The management of postoperative pain is a key to patient early recovery, in particular, where the surgery was performed to benefit another human being. In recent years it has been recognized that multimodal analgesic methods are superior for postoperative pain relief. It is also imperative to remember that inadequately managed acute postoperative pain opens the doorway to possible suffering from chronic postoperative pain later. Although the laparoscopic donor nephrectomy has reduced the disincentives associated with open surgery, still significant percentage of donors suffers from postoperative pain. In the UK, patient-controlled analgesic system (PCAS) using morphine for postoperative pain relief is being used in majority of the transplant centres. Though opioids provide good analgesia, they are far from being an ideal analgesic due to their adverse effects. This paper pragmatically looks in depth on different modalities of pain management in patients undergoing laparoscopic live donor nephrectomy. 1. Introduction The donor nephrectomy is a procedure carried out to benefit another individual and in addition it can add a lot of disincentives to the donor. Subjecting a patient to an open operation leads to increased hospital inpatient stay and a much more painful large scar, thus not only discouraged the potential donors, but also it leads to increased morbidity for long time. This has stimulated the surgeons to come up with an alternative, the laparoscopic donor nephrectomies. The first laparoscopic live donor nephrectomy (LLDN) was performed by Ratner et al.  at the Johns Hopkins Bay view Medical Center, Baltimore, USA in February 1995. The donor was discharged on first postoperative day and returned to work 2 weeks later. This technique thus revolutionized the donor nephrectomy and also removed the added disincentives of open operation. LLDN is now the preferred method and gold standard operation for kidney donation. Although the LLDN is associated with the longer operation time, it has reduced morphine requirement, hospital stay, and postoperative complications with an early return to work . Randomized controlled trials and systematic reviews confirmed that LLDN is safe and reduce the morbidity following the operation [2–4]. 2. Pain after LLDN Pain following the LLDN is multifactorial. Port pain, low abdominal incisions (to retrieve the kidney), pelvic organ nociception, diaphragmatic irritation (shoulder tip discomfort from residual pneumoperitoneum), urinary catheter discomfort add-up and contribute to the total pain experience. Several
F. Greco, M. R. Hoda, A. Alcaraz, A. Bachmann, O. W. Hakenberg, and P. Fornara, “Laparoscopic living-donor nephrectomy: analysis of the existing literature,” European Urology, vol. 58, no. 4, pp. 498–509, 2010.
W. Dillenburg, V. Poulakis, K. Skriapas et al., “Retroperitoneoscopic versus open surgical radical nephrectomy for large renal cell carcinoma in clinical stage cT2 or cT3a: quality of life, pain and reconvalescence,” European Urology, vol. 49, no. 2, pp. 314–322, 2006.
A. Bachmann, T. Wolff, O. Giannini et al., “How painful is donor nephrectomy? Retrospective analysis of early pain and pain management in open versus laparoscopic versus retroperitoneoscopic nephrectomy,” Transplantation, vol. 81, no. 12, pp. 1735–1738, 2006.
K. T. Perry, S. J. Freedland, J. C. Hu et al., “Quality of life, pain and return to normal activities following laparoscopic donor nephrectomy versus open mini-incision donor nephrectomy,” Journal of Urology, vol. 169, no. 6, pp. 2018–2021, 2003.
M. H. Andersen, L. Mathisen, O. ？yen et al., “Postoperative pain and convalescence in living kidney donors—laparoscopic versus open donor nephrectomy: a randomized study,” American Journal of Transplantation, vol. 6, no. 6, pp. 1438–1443, 2006.
S. Jackobs, T. Becker, R. Lück et al., “Quality of life following living donor nephrectomy comparing classical flank incision and anterior vertical mini-incision,” World Journal of Urology, vol. 23, no. 5, pp. 343–348, 2005.
M. Owen, P. Lorgelly, and M. Serpell, “Chronic pain following donor nephrectomy—a study of the incidence, nature and impact of chronic post-nephrectomy pain,” European Journal of Pain, vol. 14, no. 7, pp. 732–734, 2010.
S. Chatterjee, R. Nam, N. Fleshner, and L. Klotz, “Permanent flank bulge is a consequence of flank incision for radical nephrectomy in one half of patients,” Urologic Oncology, vol. 22, no. 1, pp. 36–39, 2004.
J. R. Waller, A. L. Hiley, E. J. Mullin, P. S. Veitch, and M. L. Nicholson, “Living kidney donation: a comparison of laparoscopic and conventional open operations,” Postgraduate Medical Journal, vol. 78, no. 917, pp. 153–157, 2002.
T. Tasmuth, M. Kataja, C. Blomqvist, K. Von Smitten, and E. Kalso, “Treatment-related factors predisposing to chronic pain in patients with breast cancer: a multivariate approach,” Acta Oncologica, vol. 36, no. 6, pp. 625–630, 1997.
