared to the bupivacaine group . The patients were similar regarding postoperative analgesic requirements , return of bowel function , nausea and vomiting . No adverse effect was detected in either group . Conclusions : Intraperitoneal administration of hydrocortisone is as effective as bupivacaine to reduce pain and analgesic requirements after laparoscopic cholecystectomy Abstract . Purpose : We conducted a prospect i ve study to evaluate the effect of CO2 pneumoperitoneum and increased intra-abdominal pressure on arterial blood gases , end-tidal CO2 ( ETCO2 ) , nitric oxide ( NO ) , blood and tissue malondialdehyde ( MDA ) , and total antioxidant ( TAOx ) levels during laparoscopic cholecystectomy . Methods : Fifty selected patients with cholelithiasis were r and omized to undergo either laparoscopic or open surgery .  Blood sample s were taken pre- , mid- , and postinsufflation , and 24 h postoperatively . To determine the tissue MDA level , tissue sample s were taken from the gallbladder just after removal . Results : The increased levels of ETCO2 and PCO2 , caused by CO2 pneumoperitoneum result ed in a minimal decrease in blood pH during the laparoscopic surgery . Although low levels of blood MDA were seen 30 min after the start of laparoscopy , due to less oxidative stress response and tissue trauma , increased levels of tissue MDA levels indicated that the gallbladder was more traumatized during laparoscopic dissection and h and ling . NO levels were slightly lower in the laparoscopic cholecystectomy ( LC ) group , but there were no significant differences compared with the open cholecystectomy group ( OC ) . TAOx levels were similar in both groups 30 min after the start the procedure , but were much lower in the LC group 24 h postoperatively . Conclusions : These findings suggest that the antioxidant defense system is stimulated less with less oxidative stress , providing further evidence to support the opinion that LC is a safe technique Background Laparoscopic cholecystectomy is associated with a high incidence of postoperative pain , nausea , and vomiting . Pneumoperitoneum created during the operation and residual gas after the operation are two of the factors in postoperative pain and nausea . We studied the effects of a subdiaphragmatic gas drain , which is intended to decrease the residual gas , on postoperative pain , nausea , and vomiting after laparoscopic cholecystectomy . Patients and methods Seventy patients were r and omized into two demographically and clinical ly comparable groups : drainage and control .  Postoperative pain , nausea , and vomiting were measured by verbal grading and visual analog scale 2–72 h postoperatively . Analgesic and antiemetic use and incidence of retching , vomiting and other complaints were also recorded . Results Subdiaphragmatic drain effectively reduced the incidence and amount of subdiaphragmatic gas bubble . The incidence and severity of nausea was lower in the drainage group at 72 h. Although severity of pain was lower at 8 and 12 h in the drainage group , the difference was not significant . There was also no difference between the groups in regard to analgesic and antiemetic use . Conclusions Subdiaphragmatic drain offers only minor , if any , benefit on postoperative pain , nausea , and vomiting after laparoscopic cholecystectomy , and this effect is probably clinical ly irrelevant Background Gallstones are a major cause of morbidity , and cholecystectomy is a commonly performed procedure . Minimal invasive procedures , laparoscopic cholecystectomy ( LC ) and small-incision cholecystectomy ( SIC ) , have replaced the classical open cholecystectomy . No differences have been found in primary outcome measures between LC and SIC , therefore secondary outcome measures have to be considered to determine preferences . The aim of our study was to examine health status applying evidence -based guidelines in LC and SIC in a r and omised trial . Methods Patients with symptomatic cholecystolithiasis were included in a blind r and omised trial . Operative procedures , anaesthesia , analgesics and postoperative care were st and ardised in order to limit bias . Question naires were filled in preoperatively , the first day postoperatively , and at out patients follow-up at 2 , 6 and 12 weeks . In accordance with evidence -based guidelines , the generic short form ( SF-36 ) and the disease-specific gastrointestinal quality -of-life index ( GIQLI ) question naires were used in addition to the body image question naire ( BIQ ) . Results A total of 257 patients were r and omised between LC ( 120 ) and SIC ( 137 ) . Analyses were performed according to intention-to-treat ( converted procedures included ) and also distinguishing converted from minimal invasive ( nonconverted ) procedures . Question naires were obtained with a response rate varying from 87.5 % preoperatively to 77.4 % three months postoperatively . Except for two time-specific measurements in one SF-36 subscale , there were no differences between LC and SIC . There were significant differences in several subscales in all three question naires comparing minimal invasive versus converted procedures . Conclusions Applying adequate method ological quality and evidence -based guidelines ( by using SF-36 and GIQLI ) , there are no significant differences in health status between LC and SIC Background : Nonsteroidal anti-inflammatory drugs used for postoperative analgesia have considerable adverse effects , with paracetamol having a different mechanism of action , superior side effect profile and availability in intravenous ( IV ) form , this study was conducted to compare intra-peritoneal bupivacaine with IV paracetamol for postoperative analgesia following laparoscopic cholecystectomy . Aim : The aim was to compare the efficacy of intra-peritoneal administration of bupivacaine 0.5 % and IV acetaminophen for postoperative analgesia in patients undergoing laparoscopic cholecystectomy . Setting s and Design : R and omized , prospect i ve trial . Material s and Methods : A total of 60 patients of American Society of Anesthesiologists physical Status I and II scheduled for laparoscopic cholecystectomy were enrolled for this study . Group I received 2 mg/kg of 0.5 % bupivacaine as local intra-peritoneal application and Group II patients received IV 1 g paracetamol 6 th hourly . Postoperatively , the patients were assessed for pain utilizing Visual Analog Scale ( VAS ) , Visual Rating Prince Henry Scale ( VRS ) , shoulder pain . The total number of patients requiring rescue analgesia and any side-effects were noted . Statistical Analysis : Data analysis was performed using Students unpaired t-test . SPSS version 11.5 was used . Results : The VAS was significantly higher in Group I compared with Group II at 8 th , 12 th and 24 th postoperative hour . At 1 st and 4 th postoperative hours , VAS was comparable between the two groups . Although the VRS was higher in Group I compared with Group II at 12 th and 24 th postoperative hour ; the difference was statistically significant only at 24 th postoperative hour . None of the patients in either of the groups had shoulder pain up to 8 h postoperative . The total number of patients requiring analgesics was higher in Group II than Group I at 1 st postoperative hour . Conclusion : Although local anesthetic infiltration and intra-peritoneal administration of 0.5 % bupivacaine decreases the severity of incisional , visceral and shoulder pain in the early postoperative period , IV paracetamol provides sustained pain relief for 24 postoperative hours after elective laparoscopic cholecystectomy Postoperative pain is the most common complaint after laparoscopic cholecystectomy . This study was carried out to evaluate whether preoperative administration of intramuscular dezocine can provide postoperative analgesia and reduce postoperative opioid consumption in patients undergoing laparoscopic cholecystectomy . Patients ( ASA I or II ) scheduled for laparoscopic cholecystectomy were r and omly assigned into intramuscular dezocine group ( group 1 ) or intramuscular normal saline group ( group 2 ) . Dezocine and equal volume normal saline were administered intramuscularly 10 min before the induction of anesthesia . After operation , the severity of postoperative pain , postoperative fentanyl requirement , incidence and severity of side-effects were assessed . Postoperative pain and postoperative patient-controlled fentanyl consumption were reduced significantly in group 1 compared with group 2 . The incidence and severity of side effects were similar between the two groups . Preoperative single-dose administration of intramuscular dezocine 0.1 mg/kg was effective in reducing postoperative pain and postoperative patient-controlled fentanyl requirement in patients undergoing laparoscopic cholecystectomy BACKGROUND Several authors have reported on laparoscopic pyloromyotomy ( LP ) since the technique was originally described in 1990 , but its benefits remain unproven . We performed a r and omized controlled trial comparing LP to open circumumbilical pyloromyotomy ( OP ) for hypertrophic pyloric stenosis . METHODS In a prospect i ve study , 102 infants with pyloric stenosis were r and omly assigned to either LP ( n = 50 ) or OP ( n = 52 ) . The primary outcome measure was the incidence of postoperative vomiting ; the secondary parameters were the duration s of surgery and anesthesia , surgical complications , and postoperative pain . All infants were managed according to st and ardized procedures regarding general anesthesia , surgical