Optimizing patient outcomes in laparoscopic surgery

Abstract

There is increasing recognition that the entire peri-operative care delivered plays a vital role in determining patient's outcome. Optimisation of this care helps to prevent complications beyond immediate morbidity and mortality. Of the 20 factors described in Enhanced Recovery Programmes, some have a greater impact than others, with analgesia and fluid therapy being two of the main factors. 1 Analgesia - The main analgesic regimes used so far for laparoscopic colorectal surgery have been continuous thoracic epidural and patient controlled analgesia. There is a growing body of opinion that epidural analgesia may not be required for laparoscopic surgery. 2 Individualised goal directed therapy - It is now recognized that measuring flow rather than pressure within the cardiovascular system is more important. Fluid therapy impacts on the outcome by minimizing fluid shifts, optimizing stroke volume and restricting the salt load given whilst maintaining normovolaemia. Analgesia and fluid therapy, together with the remaining enhanced recovery criteria have led to the development of the trimodal approach.

Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations

“…In open surgery, the use of epidural analgesia has proven to be superior to opioid-based alternatives for several important outcomes [81], including pain [82], PONV [83] and complications [84]. In laparoscopic surgery, emerging data indicate that alternative methods such as spinal anaesthesia, intravenous lidocain and patient-controlled anaesthesia (PCA) may be equally effective [80]. A regional block can also reduce the stress response [85].…”

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

“…IT morphine is a valuable analgesic technique to improve early postoperative analgesia and facilitates surgical recovery . However, compared with systemic opioids, the incidence of pruritus (OR 3.85, 95% CI 2.40–6.15) and respiratory depression (although rare) is increased (OR 7.86, 95% CI 1.54–40.3).…”

Chronological Changes in Ropivacaine Concentration and Analgesic Effects Between Transversus Abdominis Plane Block and Rectus Sheath Block

“…T he number of patients for whom general anesthesia has been combined with peripheral nerve block for abdominal surgery instead of epidural block has increased due to the increased frequency of laparoscopic surgery. 1 Transversus abdominis plane block (TAPB) and rectus sheath block (RSB) are the 2 main types of abdominal wall truncal blocks that are suitable for this purpose. [2][3][4][5][6][7] Compared with epidural anesthesia, more local anesthetic is required for truncal abdominal blocks to be effective.…”