الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
SUMMARY
urrently, laparoscopic sleeve gastrectomy is the gold standard
option for the management of morbid obesity,it is a less
invasive procedure with better cosmetic results and shorter
operative time and hospital stay Moreover, the current body of
evidence shows that laparoscopic interventions are generally
associated with less postoperative pain and analgesic
requirements
On the other hand, laparoscopic procedures are
associated with variable degrees of early postoperative pain;
post-laparoscopic abdominal pain, mainly visceral, is proposed
as a consequence of abdominal incision, tissue injuries, and
pneumoperitoneum with subsequent peritoneal stretch.
Moreover, concurrent shoulder tip pain may occur as a result of
peritoneal irritation by carbone dioxide and phrenic nerve
irritation by diaphragmatic muscle fibers stretch. Inadequate
management of acute post-laparoscopic pain can significantly
affect patient satisfaction, prolong hospitalization, and increase
the risk of morbidities and development of chronic pain.
Previous reports have shown that the post-laparoscopic pain is
inadequately treated in approximately one-half of all surgical
procedures. Thus, effective analgesia through a multimodal
approach can modify these consequences and improve patient
recovery and quality of life. Different multimodal approaches
including non-steroidal anti-inflammatory drugs (NSAIDs),
C
Summary
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opioids and local wound infiltration have been described.
However, NSAIDs may precipitate ischemic renal insufficiency
and coagulopathy. Opioids are associated with respiratory
depression, postoperative nausea and vomiting (PONV), and
dependence. Intraperitoneal instillation of drugs has been
proposed as an effective option for post- laparoscopic pain
management. Potentially block the visceral afferent signalling
and inhibit the release and action of prostaglandins. Moreover,
after systemic absorption from through the large peritoneal
surface, they may further modulate peritoneal and visceral
signalling to the brain, thereby attenuating the metabolic impact
of visceral manipulations The current body of evidence shows
that the intraperitoneal local anesthetics led to lower
postoperative pain scores and rare serious adverse effects
among patients who underwent laparoscopic surgeries,
regardless of the instillation time which may be prepneumoperitoneum
or near the end of surgery by different types
of drugs including bupivacaine, magnesium, and
corticosteroids. There is significant role of glutamate receptors
on peripheral nociceptive sensation; thus, an effective blockade
of glutamate receptors, such as N-methyl-D-aspartate (NMDA)
receptor, can alleviate different type of pain including
postoperative pain. Intraperitoneal magnesium has emerged as
an effective, adjuvant, local and systemic analegsic due to its
effective blockade of NMDA receptors and calcium channels
after systemic absorption through the large peritoneal surface. It
Summary
88
also increases the number of nerve fibers affected by
bupivacaine and therefore potentiates its conduction block.
The aim of the present trial is to compare the efficacy
and safety of intraperitoneal levobupivacaine, and/or
magnesium sulphate in different combinations for postoperative
pain relief in patients undergoing laparoscopic sleeve
gastrectomy.
60 patients were divided into three groups:
group A included patients received intraperitoneal instillation
of 30 ml of 0.25% Levobupivacaine alone,
group B included patients received intraperitoneal instillation
of 30 ml Magnesium Sulphate10% alone
group C included patients received intraperitoneal instillation
of 15ml Magnesium Sulfate10% plus 15 ml of 0.25%
Levobupivacaine to a total volume of 30 ml.
All the three groups were non-significant in comparison
to age, weight, height, BMI and sex.
When we analysed the VAS score nine times in 24 hours;
at zero and after one, two, four, six, eight, twelve, sixteen and
twenty four hours of surgery; the cumulative mean pain score
was less in LevMg group compared to Lev group and Mg
group and the difference was statistically significant (p<0.05).
The average Time to 1st dose of postoperative analgesia
demand was also the longest in LevMg group compared to Mg
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group and Lev group (8.75 ±4.51 hours compared to 1.40 ±
0.50 hours and 4.95 ± 1.76 hours respectively) which was also
highly significant.
When total analgesia consumption in 24 hours was
analysed, LevMg group had 35.00 ±26.66 mg, Mg group had
136.50 ±19.27 mg and Lev group 87.00 ± 33.73 mg of
Pethidine consumption which was highly significant
Bupivacaine group had mild tomoderate pain and most of the
patients in bupivacaineplus magnesium sulphate group had
mild pain in first 24hours of surgery
Regarding the comparison of the heart rate in the three
groups it was highly significant starting from 30 min-24 hours
postoperative as the least heart in LevMg group 86.90 ± 15.11-
84.00 ± 10.91 BPM to the Mg group 103.40 ± 11.82- 97.75 ±
7.87 BPM and Lev group 95.95 ± 14.12- 96.90 ± 9.99 BPM.
Finally there were no remarkable side effects recorded in
all of the three groups