Artroskopinė priekinio kryžminio raiščio rekonstrukcija – viena iš dažniausiai atliekamų ortopedinių operacijų. Adekvati skausmo kontrolė yra svarbi siekiant efektyvios ankstyvos reabilitacijos ir gerų funkcinių rezultatų, sutrumpinant gydymo ligoninėje trukmę. Atlikome randomizuotą perspektyvųjį dvigubai aklą placebu kontroliuojamą tyrimą panaudodami intrasąnarinius vaistus (morfiną ir neostigminą), derindami su vienkartine šlauninio nervo blokada. Taip pat tyrėme tęstinį skausmo malšinimą šlaunies perineuriniu kateteriu, taikydami du skirtingus paciento kontroliuojamos analgezijos režimus. Taikėme mažesnę vietinio anestetiko koncentraciją, siekdami selektyvesnės sensorinės blokados, mažesnės paros dozės, mažiau toksinių reakcijų. Tikrinome, ar tęstinis skausmo malšinimas yra veiksmingesnis nei vienkartinė nervo blokada su intrasąnarinėmis analgetikų injekcijomis. Intrasąnarinis morfinas turėjo panašų analgezinį poveikį kaip ir neostigminas paciento krūvio metu per visą tyrimo laiką (48 val.); tačiau neostigminas buvo patikimai efektyvesnis už placebą antrą pooperacinę dieną. Skausmo kontrolė ramybėje ir krūvio metu bei pacientų pasitenkinimas per visą tyrimą buvo geresni perineurinio skausmo malšinimo grupėse negu intrasąnarinėse. Intrasąnarinių grupių pacientų analgezijos efektyvumui priartėjus prie kateterinių grupių, nustatydavome didesnį papildomų analgetikų suvartojimą pirmosiose. Skausmo malšinimas 0,1% bupivakaino infuzija šlaunies perineuriniu kateteriu, taikant... [toliau žr. visą tekstą] / Choice of optimal postoperative analgesia technique after anterior crutiate ligament repair remains challenging. Aiming to evaluate and compare the efficacy of intra-articular injection of morphine and neostigmine our prospective randomized clinical study compared pain intensity, consumption of adjunct analgesics and patient satisfaction during 48 postoperative hours in patients who, in addition to spinal block, received a single-shot femoral nerve block followed by the end-of-surgery intra-articular injection of morphine, neostigmine or placebo. Additionally, the former two were compared with continuous femoral nerve block with postoperative patient controlled analgesia infusion pump containing 0.1 % bupivacaine preset in 2 different regimens: with or without basal infusion. Our results show that there was only a single difference among intra-articular groups found on the 2nd postoperative day: a significantly better pain control at motion in neostigmine group than in the placebo group. There was no additive analgesic effect of i/a morphine. Also, we observed a significantly better pain control and patient satisfaction in continuous femoral perineural block PCA groups during the whole trial. There was a significant prevalence of the PCA analgesia regimen which implies the preset basal rate of 0.1% bupivacaine: a 5 ml bolus with a lockout period 30 min and basal infusion 5 ml/h.

Choice of optimal postoperative analgesia technique after anterior crutiate ligament repair remains challenging. Aiming to evaluate and compare the efficacy of intra-articular injection of morphine and neostigmine our prospective randomized clinical study compared pain intensity, consumption of adjunct analgesics and patient satisfaction during 48 postoperative hours in patients who, in addition to spinal block, received a single-shot femoral nerve block followed by the end-of-surgery intra-articular injection of morphine, neostigmine or placebo. Additionally, the former two were compared with continuous femoral nerve block with postoperative patient controlled analgesia infusion pump containing 0.1 % bupivacaine preset in 2 different regimens: with or without basal infusion. Our results show that there was only a single difference among intra-articular groups found on the 2nd postoperative day: a significantly better pain control at motion in neostigmine group than in the placebo group. There was no additive analgesic effect of i/a morphine. Also, we observed a significantly better pain control and patient satisfaction in continuous femoral perineural block PCA groups during the whole trial. There was a significant prevalence of the PCA analgesia regimen which implies the preset basal rate of 0.1% bupivacaine: a 5 ml bolus with a lockout period 30 min and basal infusion 5 ml/h. / Artroskopinė priekinio kryžminio raiščio rekonstrukcija – viena iš dažniausiai