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ABSTRACTBackground: In the present study, the type of surgery such as laparoscopic cholecystectomy was chosen because we thought that major surgery would complicate the study model. In fact, laparoscopic cholecystectomy is not a highly invasive operation as tissue damage, performance time, and the technique do not vary significantly among patients. Objectives: This study was designed to compare the effectiveness of intraperitoneal analgesia with thoracic epidural analgesia for postoperative pain relief in laparoscopic cholecystectomy. Patients and methods: Sixty patients were included in this study (ASA I and II) of either sex. The chosen patients were scheduled for laparoscopic cholecystectomy in Zagazig University. The studied patients were divided into 3 groups: The first group received general anaesthesia using propofol for induction and maintenance supplemented by fentanyl drip for analgesia, meanwhile, using atracurium to facilitate relaxation. The second group received intraperitoneal ropivacaine 0.75% 20 ml just after creation of pneumoperitoneum into the hepatodiaphragmatic space, the area of the gallbladder and the space between the liver and kidney. At the end of the operation, another 20 ml of ropivacaine 0.75% was dispersed into the same areas. Meanwhile, patients received general anaesthesia in the same way as the first group. The third group received thoracic epidural at T8-T9 or T9-T10 with 15 ml of ropivacaine 0.75% then general anaesthesia was accomplished as the other groups but without fentanyl supplementation. Premedication was done by midazolam (0.05-0.07 mg/kg) followed by induction with propofol (2-3 mg/kg), intubation was facilitated by atracurium (0.5 mg/kg). Maintenance of anaesthesia was achieved by propofol drip (3-6 mg/kg/h), atracurium for muscle relaxation and fentanyl drip (1 μg/kg/h) in the control group only. The following parameters were assessed in all groups: Preoperatively: HR, MAP, RR, oxygen saturation and ABG. Intraoperatively every 15 minutes: HR, MAP, oxygen saturation and ETCO2. Postoperatively: ABG after 30 minutes then at 30 minutes, 1, 2, 4, 8, 12 and 24 hours. The HR, MAP, RR, PONV and VAS were assessed at rest, on coughing and with mobilization, shoulder pain and morphine consumption were also observed. Results: Intraoperatively, there was a significant decrease in the MAP allover the operation and in ETCO2 after 30 minutes in only the epidural group. Meanwhile, the need for intraoperative fentanyl was significantly lower in the epidural group than the IP group. Postoperatively, there was a significant decrease in PONV, morphine consumption and shoulder pain in the IP and epidural groups. Meanwhile, VAS was significantly lower also in both groups, however, more lowered in the epidural group. There was a significant decrease in the postoperative pH, oxygen saturation than the preoperative values in all groups, and there was a significant increase in postoperative PaCO2 than the preoperative value in IP and control groups. Conclusion: Intraperitoneal local anaesthetic instillation before and after laparoscopic cholecystectomy can reduce postoperative pain safely. On the other hand, thoracic epidural anaesthesia before GA for laparoscopic cholecystectomy can reduce postoperative pain more significantly but with the disadvantage of haemodynamic stability and in addition to the possible complications of such a technique. Definitely, both techniques can shorten the hospital stay and reduce the perioperative costs, which gives the benefits of undergoing laparoscopic cholecystectomy on an ambulatory basis. So finally, the present study recommends to start to use intraperitoneal local anaesthetics as a preemptive analgesia in all types of laparoscopy not only laparoscopic cholecystectomy and on more patients to ensure the effectiveness of the technique in the future.
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