technique , postoperative analgesia , and feeding regimen . Parents , carers , and assessors responsible for the postoperative evaluation were blinded for the technique used . RESULTS There was no difference in the incidence of postoperative vomiting between the 2 groups . The overall incidence of complications was similar , but the duration s of surgery and general anesthesia were significantly longer in the LP group than in the OP group ( P = 10(-4 ) and P = .02 , respectively ) . There were 3 cases of incomplete pyloromyotomy after laparoscopy , requiring a repeat procedure . CONCLUSIONS Laparoscopic pyloromyotomy does not decrease the incidence of postoperative vomiting , has a similar complication rate compared with the open umbilical approach , but may expose patients to a risk of inadequate pyloromyotomy Background The role of laparoscopy in the management of patients with suspected acute appendicitis remains controversial . It has been suggested that laparoscopy is useful mainly in young women of reproductive age because of the high incidence of wrong diagnosis in these patients . Methods Different management protocol s for patients with suspected acute appendicitis were prospect ively used in male and female patients ; women of reproductive age were treated laparoscopically , while men were r and omised to open or laparoscopic appendectomy . Results From September 2002 to September 2005 , 132 patients —54 women and 78 men — with suspected acute appendicitis were treated according to the protocol . The incidence of wrong diagnosis in female patients was high ( 26 % and the conversion rate low ( 5.5 % ) . In contrast , in the laparoscopic male subgroup , these rates showed a reverse relationship ( 5.2 % and 18.5 % , respectively ) . Morbidity did not differ between female and male patients or between the 2 arms of the male group . Laparoscopic appendectomy took longer to perform without affecting significantly the needs for postoperative analgesia , the duration of hospital stay and the time to return to normal activities when compared with open appendectomy in men . Conclusion Laparoscopic appendectomy is at least as safe as the open procedure in the male population , although it does not appear to offer any obvious advantage over the open procedure . The diagnostic advantage that laparoscopy offers to fertile women makes the procedure attractive for this population Background In patients with symptomatic cholelithiasis ,  laparoscopic cholecystectomy  ( LC ) is the st and ard method of treatment . Laparoscopic cholecystectomy has a low rate of postoperative infections probably owing to smaller wounds and minimal tissue damage compared with the open procedure . Objectives This study assessed the effect of cefazolin prophylaxis on postoperative infection in patients undergoing elective laparoscopic cholecystectomy .  Additionally , we determined the risk factors of cases with postoperative infection . Patients and Methods A total of 753 patients were enrolled in the study . Among these , 206 were excluded from the study . As a result , 547 patients with symptomatic cholelithiasis who underwent elective laparoscopic cholecystectomy were selected for this prospect i ve study . Patients were r and omized consecutively and divided into 2 groups : patients in the cefazolin ( CEF ) group ( n = 278 ) received 1 g of cefazolin and those in the control group ( n = 269 ) received 10 mL of isotonic sodium chloride solution . Patient characteristics and overall surgical outcomes were compared between the groups . All patients were followed for development of postoperative infections . Results Postoperative infections occurred in 4 patients in the CEF group and in 2 patients in the control group ; no significant difference existed in this regard(P = .44 ) . Risk of infection increased in patients with previous cholecystitis and /or endoscopic retro grade cholangiopancreatography ( P < 0.001 ) , patients with ruptured gallbladders , and patients for whom a suction drain was used ( respectively , P < 0.001 and P < 0.001 ) . Conclusions No correlation existed between cefazolin prophylaxis and postoperative infections in elective laparoscopic cholecystectomy patients . There may be an increased risk of infection in patients with previous cholecystitis or endoscopic retro grade cholangiopancreatography . In addition , there was an increased risk of postoperative infection in patients with gallbladder rupture and suction drain use Purpose : To evaluate the safety and feasibility of single-incision laparoscopic cholecystectomy ( SILS-C ) compared with conventional laparoscopic cholecystectomy ( CLC ) . Methods : Sixty-five patients ( SILS-C : 35 , CLC : 30 ) were prospect ively enrolled and operated with conventional straight instruments . The postoperative pain scores at 6 , 24 hours , and 1 week , nausea , vomiting , commencement of oral intake , hospital stay , resumption of normal activities and work and satisfaction levels were noted . Results : Twenty-eight percent ( 10/35 ) SILS-C patients required introduction of additional trocars to complete the procedure . No patient required conversion to open . All the morbidity parameters were similar in both the groups , except that the seroma formation in the wound was significantly higher in the SILS-C group [ SILS-C : 17 % (6/35)/CLC : 0 % , P=0.038 ] . One patient in SILS-C had a major bile duct injury . Conclusions : SILS-C is safe and feasible with conventional instruments . However , caution needs to be exercised in view of a major bile duct injury and a higher rate of seroma formation in the wound Background Laparoendoscopic single-site ( LESS ) surgery is an evolution of laparoscopic surgery aim ing at decreasing the patient ’s parietal trauma associated with abdominal operations . LESS has been found so far to be efficient and have the same good results as the st and ard four-port laparoscopic cholecystectomy . α-Defensins are antimicrobial peptides of the organism . They are the first cell components against pathogens . Cytokines are also mediators in the response to trauma . The aim of this study was to compare the inflammatory reaction in LESS and four-port laparoscopic cholecystectomy . Methods Forty patients with noncomplicated cholelithiasis were r and omly assigned into one of two groups . Group A included the patients who would undergo four-port laparoscopic cholecystectomy and group B included the patients who would undergo LESS cholecystectomy . These patients had a BMI < 30 , were ASA I or II , and had no previous upper-GI surgery . Blood was taken preoperatively and 6 and 24 h postoperatively . hsCRP ( with automated analyzer ) and α-defensins ( using ELISA ) were calculated for each sample . The same postoperative protocol was followed for both groups . Mann-Whitney U test was used to analyze the results . Pain was calculated with a visual analog scale ( VAS ) for shoulder and abdomen at 6 and 24 h. Hospital stay , nausea , and pain medication needed was noted . Results The α-defensins value was statistically significantly higher in the 24-h sample s ( P < 0.001 ) for LESS cholecystectomy . No statistically significant difference was shown for hsCRP , even though P = 0.05 for the 24-h sample s with the values of LESS higher . No LESS was converted to a classical laparoscopic cholecystectomy , and none of the patients of either group needed conversion to open cholecystectomy . Pain was statistically significantly less for the LESS group at the 24-h interval ( P < 0.0001 ) . Less medication was needed for LESS patients after the 6th postoperative hour ( P = 0.007 ) . Conclusion Higher inflammatory reaction in LESS cholecystectomy could be the result of greater tension on the tissues . More studies are needed to conclude if this has a significant clinical expression OBJECTIVES To assess the utility of laparoscopic versus conventional surgical exploration in premenopausal women with suspected acute appendicitis . METHOD Female patients aged 15 - 45 years in whom an independent decision to undertake surgical exploration had been made , were r and omised to laparoscopic or open procedures .  Comparison of patient groups was conducted on an intention-to-treat basis . RESULTS Eighteen patients underwent laparoscopic exploration  , with 1 procedure requiring conversion to lower midline laparotomy . Open surgical exploration was performed primarily in 16 patients .  