Skip to main content
SpringerLink
Log in

Prospective randomized controlled trial comparing standard analgesia with combined intra-operative cystic plate and port-site local anesthesia for post-operative pain management in elective laparoscopic cholecystectomy

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Various mechanisms, including somatic and visceral nociceptive stimulation, have been suggested as a cause for pain after laparoscopic cholecystectomy (LC). We therefore conducted a prospective randomized controlled trial (PRCT) to evaluate whether somatovisceral pain blockade reduces pain after LC.

Hypothesis

Analgesic efficacy of multimodal analgesia is superior to standard analgesia for patients undergoing elective LC for symptomatic cholelithiasis. Specifically, topical cystic plate and port-site injection with 0.25 % bupivacaine significantly reduces pain after LC.

Design

This study was designed as single-blinded PRCT.

Setting

This study was conducted in an academic medical center.

Patients and methods

Between February and May 2010 we randomly assigned 63 patients with symptomatic cholelithiasis in a 1:1 ratio to non-opioid/opioid analgesic combinations (Control Group, n = 32) and non-opioid/opioid analgesic combinations plus topical 0.25 % bupivacaine onto the cystic plate and local 0.25 % bupivacaine port-site injection, post-LC (Study Group, n = 31). Primary endpoint was patient-reported pain 1, 4, 6, 12, 24 h and 1 week post-LC using the Visual Analog Scale (VAS 0–10).

Results

Study groups were comparable clinicopathologically. There were no adverse events. A statistically significant reduction in mean pain score was apparent in Study Group patients in comparison with Control Group (mean VAS 4.83 ± 2.33 vs. 6.80 ± 1.87; p < 0.001) at all early (1–6 h) post-operative time points following LC.

Conclusion

This PRCT shows significantly improved pain control with somatovisceral pain blockade over non-opioid/opioid analgesic combinations following LC for symptomatic cholelithiasis. For centers not utilizing adjunctive local anesthetic for LC, this topical use of bupivacaine may improve patient comfort during recovery.

This trial was registered on www.ClinicalTrials.gov NCT# 01972620.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Abbreviations

ADL:

Activities of daily living

ASA:

American Society of Anesthesiologists

BMI:

Body mass index

CONSORT:

Consolidated standards of reporting trials consensus statement

IRB:

Institutional review board

LC:

Laparoscopic cholecystectomy

NSAIDs:

Nonsteroidal anti-inflammatory drugs

PRCT:

Prospective randomized controlled trial

QOL:

Quality of life

RCT:

Randomized controlled trial

VAS:

Visual Analog Scale

References

  1. Rosenmüller M, Haapamäki MM, Nordin P, Stenlund H, Nilsson E (2007) Cholecystectomy in Sweden 2000–2003: a nationwide study on procedures, patient characteristics, and mortality. BMC Gastroenterol 7:35

    Article  PubMed  PubMed Central  Google Scholar 

  2. Comitalo JB (2012) Laparoscopic cholecystectomy and newer techniques of gallbladder removal. JSLS 16(3):406–412

    Article  PubMed  PubMed Central  Google Scholar 

  3. Keus F, de Jong JAF, Gooszen HG, van Laarhoven CJHM (2006) Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 4:CD006231

    Google Scholar 

  4. Keus F, Gooszen HG, van Laarhoven CJ (2010) Open, small-incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-Biliary Group reviews. Cochrane Database Syst Rev 1:CD008318

    Google Scholar 

  5. Keus F, Gooszen HG, Van Laarhoven CJHM (2009) Systematic review: open, small-incision or laparoscopic cholecystectomy for symptomatic cholecystolithiasis. Aliment Pharmacol Ther 29(4):359–378

    Article  CAS  PubMed  Google Scholar 

  6. Steiner CA, Bass EB, Talamini MA, Pitt HA, Steinberg EP (1994) Surgical rates and operative mortality for open and laparoscopic cholecystectomy in Maryland. N Engl J Med 330(6):403–408

