ttp://www.bsava.

com CAPSULE REVIEW

Intraperitoneal and incisional analgesia

in small animals: simple, cost-effective
techniques
P. V. M. Steagall 1,*, J. Benito*, B. Monteiro *, D. Lascelles†, P. W. Kronen‡, J. C. Murrell §
,
S. Robertson¶, B. Wright║ and K. Yamashita**
*
Department of Clinical Sciences, Université de Montréal, Montreal, Quebec J2S 2M2, Canada
†
Translational Research in Pain Program, Comparative Pain Research and Education Center, College of Veterinary Medicine,
North Carolina State University, Raleigh, North Carolina 27606, USA
‡
Veterinary Anaesthesia Service – International, Winterthur 8400, Switzerland
§
Highcroft Veterinary Referrals, Whitchurch, Bristol BS14 9BE, UK
¶
Lap of Love Veterinary Hospice, Lutz, Florida 33549, USA
║
Mistral Vet, Fort Collins, Colorado 80534, USA
**
Small Animal Clinical Sciences, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8501, Japan
Corresponding author email: paulo.steagall@umontreal.ca

The World Small Animal Veterinary Association Global Pain Council (WSAVA-GPC) has recently pub-
lished its first “capsule review” by Monteiro et al. These are short articles that present a brief assess-
ment of the scientific evidence and practical recommendations on important, and sometimes
controversial, subjects in pain management. The capsules will be published regularly in the Journal of
Small Animal Practice, the official journal of the WSAVA. This second article discusses the use of
intraperitoneal and incisional analgesia in small animal practice, including their limitations and recom-
mendations by the authors.

Journal of Small Animal Practice (2019)

DOI: 10.1111/jsap.13084
Accepted: 30 September 2019

Local anaesthetics inhibit membrane depolarisation, nerve exci- CANINE STUDIES

tation and conduction primarily by blocking inward Na+ currents
through voltage-gated Na+ channels. These drugs are inexpen-
sive, not scheduled, and are readily available world-wide. Intra-
peritoneal (IP) administration of local anaesthetics reduces early
postoperative analgesic requirements, time to first-intervention
analgesia and pain scores after abdominal surgery in humans; it
is currently recommended for laparoscopic surgery as an adju-
vant analgesic technique (Boddy et al. 2006, Kahokehr et al.
2011, Hamill et al. 2017). Based on these results in the human
literature, the WSAVA-GPC (Monteiro et al. 2019) guidelines
recommended IP and incisional analgesia for the management
of pain, particularly as adjuvant techniques for pain relief in dogs
and cats undergoing abdominal surgery (Mathews et al. 2014).
Both techniques are described and demonstrated in the following
link (https://www.youtube.com/watch?v=76dwKuirqt0). Recent
studies have corroborated these findings, which are summarised
in this capsule and in Tables 1 and 2.
The pharmacokinetics of lidocaine 2% after combined IP (8 mg/
kg with epinephrine 1:400,000) and incisional (2  mg/kg with
epinephrine 1:200,000) administration showed that plasma drug
concentrations decreased rapidly after injection and did not reach
toxic concentrations (Wilson et al. 2004).
In a randomised, clinical trial, dogs that received butorpha-
nol plus bupivacaine 0.75% IP (4.4 mg/kg) and at the incision
(splash of 2 mL over the incision site) required significantly less
supplemental analgesia and had lower pain scores than control
dogs (i.e. butorphanol only) (Carpenter et al. 2004). In this same
study, similar results were not observed after the administration
of 8.8 mg/kg IP and incisional (2 mL total) lidocaine 2% with
epinephrine. However, at the 0.5-hour time point, the lidocaine
group was assessed to have a pain level intermediate between the
saline and bupivacaine groups. Based on the duration of action and
the results described above, longer-acting local anaesthetics such
as bupivacaine or ropivacaine should be probably preferred for

Journal of Small Animal Practice • © 2019 British Small Animal Veterinary Association 1
 P. V. M. Steagall et al.

