Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 1  |  Page : 126-132

Intraperitoneal hydrocortisonefor pain relief after laparoscopic cholecystectomy


1 Department of GeneralSurgery, Faculty of Medicine, Menoufia University, Shibin El Kom, Egypt
2 Department of General Surgery, Quesna Central Hospital, Quesna, Menoufia Governorate, Egypt

Date of Submission29-Oct-2016
Date of Acceptance05-Dec-2016
Date of Web Publication14-Jun-2018

Correspondence Address:
Waleed M Eldessawy Esmaeil
Shubra Bkhoom, Quesna, Menoufia Governorate
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.234220

Rights and Permissions
  Abstract 


Background
Laparoscopic cholecystectomy(LC) is associated with shorter hospital stay and less pain in comparison with open surgery. The aim of this study was to evaluate the effect of using intraperitoneal hydrocortisone on pain relief following LC.
Objectives
This study aims to evaluatethe effect of using intraperitoneal hydrocortisone after LC in decreasing postoperative pain and other adverse effects.
Patients and methods
Fifty patients were enrolled in a double-blind, randomized clinical trial. Patients (randomly assigned) underwent ordinary LC oralong with the operation received 100mg of hydrocortisone in 250ml normal saline after extraction of the gallbladder into the peritoneum. Abdominal pain and shoulder pain were evaluated using the visual analog scale after surgery and at 6, 12, and 24h postoperatively. The patients were also followed for postoperative analgesic requirements, nausea and vomiting, and return of bowel function.
Results
Forty-eight patients completed the study. Patients in the hydrocortisone group had significantly lower abdominal pain(10.75vs. 12.65,P=0.00) and shoulder pain(5.35vs. 6.74,P=0.008) scores than the control group. There were no significant differences regarding analgesic requirements in the recovery room. However, those in the hydrocortisone group required less meperidine than those in the control group(138.55±49.9vs. 69.96±38.69mg,P=0.00). There were no significant differences with respect to return of bowel function, nausea, and vomiting. No adverse reaction was observed in either group.
Conclusion
Intraperitoneal administration of hydrocortisone can significantly decrease pain and analgesic requirements after LC with no adverse effects.

Keywords: cholecystectomy, intraperitoneal hydrocortisone, laparoscopy, postoperative pain


How to cite this article:
Sultan HM, Gaber A, ShakerNassar MN, Eldessawy Esmaeil WM. Intraperitoneal hydrocortisonefor pain relief after laparoscopic cholecystectomy. Menoufia Med J 2018;31:126-32

How to cite this URL:
Sultan HM, Gaber A, ShakerNassar MN, Eldessawy Esmaeil WM. Intraperitoneal hydrocortisonefor pain relief after laparoscopic cholecystectomy. Menoufia Med J [serial online] 2018 [cited 2018 Aug 17];31:126-32. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/126/234220




  Introduction Top


Laparoscopic cholecystectomy(LC) is the treatment of choice for symptomatic cholelithiasis. Although there are clear benefits compared with open surgery, postoperative pain is still a common complaint after LC [1]. Pain can prolong hospital stay and lead to increased morbidity, which is particularly important in centers performing this operation as a day-case procedure [2]. Different methods have been proposed to relieve postoperative pain following LC [3].

Administration of intraperitoneal local anesthetics alone [4] or in combination with nonopioid analgesics has been used to reduce postoperative pain following LC. This might reduce adverse effects of opioids [5].

On the contrary, steroids have also been used successfully for postoperative pain relief in different kinds of surgery [6]. The purpose of this study is to assess the effect of using intraperitoneal hydrocortisone to reduce postoperative pain after LC under general anesthesia [7]. The primary outcome is to compare the pain scores. The secondary outcomes included postoperative analgesic requirements, frequency of nausea and vomiting, length of hospital stay [8]. time of return of bowel function, time of unassisted ambulation, and time of oral intake [9].