    Article  CAS  PubMed  Google Scholar 

  7. Alexander JI (1997) Pain after laparoscopy. Br J Anaesth 79(3):369–378

    Article  CAS  PubMed  Google Scholar 

  8. Wills VL, Hunt DR (2000) Pain after laparoscopic cholecystectomy. Br J Surg 87(3):273–284

    Article  CAS  PubMed  Google Scholar 

  9. Joshi GP (1994) Postoperative pain management. Int Anesthesiol Clin 32(3):113–126

    Article  CAS  PubMed  Google Scholar 

  10. Boddy AP, Mehta S, Rhodes M (2006) The effect of intraperitoneal local anesthesia in laparoscopic cholecystectomy: a systematic review and meta-analysis. Anesth Analg 103(3):682–688

    Article  CAS  PubMed  Google Scholar 

  11. Joris J, Thiry E, Paris P, Weerts J, Lamy M (1995) Pain after laparoscopic cholecystectomy: characteristics and effect of intraperitoneal bupivacaine. Anesth Analg 81(2):379–384

    CAS  PubMed  Google Scholar 

  12. Verma GR, Lyngdoh TS, Kaman L, Bala I (2006) Placement of 0.5% bupivacaine-soaked Surgicel in the gallbladder bed is effective for pain after laparoscopic cholecystectomy. Surg Endosc 20(10):1560–1564

    Article  CAS  PubMed  Google Scholar 

  13. Lee IO, Kim SH, Kong MH, Lee MK, Kim NS, Choi YS et al (2001) Pain after laparoscopic cholecystectomy: the effect and timing of incisional and intraperitoneal bupivacaine. Can J Anaesth 48(6):545–550

    Article  CAS  PubMed  Google Scholar 

  14. Bisgaard T, Klarskov B, Kristiansen VB, Callesen T, Schulze S, Kehlet H et al (1999) Multi-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized, double-blinded, placebo-controlled study. Anesth Analg 89(4):1017–1024

    CAS  PubMed  Google Scholar 

  15. Gupta A (2005) Local anaesthesia for pain relief after laparoscopic cholecystectomy–a systematic review. Best Pract Res Clin Anaesthesiol 19(2):275–292

    Article  CAS  PubMed  Google Scholar 

  16. Tsimoyiannis EC, Siakas P, Tassis A, Lekkas ET, Tzourou H, Kambili M (1998) Intraperitoneal normal saline infusion for postoperative pain after laparoscopic cholecystectomy. World J Surg 22(8):824–828

    Article  CAS  PubMed  Google Scholar 

  17. Pappas-Gogos G, Tsimogiannis KE, Zikos N, Nikas K, Manataki A, Tsimoyiannis EC (2008) Preincisional and intraperitoneal ropivacaine plus normal saline infusion for postoperative pain relief after laparoscopic cholecystectomy: a randomized double-blind controlled trial. Surg Endosc 22(9):2036–2045

    Article  PubMed  Google Scholar 

  18. Lepner U, Goroshina J, Samarütel J (2003) Postoperative pain relief after laparoscopic cholecystectomy: a randomised prospective double-blind clinical trial. Scand J Surg 92(2):121–124

    CAS  PubMed  Google Scholar 

  19. Gurusamy KS, Nagendran M, Guerrini GP, Toon CD, Zinnuroglu M, Davidson BR (2014) Intraperitoneal local anaesthetic instillation versus no intraperitoneal local anaesthetic instillation for laparoscopic cholecystectomy. Cochrane Database Syst Rev 3:CD007337

    Google Scholar 

  20. Loizides S, Gurusamy KS, Nagendran M, Rossi M, Guerrini GP, Davidson BR (2014) Wound infiltration with local anaesthetic agents for laparoscopic cholecystectomy. Cochrane Database Syst Rev 3:CD007049

    Google Scholar 

  21. Schulz KF, Altman DG, Moher D (2010) CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med 152(11):726–732

    Article  PubMed  Google Scholar 

  22. Bisgaard T, Klarskov B, Rosenberg J, Kehlet H (2001) Factors determining convalescence after uncomplicated laparoscopic cholecystectomy. Arch Surg 136(8):917–921

    Article  CAS  PubMed  Google Scholar 

  23. Bisgaard T, Kehlet H, Rosenberg J (2001) Pain and convalescence after laparoscopic cholecystectomy. Eur J Surg 167(2):84–96

