Treat Postoperative Abdominal Pain Using Intraperitoneal and Incisional Anesthesia
Department of Biomedical Sciences, University of Montreal, Saint-Hyacinthe, QC, Canada
The opioid crisis has left us wondering what to do without them. Alternatives to opioid usage include the practice of multimodal analgesia, which should always include local anesthetic techniques whenever possible. Intraperitoneal and incisional types of anesthesia are technically easy to perform, low in cost, and effective. Veterinarians can easily incorporate the use of these techniques into their routine practice.
The processing of nociceptive information occurs via four main steps: transduction, transmission, modulation, and perception. Transduction is the first step in processing pain. It starts with the activation of nociceptors that are present in the target tissue (such as skin, muscles, joints, and viscera), as well as those that respond to noxious stimuli. Transmission occurs when the nociceptive impulse travels from the primary afferent fiber (first-order neuron) to the dorsal horn of the spinal cord.1 Local anesthetics inhibit nerve conduction and nociceptive input by blocking primarily Na+; hence they act early in the pain pathway, blocking peripheral inputs. For these reasons, they produce excellent analgesic efficacy when used for the management of acute pain. Local anesthetics have several advantages. They are inexpensive, uncontrolled, and generally available worldwide.2
In people undergoing abdominal surgeries, the use of intraperitoneal and incisional anesthesia has been shown to reduce early postoperative analgesic requirements, reduce time to first-intervention analgesia, and reduce pain scores. For these reasons, these techniques are recommended for laparotomy and laparoscopic surgery in people, as an adjuvant analgesic technique.
In veterinary medicine, studies in dogs and cats are showing similar evidence of efficacy with a good safety profile when local anesthetics are administered at recommended dosages. For example, in dogs, both techniques have been studied separately or in combination, using either bupivacaine, lidocaine, or ropivacaine. Plasma concentrations of lidocaine after intraperitoneal and incisional anesthesia in dogs undergoing ovariohysterectomy were below toxic levels (Wilson et al. 2004).
Although some studies were inconclusive, pain scores and need of rescue analgesia were generally reduced after intraperitoneal and/or incisional anesthesia when compared with controls.3-5 In cats, only the intraperitoneal technique using bupivacaine has been studied. Plasma concentration of intraperitoneal anesthesia using bupivacaine alone, or in combination with epinephrine or dexmedetomidine, were below toxic levels.6-8 The technique was shown to reduce pain scores and need of rescue analgesia when compared with controls.7 The association of dexmedetomidine or epinephrine to bupivacaine provided similar analgesia.8
Based on the current literature, intraperitoneal and incisional anesthesia should be considered for the management of postoperative pain in any type of abdominal surgery. They are also excellent choices during spay-neuter programs. Their administration must be performed under aseptic conditions and general anesthesia. Intraperitoneal and incisional anesthesia should be used as part of a multimodal analgesic protocol, including other pharmacological and non-pharmacological therapies.
Both techniques are described and demonstrated in the following link: https://www.youtube.com/watch?v=76dwKuirqt0.
This lecture will present the current evidence on the use of intraperitoneal and incisional anesthesia in small animal practice, as well as offer recommendations on how to safely and effectively use these techniques.
1. Klinck MP, Troncy E. The physiology and pathophysiology of pain. In: BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 2016:97–112.
2. Mathews K, Krone P, Lascelles D, et al. Guidelines for recognition, assessment and treatment of pain: WSAVA Global Pain Council members and co-authors of this document. J Small Anim Pract. 2014;55(6):E10–68.
3. Campagnol D, Teixeira-Neto FJ, Monteiro ER, et al. Effect of intraperitoneal or incisional bupivacaine on pain and the analgesic requirement after ovariohysterectomy in dogs. Vet Anaesth Analg. 2012;39(4):426–430. www.ncbi.nlm.nih.gov
4. Fitzpatrick CL, Weir HL, Monnet E. Effects of infiltration of the incision site with bupivacaine on postoperative pain and incisional healing in dogs undergoing ovariohysterectomy. J Am Vet Med Assoc. 2010;237(4):395–401. http://avmajournals.avma.org
5. Lambertini C, Kluge K, Lanza-Perea M, et al. Comparison of intraperitoneal ropivacaine and bupivacaine for postoperative analgesia in dogs undergoing ovariohysterectomy. Vet Anaesth Analg. 2018;45(6):865–870. https://linkinghub.elsevier.com
6. Benito J, Monteiro BP, Beaudry F, et al. Pharmacokinetics of bupivacaine after intraperitoneal administration to cats undergoing OVH. Am J Vet Res. 2016;77(6):641–645.
7. Benito J, Monteiro B, Lavoie AM, Beauchamp G, et al. Analgesic efficacy of intraperitoneal administration of bupivacaine in cats. J Feline Med Surg. 2016;18(11):906–912.
8. Benito J, Monteiro B, Beaudry F, et al. Efficacy and pharmacokinetics of bupivacaine with epinephrine or dexmedetomidine after intraperitoneal administration in cats undergoing ovariohysterectomy. Can J Vet Res. 2018;82(2):124–130.