atliekamų ortopedinių operacijų. Adekvati skausmo kontrolė yra svarbi siekiant efektyvios ankstyvos reabilitacijos ir gerų funkcinių rezultatų, sutrumpinant gydymo ligoninėje trukmę. Atlikome randomizuotą perspektyvųjį dvigubai aklą placebu kontroliuojamą tyrimą panaudodami intrasąnarinius vaistus (morfiną ir neostigminą), derindami su vienkartine šlauninio nervo blokada. Taip pat tyrėme tęstinį skausmo malšinimą šlaunies perineuriniu kateteriu, taikydami du skirtingus paciento kontroliuojamos analgezijos režimus. Taikėme mažesnę vietinio anestetiko koncentraciją, siekdami selektyvesnės sensorinės blokados, mažesnės paros dozės, mažiau toksinių reakcijų. Tikrinome, ar tęstinis skausmo malšinimas yra veiksmingesnis nei vienkartinė nervo blokada su intrasąnarinėmis analgetikų injekcijomis. Intrasąnarinis morfinas turėjo panašų analgezinį poveikį kaip ir neostigminas paciento krūvio metu per visą tyrimo laiką (48 val.); tačiau neostigminas buvo patikimai efektyvesnis už placebą antrą pooperacinę dieną. Skausmo kontrolė ramybėje ir krūvio metu bei pacientų pasitenkinimas per visą tyrimą buvo geresni perineurinio skausmo malšinimo grupėse negu intrasąnarinėse. Intrasąnarinių grupių pacientų analgezijos efektyvumui priartėjus prie kateterinių grupių, nustatydavome didesnį papildomų analgetikų suvartojimą pirmosiose. Skausmo malšinimas 0,1% bupivakaino infuzija šlaunies perineuriniu kateteriu, taikant... [toliau žr. visą tekstą]

The doctoral dissertation analyses and compares general endotracheal and combined endotracheal epidural anesthesia’s impact on organ systems and describes the systems parameters in laparoscopic colorectal surgery. Comparing two perioperative analgesia techniques used in laparoscopic colorectal surgery the hemodynamic and respiratory parameters trends; the impact of anesthesia and postoperative analgesia methods on patients’ tracheal extubation time, intestinal motility recovery rate, duration of hospitalization and inflammatory response have been determined. Laparoscopic colorectal resection, even being a minimally invasive technique for laparoscopic surgery, stimulates the body's response to stress and pro-inflammatory mediator’s secretion. Perioperative pain management may also influence the immune response. The doctoral dissertation analyses the impact of epidural analgesia method on the body stress response, investigating variations of cortisol and interleukin-6 levels. The results showed that analgesia and patient satisfaction using epidural analgesia method for perioperative pain management were better. Tracheal extubation time was significantly shorter. Recovery of intestinal motility using epidural analgesia was significant and much prior than using intravenous analgesia. The use of epidural analgesia in laparoscopic colorectal surgery caused less stress response – less cortisol levels increase. It has not showed the increase in number of complications. / Disertacijoje analizuojama ir lyginama bendrosios endotrachėjinės ir kombinuotos endotrachėjinės epiduralinės anestezijos įtaka atskiroms organų sistemoms ir tas sistemas apibūdinantiems rodikliams laparoskopinių kolorektalinių operacijų metu. Darbe nagrinėjama dviejų perioperacinių skausmo malšinimo būdų įtaka hemodinamikos ir kvėpavimo sistemos parametrų kitimo tendencijoms, pacientų trachėjos ekstubacijos laikui, žarnyno motorikos atsinaujinimo greičiui, hospitalizacijos trukmei bei organizmo uždegiminiam atsakui. Laparoskopinės storosios žarnos rezekcinės operacijos, net ir būdamos minimaliai invazinės dėl laparoskopinės operacijos technikos, sužadina stresinį organizmo atsaką bei uždegimo mediatorių išskyrimą. Perioperacinis skausmo valdymas taip pat gali daryti įtaką imuniniam atsakui. Disertacijoje nagrinėjama epiduralinės analgezijos metodo įtaka organizmo stresiniam atsakui tiriant kortizolio kiekio kitimus ir interleukino-6, kaip vieno pagrindinių uždegimą skatinančių citokinų, koncentracijos kitimą taikant epiduralinę analgezijos metodiką. Gauti rezultatai parodė, kad analgezijai pasitelkiant epiduralinį skausmo malšinimo metodą, perioperacinis pacientų skausmo valdymas ir pasitenkinimas yra geresnis, trachėjos ekstubacijos laikas patikimai trumpesnis, žarnyno peristaltikos atsitaisymas ankstyvesnis, sukeliamas stresinis organizmo atsakas mažesnis (mažesnis kortizolio koncentracijos padidėjimas) ir nenustatyta komplikacijų padaugėjimo.