    Article  CAS  PubMed  Google Scholar 

  24. Abdallah FW, Chan VW, Brull R (2012) Transversus abdominis plane block: a systematic review. Reg Anesth Pain Med 37(2):193–209

    Article  CAS  PubMed  Google Scholar 

  25. Kahokehr A, Sammour T, Soop M, Hill AG (2011) Intraperitoneal local anaesthetic in abdominal surgery—a systematic review. ANZ J Surg 81(4):237–245

    Article  PubMed  Google Scholar 

  26. Inan A, Sen M, Dener C (2004) Local anesthesia use for laparoscopic cholecystectomy. World J Surg 28(8):741–744

    Article  PubMed  Google Scholar 

  27. Sarvestani AS, Amini S, Kalhor M, Roshanravan R, Mohammadi M, Lebaschi AH (2013) Intraperitoneal hydrocortisone for pain relief after laparoscopic cholecystectomy. Saudi J Anaesth 7(1):14–17

    Article  PubMed  PubMed Central  Google Scholar 

  28. Hernández-Palazón J, Tortosa JA, Nuño de la Rosa V, Giménez-Viudes J, Ramírez G, Robles R (2003) Intraperitoneal application of bupivacaine plus morphine for pain relief after laparoscopic cholecystectomy. Eur J Anaesthesiol 20(11):891–896

    Article  PubMed  Google Scholar 

  29. Kahokehr A (2013) Intraperitoneal local anesthetic for postoperative pain. Saudi J Anaesth 7(1):5

    Article  PubMed  PubMed Central  Google Scholar 

  30. Griffin EM, Prystowsky H, Hingson RA (1951) The use of topical anaesthesia of the peritoneum in poor risk surgery and in augmenting inadequate vertebral conduction anaesthesia. N Z Med J 50(275):31–33

    CAS  PubMed  Google Scholar 

  31. Mitra S, Khandelwal P, Roberts K, Kumar S, Vadivelu N (2012) Pain relief in laparoscopic cholecystectomy–a review of the current options. Pain Pract 12(6):485–496

    Article  PubMed  Google Scholar 

  32. Slim K, Bousquet J, Kwiatkowski F, Pezet D, Chipponi J (1997) Analysis of randomized controlled trials in laparoscopic surgery. Br J Surg 84(5):610–614

    Article  CAS  PubMed  Google Scholar 

  33. Fuhrer Y, Charpentier C, Boulanger G, Menu N, Grosdidier G, Laxenaire MC (1996) Analgesia after laparoscopic cholecystectomy by intraperitoneal administration of bupivacaine. Ann Fr Anesth Reanim 15(2):128–134

    Article  CAS  PubMed  Google Scholar 

  34. Raetzell M, Maier C, Schröder D, Wulf H (1995) Intraperitoneal application of bupivacaine during laparoscopic cholecystectomy–risk or benefit? Anesth Analg 81(5):967–972

    CAS  PubMed  Google Scholar 

  35. Pavlidis TE, Atmatzidis KS, Papaziogas BT, Makris JG, Lazaridis CN, Papaziogas TB (2003) The effect of preincisional periportal infiltration with ropivacaine in pain relief after laparoscopic procedures: a prospective, randomized controlled trial. JSLS 7(4):305–310

    PubMed  PubMed Central  Google Scholar 

  36. Noma H, Kakiuchi H, Nojiri K, Izumi R, Tashiro C (2001) Evaluation of postoperative pain relief by infiltration of bupivacaine or epidural block after laparoscopic cholecystectomy. Masui 50(11):1201–1204

    CAS  PubMed  Google Scholar 

  37. Rodríguez-Navarro AJ, Berde CB, Wiedmaier G, Mercado A, Garcia C, Iglesias V et al (2001) Comparison of neosaxitoxin versus bupivacaine via port infiltration for postoperative analgesia following laparoscopic cholecystectomy: a randomized, double-blind trial. Reg Anesth Pain Med 36(2):103–109

    Article  Google Scholar 

  38. Pourseidi B, Khorram-Manesh A (2007) Effect of intercostals neural blockade with Marcaine (bupivacaine) on postoperative pain after laparoscopic cholecystectomy. Surg Endosc 21(9):1557–1559

