Optimizing postoperative pain management in minimally invasive colorectal surgery
Article information
The adoption of Enhanced Recovery After Surgery (ERAS) protocols in colorectal surgery has significantly improved patient outcomes by reducing complications and accelerating recovery [1, 2]. ERAS protocols include multiple components that aim to maintain postoperative physiological function and reduce the surgical stress response, thus promoting faster recovery [3]. Effective postoperative pain control is a cornerstone of ERAS. Proper pain management after colorectal surgery is crucial, as it facilitates quicker recovery and enables earlier discharge.
For several decades, patient-controlled analgesia (PCA) has been the primary method for pain management, valued for its ease of use and reliable pain control [4]. However, PCA often relies on opioids, which can lead to side effects such as nausea and vomiting. Even when antiemetics are used, opioids may still impair gastrointestinal motility, potentially delaying recovery [1, 4]. Therefore, ERAS guidelines recommend reducing opioid use and adopting a multimodal analgesia approach, which involves combining 2 or more methods for pain control [1, 5]. Multimodal pain management options include cyclooxygenase-2 (COX-2) selective nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, and nerve blocks such as transversus abdominis plane and rectus sheath blocks. Other strategies include continuous wound infiltration (CWI) with a catheter for local anesthetic delivery, and the use of thermosensitive hydrogel-based applications for local anesthetics [5–7].
The present study by Choi and Bae [8] investigated the effectiveness of CWI using ropivacaine combined with intravenous (IV) PCA for reducing postoperative opioid consumption and pain in patients undergoing reduced-port laparoscopic colorectal surgery. The addition of CWI significantly decreased pain scores on postoperative day 0 (3.2±0.8 vs. 3.7±0.9, P=0.042) and opioid requirements within the first 24 hours after surgery (0.7±0.9 vs. 1.3±1.1, P=0.018), highlighting the potential of CWI as part of multimodal analgesia in colorectal surgery. Notably, this study demonstrated the beneficial role of CWI when used in combination with IV PCA, a common practice. When IV PCA is employed, its integration with CWI could lead to reduced opioid consumption, offering a promising option for enhanced multimodal pain management.
CWI in laparoscopic colorectal surgery offers several advantages and some potential drawbacks. On the positive side, CWI can effectively alleviate postoperative pain, thereby reducing the reliance on opioids and minimizing their associated side effects [9, 10]. It has also been demonstrated to enhance patient satisfaction regarding pain management and to hasten the return of bowel function [9]. Additionally, CWI is relatively straightforward to administer and maintains a favorable safety profile [10]. However, its effectiveness in laparoscopic procedures appears less marked than in open surgery [9]. The insertion of catheters in minimally invasive surgery poses challenges that may impact the efficacy of CWI. Moreover, although CWI is generally considered safe, there remain concerns about wound healing and infection risks, though significant increases in these complications have not been documented [9, 10]. In summary, while CWI holds potential in laparoscopic colorectal surgery, its advantages may be more constrained compared to its application in open surgery, necessitating further research to refine its use in minimally invasive settings [9].
In conclusion, this study reinforces the importance of CWI within ERAS protocols, especially for minimally invasive colorectal procedures that necessitate effective postoperative pain management with minimal reliance on opioids. By decreasing opioid use and enhancing early pain control, CWI provides a safe and effective alternative to conventional analgesic methods, aligning closely with the goals of ERAS. As ERAS protocols continue to develop, incorporating advanced, localized pain management techniques could further improve outcomes, setting the stage for optimal recovery pathways in minimally invasive colorectal surgery.
Notes
Conflict of interest
Soo Young Lee is an Editorial Board member of Annals of Coloproctology, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflict of interest relevant to this article was reported.
Funding
None.