Hemmerling Thomas M
Department of Anesthesia, McGill University, 1650 Cedar Avenue, Montreal, Canada.
Division of Experimental Surgery, McGill University, Montreal, Canada.
Langenbecks Arch Surg. 2018 Nov;403(7):791-803. doi: 10.1007/s00423-018-1705-y. Epub 2018 Oct 3.
Abdominal surgery has undergone major changes during the last two decades with a general shift from open, invasive surgery to closed minimally invasive surgery. Accordingly, pain management strategies have also changed, especially with the introduction of ultrasound-guided abdominal wall blocks. Despite laparoscopic abdominal surgery classified as minimal, pain can be quite significant and needs to be addressed appropriately.
This narrative review focuses on adequate pain strategies for various types of surgery. The respective techniques are described and examples of specific pain management strategies given. Advantages and disadvantages of techniques are discussed. This review can serve as a sort of empirical guideline and orientation for the reader to develop their own strategy as well as bringing surgeons up-to-date with the latest anesthetic techniques.
Pain is not less or less relevant in minimally invasive surgery. New hallmarks of a multimodal pain strategy are abdominal wall blocks, either as single shot or continuously. Minor open surgery is best performed under a combination of loco-regional blocks and continuous sedation. Abdominal wall blocks, NSAIDs, and short-acting opioids given by nurses or as PCA present the best multimodal pain strategy in abdominal surgery. Epidural analgesia and spinal anesthesia have become second-line options or are reserved for specific patient morbidities or surgical requirements.
在过去二十年中，腹部手术经历了重大变革，总体趋势是从开放式侵入性手术转向封闭式微创手术。相应地，疼痛管理策略也发生了变化，尤其是随着超声引导下腹壁阻滞技术的引入。尽管腹腔镜腹部手术被归类为微创手术，但疼痛可能相当严重，需要得到妥善处理。
本叙述性综述重点关注各类手术的适当疼痛管理策略。描述了相应技术，并给出了具体疼痛管理策略的示例。讨论了这些技术的优缺点。本综述可为读者制定自己的策略提供一种经验性指导和方向，同时使外科医生了解最新的麻醉技术。
在微创手术中，疼痛并不减轻或不那么重要。多模式疼痛管理策略的新特点是腹壁阻滞，可单次注射或持续给药。小型开放手术最好在局部区域阻滞和持续镇静相结合的情况下进行。护士给予或通过患者自控镇痛（PCA）使用的腹壁阻滞、非甾体抗炎药（NSAIDs）和短效阿片类药物是腹部手术中最佳的多模式疼痛管理策略。硬膜外镇痛和脊髓麻醉已成为二线选择，或仅用于特定患者的病情或手术需求。