  Patients and Methods Top


This study was carried out under ethicalapproval from local ethics committee of Faculty of Medicine of El Menoufia University. After obtaining informed consent, 50patients undergoing elective LC were recruited for the study.

This was a prospective study that included 50patients complaining of chronic calculous cholecystitis and undergoing elective LC.

The patients were divided into two groups, with 25patients in each group. GroupA is the control group that undergoes ordinary LC in comparison with the groupB, the subject of the research. In the patients of groupB, we did peritoneal wash with 100mg of hydrocortisone in 250ml normal saline after extraction of the gallbladder.

Exclusion criteria

Patients who had chronic pain caused by diseases other than gallstone disease; patients on opioids, tranquilizers, steroids, NSAIDs, and alcohol; patients with acute cholecystitis, allergy to corticosteroids, neuromuscular diseases, and bleeding disorders; pregnant patients; and patients with cardiac and pulmonary diseases were excluded.

Preoperative investigations

Radiological investigations

Abdominal ultrasonography and abdominal computed tomography were done in some cases.

Laboratory investigations

Complete blood count, prothrombin time and concentration, hepatitis viral profile, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase enzyme, serum bilirubin(total and direct), serum urea level, and creatinine level were investigated.

Laparoscopic instruments

Laparoscopic instruments used were manufactured byAesculap Company, Aesculap AG, Am Aesculap Platz, 78532 Tuttlingen, Germany with date of production being 11May2012 and the expiration date being 11May2018.

Operative steps

The patients were supine in position on the operating table. After receiving general anesthesia and sterilization of the abdomen and lower chest by Betadine solution, we inserted the umblical port through subumblical incision and then created the pneumoperitoneum by open technique through the subumblical incision. This port functioned as the camera port. During laparoscopy, intra-abdominal pressure was maintained at 14mmHg.

Additional operating ports were inserted in the subxiphoid area, right subcostal area, and above the level of umbilicus in the anterior axillary line.

Patients were put in anti-Trendelenburg position and slightly rotated to the left to expose the fundus of the gallbladder, which is retracted toward the diaphragm. The fundus of the gallbladder was then retracted toward the right iliac fossa to expose Calot triangle.

The cystic duct and artery were carefully defined at first. Then the gallbladder was separated from the liver bed for 2cm to allow for confirmation of the anatomy. The cystic duct and artery were then double clipped and divided. The gallbladder was then removed from its bed by sharp dissection and removed via the umbilical port. Carbon dioxide was carefully evacuated at the end of surgery by manual compression of the abdomen with open trocars.

In patients of groupB, we did peritoneal wash by 100mg hydrocortisone dissolved in 250ml normal saline. The amount of the solution was distributed in the different parts of the peritoneal cavity[Figure1].{Figure 1}

At the end, we inserted subhepatic drain. The drain was kept closed for 2h and then opened, and the sites of the ports were closed by stitches.

Postoperative abdominal pain and shoulder pain were assessed using visual analog scale(VAS) based on a 0–10 scale(with 0 meaning no pain and 10 meaning the most intense pain ever experienced), postoperative analgesic requirements[we used intramuscular meperidine(pethidin) 0.5mg/kg for VAS 4–7 and 1mg/kg for VAS 8–10 as rescue analgesic], presence of nausea and vomiting, time of unassisted ambulation, time of oral intake, and time of return of bowel function in the recovery room. Time of return of bowel function was defined as the time from end of anesthesia until the presence of intestinal sound or first passage of flatus.

Comparative points

Intraoperative

Duration of surgery, bile spillage, difficulty in dissection, intraoperative bleeding, abdominal organs' injury, and the need to do intraoperative cholangiography were the intraoperative points to consider.

Postoperative

Postoperative analgesic requirements, postoperative abdominal and shoulder pain, presence of nausea and vomiting, time of unassisted ambulation, time of return of bowel function, and duration of hospital stay were the postoperative points to consider.