    Article  CAS  PubMed  Google Scholar 

  39. Cunniffe MG, McAnena OJ, Dar MA, Calleary J, Flynn N (1998) A prospective randomized trial of intraoperative bupivacaine irrigation for management of shoulder-tip pain following laparoscopy. Am J Surg 176(3):258–261

    Article  CAS  PubMed  Google Scholar 

  40. Elfberg BA, Sjövall-Mjöberg S (2000) Intraperitoneal bupivacaine does not effectively reduce pain after laparoscopic cholecystectomy: a randomized, placebo-controlled and double-blind study. Surg Laparosc Endosc Percutan Tech 10(6):357–359

    Article  CAS  PubMed  Google Scholar 

  41. Cha SM, Kang H, Baek CW, Jung YH, Koo GH, Kim BG et al (2012) Peritrocal and intraperitoneal ropivacaine for laparoscopic cholecystectomy: a prospective, randomized, double-blind controlled trial. J Surg Res 175(2):251–258

    Article  CAS  PubMed  Google Scholar 

  42. Liu Y-Y, Yeh C-N, Lee H-L, Wang S-Y, Tsai C-Y, Lin C-C et al (2009) Local anesthesia with ropivacaine for patients undergoing laparoscopic cholecystectomy. World J Gastroenterol 15(19):2376–2380

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Labaille T, Mazoit JX, Paqueron X, Franco D, Benhamou D (2002) The clinical efficacy and pharmacokinetics of intraperitoneal ropivacaine for laparoscopic cholecystectomy. Anesth Analg 94(1):100–105

    CAS  PubMed  Google Scholar 

  44. Coughlin SM, Karanicolas PJ, Emmerton-Coughlin HMA, Kanbur B, Kanbur S, Colquhoun PHD (2010) Better late than never? Impact of local analgesia timing on postoperative pain in laparoscopic surgery: a systematic review and metaanalysis. Surg Endosc 24(12):3167–3176

    Article  PubMed  Google Scholar 

  45. Kahokehr A, Sammour T, Soop M, Hill AG (2010) Intraperitoneal use of local anesthetic in laparoscopic cholecystectomy: systematic review and metaanalysis of randomized controlled trials. J Hepatobiliary Pancreat Sci 17(5):637–656

    Article  PubMed  Google Scholar 

  46. Gupta A, Thörn SE, Axelsson K, Larsson LG, Agren G, Holmström B et al (2002) Postoperative pain relief using intermittent injections of 0.5% ropivacaine through a catheter after laparoscopic cholecystectomy. Anesth Analg 95(2):450–456

    CAS  PubMed  Google Scholar 

  47. Ure BM, Troidl H, Spangenberger W, Dietrich A, Lefering R, Neugebauer E (1994) Pain after laparoscopic cholecystectomy. Intensity and localization of pain and analysis of predictors in preoperative symptoms and intraoperative events. Surg Endosc 8(2):90–96

    Article  CAS  PubMed  Google Scholar 

  48. Nicolau AE, Merlan V, Grecu I, Nicolau M, Micu B (2008) Multimodal analgesia in elective laparoscopic cholecystectomy. A double-blind randomized controlled trial. Chirurgia (Bucur) 103(5):547–551

    CAS  Google Scholar 

  49. Cantore F, Boni L, Di Giuseppe M, Giavarini L, Rovera F, Dionigi G (2008) Pre-incision local infiltration with levobupivacaine reduces pain and analgesic consumption after laparoscopic cholecystectomy: a new device for day-case procedure. Int J Surg 6(Suppl 1):S89–S92

    Article  PubMed  Google Scholar 

  50. Buggy DJ, Wall C, Carton EG (1994) Preoperative or postoperative diclofenac for laparoscopic tubal ligation. Br J Anaesth 73(6):767–770

    Article  CAS  PubMed  Google Scholar 

  51. Papagiannopoulou P, Argiriadou H, Georgiou M, Papaziogas B, Sfyra E, Kanakoudis F (2003) Preincisional local infiltration of levobupivacaine vs ropivacaine for pain control after laparoscopic cholecystectomy. Surg Endosc 17(12):1961–1964

    Article  CAS  PubMed  Google Scholar 

  52. Uzunköy A, Coskun A, Akinci OF (2001) The value of pre-emptive analgesia in the treatment of postoperative pain after laparoscopic cholecystectomy. Eur Surg Res 33(1):39–41