Postoperative complications ( 3 patients versus 1 patient ) and diagnostic errors ( 5 patients versus 1 patient ) were more frequent in patients undergoing open surgical procedures . Laparoscopic procedures tended to be of longer duration than open operations , but were generally associated with slightly more favourable indices of postoperative recovery ( analgesic requirement , postoperative hospitalisation , return to normal activity , return to work ) . In patients found not to have acute appendicitis , the difference in mean postoperative hospitalisation following laparoscopic intervention ( 2.6 days ) and conventional surgery ( 3.4 days ) approached statistical significance ( p < 0.1 ) . CONCLUSIONS Laparoscopy may carry some diagnostic advantage over open surgery in premenopausal women with suspected acute appendicitis . Patients found not to have acute appendicitis have a marginally shorter period of hospitalisation after laparoscopic intervention . The outcome following laparoscopic appendicectomy for confirmed acute appendicitis is at least equivalent to that achieved with conventional appendicectomy . Laparoscopic exploration is an acceptable option in premonopausal women requiring surgery for suspected acute appendicitis AIM To determine the efficacy of perioperative parecoxib injection on postoperative pain relief after laparoscopic cholecystectomy . METHODS A prospect i ve , double-blind , r and omized , placebo-controlled study was conducted on 70 patients who underwent elective laparoscopic cholecystectomy under general anesthesia at Siriraj Hospital , Bangkok , from January 2006 to December 2007 . Patients were r and omized to receive either 20 mg parecoxib infusion 30 min before induction of anesthesia and at 12 h after the first dose ( treatment group ) , or normal saline infusion , in the same schedule , as a placebo ( control group ) . The degree of the postoperative pain was assessed every 3 h in the first 24 h after surgery , and then every 12 h the following day , using a visual analog scale . The consumption of analgesics was also recorded . RESULTS There were 40 patients in the treatment group , and 30 patients in the control group . The pain scores at each time point , and analgesic consumption did not differ between the two groups . However , there were fewer patients in the treatment group than placebo group who required opioid infusion within the first 24 h ( 60 % vs 37 % , P = 0.053 ) . CONCLUSION Perioperative administration of parecoxib provided no significant effect on postoperative pain relief after laparoscopic cholecystectomy . However , preoperative infusion 20 mg parecoxib could significantly reduce the postoperative opioid consumption Background : Postoperative nausea and vomiting ( PONV ) after laparoscopic cholecystectomy ( LC ) has multifactorial etiology . Pain and use of opioids are among the important factors . Objectives : The present study aim ed to evaluate the efficacy of intrapritoneal ( IP ) injection of bupivacaine on PONV . Patients and Methods : This was a double-blind r and omized clinical trial , conducted on 66 patients aged 20 - 60 , ASA I or II , c and i date s for LC . Patients were r and omly assigned to two groups . Bupivacaine group received 20 mL bupivacaine 0.25 % in the gallbladder bed , before and after cholecystectomy and the control group did not . The incidence of nausea and postoperative pain intensity was measured with Visual analogue scale ( VAS ) at 1 , 2 , 3 and 4 hours after operation , at rest and when coughing and changing positions . Nausea and vomiting occurrence were assessed at the same times . Results : There were no demographic data differences between groups . No differences were found between the two groups , in terms of incidence of nausea and vomiting . Furthermore , both groups were similar with respect to opioid consumption , during four hours post-operation . Conclusions : Intraperitoneal bupivacaine administration at the beginning and end of laparoscopic cholecystectomy reduced only visceral and shoulder pains at the 4th postoperative hour , but had no effect on reducing neither PONV , nor opioid dem and , during the first four postoperative hours Background The aim if this study was to compare percutaneous drainage ( PD ) of the gallbladder to emergency cholecystectomy ( EC ) in a well-defined patient group with sepsis related to acute calculous/acalculous cholecystitis ( ACC/AAC ) . Methods Between 2001 and 2007 , all consecutive patients of our ICU treated by either PD or EC were retrospectively analyzed . Cases were collected from a prospect i ve data base . Percutaneous drainage was performed by a transhepatic route and EC by open or laparoscopic approach . Patients ’ general condition and organ dysfunction were assessed by two vali date d scoring systems ( SAPS II and SOFA , respectively ) . Morbidity , mortality , and long-term outcome were systematic ally review ed and analyzed in both groups . Results Forty-two patients [ median age = 65.5 years ( range = 32–94 ) ] were included ; 45 % underwent EC  ( ten laparoscopic , nine open ) and 55 % PD ( n = 23 ) . Both patient groups had similar preoperative characteristics .  Percutaneous drainage and EC  were successful in 91 and 100 % of patients , respectively . Organ dysfunctions were similarly improved by the third postoperative/postdrainage days . Despite undergoing PD , two patients required EC due to gangrenous cholecystitis . The conversion rate after laparoscopy was 20 % . Overall morbidity was 8.7 % after PD and 47 % after EC ( P = 0.011 ) . Major morbidity was 0 % after PD and 21 % after EC ( P = 0.034 ) . The mortality rate was not different ( 13 % after PD and 16 % after EC , P = 1.0 ) and the deaths were all related to the patients ’ preexisting disease . Hospital and ICU stays were not different . Recurrent symptoms ( 17 % ) occurred only after ACC in the PD group . Conclusions In high-risk patients , PD and EC are both efficient in the resolution of acute cholecystitis sepsis . However , EC is associated with a higher procedure-related morbidity and the laparoscopic approach is not always possible . Percutaneous drainage represents a valuable intervention , but secondary cholecystectomy is m and atory in cases of acute calculous cholecystitis Laparoscopy enables hernial orifices to be observed and tension-free mesh repair to be carried out effectively . In the first r and omised controlled trial on hernia repair , which compared laparoscopic transabdominal pre-peritoneal ( TAPP ) mesh with open darn repairs , laparoscopic repair was less painful and enabled patients to return to work and normal activity more quickly.1 Since then , several r and omised controlled studies and systematic review s have largely confirmed these results . 2 3 More recently in the United Kingdom , the National Institute for Clinical Excellence review ed the available early results and published its guidance on the use of laparoscopic surgery for inguinal hernias.4 We present results of a r and omised controlled trial of  inguinal hernia repair with over five years ' follow up , comparing laparoscopic TAPP mesh repair with Lichtenstein open mesh repair . The main long term objective of this study was to compare the complication rates of these procedures . We conducted the trial Background Laparoscopic cholecystectomy is now considered the first option for gallbladder surgery . However , 20 % to 30 % of cholecystectomies are completed as open operations often on elderly and fragile patients . The external validity of r and omised trials comparing mini-laparotomy cholecystectomy and laparoscopic cholecystectomy has not been studied . The aim of this study is to analyse characteristics , procedures , and outcomes for all patients who underwent cholecystectomy without being included in such a trial . Methods Characteristics ( age , sex , co-morbidity , and ASA-score ) , operation time , hospital stay , and mortality were compared for patients who underwent cholecystectomy outside and within a r and omised controlled trial comparing mini-laparotomy and laparoscopic cholecystectomy .  Results During the inclusion period 1719 patients underwent cholecystectomy . 726 patients were r and omised and 724 of them completed the trial ; 993 patients underwent cholecystectomy outside the trial . The non-r and omised patients were older – and had more complications from gallstone disease , higher co-morbidity , and higher ASA – score when compared with trial patients . They were also more likely to undergo acute surgery and they had a longer postoperative hospital stay , with a median 3 versus 2 days ( p < 0.001 for all comparisons ) . St and ardised mortality ratio within 90 days of operation was 3.42 ( mean ) ( 95 % CI 2.17 to 5.13 ) for non-r and omised patients and 1.61 ( mean ) ( 95%CI 0.02 to 3.46 ) for trial patients . For non-r and omised patients , operation time did not differ significantly between mini-laparotomy and open cholecystectomy in multivariate analysis . However , the operation for laparoscopic cholecystectomy lasted 20 minutes longer than open cholecystectomy . Hospital stay was significantly shorter for both mini-laparotomy and laparoscopic cholecystectomy compared to open cholecystectomy . Conclusion Non-r and omised patients were older and more sick than trial patients . The assignment of healthier patients to trials comparing mini-laparotomy cholecystectomy and laparoscopic cholecystectomy limits the external validity of conclusions reached in such trials Background and Objective : With the safety of  laparoscopic cholecystectomy ( LC ) having been established , the current stress is on reducing the postoperative morbidity associated with this procedure . Hence , this study was undertaken to compare the effect of low-pressure ( 8 mm Hg ) ( LPLC ) versus st and ard-pressure ( 12 mm Hg ) ( SPLC ) pneumoperitoneum on postoperative pain , respiratory and liver functions , the stress response , and the intraoperative surgeon comfort in patients undergoing LC . Material s and Methods : Patients undergoing LC ( n=43 ) were r and omized into the  LPLC ( 8 mm Hg ) group ( n=22 ) and the  SPLC  ( 12 mm Hg ) group ( n=21 ) . Postoperative pain , changes in liver function , peak expiration flow rate , C-reactive protein level , and intraoperative surgeon comfort were assessed . Results : The postoperative pain scores ( P=0.003 , 0.000 , 0.001 , and 0.002 at 0 , 4 , 8 , and 24 h ) , total analgesic requirement ( P=0.001 ) , and the number ( total and good ) of dem and s for analgesic in the first 24 hours ( P=0.002 and 0.001 ) were lower in the LPLC group . The surgeon comfort in the LPLC group was significantly lesser ( P=0.000 ) . The liver function and peak expiration flow rate did not show any significant changes . C-reactive protein levels varied significantly only at 24 hours postoperatively ( P=0.001 ) . Conclusions : The use of low-pressure pneumoperitoneum ( 8 mm Hg ) for LC is associated with a significantly lower postoperative pain . However , the use of this low-pressure pneumoperitoneum can jeopardize the surgeon ’s comfort Background During laparoscopic cholecystectomy ( LCHE ) , the insufflation with warmed and humidified carbon dioxide ( CO2 ) may reduce postoperative pain . The aim of the study was to evaluate the positive effects of heated and humidified carbon dioxide gas on patients with regard to postoperative pain after LCHE . Patients and methods This is a prospect i ve , r and omized , double-blinded , controlled clinical trial . 