Statistical analysis

Arithmetic mean and SD values for different variables were calculated, and statistical analyses were performed for each group. We used independent Student's t-test to compare continuous variables exhibiting normal distribution, and c2-test and Mann–Whitney U-test for noncontinuous variables. P value less than 0.05 was considered significant.


  Results Top


Fifty patients were included in the study. However, two were excluded as conversion to open cholecystectomy was necessary in both cases because of dense inflammatory adhesions. The patients were divided into two groups, each group consisting of 24patients. In all the following tables, groupA represents the control group and groupB represents the hydrocortisone group.

There were no statistically significant differences between the two groups regarding demographic data. The mean age was 46.4±3.6years in groupA and 45.7±3.5years in groupB. The mean weight was 79±8kg in groupA and 77±9kg in groupB. The percentage ratio in groupA was 75% female-to-25% male and in groupB was 70.2% female-to-29.8% male[Table1].
Table 1: Patients data and operation characteristics

Click here to view


There were insignificant differences in the two groups in durations of surgery. The mean duration of surgery in groupA was 88±9min and in groupB was 85±13min(P=0.879). Factors likely to increase postoperative pain included bile spillage from punctured gallbladder in four patients each from both the groups, with a percentage of 16.66%(P=0.885), and difficulty in dissection owing to adhesions from previous surgery in three patients in groupA, with percentage of 12.5%, and two patients in groupB, with percentage of 8.33%(P=0.721). In all cases, there was no bleeding, need for cholangiography, or injury to bowel or other organs[Table2].
Table 2: Operations details

Click here to view


The abdominal and shoulder pain scores were significantly lower in the hydrocortisone group in the recovery room and at 6, 12, and 24h postoperatively[total abdominal pain scores 10.75vs. 12.65 in the hydrocortisone and control group, respectively (P=0.00); and total shoulder pain scores of 5.35vs. 6.74 in the hydrocortisone and control group, respectively (P=0.008)][Table 3] and [Table 4] [Figure2] and [Figure3].
Table 3: Visual analog abdominal pain scores in the two groups

Click here to view
Table 4: Visual analog shoulder pain scores in the two groups

Click here to view
Figure 2: Diagram of postoperative abdominal pain.

Click here to view
Figure 3: Diagram of postoperative shoulder pain.

Click here to view


There were no significant differences regarding analgesic requirements in the recovery room. Nevertheless, patients in the control group required more meperidine than the hydrocortisone group at 6, 12, and 24h, postoperatively(151.66±49.9vs. 69.96±38.69mg, P=0.00)[Table5][Figure4].
Table 5: Postoperative meperidine requirements in the two groups

Click here to view
Figure 4: Diagram of postoperative analgesic requirements.

Click here to view


Regarding presence of postoperative nausea and vomiting, length of hospital stay, time of return of bowel function, time of unassisted ambulation, and time of oral intake, there were no significant differences between the two groups. The mean time for unassisted ambulation was 12.6±1.40h in groupA and 12.5±1.45h in groupB(P=0.735). The mean time of return of bowel function was 18.6±1.5h in groupA and 17.2±1.3h in groupB(P=0.018). The mean time of oral intake was 11.52±2.2h in groupA and 11.33±2.8h in groupB(P=0.736). The mean duration of hospital stay was 24.2±3.5h in groupA and 23.5±2.7h in groupB(P=0.093)[Table6].
Table 6: Recovery variables between the two groups

Click here to view



  Discussion Top


LC is one of the commonest day-case surgeries. The postoperative pain associated with this minimally invasive procedure is generally less intense and lasts a shorter time than that following open cholecystectomy, but it remains a prevalent problem in the early postoperative period and may delay the discharge of the patient, especially in day-case departments [10]. It peaks within the first few hours following the operation but diminishes with time [11]. The origin of pain after LC is multifactorial; therefore, multimodal therapy may be needed to optimize pain relief. After LC, patients complain of pain from the incision of the skin (somatic pain), visceral pain, and shoulder pain from diaphragm stimulation [12].

