Journal of Clinical and Diagnostic Research. 2017 Oct, Vol-11(10): UC06-UC09 6 6 DOI: 10.7860/JCDR/2017/30356.10794 Original Article Is Local Surgical Site Infiltration as Efficacious as Epidural Analgesia in Laparoscopic Low Anterior Resection? Anaesthesia Section INTRODUCTION Surgery remains the main stay of treatment in the multimodal management of rectal cancer [1]. Rectal resections have been traditionally done by open method. In the last two decades, the role of laparoscopic surgery for rectal cancer is becoming more established as it has been shown to be on par with open surgery with respect to both short and long term oncological outcomes [2]. Laparoscopic approach to rectal resections has resulted in faster recovery and quicker initiation of adjuvant therapy [3]. Mechanism of postoperative pain in laparoscopic operations is different from that of open operations [4]. In addition to somatic component of pain due to penetrating trocar or abdominal wall suturing [5], there is a visceral mechanism postulated which is caused by traction of the peritoneum and adjacent nerves, irritation of the diaphragm due to surgical manipulation, carbon dioxide insufflation and due to retained gas after laparoscopy [6,7]. In addition, the tissue and nerve injury due to surgical trauma leads to increased levels of inflammatory cytokines and other chemicals which can induce central and peripheral nervous system sensitisation augmenting pain [8,9]. It has been observed that laparoscopic operations performed with pressures maintained under 10 mmHg have been less painful than higher pressures of pneumo–peritoneum [10,11]. Improper and inadequate pain management can result in various cardiovascular, respiratory, psychological and gastrointestinal complications including chronic post surgical pain [12-14]. There are various methods of postoperative pain control in laparoscopic rectal resections like Transversus Abdominis Plane (TAP) blocks, epidural analgesia, local wound infiltration, systemically administered opioids, non steroidal anti-inflammatory drugs and other multimodal adjuncts. Appropriate modality of pain control has to be chosen based on the type of rectal resection [15]. It was thought that in laparoscopic low anterior resection, since the specimen extraction site was small and usually less than 7 cm in length in addition to four other port insertion sites; adequate surgical site infiltration with local anaesthetic agent would suffice. Some centers also advocate patient controlled analgesia and TAP block for immediate postoperative pain management [16,17]. There is a paucity of literature comparing the efficacy of surgical site infiltration versus epidural analgesia in laparoscopic rectal resection. The aim of our study was to compare the efficacy of local surgical site infiltration versus epidural analgesia in laparoscopic low anterior resection for adenocarcinoma rectum. Since laparoscopic low anterior resection was done routinely with a left lower abdominal transverse extraction incision along with a covering loop ileostomy in our center, it was proposed to compare the two modalities of postoperative analgesia in these specific group of patients for uniformity in the port insertion sites, specimen extraction site and the expertise of surgeons performing the operation. MATERIALS AND METHODS This was a retrospective cohort study done in the colorectal surgical unit at the Christian Medical College Vellore, which is a tertiary JYOTHI AVULA 1 , GIGI VARGHESE 2 , TUNNY SEBASTIAN 3 , MARK RANJAN JESUDASON 4 Keywords: Analgesia methods, Laparoscopy, Pain, Postoperative, Rectal resection ABSTRACT Introduction: Role of epidural analgesia in laparoscopic surgery is questionable. There is paucity of data comparing local surgical site infiltration with epidural analgesia in laparoscopic colorectal resections. Aim: To evaluate the efficacy and feasibility of local surgical site infiltration versus epidural analgesia in laparoscopic low anterior resection done for adenocarcinoma of the rectum. Materials and Methods: This retrospective cohort study was done on 37 patients who had undergone laparoscopic low anterior resection at a single institution from January 2014 to March 2016. Patients were divided into two cohorts; Infiltration group (n=23) and Epidural group (n=14). Baseline characteristics and postoperative outcomes like number of patients requiring opioid rescue analgesia, incidence of urinary tract infection, postoperative hospital stay and overall morbidity were compared. Statistical analysis was done using SPSS software version 16.0. Mann-Whitney U test, Fischer’s-exact test and Pearson Chi-square test were used to test the significance wherever necessary. Results: The number of patients requiring rescue opioid analgesia within the first 48 hours following surgery were 5 (35.7%) in the epidural group versus 4 (17.4%) in the infiltration group (p=0.255). The incidence of urinary tract infection at the index admission was 2 (14.3%) in the epidural group versus 2 (8.7%) in the infiltration group (p=0.625). Overall morbidity calculated using Clavien Dindo classification was 8 (57.14%) and 14 (60.8%) respectively in epidural and infiltration group (p=0.836). The median (interquartile range) postoperative hospital stay for the epidural group was nine days (5-13 days) and for the infiltration group was eight days (5-15 days). Conclusion: Surgical site infiltration is a simple technique comparable to epidural analgesia for immediate postoperative pain control in terms of efficacy and feasibility in laparoscopic low anterior resections.