Disertacijoje analizuojama ir lyginama bendrosios endotrachėjinės ir kombinuotos endotrachėjinės epiduralinės anestezijos įtaka atskiroms organų sistemoms ir tas sistemas apibūdinantiems rodikliams laparoskopinių kolorektalinių operacijų metu. Darbe nagrinėjama dviejų perioperacinių skausmo malšinimo būdų įtaka hemodinamikos ir kvėpavimo sistemos parametrų kitimo tendencijoms, pacientų trachėjos ekstubacijos laikui, žarnyno motorikos atsinaujinimo greičiui, hospitalizacijos trukmei bei organizmo uždegiminiam atsakui. Laparoskopinės storosios žarnos rezekcinės operacijos, net ir būdamos minimaliai invazinės dėl laparoskopinės operacijos technikos, sužadina stresinį organizmo atsaką bei uždegimo mediatorių išskyrimą. Perioperacinis skausmo valdymas taip pat gali daryti įtaką imuniniam atsakui. Disertacijoje nagrinėjama epiduralinės analgezijos metodo įtaka organizmo stresiniam atsakui tiriant kortizolio kiekio kitimus ir interleukino-6, kaip vieno pagrindinių uždegimą skatinančių citokinų, koncentracijos kitimą taikant epiduralinę analgezijos metodiką. Gauti rezultatai parodė, kad analgezijai pasitelkiant epiduralinį skausmo malšinimo metodą, perioperacinis pacientų skausmo valdymas ir pasitenkinimas yra geresnis, trachėjos ekstubacijos laikas patikimai trumpesnis, žarnyno peristaltikos atsitaisymas ankstyvesnis, sukeliamas stresinis organizmo atsakas mažesnis (mažesnis kortizolio koncentracijos padidėjimas) ir nenustatyta komplikacijų padaugėjimo. / The doctoral dissertation analyses and compares general endotracheal and combined endotracheal epidural anesthesia’s impact on organ systems and describes the systems parameters in laparoscopic colorectal surgery. Comparing two perioperative analgesia techniques used in laparoscopic colorectal surgery the hemodynamic and respiratory parameters trends; the impact of anesthesia and postoperative analgesia methods on patients’ tracheal extubation time, intestinal motility recovery rate, duration of hospitalization and inflammatory response have been determined. Laparoscopic colorectal resection, even being a minimally invasive technique for laparoscopic surgery, stimulates the body's response to stress and pro-inflammatory mediator’s secretion. Perioperative pain management may also influence the immune response. The doctoral dissertation analyses the impact of epidural analgesia method on the body stress response, investigating variations of cortisol and interleukin-6 levels. The results showed that analgesia and patient satisfaction using epidural analgesia method for perioperative pain management were better. Tracheal extubation time was significantly shorter. Recovery of intestinal motility using epidural analgesia was significant and much prior than using intravenous analgesia. The use of epidural analgesia in laparoscopic colorectal surgery caused less stress response – less cortisol levels increase. It has not showed the increase in number of complications.

Magistro darbas buvo parengtas Lietuvos sveikatos mokslų universitete, Veterinarijos akademijoje 2012 – 2013 metais. Magistro darbas susideda iš turinio, įvado , literatūros apžvalgos , rezultatų ir jų aptarimo, išvadų bei padėkos .Visą darbą sudaro 41 puslapiai , 10 lentelių ir 6 diagramos. Tikslas: Įvertinti Lietuvos sveikatos mokslų universiteto Veterinarijos akademijos dr. L.Kriaučeliūno smulkiųjų gyvūnų klinikoje chirurginėje praktikoje naudojamų bendrosios nejautros metodų efektyvumą ir gyvybinių funkcijų stebėsenos svarbą. Darbo uždaviniai:1. Išnagrinėti bendrosios nejautros būdų taikymą smulkiųjų gyvūnų klinikoje.2. Įvertinti stebėjimo (monitoravimo) rodiklius.3. Stebėti ir įvertinti pasitaikančias komplikacijas, taikomus būdus joms pašalinti bei jų prevenciją. / This master work was prepared in Lithuanian University of Health Sciences, Veterinary Academy in 2012 – 2013 years. This master work compiles from a content, introduction, review of literature, results, consideration, conclusion, and thanks. The master work consists of 41 pages and includes 10 tables and 6 pictures. The aim: Rate of small animal surgical techniques used in general anesthesia effectiveness and the importance of monitoring vital functions. The tasks: 1. Examine general anesthesia techniques by the small animal clinic.2. Monitoring indicators.3. Monitoring of common complications, their prevention and ways to remove them. After study shows that the development is an important vital functions the animal's age, breed, health status, complexity of procedures performed and the medicinal use for its intended purpose.

