Minimally invasive postoperative analgesia for pain relief after minimally invasive surgical procedures: the role of local anesthetic infusion

Excerpt

Surgery is increasingly moving toward minimally invasive procedures that lead to less tissue injury, less operative stress for the patient and less postoperative pain, allowing for patients to have a faster recovery than after conventional surgical approaches. Colorectal surgery is now widely performed by laparoscopy and is one of the most well-documented examples of this concept of “minimally invasive surgery.” Anesthetic and analgesic strategies should evolve accordingly. All of the items that need to be controlled in order to make patients suitable for faster hospital discharge are mentioned in the Enhanced Recovery After Surgery (ERAS) Program, established by European experts involved in this process [1]. Although epidural analgesia (EA) remains one of the cornerstones of the ERAS program, the risks and benefits of this technique should be reevaluated in light of the development of multimodal analgesia, and other loco-regional alternative techniques, as well as recent pathophysiological concepts. Indeed, several studies have reported a very small benefit of EA after laparoscopic colorectal surgery [2, 3]. Furthermore, interesting recent data have emphasized the involvement of visceral nociceptive input, especially afferent fibers in the peritoneum, in the stress and pain response, induced by abdominal surgery [4]. It has been suggested that at least a part of these visceral afferents are transmitted directly along the vagal nerve, without passing through the spinal pathway, which raises some questions about the ability of EA to control them. This is supported by clinical trials showing that direct intraperitoneal [5] or preperitoneal wound infusions [6] would provide additional benefits when used in combination with epidural analgesia. …