Postoperative Analgesic Efficacy of Intraperitoneal Bupivacaine With Tramadol Versus Bupivacaine Alone in Laparoscopic Surgeries: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Abstract

Background and Objectives:

Despite widespread adoption of laparoscopic surgery, effective management of postoperative pain arising from peritoneal irritation, port-site trauma, and residual carbon dioxide remains an unresolved clinical challenge. Intraperitoneal local anaesthetic instillation has been advocated as a component of multimodal analgesic strategies. This systematic review and meta-analysis was conducted to synthesise evidence from randomised controlled trials published between January 2020 and December 2025 evaluating the postoperative analgesic efficacy, opioid-sparing effect, and safety of intraperitoneal bupivacaine combined with tramadol (Group BT) versus bupivacaine alone (Group B) in patients undergoing elective laparoscopic procedures.

Methods:

A systematic literature search was performed across PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, and ClinicalTrials.gov for studies published from January 2020 to December 2025, adhering to PRISMA 2020 guidelines. Two independent reviewers screened titles, abstracts, and full texts for eligibility. Randomised controlled trials comparing intraperitoneal bupivacaine combined with tramadol against intraperitoneal bupivacaine alone in adult patients undergoing elective laparoscopic surgery were included. Primary outcomes were Visual Analogue Scale (VAS) pain scores and time to first rescue analgesic. Secondary outcomes comprised total 24-hour rescue analgesic consumption, incidence of adverse effects, and haemodynamic parameters. Statistical pooling employed the random-effects model (DerSimonian–Laird method). Heterogeneity was assessed using the I² statistic and Cochran Q test. Risk of bias was evaluated using the revised Cochrane RoB 2.0 tool.

Results:

Eight randomised controlled trials encompassing 760 patients (380 in each treatment arm) were identified and included in the quantitative synthesis. Pooled analysis demonstrated that Group BT was associated with significantly lower VAS pain scores at 2 hours (mean difference [MD] −12.84 mm, 95% CI: −16.02 to −9.66; I²=46%; p<0.001), 6 hours (MD −10.62 mm, 95% CI: −13.88 to −7.36; I²=52%; p<0.001), and 24 hours (MD −6.74 mm, 95% CI: −9.12 to −4.36; I²=38%; p<0.001) postoperatively. Time to first rescue analgesic was significantly prolonged in Group BT (MD +82.4 min, 95% CI: +64.2 to +100.6; I²=48%; p<0.001). Total 24-hour rescue analgesic consumption was markedly reduced in Group BT (MD −38.6 mg diclofenac equivalent, 95% CI: −48.2 to −29.0; I²=42%; p<0.001). The incidence of nausea and vomiting was comparable between groups (risk ratio 1.38, 95% CI: 0.92 to 2.08; p=0.12). No serious adverse events were documented in either group across included trials.

Conclusion:

This meta-analysis demonstrates that intraperitoneal instillation of bupivacaine combined with tramadol provides statistically and clinically superior postoperative analgesia compared with bupivacaine monotherapy in laparoscopic surgery. The combination significantly reduces pain intensity across all postoperative time points, prolongs the analgesic interval, and reduces rescue analgesic consumption, without a significant increase in adverse effects. This pharmacologically synergistic combination merits integration into routine multimodal perioperative analgesic protocols for laparoscopic procedures.