Pain relief in laparoscopic cholecystectomy--a review of the current options

Pain relief after laparoscopic cholecystectomy (LC) is an issue of great practical importance. Pain after LC has several origins: incisional, local visceral, peritoneal, and referred. Several modalities have been employed for achieving effective and safe analgesia: nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors, gabapentinoids, local anesthetics, and transversus abdominis plane (TAP) block. They have their advantages and disadvantages, and multimodal approaches are often followed because of the multiple sources of pain. Among COX-2 inhibitors, parecoxib and valdecoxib are useful, and fears regarding their cardiovascular adverse effects in noncardiac surgery (such as LC) have not been substantiated when used in short term. Gabapentin is useful but more data are needed regarding pregabalin because of inconsistent results. Local anesthetics (LA) can be particularly useful, both port-site infiltration and intraperitoneal instillation in the intra-operative period. Factors enhancing the effectiveness of these agents include early instillation before creating the pneumoperitoneum, larger volume of medium used for instillation, and favorable pharmacological characteristics of the agent. Combination of LA with either NSAID/COX-2 inhibitors or fibrin sealant appears to be effective, although more research is required for determining the exact combinations and efficacy using direct comparisons with single-modality interventions. Finally, newer procedures such as TAP block appear promising if replicated.