148 patients ( female = 98 , male = 50 ) scheduled for elective LCHE were r and omized into two groups : receiving either heated humidified carbon dioxide , or st and ard gas . Intraoperative core temperature was measured . The perioperative management was identical for both groups . Postoperative pain intensity was assessed using a visual analog pain scale , and the amount of analgesic consumption was recorded . The postoperative pain management was also st and ardized and equal for both groups . Results 67 out of 148 received st and ard gas ( group A ) , and 81 received warmed , humidified gas ( group B ) . The groups were comparable demographically . The amount of analgesic consumption was recorded . Intraoperative core temperature was significant higher in group B than in group A. Pain was significantly less in group B ( p = 0.025 ) 6 h postoperatively . On the first postoperative day , no significant difference in pain between the two groups was detectable ( p = 0.437 ) . Conclusion The use of warmed and humidified carbon dioxide during LCHE reduces postoperative pain at the day of operation Background The creation of a stoma is an established therapeutic concept for the palliation of non-resectable rectal carcinomas and advanced tumours infiltrating the pelvis . Material s and methods In two prospect i ve country-wide multicentre studies , each conducted over a similar period of time , the peri-operative course and postoperative short-term outcomes of laparoscopic vs laparotomy-based stoma construction were compared . Results A total of 90 patients underwent palliative laparoscopic construction ; 550 patients received a  stoma via a laparotomy . The intra-operative complication rate was lower after open surgery than after laparoscopic surgery ( 2.7 vs 5.6 % ; p = 0.15 ) , although the difference was not significant . With regard to general ( 30.9 vs 15.6 % ; p = 0.003 ) and also specific postoperative complications ( 13.8 vs 5.6 % ; p = 0.029 ) , however , a significant advantage of the laparoscopic approach was seen . Furthermore , mortality in the laparoscopic group was also significantly lower ( 4.4 vs 14.0 % ; p = 0.011 ) . Conclusion Palliative stoma done via laparoscopy had significantly better outcomes in terms of postoperative morbidity and mortality in comparison with the open surgical procedure INTRODUCTION The aim of this study is to compare laparoscopic cholecystectomy ( LC ) with that performed using single umbilical incision laparoscopic surgery ( SILS ) in a major outpatient surgery ( MOS ) unit . MATERIAL AND METHODS A total of 50 patients with symptomatic cholelithiasis were prospect ively r and omised between October 2009 and June 2011 , with 26 of them subjected to SILS , and 24 to CL .  The variables analysed were , postoperative pain , analgesia requirements , presence of nausea/vomiting , operation time , complications , outpatient success rate , and aesthetic results . RESULTS There were no differences as regards postoperative pain , analgesia rescue , nausea/vomiting , or operation time ( SILS 54 ± 21 min , CL 48.5 ± 17 min , P=.29 ) . There was one case of morbidity in the SILS group which required further surgery . The outpatient surgical procedure was completed in 77 % of patients of the SILS group , and in 83 % of the CL group . Six patients ( 23 % ) from the SILS group , and 4 ( 17 % ) from the CL group remained in the unit for more than 24h ( P=.58 ) . The aesthetic results were subjectively assessed as " very good " in the SILS group , and " good " in the CL group . CONCLUSION SILS cholecystectomy is feasible and safe when comparing it with laparoscopic cholecystectomy in selected patients , and obtains similar results when performed in a MOS unit . Larger studies are needed to determine the real benefits of this approach before recommending it as a routine technique . With more experienced surgical teams and greater awareness of the patients could possibly increase the number of c and i date s for outpatient cholecystectomy Background Remifentanil is a short-acting drug with a rapid onset that is useful in general anesthesia . Recently , however , it has been suggested that the use of opioids during surgery may cause opioid-induced hyperalgesia ( OIH ) . Research ers have recently reported that esmolol , an ultra-short-acing β1 receptor antagonist , reduces the postoperative requirement for morphine and provides more effective analgesia than the administration of remifentanil and ketamine . Hence , this study was conducted to determine whether esmolol reduces early postoperative pain in patients who are continuously infused with remifentanil for anesthesia during laparoscopic cholecystectomy . Methods Sixty patients scheduled to undergo laparoscopic cholecystectomy were r and omly divided into three groups . Anesthesia was maintained with sevoflurane and 4 ng/ml ( target-controlled infusion ) of remifentanil in all patients . Esmolol ( 0.5 mg/kg ) was injected and followed with a continuous dosage of 10 µg/kg/min in the esmolol group ( n = 20 ) . Ketamine ( 0.3 mg/kg ) was injected and followed with a continuous dosage of 3 µg/kg/min in the ketamine group ( n = 20 ) , while the control group was injected and infused with an equal amount of normal  saline . Postoperative pain score ( visual analog scale [ VAS ] ) and analgesic requirements were compared for the first 6 hours of the postoperative period . Results The pain score ( VAS ) and fentanyl requirement for 15 minutes after surgery were lower in the esmolol and ketamine groups compared with the control group ( P < 0.05 ) . There were no differences between the esmolol and ketamine groups . Conclusions Intraoperative esmolol infusion during laparoscopic cholecystectomy reduced opioid requirement and pain score ( VAS ) during the early postoperative period after remifentanil-based anesthesia INTRODUCTION Laparoscopic Cholecystectomy ( LC ) is the most frequently performed elective daycare surgery and provision of postoperative pain relief is of importance . After laparoscopic cholecystectomy shoulder and abdominal pain causes considerable distress . Visceral pain during coughing , respiration and mobilization increases morbidity , hospital stay and costs . AIM To compare the analgesic efficacy of intraperitoneally instilled equipotent concentrations of bupivacaine and ropivacaine versus placebo in relieving postoperative pain after laparoscopic cholecystectomy when used as a part of multimodal analgesia . MATERIAL S AND METHODS In this r and omised , prospect i ve , double blind , placebo controlled study , 90 ASA Class I or II patients were r and omly divided into three groups of 30 each . Group S received intraperitoneal infiltration with 35 ml of 0.9 % normal saline , Group B with 35 ml of 0.25 % bupivacaine and Group R with 35 ml of 0.375 % ropivacaine . All groups received st and ard general endotracheal anaesthesia and analgesia with IV paracetamol 15 mg/kg and diclofenac 1.5 mg/kg . Numerical Rating Scale ( NRS ) score of analgesia at rest and on cough/movement , duration of analgesia , haemodynamic parameters , need for a rescue analgesic ( IV tramadol 1 mg/kg ) was recorded and adverse effects of procedure and drugs if any were monitored . Data was analysed with SPSS statistical software version 21.0 . One way ANOVA or the Kruskal-Wallis test was used to compare continuous data across all three groups as appropriate . Subsequent analysis of continuous data between two groups was achieved by Tukey 's post hoc test . Significance was accepted as p<0.05 . RESULTS The mean NRS was < 5 till only four hours in Group S , till eight hours in Group B and till 16 hours in Group R. The duration of analgesia was 13.47±1.38 hours in Group R , 7.93±1.44 hours in Group B and 4.47±0.86 hours in Group S. CONCLUSION Intraperitoneal infiltration of LA significantly reduces pain intensity scores in the early postoperative period after LC surgery and helps in improving the postoperative recovery profile and outcome . This makes LC surgery more amenable to day care surgical setup . Ropivacaine ( 0.375 % ) is more efficacious , longer acting with a higher intensity of postoperative analgesia than bupivacaine ( 0.25 % ) Background Single-incision laparoscopic cholecystectomy ( SILC ) is a newer approach that may be a safe alternative to traditional laparoscopic cholecystectomy ( TLC ) based on retrospective and small prospect i ve studies . As the dem and for single-incision surgery may be driven by patient perceptions of benefits , we design ed a prospect i ve r and omized study using patient-reported outcomes as our end points . Methods Patients deemed c and i date s for either SILC or TLC were offered enrollment in the study . After induction of anesthesia , patients were r and omized to SILC or TLC .  