Table 1. Summary of studies evaluating the effects after the administration of intraperitoneal and/or incisional
anaesthetics in dogs undergoing abdominal procedures
Technique Drug Dose Number Procedure Main findings References
of dogs
IP and IC Lidocaine 2% with IP: 8 mg/kg 6 OVH Plasma concentrations were Wilson et al. 2004
epinephrine IC: 2 mg/kg below toxic levels.
IP and IC Lidocaine 2% with Lido: 8.8 mg/kg 30 OVH Butorphanol with IP and Carpenter et al.
epinephrine or (IP) + 40 mg total (IC) IC anaesthesia using 2004
Bupivacaine 0.75% Bupi: 4.4 mg/kg bupivacaine resulted in
(IP) + 15 mg (IP) lower pain scores and less
need of rescue analgesia
than butorphanol only.
IP and IC Bupivacaine 0.5% IP: 4.4 mg/kg 16 Laparoscopic IP and IC anaesthesia Kim et al. 2012
IC: 5 mg total OVH resulted in lower pain
scores than IC anaesthesia
only.
IC Bupivacaine 0.25% IC: 2 mg/kg 60 Celiotomy Preoperative IC anaesthesia Savvas et al. 2008
resulted in lower pain
scores and less need
of rescue analgesia
than postoperative IC
anaesthesia.
Mesovarium Lidocaine 2% Mesovarium: 10 mg 20 OVH Methadone with local Bubalo et al. 2008
and IC total anaesthesia of the
IC: 2 mg/kg mesovarium and IC
anaesthesia did not reduce
autonomic responses to
surgery.
IC Bupivacaine (unknown IC: 2 mg/kg 92 OVH Morphine and carprofen Fitzpatrick et al.
concentration) with preoperative 2010
or postoperative IC
anaesthesia resulted in
similar pain scores than
morphine only.
IC Lidocaine with Lido: 4 mg/kg 59 OVH Morphine with or without IC McKune et al.
Bupivacaine Bupi: 1 mg/kg anaesthesia using lidocaine 2014
(unknown and bupivacaine resulted
concentrations) in similar pain scores to
controls (i.e. saline).
IP or IC Bupivacaine 0.5% with IP: 5 mg/kg 30 OVH Butorphanol with IP Campagnol et al.
epinephrine IC: 1 mg/kg anaesthesia resulted in 2012
lower pain scores than
controls (i.e. saline).
Butorphanol with IC
anaesthesia was not
different from controls.
IP alone or Bupivacaine 0.5% IP: 3 mg/kg 39 OVH Morphine and carprofen with Kalchofner
with IC IC: 1 mg/kg IP anaesthesia resulted Guerrero et al.
in similar pain scores to 2016
morphine and carprofen with
IP and IC anaesthesia.
IP Ropivacaine 0.75% or Ropi: 3 mg/kg 45 OVH Morphine and carprofen Lambertini et al.
Bupivacaine 0.5% Bupi: 3 mg/kg with IP anaesthesia using 2018
ropivacaine or bupivacaine
resulted in similar pain
scores and need of rescue
analgesia.
IP Intraperitoneal, IC Incisional, Lido Lidocaine, Bupi Bupivacaine, Ropi Ropivacaine, OVH Ovariohysterectomy

these techniques. In dogs undergoing laparoscopic ovariohyster-
ectomy, preoperative incisional (i.e. before the portal placement)
bupivacaine 0.5% (1 mL) and bupivacaine sprayed IP (4.4 mg/
kg; IP dose only) provided pain relief and prevented surgery-
induced increases in cortisol concentration (Kim et al. 2012). It is
not known whether the postoperative analgesic effects observed in
these studies were due to the IP or incisional technique.
The effects of incisional anaesthesia alone have been inves-
tigated further and provide conflicting results. Preoperative
administration of incisional (i.e. subcutaneous and intramus-
cular infiltration) bupivacaine 0.25% (2 mg/kg) was associated
with significantly lower pain scores and less need for postop-
erative opioid administration when compared with postopera-
tive administration of incisional bupivacaine or placebo in dogs
undergoing celiotomy (Savvas et al. 2008). This study demon-
strated the benefits of pre-emptive administration of incisional
anaesthesia. Conversely, incisional infiltration of the linea alba
with lidocaine 1% (2 mg/kg) and anaesthesia of the mesovarium

2 Journal of Small Animal Practice • © 2019 British Small Animal Veterinary Association
 WSAVA global pain council capsules

Table 2. Summary of studies evaluating the effects after the administration of intraperitoneal and/or incisional
anaesthetics in cats undergoing abdominal procedures
Technique Drug Dose Number of cats Procedure Main findings References
IP Bupivacaine 0.25% Bupi: 2 mg/kg 8 OVH Plasma concentrations were below Benito et al. 2016a
toxic levels.
IP Bupivacaine 0.25% Bupi: 2 mg/kg 45 OVH Buprenorphine administered in Benito et al. 2016b
combination with IP anaesthesia
resulted in similar pain scores and
need for rescue analgesia when
compared with buprenorphine and
meloxicam, and in lower pain scores
than buprenorphine alone.
IP Bupivacaine 0.25% Bupi: 2 mg/kg 16 OVH Plasma concentrations of IP Benito et al. 2018
with epinephrine or anaesthesia using bupivacaine with
dexmedetomidine epinephrine or dexmedetomidine
were below toxic levels.
Buprenorphine and meloxicam
with IP anaesthesia using
bupivacaine with epinephrine or
dexmedetomidine provided similar
analgesia.
IP Bupivacaine 0.25% Bupi: 2 mg/kg 60 OVH In terms of prevalence of rescue Benito et al. 2019
alone or with analgesia, but not duration of
dexmedetomidine action, the analgesic efficacy of
bupivacaine-dexmedetomidine was
similar to bupivacaine alone.
IP Intraperitoneal, IC Incisional, Bupi Bupivacaine, Epi Epinephrine, Dex Dexmedetomidine, OVH Ovariohysterectomy