<p>UVOD. Bilijarna kalkuloza je najče&scaron;će oboljenje hepatobilijarnog sistema, a holecistektomija predstavlja jedan od najče&scaron;će izvođenih operativnih zahvata. Laparoskopska holecistektomija je danas zlatni standard lečenja holelitijaze. Laparoskopska holecistektomija je pokazala pobolj&scaron;anje u klinički značajnim ishodima kao &scaron;to su skraćenje operativnog vremena, kraća hospitalizacija, smanjenje jačine i trajanja postoperativnog bola i brži povratak dnevnim i radnim aktivnostima. Postoperativna bol i vreme potpunog oporavka ostaju dva glavna problema posle nekomplikovane laparoskopske holecistektomije koje bi trebalo pobolj&scaron;ati. Bol koji je povezan sa laparoskopskom holecistektomijom je kompleksan i multifaktorijalan. On nastaje o&scaron;tećenjem tkiva, disekcijom i uklanjanjem žučne kesice iz svoje lože, stimulacijom periportalnih nerava, iritacijom dijafragme, mehaničkim i hemijskim interakcijama gasa i pneumoperitoneuma, incizijama portova. Istraživanja su označila parijetalni i visceralni bol kao dva glavna mehanizma nastanka bola kod laparoskopske holecistektomije. Bol se ne može meriti nego proceniti jer je subjektivni osećaj. Pokazalo se potrebnim da se na čvr&scaron;ćim naučnim osnovama da odgovor na pitanje da li je moguće blokirati parijetalni i visceralni bol posle laparoskopske holecistektomije u akutnoj fazi. CILJEVI. Cilj studije je da uporedi standardnu analgeziju (ne-opioidnu) (grupa O) sa davanjem parijetalne blokade (grupa P), ili davanjem visceralne blokade (grupa V), ili sa obe date blokade (grupa P+V). Primarni ishodi studije su bolesnikov procenjeni bol pre operacije i posle operacije na 1, 2, 4, 6, 12, 24, 48 sati i 7. dana. Sekundarni ishodi studije su bolesnikova procenjena mučnina na 1,2,4,6,12 sati i bolesnikova procenjena mobilnost 1. 2. i 7. dan. HIPOTEZA. Blokada postoperativnog visceralnog bola i blokada postoperativnog parijetalnog bola posle laparoskopske holecistektomije putem intraperitonealne lokalne infiltracije anestetikom i putem lokalne infiltracije anestetikom pristupnih laparoskopskih portova može značajno smanjiti rani postoperativni bol. MATERIJAL I METODE. Ova prospektivna, randomizirana jednostruko slepa studija je započela septembra 2014. godine i trajala je do januara 2016. godine. Istraživanje je sprovedeno na Klinici za abdominalnu, endokrinu i transplantacionu hirurgiju i Urgentnom centru Kliničkog centra Vojvodine u Novom Sadu kod bolesnika operisanih metodom laparoskopske holecistektomije. Rad je podeljen u nekoliko celina. 1. Procena veličine uzorka; 2. Procena podobnosti za studiju; 3. Anketiranje i uključivanje u studiju; 4. Razvrstavanje u grupe i operativni rad; 5. Period postoperativnog praćenja; 6. Statistička obrada i pisanje rada.<br />1. Procena veličine uzorka. Studija je realizovana podelom bolesnika u 4 grupe. Neophodni broj bolesnika je izračunat uzimajući podatke iz pilot istraživanja slične studije iz 2012. godine. Veličina uzorka je računata za primarni ishod studije&nbsp; (bolesnikov procenjen bol sa NAS) na pretpostavci da treba biti 20% smanjenja bola u prvom postoperativnom satu, uz verovatnoću Tip 1 gre&scaron;ke &alpha;=0.05 i Tipa 2 gre&scaron;ke &beta;=0.10 da postigne adekvatnu statističku snagu oko 80% i da otkrije 20% razlike u srednjoj vrednosti procenjenog bola jedan sat nakon laparoskopske&nbsp; holecistektomije. Procenjeni broj ispitanika po grupama prema zadatim kriterijumima je bio (P+V=65; P=68; V=68; O=65). Studija je započela uključivanjem prvog bolesnika u studiju a zavr&scaron;ena ispunjenim periodom praćenja sve dok poslednji bolesnik nije doneo upitnike o bolu, mučnini i kretanju. 2. Procena podobnosti za studiju. U periodu studije ukupan broj holecistektomiranih bolesnika je bio 1024 (440 klasično i 584 laparoskopski). Samo pogodni bolesnici su anketirani (584) i pročitali su informacioni list o istraživanju. Uključivanje ili procena podobnosti bolesnika za studiju sprovedena je na osnovu uključnih i isključnih kriterijuma. U studiju nije uključeno ukupno 226 bolesnika. Od tog broja 82 bolesnika je odbilo učestvovati u studiji a 144 bolesnika nije ispunilo uključne postavljene kriterijume. Svojim potpisom potvrdilo je uče&scaron;će u studiji 358 bolesnika. 3. Anketiranje i uključivanje u studiju. Nakon prijema bolesnika u bolnicu ispitivači su uzimali anamnezu i bolesnicima je ponuđen informacioni list i informisani pristanak. Nakon čitanja informacije, potpisivanja informisanog pristanka i zadovoljavanja&nbsp; uključnih i isključnih kriterijuma 358 bolesnika je uključeno u studiju. Obavljena je preoperativna priprema i ispitivači su popunili deo podataka u individualnom listu. 