Incisional pain is defined as superficial pain, wound pain, or pain located in the abdominal wall. Visceral pain is defined as the pain inside the abdomen, which may be deep, dull, and more difficult to localize and may resemble biliary colic. Rapid distension of the peritoneum by carbon dioxide insufflation results in tearing of blood vessels, traction of nerves, and release of inflammatory mediators producing visceral pain; inflammation or local irritation around the gallbladder bed, liver, diaphragm or peritoneum or both, secondary to gallbladder removal and abdominal muscle distension add to tissue injury and produce visceral pain [13].

Shoulder pain is defined as a sensation of pain in the shoulder. The exact mechanism of shoulder pain after laparoscopic surgery still remains unclear. Shoulder pain results from peritoneal insufflation especially when an exaggerated Trendelenburg position is used. Most authors believe it is an irritation of the phrenic nerve, causing referred pain of C4 projected to the shoulder [14].

Because LC has become the treatment of choice for many gallbladder diseases, postoperative analgesia for LC pain has been evaluated in several prospective studies. Pain after LC is less intense and lasts a shorter time, compared with pain after open cholecystectomy. This explains why patients can be discharged within days of LC surgery and can return to their normal daily activities more quickly, compared with open cholecystectomy. However, LC is not a pain-free procedure [15].

Because pain is multifactorial, no consensus has been reached regarding effective postoperative pain relief for patients who have undergone LC. Anumber of studies have been conducted in an effort to reduce postoperative pain after this surgery, but the results have varied [16].

Postoperative pain control is directed at early mobilization, recovery, and discharge. However, pain can play a major role in metabolic and endocrine responses and can impair postoperative pulmonary function. Various methods have been proposed to control LC postoperative pain such as the use of local anesthesia [17], intraperitoneal infiltration of local anesthesia [18], preoperative administration of anti-inflammatory drugs [19], utilizing carbon dioxide at body temperature, applying intrapleural morphine [20], and the combined use of NSAIDs and opioids [21].

It has been shown that glucocorticoids can play a crucial role in the regulation of inflammatory responses through both genomic and nongenomic mechanisms, and therefore may reduce pain [22].

Among corticosteroids, dexamethasone has been used widely to reduce postoperative pain. The mechanism of analgesic effect of steroids is not well known [23].

The proposed mechanisms include suppression of tissue levels of bradykinin and the release of neuropeptides from nerve endings; reduction in prostaglandin production, resulting in inhibition of the synthesis of the cyclooxygenase isoform-2 in peripheral tissues and in the central nervous system; and inhibition of other mediators of inflammatory hyperalgesia, for example, tumor necrosis factor-α, interleukin-17β, and interleukin-6 [24].

We demonstrated that intraperitoneal injection of hydrocortisone can reduce pain and analgesic requirements following LC without significant adverse effects.

In our research, we used 100mg hydrocortisone in 250ml saline for peritoneal wash after extraction of the gallbladder for decreasing postoperative abdominal and shoulder pain following LC. Atotal of 50patients complaining of chronic calculous cholecystitis were included in this study. However, two of them were excluded as conversion to open cholecystectomy was necessary because of massive adhesions. The patients were divided to two groups, each consisting of 24patients. Postoperative shoulder pain and abdominal pain were recorded by VAS, and the dose of analgesic required postoperatively and at 6, 12, and 24h and also intraoperative and postoperative complications were recorded in the two groups. The results showed that the use of hydrocortisone for peritoneal wash can significantly decrease postoperative shoulder and abdominal pain and also the doses of analgesics required after LC without significant adverse effects or complications. Total abdominal pain scores were 10.75 and 12.65 in the hydrocortisone and control group, respectively(P=0.00). Total shoulder pain scores were 5.35 and 6.74 in the hydrocortisone and control group, respectively(P=0.008). Regarding analgesic requirements, there were no significant differences in the recovery room. The mean doses of analgesics were 43.5mg in control group and 41.2mg in the hydrocortisone group(P=0.23). Otherwise, the analgesic requirements had been significantly decreased in hydrocortisone group. The mean dose of analgesics required at 6h was 44.33mg in the control group and 23.26mg in the hydrocortisone group, at 12h was 42.72mg in control group and 5.5mg in the hydrocortisone group, and at 24h was 18mg in control group. In hydrocortisone group, the patients did not need analgesics at 24h after the operation. There were no significant differences regarding durations of surgery or periods of hospital stay. The mean durations of surgery were 85 and 88min in hydrocortisone group and control group, respectively(P=0.879). The mean periods of hospital stay were 23.5h in the hydrocortisone group versus 24.2h in the control group(P=0.093).