    Article  PubMed  Google Scholar 

  53. Karaaslan D, Sivaci RG, Akbulut G, Dilek ON (2006) Preemptive analgesia in laparoscopic cholecystectomy: a randomized controlled study. Pain Pract 6(4):237–241

    Article  PubMed  Google Scholar 

  54. El-Dawlatly AA, Turkistani A, Kettner SC, Machata A-M, Delvi MB, Thallaj A et al (2009) Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth 102(6):763–767

    Article  CAS  PubMed  Google Scholar 

  55. Ortiz J, Suliburk JW, Wu K, Bailard NS, Mason C, Minard CG et al (2012) Bilateral transversus abdominis plane block does not decrease postoperative pain after laparoscopic cholecystectomy when compared with local anesthetic infiltration of trocar insertion sites. Reg Anesth Pain Med 37(2):188–192

    Article  CAS  PubMed  Google Scholar 

  56. Hilvering B, Draaisma WA, van der Bilt JDW, Valk RM, Kofman KE, Consten ECJ (2011) Randomized clinical trial of combined preincisional infiltration and intraperitoneal instillation of levobupivacaine for postoperative pain after laparoscopic cholecystectomy. Br J Surg 98(6):784–789

    Article  CAS  PubMed  Google Scholar 

  57. Boccara G, Chaumeron A, Pouzeratte Y, Mann C (2005) The preoperative administration of ketoprofen improves analgesia after laparoscopic cholecystectomy in comparison with propacetamol or postoperative ketoprofen. Br J Anaesth 94(3):347–351

    Article  CAS  PubMed  Google Scholar 

  58. Papadima A, Lagoudianakis EE, Antonakis P, Filis K, Makri I, Markogiannakis H et al (2009) Repeated intraperitoneal instillation of levobupivacaine for the management of pain after laparoscopic cholecystectomy. Surgery 146(3):475–482

    Article  PubMed  Google Scholar 

  59. Jabbour-Khoury SI, Dabbous AS, Gerges FJ, Azar MS, Ayoub CM, Khoury GS (2005) Intraperitoneal and intravenous routes for pain relief in laparoscopic cholecystectomy. JSLS 9(3):316–321

    PubMed  PubMed Central  Google Scholar 

  60. Louizos AA, Hadzilia SJ, Leandros E, Kouroukli IK, Georgiou LG, Bramis JP (2005) Postoperative pain relief after laparoscopic cholecystectomy: a placebo-controlled double-blind randomized trial of preincisional infiltration and intraperitoneal instillation of levobupivacaine 0.25%. Surg Endosc 19(11):1503–1506

    Article  CAS  PubMed  Google Scholar 

  61. DeLoach LJ, Higgins MS, Caplan AB, Stiff JL (1998) The visual analog scale in the immediate postoperative period: intrasubject variability and correlation with a numeric scale. Anesth Analg 86(1):102–106

    CAS  PubMed  Google Scholar 

  62. Schwenk W, Mall JW, Neudecker J, Müller JM (2002) One visual analogue pain score is sufficient after laparoscopic cholecystectomy. Br J Surg 89(1):114–115

    Article  CAS  PubMed  Google Scholar 

  63. Liang H, Feng Y, Liu Y, An H, Yang B (2011) Effect of flurbiprofen combined different concentrations of ropivacaine local infiltration on postoperative analgesia after laparoscopic cholecystectomy. Beijing Da Xue Xue Bao 43(5):753–756

    PubMed  Google Scholar 

  64. Collard V, Mistraletti G, Taqi A, Asenjo JF, Feldman LS, Fried GM et al (2007) Intraoperative esmolol infusion in the absence of opioids spares postoperative fentanyl in patients undergoing ambulatory laparoscopic cholecystectomy. Anesth Analg 105(5):1255–1262

    Article  PubMed  Google Scholar 

  65. Michaloliakou C, Chung F, Sharma S (1996) Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 82(1):44–51

    CAS  PubMed  Google Scholar 

Download references

Acknowledgments

We are grateful to our study biostatistician, Zoran Potic, Dipl. Eng., Agency for Consulting and Management, for his statistical expertise and contributions to this clinical trial.