4. Razvrstavanje u grupe i operativni rad. Neposredno preoperativno od strane nezavisne osobe neuključene u studiju napravljena je randomizacija izabranih (n=358) u studijske grupe tablicama slučajnog izbora, tako da bolesnici nisu znali kojoj grupi pripadaju, dok su operater i osoblje to znali na početku operacije (jednostruko slepa studija). Nakon randomizacije i operacije bolesnici pripadaju jednoj od sledeće 4 grupe: Kontrolna grupa O=89, u kojoj su bolesnici sa urađenom laparoskopskom&nbsp; holecistektomijom bez visceralne blokade anestetikom i bez parijetalne blokade anestetikom. Eksperimentalna grupa P=88, u kojoj su bolesnici sa urađenom laparoskopskom holecistektomijom bez visceralne blokade anestetikom i sa parijetalnom blokadom anestetikom. Eksperimentalna grupa V=92, u kojoj su bolesnici sa urađenom laparoskopskom holecistektomijom sa visceralnom blokadom anestetikom i bez parijetalne blokade anestetikom. Eksperimentalna grupa P+V=89, u kojoj će biti bolesnici sa urađenom laparoskopskom holecistektomijom sa visceralnom blokadom anestetikom i sa parijetalnom blokadom anestetikom. Primenjivan je uobičajni, standardni protokol anestezije za laparoskopske operacije kod svih ispitanika. Svim bolesnicima plasirana je orogastrična sonda koja se nakon operacije odstranjivala. Kod&nbsp; bolesnika kod kojih je primenjivan lokalni anestetik neposredno pre početka operacije pravio se rastvor lokalnog anestetika (Marcaine&reg; 0,25%). Bolesnici su otpu&scaron;teni sa bolničkog lečenja prvog postoperativnog dana, pod uslovom da nisu imali komplikacija. 5. Postoperativno praćenje i ispunjavanje upitnika. Po dolasku na odeljenje&nbsp; bolesnicima je odmah uključivana ista analgezija. Tokom ispunjavanja informisanog pristanka, bolesnici su dobili upitnik na kojoj će sami procenjivati nivo bola, mučnine i kretanja tokom ležanja u bolnici i vremena praćenja od 7 dana kući. Bolesnici su dolazili na unapred zakazane postoperativne kontrole 7 do 10 dana posle operacije i donosili ispunjene upitnike. Otpu&scaron;teno je i za praćenje ostalo n=302 laparoskopski operisanih bolesnika a isključeno iz studije n=20 bolesnika. 6. Statistička obrada i pisanje rada. Ukupno je analizirano 274 listića operisanih bolesnika: u Grupi P+V =67; u Grupi P =70; u Grupi V =70 i u Grupi O =67. Od osnovnih deskriptivnih statističkih parametara za kvalitativnu i kvantitativnu procenu dobijenih rezultata su kori&scaron;ćeni apsolutni brojevi, relativni brojevi, mediana, mod, aritmetička sredina i standardna devijacija (SD). Obrada podataka se vr&scaron;ila&nbsp; osnovnim i naprednim statističkim metodama i programima. Rezultati su prikazani tabelarno i grafički. REZULTATI. Demografski podaci. Ukupno je bilo 188 žena i 86 mu&scaron;karaca, u odnosu 2,2 : 1. Prosečna starost cele grupe je bila 52,1 &plusmn; 15,72 godine. Ukupno je bilo 179 zaposlenih i 95 nezaposlenih. Ukupno je bilo 45 ispitanika sa osnovnim obrazovanjem, 153 ispitanika sa srednjim obrazovanjem i 76 ispitanika sa visokim obrazovanjem. Ukupno je bilo 186 nepu&scaron;ača i 88 pu&scaron;ača. Prosečna vrednost BMI cele grupe je bila 27,24 &plusmn; 4,21 kg/m2. Prosečna vrednost ASA u celoj grupi je bila 2,03 (mediana=2, mod=2). Ne postoji statistički značajna razlika između posmatranih grupa u odnosu na posmatrane parametre. Laboratorijski podaci. Postoji statistički značajna razlika u vrednosti leukocita između posmatranih grupa (p=0,039), u vrednosti uree između posmatranih grupa (p=0,040). Ne postoji statistički značajna razlika u vrednosti eritrocita, trombocita, hemoglobina, &Scaron;UK-a, kreatinina i bilirubina posmatranih grupa. Operativni i postoperativni podaci. Ne postoji statistički značajna razlika u količini upotrebljenog Fentanila između posmatranih grupa. Postoji statistički značajna razlika u dužini trajanja operacije između posmatranih grupa (p=0,003), u trajanju postavljenog abdominalnog drena između posmatranih grupa (p=0,024), u trajanju hospitalizacije između posmatranih grupa (p=0,027), u broju dana do povratka uobičajenim aktivnostima između posmatranih grupa (p=0,000), u broju uzetih tableta između posmatranih grupa (p=0,000). Prosečna ocena zadovoljstva bolesnika posle operacije u celoj grupi je bila 8,80 (mediana=9; mod=10). Najbolju ocenu zadovoljstva bolesnika posle operacije je imala grupa P+V. Procena bola, mučnine i kretanja. Postoji statistički značajna razlika između posmatranih grupa u proceni jačine bola pre operacije (p=0,003). Postoji statistički značajna razlika između posmatranih grupa u proceni jačine bola 1h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 2h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 4h posle operacije (najbolju procenu bola je imala grupa P); u proceni jačine bola 6h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 12h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 24h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 48h posle operacije (najbolju procenu bola je imala grupa P) i u proceni jačine bola 7 dana posle operacije (najbolju procenu bola je imala grupa P). Procenjena bol se pojačava otprilike 2,5 sata posle operacije sa vrhom 3 sata posle operacije, a smanjuje se na istu vrednost kao 