(0.5  mL of lidocaine 2%) did not blunt autonomic responses
to surgery (Bubalo et al. 2008). Furthermore, two other stud-
ies did not show any benefits of incisional anaesthesia in dogs
undergoing ovariohysterectomy either because the technique
was administered as part of multimodal analgesia (Epstein et al.
2010, Fitzpatrick et al. 2010) or because of the challenges of rec-
ognising pain in the clinical setting (McKune et al. 2014).
IP and incisional techniques were compared in a prospective,
randomised, placebo-controlled, clinical study. IP (5 mg/kg) or
incisional (i.e. subcutaneous infiltration of linea alba at 1 mg/kg)
bupivacaine 0.5% with epinephrine was evaluated in dogs under-
going ovariohysterectomy and receiving butorphanol. Pain scores
based on a visual analog scale were significantly lower after IP
bupivacaine than in controls (i.e. butorphanol only). Although
there was a trend for a decreased need for rescue analgesia in the
IP bupivacaine group, this was not significantly different between
saline and bupivacaine treatments, most likely due to small sam-
ple size and scoring systems used for acute pain assessment (Cam-
pagnol et al. 2012). Based on these findings, the WSAVA-GPC
suggests that the IP route of administration should be given prior-
ity over the incisional technique when maximum recommended
doses and volumes of local anaesthetics are used, to avoid toxic-
ity. Finally, a recent study did not show any benefits of using IP
(3 mg/kg) and incisional (i.e. subcutaneous “splash” of 1 mg/kg)
bupivacaine over the IP technique alone before complete closure
of the linea alba after ovariohysterectomy in dogs. However, as
previously observed with incisional anaesthesia (Fitzpatrick et al.
2010), the results were likely confounded by the concurrent use
of other analgesics such as morphine and carprofen (Kalchofner
Guerrero et al. 2016). In a follow-up study, the IP administration
of ropivacaine 0.75% (3 mg/kg) or bupivacaine 0.5% (3 mg/kg)
without incisional anaesthesia provided similar postoperative
analgesia when administered in combination with morphine and
carprofen (Lambertini et al. 2018) but 15 out 44 dogs required
the administration of rescue analgesia.
So-called incisional “splash block” techniques have, as
described above, been incorporated into several studies. How-
ever, thus far, no studies have evaluated the efficacy of an inci-
sional “splash” block, and indeed, it is unclear what is meant
by a splash block. For example, the IP technique has been also
referred as a “splash block”. Carpenter et al. 2004 placed local
anaesthetic on the wound and “no attempt was made to prevent
it from running off during closure”. Conversely, a “splash block”
was described where sutures were used to elevate wound edges to
keep the local anaesthetic in contact with the wound tissues for
20 minutes in dogs undergoing ear canal ablation (Buback et al.
1996). The WSAVA-GPC cautions against relying on splashing
local anaesthetic onto a wound since there is usually not enough
time for drug absorption. Of note is that this early description in
human paediatrics described the technique as “installation”, not
“splash” – the term splash was used later.
FELINE STUDIES
The pharmacokinetics, safety and efficacy of IP bupivacaine
have recently been published in cats (Benito et al. 2016a,
2016b, 2018). The IP technique was always performed imme-
diately before ovariohysterectomy by the same experienced
surgeon. A pharmacokinetic study revealed that plasma con-
centrations of IP bupivacaine 0.25% (2 mg/kg) were detectable,
but at much lower concentrations than those associated with
toxic effects (Benito et al. 2016a); outwardly detectable adverse
effects were not observed in these cats. In a randomised, pro-

