Analgesia for enhanced recovery after surgery in laparoscopic surgery

Effectual analgesia is one of the essential cornerstones of enhanced recovery after surgery (ERAS) programmes and indeed all anaesthetic care. It is a vital element in reducing the surgical stress response, encouraging a return to normal functions—breathing, eating, sleeping—early mobilisation and for basic humane reasons. Opioid usage is associated with side effects including postoperative nausea and vomiting, constipation, ileus, pruritis, delirium, urinary retention and respiratory depression along with a potential to cause chronic dependence. The avoidance of opioids is associated with earlier mobilisation, return of bowel function and a reduced length of stay, leading to a preference for multimodal analgesia. While laparoscopic surgical techniques have been shown to reduce the intensity of postoperative pain when compared to open surgery, pain after laparoscopic surgery can be due to a myriad of factors. This article will give an overview of the best practice choices available. Multimodal analgesia aims to reduce the side effects of individual analgesics whilst still providing adequate analgesia by using a combination of pharmacological mechanisms. Basic analgesics include paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) with other non-opioid systemic agents include lidocaine, alpha-2-agonists (dexmedetomidine and clonidine), ketamine, magnesium, gabapentinoids and dexamethasone. Local anaesthetic administration can provide analgesia in a variety of ways. This includes neuraxial blockade (spinal or epidural), regional nerve blocks [including transversus abdominis plane (TAP) blocks], wound catheter local anaesthetic infusions as well as direct local infiltration. Spinal anaesthetics are a superior alternative to epidurals for laparoscopic surgery given the good analgesia, quick delivery, limited duration and moderate attenuation of the stress response alongside lower complication rate. Analgesia is one of the cornerstones of ERAS pathways and anaesthetic practice in general. The general consensus is that a multimodal approach is best, to ensure sparing of opioids. This can involve the use of both systemic analgesia and local anaesthetics.