Preoperative characteristics and operative data were recorded , including length of stay ( LOS ) . Pain scores in recovery and for 48 h and satisfaction with wound appearance at 2 and 4 weeks were reported by patients . We used the gastrointestinal quality of life index ( GIQLI ) survey preoperatively and at 2 and 4 weeks postoperatively to assess recovery . Procedural and total hospital costs per case were abstract ed from hospital billing systems . Results Mean age of the study group was 44.1 years ( ±14.8 ) , 87 % were Caucasian , and 77 % were female , with no difference between  groups . Operative times were longer for SILC ( median = 57 vs. 47 min , p = 0.008 ) , but mean LOS was similar ( 6.8 ± 4.2 h SILC vs. 6.2 ± 4.8 h TLC , p = 0.59 ) . Operating room cost and encounter cost were similar . GIQLI scores were not significantly different preoperatively or at 2 or 4 weeks postoperatively . Patients reported higher satisfaction with wound appearance at 2 weeks with SILC . There were no differences in pain scores in recovery or in the first 48 h , although SILC patients required significantly more narcotic in recovery ( 19 mg morphine equivalent vs. 11.5 , p = 0.03 ) . Conclusions SILC is a longer operation but can be done at the same cost as  TLC . Recovery and pain scores are not significantly different . There may be an improvement in patient satisfaction with wound appearance . Both procedures are valid approaches to cholecystectomy UNLABELLED Pain is the dominant complaint after laparoscopic cholecystectomy . No study has examined the combined effects of a somato-visceral blockade during laparoscopic cholecystectomy . Therefore , we investigated the effects of a somato-visceral local anesthetic blockade on pain and nausea in patients undergoing elective laparoscopic cholecystectomy . In addition , all patients received multi-modal prophylactic analgesic treatment .  Fifty-eight patients were r and omized to receive a total of 286 mg ( 66 mL  ) ropivacaine or  66  mL saline via periportal and intraperitoneal infiltration . During the first 3 postoperative h , the use of morphine and antiemetics was registered , and pain and nausea were rated hourly . Daily pain intensity , pain localization , and supplemental analgesic consumption were registered the first postoperative week . Ropivacaine reduced overall pain the first two hours and incisional pain for the first three postoperative hours ( P < 0.01 ) but had no apparent effects on intraabdominal or shoulder pain . During the first 3 postoperative h , morphine requirements were lower ( P < 0.05 ) , and nausea was reduced in the ropivacaine group ( P < 0.05 ) . Throughout the first postoperative week , incisional pain dominated over other pain localizations in both groups ( P < 0.01 ) . We conclude that the somato-visceral local anesthetic blockade reduced overall pain during the first 2 postoperative h , and nausea , morphine requirements , and incisional pain were reduced during the first 3 postoperative h in patients receiving prophylactic multi-modal analgesic treatment . IMPLICATION S A combination of incisional and intraabdominal local anesthetic treatment reduced incisional pain but had no effect on deep intraabdominal pain or shoulder pain in patients receiving multimodal prophylactic analgesia after laparoscopic cholecystectomy . Incisional pain dominated during the first postoperative week . Incisional infiltration of local anesthetics is recommended in patients undergoing laparoscopic cholecystectomy Background Although opioids are the main choice for acute postoperative pain control , many side effects have been reported for them . NSAIDs and paracetamol have been used extensively as alternatives , and it seems that they are more effective for minor to moderate pain control postoperatively when have been used alone or in combination with opioids . As laparoscopic cholecystectomy poses moderate pain postoperatively , this study was planned to assess whether paracetamol is able to provide effective analgesia as a sole analgesic at least in the first few hours post operatively . Objectives We evaluated the effect of intravenous Paracetamol on postoperative pain in patients undergoing laparoscopic cholecystectomy . Patients and Methods This is a r and omized double- blind clinical trial study . 30 patients ASA class I , aged 18 to 50 years , c and i date for laparoscopic cholecystectomy were recruited , and r and omly divided into two equal groups . Group A ( paracetamol group ) received 1 gr paracetamol and group B received placebo ten minutes after the induction of anesthesia . 0.1 mg/Kg Morphine was administered intravenously based on patients compliant and pain score > 3 . Pain score and the opioids consumption were recorded in the first six hours postoperative . Patient 's pain was measured by the VAS ( Visual Analog Scale ) . Results The pain score was lower in group A ( P= 0.01 ) , but the  morphine consumption showed no significant difference between the groups ( P= 0.24 ) during the first 6 hours postoperatively . Conclusions Although paracetamol ( 1gr ) has caused a better pain relief quality but it is not a suitable analgesic for moderate pain control in acute phase after surgery alone Background Natural orifice transluminal endoscopic surgery ( NOTES ) and transumbilical endoscopic surgery ( TUES ) are being developed to improve minimally invasive surgery further . In 2006 , the authors developed TUES using a single triple-channel trocar or single-trocar ( ST ) technique . To minimize the risk and improve the surgical efficiency further , the procedure was optimized using a two-trocar ( TT ) technique , with both trocars in the umbilicus . This study compared the clinical results for the TT and ST techniques . Methods For this study , 32 patients with chronic gallbladder disease and indications for cholecystectomy were r and omly assigned to undergo surgery with either the TT technique ( 17 patients ) or the ST technique ( 15 patients ) . With the TT procedure , two modified 5-mm trocars with small h and les were inserted through the navel , one above and one below the umbilicus . Another 2-mm trocar was inserted for a grasper in the right upper abdomen . With the ST procedure , one 15-mm umbilical incision was made for insertion of a previously developed triple-channel trocar to apply the laparoscope , grasper , and dissector individually . Operation time , postoperative hospital stay , and postoperative pain were compared between the two procedures . Results The mean operative time was significantly shorter with the TT technique ( 35.71 ± 9.74 min ) than with the ST technique ( 125.25 ± 18.9 min ( p < 0.001 ) . Use of analgesics after surgery also was less in the TT group than in the ST group ( 0 vs. 7 , respectively ; p < 0.05 ) . The postoperative hospital stay did not differ significantly between the two groups ( p > 0.05 ) . Conclusions Although both procedures were based on the transumbilical approach , the TT approach was found to be faster and less painful than the ST approach . The difference in the cosmetic result was minimal OBJECTIVES We aim ed to investigate whether the timing of administration , using a combination of incisional and intraperitoneal levobupivacaine ( 0.25 % ) , has an effect on the postoperative pain after laparoscopic cholecystectomy in a prospect i ve , r and omized , and controlled study . METHODS Sixty six patients were allocated to one of the three groups . Group BS received levobupivacaine before trocar site incision and intraperitoneal levobupivacaine immediately after pneumoperitoneum . Group AS received intraperitoneal levobupivacaine before trocars were withdrawn and incisional levobupivacaine administered at the end of surgery . Group C received no treatment . Data of intraoperative variables , postoperative pain relief , rescue analgesic consumption , and patient satisfaction were compared . RESULTS The intraoperative fentanyl consumption was found lower in Group BS , compared to Groups AS and C ( p<0.05 ) . VAS scores were lower in both Groups BS and AS , compared to Group C immediately after the operation ( p<0.05 ) . VAS scores were significantly decreased during the first two hours in Group AS , compared to Group C. The mean doses and number of patients needing rescue meperidine  were lower in Group AS , compared to the Groups BS and C ( p<0.05 ) . CONCLUSION The combination of incisional and intraperitoneal levobupivacaine administered before or after surgery can reduce postoperative pain and analgesic and antiemetic consumption together with improved patient satisfaction . However , administering levobupivacaine before surgery might be advantageous for less intraoperative fentanyl consumption , while levobupivacaine after surgery is advantageous for less postoperative rescue analgesic requirement Objective Better patient-reported outcomes ( PROs ) of laparoscopic cholecystectomy  ( LC ) are premised upon PROs such as postoperative pain and fatigue . These PROs are indices of convalescence and return to normal activity . Curcumin ( turmeric ) is used in India for traumatic pain and fatigue for its anti-inflammatory/antioxidant and tissue modulation/healing properties . We studied the effect of curcumin on pain and postoperative fatigue in patients of LC . Methods and procedures From July to September 2009 , 50 consecutive day-care LC c and i date s were enrolled for a prospect i ve , double-blind r and omized placebo-controlled study . A uniform general anesthesia and analgesia protocol was followed . Curcumin/placebo and rescue analgesic were prescribed at discharge . Patients were told to maintain pain/fatigue/adverse event diaries based upon 100-point visual analog pain scale ( VAS ) and 10-point interval rating fatigue scale ( IRS ) . Patients were followed up at third day ( D3 ) , first week ( W1 ) , second week ( W2 ) , and third week ( W3 ) . The blind labels were opened at the end of study . Results Demographic characteristics , comorbidity , and gallbladder pathology profiles were comparable in the study ( n = 25 ) and control groups ( n = 25 ) . There was no adverse surgical outcome , adverse PRO or withdrawal . Pain and fatigue scores at D3 were similar in the two groups . At W1 and W2 , the study group showed significantly lower ( p value 0.000 ) mean pain scores , i.e. , 15 ± 5.204 versus 30 ± 13 in controls . Fatigue scores at W1 , W2 , and W3 were significantly lower ( p value 0.000 ) in the study group , i.e. , 2.16 ± 1.748 , 1 , and 0 , respectively , versus 5.16 ± 1.375 , 4.20 ± 1.633 , and 1 in controls . All patients were pain free at W3 . Analgesic tablet usage was significantly lower ( p value 0.000 ) in the study group , i.e. , 6.96 ± 1.837 versus 39.32 ± 16.509 in controls . Conclusions Turmeric ( curcumin ) improves postoperative pain- and fatigue-related PROs following LC Background and Objectives : The purpose of the present study was to evaluate the results of diagnostic laparoscopy in children with chronic recurrent abdominal pain .  Patients and Methods : Thirteen children with chronic recurrent abdominal pain were subjected to diagnostic laparoscopy .  Ages varied from 10 to 17 years . There were six males and seven females .  Abdominal pain was present from 3 weeks to 12 months ( mean , 2 months ) . Extensive laboratory and imaging studies did not contribute to the diagnosis . In all patients , the pain was disabling and severe enough to warrant repeated visits to the pediatrician , emergency room visits , or hospital admissions , as well as absence from school . Results : All children recovered uneventfully . Laparoscopic findings that identified the cause of abdominal pain were obtained in 12 of 13 patients . Laparoscopic appendectomy was done in all patients . There were no operative complications . One child presented three months later with incomplete small bowel obstruction , which resolved with conservative management . There were no other postoperative complications . Follow-up varied from six months to three years . Abdominal pain resolved in ten patients . One patient presented eight months later with biliary dyskinesia . She improved following laparoscopic cholecystectomy and later on sphincterotomy , but her pain has not yet completely resolved . One patient presented six months later with abdominal pain secondary to intestinal adhesions . Her pain completely resolved after laparoscopic lysis of adhesions . A third patient who developed lower abdominal pain six months after laparoscopy improved with conservative management and antibiotics for pelvic inflammatory disease . Conclusions : Diagnostic laparoscopy is a valuable procedure in the management of children with chronic recurrent abdominal pain .  In the present study , laparoscopic examination revealed the cause of abdominal pain in most patients , and this pain resolved in most cases . Based on our experience , we recommend diagnostic laparoscopy early in the course of debilitating chronic recurrent abdominal pain in children .  Appendectomy should be done when no other significant cause of abdominal pain has been identified , even if the appendix looks normal OBJECTIVE To compare the results of open with laparoscopic appendectomy in terms of postoperative pain , rate of wound infection and hospital stay . METHODS This quasi-experimental study was conducted in Deprtment of Surgery , Ziauddin University Hospital , Karachi , over a period of six months . Patients undergoing surgery for acute appendicitis were r and omly assigned into one of the two groups ( A or B ) after obtaining written and informed consent . In Group-A patients underwent open appendectomy and in Group B laparoscopic appendectomy was performed . Post operatively pain chart and wound infection was recorded and , at the time of discharge , number of days in hospital was calculated . RESULT Sixty patients ( 38 male , 22 female ) , with clinical diagnosis of acute appendicitis based on Alvarado score of six and above , were included in the study . They were r and omized into 2 groups of A and B with 30 patients in each group . Group-A comprised open appendectomy procedure and Group-B comprised laparoscopic appendectomy .  Mean comparison of postoperative pain by visual analogue scale , was significantly low in Group B , compared with Group A , on day 0 , 1 and 2 . Number of days in Hospital was 4.1 + /- 0.8 days in Group A and 1.5 + /- 0.06 days in Group B. None of the patients in Group B , while 8 ( 26.67 % ) patients in-Group A , developed postoperative wound infection at 1 week follow up . CONCLUSION Laparoscopic appendectomy is safe and effective . Wound infection and postoperative pain is significantly lower after this mode of INTRODUCTION Insufflation of carbon dioxide during laparoscopic cholecystectomy leads to postoperative shoulder tip pain . The origin of shoulder pain is commonly assumed to be due to overstretching of the diaphragmatic muscle fibres owing to a high carbon dioxide pressure . AIMS To study the frequency and intensity of post operative shoulder tip pain in laparoscopic cholecystectomy and compare low and st and ard pressure pneumoperitoneum during laparoscopic cholecystectomy with respect to post operative shoulder tip pain . METHODS Patients admitted in the department of surgery for elective cholecystectomy were enrolled in the study . The patients were r and omly allocated to two groups ( group A and group B ) . In group A ( n = 50 ) , low pressure pneumoperitoneum ( 8 mm Hg ) and in group B ( n = 50 ) , st and ard pressure pneumoperitoneum ( 14 mm Hg ) was generated during laparoscopic cholecystectomy . Postoperative shoulder tip pain was assessed at 4 , 8 and 24 h after operation by the Visual Analogue Scale of Pain . RESULTS 14 patients ( 28 % ) in group B complained of post operative shoulder tip pain as compared to only 5 patients ( 10 % ) in group A. The mean intensity of post operative shoulder tip pain assessed by visual analogue scoring scale at 4 , 8 and 24 h was less in group A as compared to group B , although statistical significance was seen only at 4 h. Analgesic requirements and the mean length of post operative stay in the hospital were also less in group A as compared to group B. CONCLUSION Low pressure laparoscopic cholecystectomy ( LPLC ) significantly decreases the frequency and intensity of postoperative shoulder tip pain . LPLC decreases the dem and for postoperative analgesics , decreases postoperative hospital stay and hence improves the quality of life in the early stage of postoperative rehabilitation BACKGROUND / PURPOSE Dexamethasone has been reported to reduce postoperative nausea and vomiting ( PONV ) after laparoscopic cholecystectomy ( LC ) . However , its effect on other surgical outcomes such as pain and fatigue have been unclear . The purpose of this clinical study was to evaluate the efficacy of preoperative dexamethasone in ameliorating postoperative symptoms after LC . METHODS In this prospect i ve , double-blind , placebo-controlled study , 80 patients scheduled for LC were analyzed after r and omization to intravenous dexamethasone ( 8 mg ) or placebo .  All patients underwent st and ardized procedures for general anesthesia and surgery , and were recommended to remain in hospital for 3 postoperative days . Episodes of PONV , and pain and fatigue scores on a visual analogue scale ( VAS ) were recorded . Analgesic and antiemetic requirements were also recorded . RESULTS There were no apparent side effects of the study drug . Seven patients ( 18 % ) in the dexamethasone group reported nausea , compared with 16 ( 40 % ) in the placebo group ( p = 0.026 ) . One patient ( 3 % ) in the dexamethasone group and 7 ( 18 % ) in the placebo group reported vomiting ( p = 0.025 ) . Dexamethasone significantly reduced the postoperative VAS pain score ( p = 0.030 ) and VAS fatigue score ( p = 0.023 ) . The mean number of patients requiring diclofenac sodium 50 mg was 0.9 + /- 1.3 in the dexamethasone group and 2.2 + /- 2.5 in the placebo group ( p = 0.002 ) . CONCLUSIONS The regimen we employed is safe and without apparent side effects . These results suggest that preoperative dexamethasone ( 8 mg ) significantly reduces the incidence of PONV , pain , and fatigue after LC Background Pain after laparoscopy is multifactorial and different treatments have been proposed to provide pain relief . Multimodal analgesia is now recommended to prevent and treat post-laparoscopy pain . Dexmedetomidine , an α2 agonist , has well-known anesthetic and analgesic-sparing effects . We evaluated the analgesic effect of perioperative dexmedetomidine infusion during laparoscopic cholecystectomy with multimodal analgesia . Methods Forty-two patients aged 20 to 60 years old were allocated r and omly into one of 2 groups ( n = 21 , in each ) . All patients underwent laparoscopic cholecystectomy  under multimodal analgesia . The patients in group P received dexmedetomidine 1 µg/kg during 10 min before induction and then 0.5 µg/kg/h continuously until the removal of the gall bladder while the patients in the group C received saline by the same methods as group P. Total analgesic consumption and VAS score were recorded for the first 24 hr . Results There were no significant differences in VAS scores between group P and group C during 24 hr after laparoscopic cholecystectomy . VAS scores of group P were lower than that of group C during the 1st hr after operation . The amount of ketorolac required during the 24 hr after the operation was significantly less in group P compared to group C. Conclusions The administration of dexmedetomidine during laparoscopic cholecystectomy with multimodal analgesia has minimal benefits on the reduction of the postoperative pain score . The amount of ketorolac requirements during 24 hr after the operation showed significant difference . Dexmedetomidine might be helpful for the postoperative pain after laparoscopic cholecystectomy with multimodal analgesia BACKGROUND The current literature regarding hemorrhagic complications in patients on long-term antiplatelet therapy undergoing emergent laparoscopic cholecystectomy  is limited . The aim of our study was to describe hemorrhagic complications in patients on prehospital aspirin ( ASP ) therapy undergoing emergent cholecystectomy .  