Journal of Small Animal Practice • © 2019 British Small Animal Veterinary Association 3
 P. V. M. Steagall et al.
spective, controlled clinical trial, IP bupivacaine 0.25% (2 mg/
kg) in cats premedicated with buprenorphine showed similar
postoperative pain scores and prevalence of rescue analgesia
when compared with cats receiving meloxicam and buprenor-
phine, and superior analgesia than buprenorphine alone. Anal-
gesic effects were observed for up to 8  hours postoperatively
(Benito et al. 2016b). The efficacy and pharmacokinetics of IP
bupivacaine 0.25% in combination with epinephrine (2  μg/
kg) or dexmedetomidine (1 μg/kg) in cats undergoing ovario-
hysterectomy have also been investigated (Benito et al. 2018).
These adjuvant drugs can produce local vasoconstriction which
delays systemic absorption and improves the safety and efficacy
of IP anaesthesia. Both treatments produced plasma concen-
trations below toxic levels and similar analgesic effects when
administered with buprenorphine and meloxicam. These adju-
vant drugs produced delayed absorption and a longer terminal
half-life when compared with bupivacaine alone (Benito et al.
2018). However, the prevalence of rescue analgesia was not sig-
nificantly different between IP bupivacaine alone and bupiva-
caine in combination with dexmedetomidine in a clinical trial
involving 60 cats undergoing ovariohysterectomy (Benito et al.
2019). It appears that the use of such vasoactive drugs for IP
analgesia is not supported by strong evidence at this time. The
intraoperative effects of incisional anaesthesia on physiologic
parameters have been reported in cats anaesthetised with ket-
amine-medetomidine-buprenorphine for ovariohysterectomy.
The technique partially blunted sympathetic responses to sur-
gery when using preoperative incisional lidocaine 1% (1.5 mg/
kg) or the combination of lidocaine 1% and bupivacaine
0.25% (1  mg/kg for each drug), but not saline (0.3 mL/kg)
(Vicente & Bergstrom 2018).
INDICATIONS FOR IP AND INCISIONAL
ANAESTHESIA
Based on the aforementioned study findings and a consensus of
the WSAVA GPC members, some recommendations are pre-
sented below:
• It is our consensus that these techniques should be used
for any type of abdominal surgery such as intestinal for-
eign body removal, enterotomy, splenectomy, etc. Further
research should investigate and provide evidence on the ben-
efits of incisional and IP techniques for these procedures.
• Based on the safety and efficacy of IP analgesia with bupiva-
caine as part of multimodal analgesia in dogs and cats (Car-
penter et al. 2004, Campagnol et al. 2012, Benito et al. 2016a,
2016b, 2018), this technique should be readily applied in ster-
ilisation programs, especially in countries with limited drug
availability.
• They should always be performed under strict aseptic condi-
tions and general anaesthesia. There is no evidence that these
techniques should replace other analgesics such as nonsteroidal
anti-inflammatory drugs (NSAIDs) but, rather, should be used
in addition.
4 Journal of Small Animal Practice
• IP and incisional analgesia should be used as part of a mul-
timodal analgesic plan (Benito et al. 2018). For example, the
combination of an opioid, NSAID and IP and incisional
anaesthesia provides adequate postoperative analgesia in cats
undergoing ovariohysterectomy (Benito et al. 2018).
• Total doses of bupivacaine 0.5% should not exceed 4 mg/kg in
dogs and 2 mg/kg in cats (Benito et al. 2016a, 2016b, 2018).
Based on the experience of the authors, if both techniques are
used, one-fourth of the total dose is administered for inci-
sional anaesthesia whereas the remaining volume is used for
IP analgesia.
• In cats, bupivacaine 0.5% can be diluted in equal parts with
saline to increase the volume of IP injection. The final concen-
tration before drug administration is then 0.25% (Benito et al.
2016a, 2016b, 2018).
• Based on the concept of pre-emptive analgesia and the study by
Savvas et al. (2008), preoperative administration of incisional
anaesthesia is preferred over postoperative use.
LIMITATIONS
The current literature on IP and incisional analgesia has several
limitations. Published studies used different surgeons and anaes-
thetists with different clinical experience (including veterinary
students and other individuals under training), and with differ-
ent doses, drugs and volumes of local anaesthetics (Tables 1 and
2). The definition of incisional anaesthesia, timing of incisional
injection (pre- versus post-operative) and location of IP adminis-
tration varied which renders results difficult to interpret. Acute
pain assessment was performed using different pain scoring sys-
tems that have variable validity. The amount of observer training
in pain assessment is not often described and may be a significant
source of bias in the interpretation of these results.
In conclusion, based on current evidence, the WSAVA-GPC
supports both techniques for the treatment of perioperative pain
as part of a multimodal analgesia regimen. IP and incisional anaes-
thesia are simple, safe and cost-effective adjunct methods to reduce
pain after abdominal surgery in companion animals and are not
limited by geographical drug availability. However, readers should
be aware that some of our recommendations were based on a con-
sensus and low-level of evidence provided by the current litera-
ture. Future studies should continue to investigate the efficacy and
safety of both techniques in a large number of clinical patients.
Conflict of interest
No conflict of interest has been declared.
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