We assumed that early postoperative pain was mainly generated by irritation of the peritoneum, and the application of corticosteroids may attenuate this pain. We used intraperitoneal hydrocortisone successfully to reduce pain following LC. Although meperidine requirement was similar in both groups in the recovery room, patients in the hydrocortisone group required less analgesic afterward. This might be attributed to short analgesic effect of intraoperative remifentanil.

The effect of intraperitoneal corticosteroids on pain after elective LC has been investigated by Amene etal. [25]. This research was done on 60patients and used the same technique as our research. The results of this research was consistent with our research, as total postoperative pain score was 10.95 in hydrocortisone group versus 12.95 in control group. Moreover, the mean dose of analgesic required at recovery room was 41.66mg in the control group and 40.0mg in the hydrocortisone group(P=0.25), at 6h was 21.66mg in the control group versus 46.66mg in the hydrocortisone group, at 12h was 41.66mg in the control group versus no requirement in the hydrocortisone group, and at 24h was 20mg in the control group versus no requirement in the hydrocortisone. In comparison with our research, we found that the results were approximately the same in the hydrocortisone group regarding pain score(10.95vs. 10.75 in our research) and postoperative analgesic requirements at recovery room(40.0vs. 41.2mg in our research) and at 6h(21.6vs. 23.2mg in our research). The patients needed no analgesics at 12 and 24h postoperatively. Also there were no significant differences regarding durations of hospital stay or duration of surgery.

Amini etal. [26] also compared the effect of preoperative hydrocortisone with bupivacaine on postoperative pain after LC. The results of this research in hydrocortisone group were consistent with our results. This research also had been done on 60patients. In the hydrocortisone group, total abdominal pain score was 10.98(10.75 in our research) and total shoulder pain was 5.36(5.35 in our research). The dose of analgesics at the recovery room postoperatively was 40mg(41.2mg in our research) and 21.66mg at 6h postoperatively(23.26mg in our research). The patients needed no analgesics at 12 and 24h postoperatively. No significant adverse effects appeared after usage of hydrocortisone.

In comparison with others methods that aimed to reduce postoperative pain, we found that Aman etal. [27] studied the effect of bupivacaine-soaked gauze in postoperative pain in LC. The results showed that corticosteroids are more effective in reducing pain than bupivacaine. The mean postoperative total abdominal pain score 12.6 versus 10.75 in our research.

Mohtadi etal. [28] studied the effect of single-dose administration of intravenous dexamethasone on postoperative pain in patients undergoing LC. This study was done on 61patients and scored pain at 2, 6, and 12h only, so the mean total pain score was relatively high in comparison with our research. The results showed that usage of corticosteroids locally in the peritoneum is more effective for reducing pain than its usage through intravenous route. The mean total pain score in patients receiving preoperative dexamethasone was 18.12 versus 10.75 in our research. Total dose of meperidine was significantly decreased than used in our research(44.26vs. 69.96mg).


