Parietal and Peritoneal Local Anaesthetic in the Recovery of Children after Laparoscopic Appendectomy

Abstract

Aim The primary aim of this research was to reduce the intensity of pain experienced by children after laparoscopic appendicectomy. No instrument that can assess location of pain has been designed specifically for abdominal surgery in children. Therefore, a secondary aim was to develop and validate a tool to record accurately where children feel pain after laparoscopic appendicectomy. Methods A new instrument (‘Location and Level of Intensity of Postoperative Pain Score’, Lolipops) was developed to establish the location of pain in paediatric surgery. An ultrasonography-guided rectus sheath block for paediatric laparoscopic appendicectomy was investigated in a randomised, placebo-controlled, parallel-group trial (called ‘Sonographic Nerve-block for laparoscopic APpendicectomy’, SNAP). The efficacy of intraperitoneal local anaesthesia in paediatric laparoscopic appendicectomy was evaluated in a randomised placebo-controlled parallel-group trial (called ‘Sprayed Peritoneal Regional Anaesthesia in appendicectomY’, SPRAY). Findings Pain location instrument: The Lolipops pain tool demonstrated construct validity by detecting increased pain at incision sites when compared with non-incision sites, increased pain in the right iliac fossa (expected site of pain from appendicitis) when compared with abdominal sites not expected to be painful, and a more diffuse pain pattern in perforated appendicitis as predicted. Randomised controlled trials: The SNAP trial showed a significant benefit from an ultrasonography-guided rectus sheath nerve block (estimated effect size, a 1.8 reduction in pain score, p = 0.008). However, there was no significant effect beyond 3 hours after the end of surgery or any effect on opioid consumption, length of hospital stay, or complications. The SPRAY trial showed that intraperitoneal local anaesthesia had no effect of pain (estimated effect size, a 0.13 reduction in pain score, p = 0.80) or any effect on opioid consumption, length of hospital stay, or complications. Conclusions A rectus sheath block could contribute to a multimodal system of recovery after laparoscopic appendicectomy. The evidence presented in this thesis would not support the use of intraperitoneal local anaesthesia in children undergoing laparoscopic surgery outside of a randomised controlled trial. Pain location scores offer potentially valuable information on the spatial origin of pain.