Funding

This study was supported by the California Oncology Research Institute (CORI).

Author contributions

Veljkovic and Protic were involved in conception and design; Protic, Veljkovic, Popovic, and Kresoja participated in acquisition of data; Popovic and Veljkovic contributed to outcomes assessment and recording; Protic, Veljkovic, Popovic, Kresoja, Avital, and Stojadinovic were involved in analysis and interpretation of data; Protic, Veljkovic, Popovic, Avital, and Stojadinovic drafted the manuscript; Bilchik, Nissan, Avital, and Stojadinovic were involved in critical revision; Protic, Avital, and Stojadinovic provided statistical expertise; Veljkovic, Bilchik, Avital, and Stojadinovic were involved in supervision of the study.

Contributing author declaration

We certify that all individuals who qualify as authors have been listed; each has participated in one or more of the following areas: conception and design of this work, the acquisition and/or analysis of data, the writing, and/or critical revision of the document, and supervision of this cooperative research effort. All contributing authors approve of the submission of this version of the document and assert that it represents valid work. If information derived from another source was used in this document, we obtained all necessary approvals to use it and made appropriate acknowledgments in the document. All contributing authors take public responsibility for this work.

Author information

Author notes

    Authors and Affiliations

    1. Clinic of Abdominal, Endocrine and Transplantation Surgery, Clinical Center of Vojvodina, Novi Sad, Serbia

      Mladjan Protic, Radovan Veljkovic & Milana Kresoja

    2. Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia

      Mladjan Protic, Radovan Veljkovic & Milana Kresoja

    3. University of California Los Angeles, Los Angeles, CA, USA

      Anton J. Bilchik

    4. California Oncology Research Institute, Santa Monica, CA, USA

      Mladjan Protic, Anton J. Bilchik, Aviram Nissan, Itzhak Avital & Alexander Stojadinovic

    5. John Wayne Cancer Institute, Santa Monica, CA, USA

      Anton J. Bilchik

    6. Health Center “dr Nika Labovic”, Berane, Montenegro

      Ana Popovic

    7. Department of Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel

      Aviram Nissan

    8. Uniformed Services University of the Health Sciences, Bethesda, MD, USA

      Itzhak Avital & Alexander Stojadinovic

    Authors
    1. Mladjan Protic
      View author publications

      You can also search for this author in PubMed Google Scholar

    2. Radovan Veljkovic
      View author publications

      You can also search for this author in PubMed Google Scholar

    3. Anton J. Bilchik
      View author publications

      You can also search for this author in PubMed Google Scholar

    4. Ana Popovic
      View author publications

      You can also search for this author in PubMed Google Scholar

    5. Milana Kresoja
      View author publications

      You can also search for this author in PubMed Google Scholar

    6. Aviram Nissan
      View author publications

      You can also search for this author in PubMed Google Scholar

    7. Itzhak Avital
      View author publications

      You can also search for this author in PubMed Google Scholar

    8. Alexander Stojadinovic
      View author publications

      You can also search for this author in PubMed Google Scholar

    Corresponding author

    Correspondence to Mladjan Protic.

    Ethics declarations

    Disclosure

    Drs. Mladjan Protic, Radovan Veljkovic, Anton J. Bilchik, Ana Popovic, Milana Kresoja, Aviram Nissan, Itzhak Avital, and Alexander Stojadinovic have no conflicts of interest or financial ties to disclose.

    Additional information

    Mladjan Protic and Radovan Veljkovic have contributed equally to this study and will share first authorship.

    Rights and permissions

    Reprints and permissions

    About this article

    Check for updates. Verify currency and authenticity via CrossMark

    Cite this article

    Protic, M., Veljkovic, R., Bilchik, A.J. et al. Prospective randomized controlled trial comparing standard analgesia with combined intra-operative cystic plate and port-site local anesthesia for post-operative pain management in elective laparoscopic cholecystectomy. Surg Endosc 31, 704–713 (2017). https://doi.org/10.1007/s00464-016-5024-5

    Download citation

    • Received:

    • Accepted:

    • Published:

    • Issue Date:

    • DOI: https://doi.org/10.1007/s00464-016-5024-5

    Keywords

    Search

    Navigation