Laparoscopic cholecystectomy (LC) is very commonly performed nowadays, and it has now
completely replaced open cholecystectomy in the management of biliary lithiasis. Although it
is minimally invasive surgery, pain in postoperative period is always major concern as it
increases perioperative stress, morbidity, and hospital stay.
There are two components involved in pain after LC; the visceral component is due to tissue
damage in anterior abdominal wall during the insertion of trocar and shoulder tip pain due to
diaphragmatic irritation caused by Spillage of blood or bile and peritoneum stretching caused
by pneumoperitoneum.
There are several methods employed in the management of postoperative pain after LC such as
conventional systemic analgesics, including paracetamol, non-steroidal anti-inflammatory
drugs, systemic opioids, thoracic epidural analgesia, low-pressure pneumoperitoneum, and warm
air with all having its side effects .
Transversus abdominis plane (TAP) block has got a substantial role in postoperative analgesia
after abdominal surgery because deposition of local anesthetics in transversus abdominis
fascial plane can produce sensory block over the anterior abdominal wall from T7 to L1. Many
clinical studies reported beneficial effects of TAP but results were mainly connected to
lower abdominal surgery. Since the major part of pain after LC derives from abdominal wall
incisions, some trials investigated TAP block as potential analgesic option. Some studies
showed that TAP block can reduce opioid requirements and pain scores but the results were not
conclusive enough because many differences in study designs.
The ultrasound-guided (USG) subcostal transversus abdominis plane block (STAP), first
described by Hebbard 2008, is a variation of TAP which successfully solve the problem of
unreliable supraumbilical distribution of the block. Results obtained in a few small studies
showed significantly better analgesia after LC compare to traditional opioid analgesia,
port-site infiltration and standard TAP.
Intraperitoneal (IP) instillation of local anaesthetics around the operative site is used as
an analgesic technique on the assumption that conduction from visceral sites is obstructed
and may lessen the intensity of referred pain to the shoulder (C3, C4) which results from
irritation of diaphragmatic innervations, i.e., phrenic nerve (C3, C4, C5) and diaphragmatic
stretching due to gaseous distension, in the postoperative period. Narchi I' et al., as early
as in 1991 had reported that instillation of local anaesthetic (80 mL of bupivacaine 0.125%,
epinephrine (1:200,000) under the right diaphragm reduced shoulder pain after minor
gynaecologic laparoscopy.
Dexmedetomidine is a selective, short acting, agonist of the α2-adrenergic receptors. It has
high affinity to α2-adrenergic receptors (more than eight-fold) and lower affinity to
α1-receptors, compared with other α2-agonists agents, besides its great selectivity to
α2A-adrenergic receptors, which is responsible for its analgesic effect. It has been used
clinically as an adjunct to anesthesia and analgesia, and it is useful for painful surgical
procedure and ICU sedation.