2. sata posle operacije, otprilike 5. sata posle operacije. U vremenskim intervalima 1, 2. i 7. postoperativni dan postoji značajno pobolj&scaron;anje u postoperativnoj mobilnosti bolesnika. U vremenskim intervalima 1, 2, 4, 6 i 12 sati postoji značajno pobolj&scaron;anje u procenjenoj vrednosti mučnine bolesnika. Korelacije. Statistički značajna pozitivna korelacija ocene bola posle 1. sata, posle 2. sata, posle 6. sata, posle 12. sata je utvrđena sa brojem uzetih tableta (p=0,000), kao i procene mučnine (p=0,000). Statistički značajna pozitivna korelacija procene bola posle 4. sata je utvrđena sa brojem uzetih tableta (p=0,006), kao i aktivnosti (p=0,014). Statistički značajna korelacija procene bola posle 24. sata je utvrđena sa brojem uzetih tableta (p=0,000; pozitivna) i trajanjem operacije (p=0,028; negativna). Statistički značajna pozitivna korelacija procene bola posle 48. sata i posle 7 dana je utvrđena sa brojem uzetih tableta (p=0,000). ZAKLJUČCI: Primena lokalnog anestetika datog na bilo koji način značajno smanjuje bol posle laparoskopske holecistektomije. Primena lokalnog anestetika datog i&nbsp; portalno i visceralno (P+V) značajno smanjuje bol u odnosu na samo portalnu (P) ili visceralnu (V) primenu u vremenskim intervalima 2, 6, 12 sat posle laparoskopske holecistektomije. Portalna (P) primena sa ili bez visceralne (V) primene lokalnog anestetika značajno smanjuje bol u vremenskim intervalima 1, 4, 24, 48 sati i 7 dana posle laparoskopske holecistektomije. Najbolje kretanje je bilo u grupi P+V posle laparoskopske holecistektomije. Najbolje smanjenje procenjene mučnine je bilo u grupi P posle laparoskopske holecistektomije. Najraniji povratak uobičajenim aktivnostima zabeležen je u grupi P+V. Najbolja ocena zadovoljstva bolesnika hirur&scaron;kim lečenjem bila je u grupi P+V. Postoperativna bol ima najznačajniju pozitivnu korelaciju sa procenjenom mučninom i brojem tableta uzetih od momenta otpusta do prve kontrole bolesnika.</p> / <p>INTRODUCTION: Biliary calculosis is the most frequent disease of the hepatobiliary system, and cholecystectomy is one of the most frequently performed surgical procedures. Today laparoscopic cholecystectomy represents the golden standard in treating cholelithiasis. Laparoscopic cholecystectomy showed improvement in the clinically significant outcomes, such as: reducing the duration of the surgery, shorter hospital stay, reducing the intensity and duration of postoperative pain and faster return to normal daily and working activities. Postoperative pain and the time of full recovery remain the two major problems after a non-complicated laparoscopic cholecystectomy and they should be improved. The pain related to laparoscopic cholecystectomy is complex and multi-factorial in origin. The pain occurs due to damaged tissues, dissection and removal of gallbladder from its cavity, stimulation of periportal nerves, irritation of the diaphragm, mechanical and chemical interaction of gases and pneumoperitoneum and port incisions. Researches have denoted parietal and visceral pains as two major mechanisms in occurrence of pain in laparoscopic cholecystectomy. Pain cannot be measured, but estimated, as it is a subjective feeling. It was considered necessary to find the answer, based on solid scientific evidence, if it was possible to block parietal and visceral pain after laparoscopic cholecystectomy in its acute phase. OBJECTIVES: The aim of this study is to compare standard, non-opioid, analgesia (group O) with applying parietal blockade (group P), or visceral blockade (group V), or compare with both applied blockades (group P+V). The primary outcomes of the study are the patient&acute;s estimated pain before surgery and 1, 2, 4, 6, 12, 24, 48 hours and 7th day after the surgery. The secondary outcomes of this study are the patient&acute;s estimated nausea level during 1, 2, 4, 6, 12 hours, along with the patient&acute;s estimated mobility 1st, 2nd and 7th day, postoperatively. HYPOTHESIS. Blockade of postoperative visceral pain and blockade of postoperative parietal pain following laparoscopic cholecystectomy, applying intraperitoneal local infiltration with anesthetic and also by local infiltration with anesthetic through accessible laparoscopic ports, can significantly reduce early postoperative pain. MATERIAL AND METHODS: This prospectively randomized single-blinded study started in September 2014 and lasted up to January 2016. The research was carried out at the Clinic for Abdominal, Endocrine and Transplantation Surgery and Emergency Center, Clinical Center of Vojvodina in Novi Sad and it involved patients who underwent laparoscopic cholecystectomy. This study has been divided into several units. 