H. J. Gerbershagen, O. Dagtekin, T. Rothe et al., “Risk factors for acute and chronic postoperative pain in patients with benign and malignant renal disease after nephrectomy,” European Journal of Pain, vol. 13, no. 8, pp. 853–860, 2009.
C. H. Wilder-Smith, L. Hill, J. Wilkins, and L. Denny, “Effects of morphine and tramadol on somatic and visceral sensory function and gastrointestinal motility after abdominal surgery,” Anesthesiology, vol. 91, no. 3, pp. 639–647, 1999.
H. Kehlet, “Modification of responses to surgery by neural blockade: clinical implications,” in Neural Blockade in Clinical Aneathesia and Management of Pain, M. J. Cousins and Bridenbaugh, Eds., pp. 129–171, Lippincott-Raven, Philadelphia, Pa, USA, 3rd edition, 1998.
B. L. Strom, J. A. Berlin, J. L. Kinman et al., “Parenteral ketorolac and risk of gastrointestinal and operative site bleeding: a postmarketing surveillance study,” Journal of the American Medical Association, vol. 275, no. 5, pp. 376–382, 1996.
A. M. Chang, W. Y. Ip, and T. H. Cheung, “Patient-controlled analgesia versus conventional intramuscular injection: a cost effectiveness analysis,” Journal of Advanced Nursing, vol. 46, no. 5, pp. 531–541, 2004.
D. M. Rosen, A. M. Lam, M. A. Carlton, G. M. Cario, and L. McBride, “Analgesia following major gynecological laparoscopic surgery–PCA versus intermittent intramuscular injection,” Journal of the Society of Laparoendoscopic Surgeons, vol. 2, no. 1, pp. 25–29, 1998.
E. Gorevski, S. Wead, A. Tevar, P. Succop, P. Volek, and J. Martin-Boone, “Retrospective evaluation of donor pain and pain management after laprascopic nephrectomy,” Transplantation Proceedings, vol. 43, no. 7, pp. 2487–2491, 2011.
J. C. Ballantyne, D. B. Carr, T. C. Chalmers, K. B. G. Dear, I. F. Angelillo, and F. Mosteller, “Postoperative patient-controlled analgesia: meta-analyses of initial randomized control trials,” Journal of Clinical Anesthesia, vol. 5, no. 3, pp. 182–193, 1993.
A. Boulanger, M. Choiniere, D. Roy et al., “Comparison between patient-controlled analgesia and intramuscular meperidine after thoracotomy,” Canadian Journal of Anaesthesia, vol. 40, no. 5 I, pp. 409–415, 1993.
V. W. S. Chan, F. Chung, M. McQuestion, and M. Gomez, “Impact of patient-controlled analgesia on required nursing time and duration of postoperative recovery,” Regional Anesthesia, vol. 20, no. 6, pp. 506–514, 1995.
C. W. Colwell Jr. and B. A. Morris, “Patient-controlled analgesia compared with intramuscular injection of analgesics for the management of pain after an orthopaedic procedure,” Journal of Bone and Joint Surgery A, vol. 77, no. 5, pp. 726–733, 1995.
A. M. Egbert, L. H. Parks, L. M. Short, and M. L. Burnett, “Randomized trial of postoperative patient-controlled analgesia vs intramuscular narcotics in frail elderly men,” Archives of Internal Medicine, vol. 150, no. 9, pp. 1897–1903, 1990.
R. Gust, S. Pecher, A. Gust, V. Hoffmann, H. B？hrer, and E. Martin, “Effect of patient-controlled analgesia on pulmonary complications after coronary artery bypass grafting,” Critical Care Medicine, vol. 27, no. 10, pp. 2218–2223, 1999.
L. Suarez-Sanchez, E. Perales-Caldera, M. C. Pelaez-Luna, and R. Bernal-Flores, “Postoperative outcome of open donor nephrectomy under epidural analgesia: a descriptive analysis,” Transplantation Proceedings, vol. 38, no. 3, pp. 877–881, 2006.
E. E. Ashcraft, G. M. Baillie, S. F. Shafizadeh et al., “Further improvements in laparoscopic donor nephrectomy: decreased pain and accelerated recovery,” Clinical Transplantation, vol. 15, no. 6, pp. 59–61, 2001.
H. Kehlet, “General versus regional anaesthesia,” in Principles and Practice of Anesthesiology, M. Rogers, J. Tinker, B. Covino, and D. E. Longnecker, Eds., pp. 1218–1234, Mosby, St. Louis, Mo, USA, 1993.
S. Yndgaard, P. Holst, K. Bjerre-Jepsen, C. B. Thomsen, J. Struckmann, and T. Mogensen, “Subcutaneously versus subfascially administered lidocaine in pain treatment after inguinal herniotomy,” Anesthesia and Analgesia, vol. 79, no. 2, pp. 324–327, 1994.