METHODS We performed a 1-year retrospective analysis of our prospect ively maintained acute care surgery data base . The 2 groups ( ASP group vs No ASP group ) were matched in a 1:1 ratio for age , sex , previous abdominal surgeries , and comorbidities . Primary outcome measures were intraoperative hemorrhage , postoperative anemia , need for blood transfusion , and conversion to open cholecystectomy . Intraoperative hemorrhage was defined as intraoperative blood loss of ≥ 100 mL ; postoperative anemia was defined by ≥ 2 g/dL drop in hemoglobin . RESULTS A total of 112 ( ASP : 56 , no ASP : 56 ) patients were included in the analysis . The mean age was 65.9 ± 10 years , and 50 % were male . There was no difference in age ( P = .9 ) , sex ( P = .9 ) , and comorbidities ( P = .7 ) between the 2 groups . There was no difference in intraoperative blood loss > 100 mL ( P = .5 ) , postoperative anemia ( P = .8 ) , blood transfusion requirement ( P = .9 ) , and conversion to open surgery ( P = .7 ) between patients on American Society of Anesthesiologists therapy and patients not on American Society of Anesthesiologists therapy . CONCLUSIONS Emergent laparoscopic cholecystectomy is a safe procedure in patients on long-term ASP . Prehospital use of ASP as an independent factor should not be used to delay emergent cholecystectomy Postoperative pain after laparoscopic cholecystectomy is an ongoing problem . To relieve this pain , practitioners have used many anesthetic and analgesic drugs . This study was undertaken to assess the effects of incisional and intraperitoneal administration of ropivacaine on postoperative pain and stress response in patients undergoing laparoscopic cholecystectomy . In this prospect i ve , singleblinded , r and omized study , 45 patients with ASA ( American Society of Anesthesiologists ) scores I and II who were about to undergo laparoscopic cholecystectomy were divided into 3 groups . After cholecystectomy , a total of 40 mL of 3.75 % ropivacaine was administered preincisionally and intraperitoneally to patients in group 1 ( n=14 ) ; preincisionally and intraperitoneally to patients in group 2 ( n=17 ) ; and intraperitoneally and locally at incision sites to patients in group 3 ( n=14 ) . Blood levels of epinephrine and norepinephrine were examined preoperatively , 15 min after insufflation , and at the end of the operation . Visual analog pain scale scores and analgesic requirements were used for 24-h postoperative follow-up of pain levels reported by patients . No statistically significant difference was found among the 3 groups with respect to visual analog pain scale scores , total analgesic requirements , and accompanying pain , nausea , and vomiting . The earliest analgesic requirements were seen in group 2 ( P < .005 ) , and less shoulder pain was noted in group 3 ( P < .005 ) . Norepinephrine and epinephrine levels showed no statistically significant differences between the 3 groups . Administration of ropivacaine preoperatively and postoperatively for laparoscopic cholecystectomy has similar effects on postoperative pain and the stress response of patients & NA ; Small‐scale studies have suggested a large inter‐individual variation in early postoperative pain after laparoscopic cholecystectomy , emphasizing the need for improved analgesic treatment and valid predictors . We investigated prospect ively the association between a preoperative nociceptive stimulus by ice water ( cold pressor test ) , neuroticism , dyspepsia , patient history of biliary symptoms , intraoperative factors , and demographic information in 150 consecutive patients undergoing uncomplicated laparoscopic cholecystectomy  for their influence on early postoperative pain . During the first postoperative week patients registered overall pain , incisional , visceral , and shoulder pain on a visual analogue scale and verbal rating scale , and daily analgesic requirements were noted . Throughout the first postoperative week overall pain showed a pronounced inter‐individual variability . Incisional pain dominated in incidence and intensity compared with visceral pain , which in turn dominated over shoulder pain . In a multivariate analysis model , preoperative neuroticism , sensitivity to cold pressor‐induced pain , and age were identified as independent risk factors for early postoperative pain . Our results suggest that future analgesic studies after laparoscopic cholecystectomy should focus on reduction of incisional pain Single‐incision laparoscopic cholecystectomy ( SILC ) is increasingly practice d , but there have been no well‐powered r and omized trials investigating the technique . This non‐inferiority trial aims to compare SILC with conventional four‐port laparoscopic cholecystectomy ( LC ) with postoperative pain as the primary endpoint In general , laparoscopic cholecystectomy produces a surgical stress response very similar to which occurs after open cholecystectomy . The question is whether the pneumoperitoneum constitutes a significant pathophysiologic trauma , which might be followed by profound changes in the stress response . We conducted a prospect i ve , r and omized trial involving 50 consecutive patients scheduled for laparoscopic cholecystectomy , who had a body mass index equal to or less than 30 kg/m2 with no acute cholecystitis , pancreatitis , or liver or renal disease . These patients were r and omized to undergo either the gasless ( GLC , n= 24 ) or the carbon dioxide pneumoperitoneum ( CLC , n = 26 ) procedure . Perioperative assessment of cortisol , insulin , glucose , and C-reactive protein levels was the main determinant of outcome . During the operative procedure , significantly higher levels of serum cortisol and insulin were found in the CLC group than in the GLC group ( P < 0.05 ) . No difference in glucose levels was observed between the two groups . The inflammatory response was moderate in both groups . However , on postoperative day 1 the median C-reactive protein level was significantly higher in the GLC group than that in the CLC group ( P < 0.05 ) . Carbon dioxide and the positive intra-abdominal pressure during conventional laparoscopy may contribute to the activation of the surgical stress response Purpose of review To evaluate the efficacy of a single preoperative dose of 600 mg of gabapentin for reducing postoperative pain and tramadol consumption  after minilap open cholecystectomy . Method A total of 120 adult patients of either sex were r and omly assigned to receive 600 mg of gabapentin or a matched placebo orally 2 h before operation in a double-blind manner . All the patients received gabapentin using the same technique . Postoperative analgesia was provided with intravenous patient-controlled analgesia with tramadol using a 50-mg initial bolus dose , 20-mg incremental dose , 15-min lockout interval and 4-h limit of 240 mg . Patients were assessed at 0 , 2 , 4 , 8 , 12 , 24 and 48 h after operation for verbal analogue pain scores at rest and at movement . Consumption of tramadol on first and second postoperative days and any adverse effects were also recorded . Results Verbal analogue pain scores were significantly lower on first postoperative day at all times of observation both at rest and at movement in gabapentin group than in placebo group ( P < 0.01 ) . Tramadol consumption was also reduced by 33 % in gabapentin group . But pain scores and tramadol consumption were similar in two groups on second postoperative day . Sedation was common but the incidence of postoperative nausea and vomiting was significantly lower in gabapentin group . Conclusion Preoperative administration of 600 mg of gabapentin result ed in significant reduction in postoperative verbal analogue pain scores at rest and at movement as well as tramadol consumption compared with placebo on first postoperative day . Lower incidence of nausea and vomiting was an additional advantage . Sedation was the commonest side effect Objectives : To evaluate the efficacy and tolerability of pregabalin in postoperative pain management  after laparoscopic cholecystectomy ( LC ) . Patients and Methods : A prospect i ve , r and omized , placebo , controlled , double-blinded study was conducted at Anesthesia Department , Laparoscopy Surgery Unit , Ain Shams University Hospital . Ninety patients with ASA physical status I-II scheduled for elective LC under general anesthesia were included . Patients