1. Assessment of sample size; 2. Assessment of eligibility for the study; 3. Survey and inclusion in the study; 4. Group formation and operational work; 5. Period of postoperative follow-up; 6. Statistical processing and writing the paper.1. Assessment of sample size. The study was realized by dividing the patients into 4 groups. The number of patients necessary was determined based on the data taken as pilot study from a similar study from 2012. Sample size was calculated for the primary outcome of the study (patient&acute;s estimated pain with NAS) based on the assumption that a pain reduction of 20% should occur during the first postoperative hour, with the probability of Type 1 error &alpha;=0.05 and Type 2 error &beta;=0.10 to reach the adequate statistical power of about 80%, and to reveal 20% difference in the average value of the estimated pain one hour after the laparoscopic cholecystectomy. The assessed number of respondents in groups according to the set criteria was (P+V =65;P =68;V =68; O =65). The study started when the first patient was included and it ended with the complete follow-up period when the last patient handed in the survey about pain, nausea and mobility. 2. Assessment of eligibility for the study. During the study the number of patients undergoing surgery applying the method of cholecystectomy was 1024 (440 classical and 584 laparoscopic). Only the suitable patients were surveyed (584) and given to read the information leaflet about the study. Inclusion and assessment of patients&acute; eligibility was performed on the basis of inclusion and exclusion criteria. A total of 226 patients was not included in the study. Out of that number 82 patients refused to participate in the study and 144 did not fulfill the inclusive criteria set. By signing 358 patients confirmed their participation in the study. 3. Survey and inclusion in the study. After admitting the patients to hospital the surveyors took their anamnesis and the patients were offered an information leaflet and informed consent. Following the reading of the information leaflet, signing the informed consent and satisfying the criteria for inclusion and exclusion, 358 patients were included in the study. Preoperative preparations were performed and the surveyors filled in some of the data on the individual list. 4. Group formation and operational work. Prior to the surgery an independent person not included in the study carried out the randomisation of the patients chosen (n=358) into study groups by random selection tables. The patients did not know which group they belonged to, while it became known to the surgeon and the operation stuff at the beginning of the surgery (singleblinded study). After randomization and surgery the patients belonged to one of the following groups: Control group O=89 of patients with performed laparoscopic cholecystectomy without visceral blockade by anesthetic and without parietal blockade by anesthetic. Experimental group P=88 of patients with performed laparoscopic cholecystectomy without visceral blockade by anesthetic but with parietal blockade by anesthetic. Experimental group V=92 of patients with performed laparoscopic cholecystectomy with visceral blockade by anesthetic but without parietal blockade by anesthetic. Experimental group P+V=89 of patients with performed laparoscopic cholecystectomy with visceral blockade by anesthetic and with parietal blockade by anesthetic. The standard protocol of anesthesia for laparoscopic cholecystectomy was applied to all patients. An orogastric tube used during the surgery, was removed after it. In patients with applied local anesthetic immediately before surgery a solution of local anesthetic was made (Marcaine&reg; 0,25%). The patients were discharged from hospital the first postoperative day, provided that no complications occurred. 5. Postoperative follow-up and completing the questionnaire. When admitted to the ward the patients were given the same kind of analgesia. While completing the informed consent the patients were given a questionnaire for estimating their pain level, nausea and mobility during their stay in hospital and during the 7-day follow-up period at home. The patients were required to come for 7 and 10-day postoperative check-ups by appointment and then they handed in the questionnaires. n=302 patients with performed laparoscopic cholecystectomy were released and designated for follow-up, and n=20 patients were excluded from the study. 