Efficacy of CPPLAI in Laparoscopic Sleeve Gastrectomy Patients
Efficacy of CPPLAI in Laparoscopic Sleeve Gastrectomy Patients
The high demand for bariatric surgery due to the increasing prevalence of obesity worldwide
 necessitate evidence-based clinical pathway such as Enhanced Recovery After Bariatric Surgery
 (ERABS). The paradigm of surgery has been shifted from open to laparoscopic in morbidly obese
 patients. Laparoscopic Sleeve Gastrectomy (LSG) is the most common procedure performed in our
 institute for sustained weight loss and amelioration of obesity-related comorbidities. Pain
 control in ERABS is one of the key factors for improved outcomes. Surgery induced acute
 postoperative pain, stress response and fatigue lead to prolonged convalescence and hospital
 stay. Optimal titrated safe postoperative pain management in LSG patients still remains a
 challenge.
Obesity is a complex multifactorial disease. The worldwide prevalence of obesity has doubled
 since 1980 to a level that now almost a third of the world's population is classified as
 overweight. Laparoscopic Sleeve Gastrectomy (LSG) is one of the effective treatments for
 sustained weight loss and to ameliorate the obesity-related comorbidities, and now the most
 commonly performed bariatric surgery worldwide. Postoperative pain from the laparoscopic
 portal sites and the visceral pain after gastrectomy requires a multimodal approach for pain
 management. As obese patients are sensitive to opioids overdose and at risk of respiratory
 depression and obstructive sleep apnoea, local anesthetic infiltration at the surgical
 incision sites and preperitoneal can decrease postoperative opioid consumption after LSG.
 Perioperative multimodal analgesia uses combinations of analgesic medications that act on
 different sites and pathways in an additive or synergistic manner to achieve pain relief with
 minimal or no opiate consumption. Although all medications have side effects, opiates have
 particularly concerning, multisystemic, long-term, and short-term side effects, which
 increase morbidity and prolong admissions. local infiltration analgesia (LIA) used widely as
 an effective component of multimodal analgesia and represents valuable options for
 controlling perioperative pain. LIA involves the injection and/or infusion of a local
 anesthetic near the site of surgical incision to provide targeted analgesia. A wide variety
 of techniques have been described, including single-injection intraoperative wound
 infiltration, indwelling wound infusion catheters, and the recent high-volume LIA technique
 associated with joint replacement surgery. Although, preperitoneal local anesthetic
 infiltration is a novel technique that was first described for pain relief after laparoscopic
 hernia repair. Recently, the investigators have used this technique in our institute during
 laparoscopic hernia repair which is now gaining popularity worldwide. Another investigator
 reported that continuous preperitoneal analgesia better attenuated postoperative inflammatory
 response and provided comparable overall analgesia to that with continuous epidural analgesia
 following radical cystectomy. Recently, a large systematic review and meta-analysis comparing
 preperitoneal or subcutaneous wound catheters with epidural analgesia in abdominal surgery
 showed preperitoneal wound catheters are an effective pain modality in abdominal surgery.
 Pain control was as effective as epidural analgesia and recovery parameters, opioid
 consumption, the incidence of hypotension, and patient satisfaction seemed to be in favor of
 preperitoneal wound catheters compared with active alternatives, as well as placebo. The
 trend for bariatric surgery is now moving towards opiates-almost free anesthesia. Since the
 first description of preperitoneal local anesthetic infiltration almost 2 decades ago little
 work has been done to test its efficacy, especially in LSG patients. The investigators of
 this study hypothesis that CPPLAI is an effective technique to reduce postoperative pain and
 favors early mobilization and patient satisfaction due to its fewer side effects.
Inclusion Criteria:

 -  American Society of Anesthesiologist (ASA) physical status I-III

 -  Age 18-60 years

 -  Either gender

 -  Obese patients (BMI >35 for laparoscopic sleeve gastrectomy

 Exclusion Criteria:

 -  American Society of Anesthesiologist (ASA) physical status IV

 -  Patients uncontrolled HTN

 -  Anticipated difficult intubation

 -  Allergic to morphine

 -  Clinically significant neurological, cardiovascular, renal hepatic disease planned for
 postoperative surgical intensive care (SICU) admission

 -  History of drug abuse or chronic opioid use