  Conclusion Top


This study proved that usage of intraperitoneal corticosteroids can significantly reduce postoperative abdominal pain and shoulder pain in LC and also analgesic requirements without significant adverse effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
El-LabbanGM, HokkamEN, El-LabbanMA, MorsyK, SaadlS, HeissamKS. Intraincisional vs intraperitoneal infiltration of local anaesthetic for controlling early post-laparoscopic cholecystectomy pain. JMinim Access Surg 2011; 7:173–177.  Back to cited text no. 1
    
2.
BoddyAP, MehtaS, RhodesM. The effect of intraperitoneal local anesthesia in laparoscopic cholecystectomy: a systematic review and meta-analysis. Anesth Analg 2006; 8:682–688.  Back to cited text no. 2
    
3.
AbdullaS, EckhardtR, NetterU, AbdullaW. Arandomized double-blind, controlled trial on non-opioid analgesics and opioid consumption for postoperative pain relief after laparoscopic cholecystectomy. Acta Anaesthesiol Belg 2012:63:43–50.  Back to cited text no. 3
    
4.
Golubović S, Golubović V, Cindrić-StancinM, TokmadzicVS. Intraperitoneal analgesia for laparoscopic cholecystectomy: bupivacaine versus bupivacaine with tramadol. Coll Antropol 2009; 33:299–302.  Back to cited text no. 4
    
5.
AkaraviputhT, LeelouhapongC, LohsiriwatV, AroonpruksakulS. Efficacy of perioperative parecoxib injection on postoperative pain relief after laparoscopic cholecystectomy: a prospective, randomized study. World J Gastroenterol 2009; 15:123–185.  Back to cited text no. 5
    
6.
SafaviM, HonarmandA, HabibabadyMR, BaratyS, AghadavoudiO. Assessing intravenous ketamine and intravenous dexamethasone separately and in combination for early oral intake, vomiting and postoperative pain relief in children following tonsillectomy. Med Arh 2012; 66:111–115.  Back to cited text no. 6
    
7.
KhanMR, RazaR, ZafarSN, ShamimF, RazaSA, Pal KM, etal. Intraperitoneal lignocaine(lidocaine) versus bupivacaine after laparoscopic cholecystectomy: results of a randomized controlled trial. JSurg Res 2012; 178:662–669.  Back to cited text no. 7
    
8.
RobertsKJ, GilmourJ, PandeR, NightingaleP, TanLC, KhanS, etal. Efficacy of intraperitoneal local anaesthetic techniques during laparoscopic cholecystectomy. Surg Endosc 2011; 128:632–691.  Back to cited text no. 8
    
9.
ChoiYS, ShimJK, SongJW, KimJC, YooYC, KwakYL. Combination of pregabalin and dexamethasone for postoperative pain and functional outcome in patients undergoing lumbar spinal surgery: a randomized placebo-controlled trial. Clin J Pain 2013; 29:9–14.  Back to cited text no. 9
    
10.
SultanHM. Complications bile duct stones and its treatment: a randomized placebo-controlled trial. Menoufia Med J 2001; 5:315–316.  Back to cited text no. 10
    
11.
InanS, JaishriB, SulekhaS. The effect of intraperitoneal ropivacaine for post-operative pain management in patients undergoing laparoscopic cholecystectomy: a prospective double-blind randomized control study Open J Anesthesiol 2013; 3:31725–31726.  Back to cited text no. 11
    
12.
ChaSM, KangH, BaekCW, JungYH, KooGH, KimBG, etal. Peritrocal and intraperitoneal ropivacaine for laparoscopic cholecystectomy: a prospective, randomized, double-blind controlled trial. JSurg Res 2012; 175:251–258.  Back to cited text no. 12
    
13.
MaestroniU, SortiniD, DevitoC, Pour MoradKB, AnaniaG, PavanelliL. Anew method of preemptive analgesia in laparoscopic cholecystectomy. Surg Endosc 2002; 16:1336–1340.  Back to cited text no. 13
    
14.
SalihogluZ, YildirimM, DemirolukS, KayaG, KaratasA, ErtemM, etal. Evaluation of intravenous paracetamol administration on postoperative pain and recovery characteristics in patients undergoing laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2009; 19:321–323.  Back to cited text no. 14
    
15.
GlinatsisMT, GriffithJP, McMahonMJ. Open versus laparoscopic cholecystectomy: a retrospective comparative study. JLaparoendosc Surg 1992; 2:81–86.  Back to cited text no. 15
    