6. Statistical processing and writing the paper. In total 274 operated patients&acute; slips were analysed, by groups as follows: in Group P+V =67; in Group P =70; in Group V =70 and in Group O =67. From the basic descriptive statistical parametres for qualitative and quantitative assessment of results obtained, absolute numbers, relative numbers, the median, mode, arithmetic mean and standard deviation (SD) were used. Data processing was carried out using basic and advanced statistical methods and programmes. The results are presented in tabular and graphical manner. RESULTS. Demographic data. In total there were 188 women and 86 men, in proportion 2,2 : 1. The average age of the whole group was 52,1 &plusmn; 15,72 years. In total there were 179 employed and 95 unemployed persons. In total there were 45 surveyed patients with primary education, 153 surveyed patients with secondary education and 76 surveyed patients with higher education. In total there were 186 nonsmokers and 88 smokers. The mean BMI value of the whole group was 27,24 &plusmn; 4,21 kg/m2. The mean value of ASA of the whole group was 2,03 (the median=2, mode=2). There is no significant difference among the groups observed considering the observed parametres. Laboratory data. There is a statistically significant difference in the value of leukocytes among the observed groups (p=0,039), and in the value of urea among the observed groups (p=0,040). There is no statistically significant difference in the value of the erythrocyte, platelets, hemoglobin, blood glucose, creatinine and bilirubin of the&nbsp; observed groups. Operative and postoperative data. There is no statistically significant difference in the amount of Fentanyl&reg; applied among the observed groups. There is statistically significant difference in the length of the surgery among the observed groups (p=0,003), in the duration of the positioning of abdominal drainage among the observed groups (p=0,024), in the duration of hospital stay among the observed groups (p=0,027), in the number of days until getting back to regular activities among the observed groups&nbsp; (p=0,000), in the number of taken pills among the observed groups (p=0,000). The patients&acute; average satisfaction grade after surgery in the whole group was 8,80 (the median=9; mode=10). Group P+V had the best patient&lsquo;s satisfaction grade after the surgery. Assessment of pain, nausea and mobility. There is statistically significant difference in the estimation of pain intensity before surgery among the observed groups (p=0,003). There is statistically significant difference in the estimation of pain intensity 1 hour after surgery among the observed groups (P+V having the best estimated pain); in the estimation of pain intensity 2 hours after&nbsp; surgery (P+V having the best estimated pain); in the estimation of pain intensity 4 hours after surgery (P having the best estimated pain); in the estimation of pain intensity 6 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 12 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 24 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 48 hours after surgery (P having the best estimated pain) also in the estimation of pain intensity 7 days after surgery (P having the best estimated pain). The estimated pain intensifies at about 2,5 hours after surgery and peaks 3 hours after surgery, and decreases to the same level as it was during 2nd hour after surgery approximately during 5th hour after surgery. There is considerable improvement in mobility of patients in the time interval 1st, 2nd and 7th postoperative days. There is considerable improvement in estimated nausea level of patients in the time interval 1, 2, 4, 6 and 12 hours. Correlations. Statistically significant positive correlation in estimated pain after 1st hour, after 2nd hour, after 6th hour and after 12th hour was determined by the number of tablets taken (p=0,000), just like the estimated nausea level (p=0,000). Statistically significant positive correlation in estimated pain after 4th hour was determined by the number of tablets taken (p=0,006), just like the activities (p=0,014). Statistically significant positive correlation in estimated pain after 24th hour was determined by the number of tablets taken (p=0,000; positive), and by the duration of the surgery (p=0,028; negative). Statistically significant positive correlation in estimated pain after 48th hour and after 7 days was determined by the number of tablets taken (p=0,000). CONCLUSIONS: The application of local anesthetic, regardless of how it was applied, considerably reduces pain after laparoscopic cholecystectomy. The application of local anesthetic by port or viscerally (P+V) considerably reduces pain compared to only by port (P) or only visceral (V) application in the time intervals of 2, 6, and 12 hours after laparoscopic cholecystectomy. The application of local anesthetic by port (P), with or without visceral (V), considerably reduces pain in the time intervals of 1, 4, 24, and 48 hours and 7 days after laparoscopic cholecystectomy. The best mobility was shown by group P+V after laparoscopic cholecystectomy. Estimated nausea was most reduced in group P after laparoscopic cholecystectomy. Group P+V presented the earliest return to regular activities. The best patients&acute; satisfaction grade with surgical treatment was shown by group P+V. Postoperative pain is most considerably positively correlated with the estimated nausea and pills taken, from the moment of patient&acute;s release from hospital to the first check-up.<br />&nbsp;</p>