were r and omly assigned to the following groups ( n=30 each ) : pregabalin group ( P ) , received 150 mg pregabalin capsules 2 hours preoperatively , 12 hours postoperatively , and twice daily for 2 days ; gabapentin group ( G ) , received 1200 mg gabapentin capsules ( 400 mg , ×3 ) 2 hours preoperatively , 12 hours postoperatively , and 400 mg three times daily for 2 days ; and control group ( C ) , received placebo capsules . Postoperative pain scores were recorded on a visual analogue scale . The following data were recorded : total daily pethidine and diclofenac consumption , numeric sedation score , and the postoperative nausea , vomiting , and dizziness scores . Results : The 24-hour pethidine consumption was significantly lower ( P<0.001 ) in both pregabalin and gabapentin groups versus control . Both groups had significantly less ( P<0.001 ) patients with postoperative nausea , vomiting , sedation , and dizziness versus control . Overall patient satisfaction with pain management was significantly higher ( P<0.001 ) in pregabalin group versus gabapentin or control groups . Conclusions : Gabapentin 1200 mg and pregabalin 150 mg are effective and safe analgesics for reducing postoperative pain in LC . The perioperative oral administration of pregabalin 150 mg in patients undergoing LC is an effective and safe method of analgesia with a low incidence of adverse effects and reduces postoperative pethidine consumption Elective laparoscopic cholecystectomy is established as the treatment of choice for symptomatic cholecystolithiasis and is now proposed for the treatment of acute cholecystitis . The aim of this study is to evaluate biochemical aspects of open ( OC ) and laparoscopic cholecystectomy ( LC ) . We measured the levels of malondialdehyde ( MDA ) and the levels of nitrite+nitrate as stable end products of nitric oxide ( NO ) . MDA and nitrite+nitrate levels were increased at both surgical procedures compared to preoperative period , but the rise was more significant in OC than LC . These results showed that both OC and  LC  caused an increase in oxidative stress . However LC caused significantly less oxidative stress and the changes during surgery returned to preoperative values after LC in a shorter period . The beneficial effects of laparoscopic surgery may be related , partially , to less oxidative stress in the immediate postoperative period Background The benefit of laparoscopy to patients has been clearly established in adults undergoing cholecystectomy . Results are less clear for appendectomy . The current study was undertaken to compare the respective 3-day postoperative periods after laparoscopic and open appendectomy in children . Methods Sixty-three children ( aged 8 - 15 yr ) scheduled for appendectomy were r and omly assigned to two groups : open and laparoscopic . Postoperative evaluation included delay of postoperative recovery ( walking and feeding ) , pain assessment by visual analog scale during the 3 subsequent days , amount of nalbuphine administered via a patient-controlled analgesia system during the first 48 h and responses by children , parents , and nurses on the overall quality of analgesia . Results There was no difference between groups for demographic data ( particularly macroscopic aspect of appendix ) , analgesia , sedation , delay before eating and walking , incidence of urinary retention , nausea , vomiting . Operative time was longer ( P less or equal to 0.05 ) in the laparoscopic group ( 54+/-17 min ) than in the open group ( 39 + /-18 min ) . Thirty five percent of the children had pain at the shoulder in the LAP group versus ten percent in the open group ( P less or equal to 0.05 ) . Conclusions Laparoscopy did not improve analgesia and postoperative recovery after appendectomy in children Background Despite the laparoscopic approach becoming the st and ard in colorectal surgery , postoperative pain management for minimally invasive surgery is still mainly based on strategies that have been established for open surgical procedures . Patient-controlled epidural and intravenous analgesia are considered st and ard postoperative analgesia regimens in colorectal surgery . Epidural analgesia provides excellent analgesia , but is increasingly scrutinized in laparoscopic surgery since postoperative pain after the laparoscopic approach is significantly reduced . Moreover , epidural analgesia can be associated with numerous complications . Therefore , epidural analgesia is no longer recommended for the management of postoperative pain in laparoscopic colorectal surgery . Likewise , patient-controlled intravenous analgesia is subject to significant side effects . Given these important limitations of the traditional strategies for postoperative analgesia , effective and efficient alternatives in patients undergoing laparoscopic colorectal surgery are needed . Both the transversus abdominis plane block and systemically administered lidocaine have already been reported to effectively reduce pain after laparoscopic colorectal surgery . We hypothesize that the transversus abdominis plane block is superior to perioperative intravenous lidocaine . Methods / design One hundred and twenty five patients undergoing laparoscopic colorectal surgery will be included in this prospect i ve , r and omized , double-blind controlled clinical trial . Patients will be r and omly allocated to three different postoperative strategies : postoperative patient-controlled intravenous analgesia with morphine ( control group , n = 25 ) , a transversus abdominis plane block with ropivacaine 0.375 % at the end of surgery plus postoperative patient-controlled intravenous analgesia with morphine ( TAP group , n = 50 ) , or perioperative intravenous lidocaine plus postoperative patient-controlled intravenous analgesia with morphine ( LIDO group , n = 50 ) . As the primary outcome parameter , we will evaluate the opioid consumption during the first 24 postoperative hours . Secondary endpoints include the Numeric Rating Scale , time to return of intestinal function , time to mobilization , inflammatory response , incidence of postoperative nausea and vomiting , length of hospital stay and postoperative morbidity as assessed with the Clavien-Dindo classification . Discussion Recognizing the importance of a multimodal approach for perioperative pain management , we aim to investigate whether a transversus abdominis plane block delivers superior pain control in comparison to perioperative intravenous lidocaine and patient-controlled intravenous analgesia with morphine alone . Trial registration EudraCT Identifier : 2014 - 001499 - 73 ; 31 July 2014 Introduction An increasing body of evidence is being published about single-incision laparoscopic cholecystectomy ( SILC ) , but there are no well-powered trials with an adequate evaluation of post-operative pain . This r and omized trial compares SILC against four-port laparoscopic cholecystectomy ( LC ) with post-operative pain as the primary endpoint . Methods Hundred patients were r and omized to either SILC ( n = 50 ) or LC ( n = 50 ) . Exclusion criteria were ( 1 ) Acute cholecystitis ; ( 2 ) ASA 3 or above ; ( 3 ) Bleeding disorders ; and ( 4 ) Previous open upper abdominal surgery . Patients and post-operative assessors were blinded to the procedure performed . The site and severity of pain were compared at 4 h , 24 h , 14 days and 6 months post-procedure using the visual analog scale ; non-inferiority was assumed when the lower boundary of the 95 % confidence interval of the difference was above −1 and superiority when p ≤ 0.05 . Results The study arms were demographically similar . At 24 h post-procedure , SILC was associated with less pain at extra-umbilical sites ( rest : p = 0.004 ; movement : p = 0.008 ) . Pain data were inconclusive at 24 h at the umbilical site on movement ; SILC was otherwise non-inferior for pain at all other points . Operating duration was longer in SILC ( 79.46 vs 58.88 min , p = 0.003 ) . 8 % of patients in each arm suffered complications ( p = 1.000 ) . Re-intervention rates , analgesic use , return to function , and patient satisfaction did not differ significantly . Conclusions SILC has improved short-term pain outcomes compared to LC and is not inferior in both short-term and long-term pain outcomes . The operating time is longer , but remains feasible in routine surgical practice This prospect i ve , r and omized study compared the outcomes of h and -assisted laparoscopic surgery ( HALS ) with open surgery for the resection of rectal cancer . The main outcome measures were procedure time , blood loss , post-operative pain , time to oral intake , return of bowel function , length of hospital stay , morbidity and functional recovery .  Patients in each group were similar with regard to general status , procedure types and the histopathological features of tumours .  Procedure times were significantly longer with HALS versus open surgery .  Analgesic requirements , surgical blood loss , time to first passing flatus , time to first oral fluids and postoperative hospital stay length were all significantly shorter in the HALS group . At a median follow-up of 16.3 months , local recurrence of tumour was not observed in either group . In this study , the HALS approach for curative resection of rectal cancer was safe and effective and may offer several potential advantages to patients in their post-operative recovery
This approach has been design ed to provide adequate analgesia while minimizing exposure to adverse events
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 .