16.
RodriguezAJ, BerdeCB, WiedmaierG, MercadoA, GarciaC, IglesiasV, etal. Comparison of neosaxitoxin versus bupivacaine via port infiltration for postoperative analgesia following laparoscopic cholecystectomy: a randomized, double-blind trial. Reg Anesth Pain Med 2011; 36:103–109.  Back to cited text no. 16
    
17.
KahokehrA, SammourT, SoopM, HillAG. Intraperitoneal use of local anesthetic in laparoscopic cholecystectomy: systematic review and metaanalysis of randomized controlled trials. JHepatobiliary Pancreat Sci 2010; 17:637–656.  Back to cited text no. 17
    
18.
SarliL, CostiR, SansebastianoG, TrivelliM, RoncoroniL. Prospective randomized trial of low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy. Br J Surg 2000; 87:1161–1165.  Back to cited text no. 18
    
19.
KanwerDB, KamanL, NedounsejianeM, MedhiB, VermaGR, BalaI. Comparative study of low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy–a randomised controlled trial. Trop Gastroenterol 2009; 30:171–174.  Back to cited text no. 19
    
20.
JoshipuraVP, HaribhaktiSP, PatelNR, NaikRP, SoniHN, PatelB, etal. Aprospective randomized, controlled study comparing low pressure versus high pressure pneumoperitoneum during laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2009; 19:234–240.  Back to cited text no. 20
    
21.
SunS, YangK, GaoM, HeX, TianJ, MaB. Three-port versus four-port laparoscopic cholecystectomy: meta-analysis of randomized clinical trials. World J Surg 2009; 33:1904–1908.  Back to cited text no. 21
    
22.
LimG, WangS, ZengQ, SungB, MaoJ. Spinal glucocorticoid receptors contribute to the development of morphine tolerance in rats. Anesthesiology 2005; 102:832–837.  Back to cited text no. 22
    
23.
HongJY, HanSW, KimWO, KimEJ, KilHK. Effect of dexamethasone in combination with caudal analgesia on postoperative pain control in day-case paediatric orchiopexy. Br J Anaesth 2010; 105:506–510.  Back to cited text no. 23
    
24.
LouizosAA, HadziliaSJ, LeandrosE, KouroukliIK, GeorgiouLG, BramisJP. Postoperative pain relief after laparoscopic cholecystectomy: Aplacebo-controlled double-blind randomized trial of preincisional infiltration and intraperitoneal instillation of levobupivacaine 0.25%. Surg Endosc 2005; 19:1503–1506.  Back to cited text no. 24
    
25.
AmeneS, ShahramA, MohsenK, RezaR, MohammadiM, AmirH. Intraperitoneal hydrocortisone for pain relief after laparoscopic cholecystectomy. Saudi J Anaesth 2013; 13:150–165.  Back to cited text no. 25
    
26.
AminiS, SarvestaniAS. Comparing the impact of intraperitoneal hydrocortisone with bupivacaine on postoperative pain after laparoscopic cholecystectomy. Anesth Pain Med. 2014; 4:e17206.  Back to cited text no. 26
    
27.
AmanA, SalmanF, FaisalS, MuhammadME, MehmoodK. Effect of bupivacaine soaked gauze in postoperative pain relief in laparoscopic cholecystectomy. Patient Saf Surg 2015; 9:131–155.  Back to cited text no. 27
    
28.
MohtadiA, NesioonpourS, SalariA, AkhondzadehR, RadBM, AslaniSMM. The effect of single-dose administration of dexamethasone on postoperative pain in patients undergoing laparoscopic cholecystectomy. Anesth Pain Med. 2014; 4:e17872.  Back to cited text no. 28
    


    Figures

  [Figure1], [Figure2], [Figure3], [Figure4]
 
 
    Tables

  [Table1], [Table2], [Table 3], [Table 4], [Table5], [Table6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed63    
    Printed6    
    Emailed0    
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]