J. G. McDonnell, B. O'Donnell, G. Curley, A. Heffernan, C. Power, and J. G. Laffey, “The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial,” Anesthesia and Analgesia, vol. 104, no. 1, pp. 193–197, 2007.
J. G. McDonnell, G. Curley, J. Carney et al., “The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial,” Anesthesia and Analgesia, vol. 106, no. 1, pp. 186–191, 2008.
A. R. Biglarnia, G. Tufveson, T. Lorant, F. Lennmyr, and J. Wadstr？m, “Efficacy and safety of continuous local infusion of ropivacaine after retroperitoneoscopic live donor nephrectomy,” American Journal of Transplantation, vol. 11, no. 1, pp. 93–100, 2011.
J. D. Vloka, A. Had？i？, R. Mulcare, J. B. Lesser, E. Kitain, and D. M. Thys, “Femoral and genitofemoral nerve blocks versus spinal anesthesia for outpatients undergoing long saphenous vein stripping surgery,” Anesthesia and Analgesia, vol. 84, no. 4, pp. 749–752, 1997.
S. Li, M. Coloma, P. F. White et al., “Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery,” Anesthesiology, vol. 93, no. 5, pp. 1225–1230, 2000.
D. Song, N. B. Greilich, P. F. White, M. F. Watcha, and W. K. Tongier, “Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy,” Anesthesia and Analgesia, vol. 91, no. 4, pp. 876–881, 2000.
C. Michaloliakou, F. Chung, and S. Sharma, “Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy,” Anesthesia and Analgesia, vol. 82, no. 1, pp. 44–51, 1996.
K. I. A. Gharaibeh and T. M. Al-Jaberi, “Bupivacaine instillation into gallbladder bed after laparoscopic cholecystectomy: does it decrease shoulder pain?” Journal of Laparoendoscopic and Advanced Surgical Techniques A, vol. 10, no. 3, pp. 137–141, 2000.
T. Bisgaard, B. Klarskov, V. B. Kristiansen et al., “Multi-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized, double-blinded, placebo-controlled study,” Anesthesia and Analgesia, vol. 89, no. 4, pp. 1017–1024, 1999.
S. Y. Fong, T. J. Pavy, S. T. Yeo, M. J. Paech, and L. C. Gurrin, “Assessment of wound infiltration with bupivacaine in women undergoing day-case gynecological laparoscopy,” Regional Anesthesia and Pain Medicine, vol. 26, no. 2, pp. 131–136, 2001.
N. W. Hasaniya, F. F. Zayed, H. Faiz, and R. Severino, “Preinsertion local anesthesia at the trocar site improves perioperative pain and decreases costs of laparoscopic cholecystectomy,” Surgical Endoscopy, vol. 15, no. 9, pp. 962–964, 2001.
A. M. Sarac, A. O. Aktan, N. Baykan, C. Yegen, and R. Yalin, “The effect and timing of local anesthesia in laparoscopic cholecystectomy,” Surgical Laparoscopy, Endoscopy and Percutaneous Techniques, vol. 6, no. 5, pp. 362–366, 1996.
S. M？iniche, H. J？rgensen, J. Wetterslev, and J. B. Dahl, “Local anesthetic infiltration for postoperative pain relief after laparoscopy: a qualitative and quantitative systematic review of intraperitoneal, port-site infiltration and mesosalpinx block,” Anesthesia and Analgesia, vol. 90, no. 4, pp. 899–912, 2000.
S. Hariharan, H. Moseley, A. Kumar, and S. Raju, “The effect of preemptive analgesia in postoperative pain relief—a prospective double-blind randomized study,” Pain Medicine, vol. 10, no. 1, pp. 49–53, 2009.
J. R. Klein, J. P. Heaton, J. P. Thompson, B. R. Cotton, A. C. Davidson, and G. Smith, “Infiltration of the abdominal wall with local anaesthetic after total abdominal hysterectomy has no opioid-sparing effect,” British Journal of Anaesthesia, vol. 84, no. 2, pp. 248–249, 2000.
L. Lowenstein, E. Z. Zimmer, M. Deutsch, Y. Paz, D. Yaniv, and P. Jakobi, “Preoperative analgesia with local lidocaine infiltration for abdominal hysterectomy pain management,” European Journal of Obstetrics Gynecology and Reproductive Biology, vol. 136, no. 2, pp. 239–242, 2008.
J. W. Harvey, M. Otterson, H. Yun, L. A. Connolly, D. Eastwood, and K. Colpaert, “Acetazolamide reduces referred postoperative pain after laparoscopic surgery with carbon dioxide insufflation,” Anesthesiology, vol. 99, no. 4, pp. 924–928, 2003.
R. Singh, I. Sen, J. Wig, M. Minz, A. Sharma, and I. Bala, “An acetazolamide based multimodal analgesic approach versus conventional pain management in patients undergoing laparoscopic living donor nephrectomy,” Indian Journal of Anaesthesia, vol. 53, no. 4, pp. 434–441, 2009.