**4. Prophylactic (preemptive) analgesia**

This kind of analgesia is a new approach to treating postoperative pain and blocks surgically caused painful sensitivity using regional or systematic anesthesia, prior to its onset. Therapeutic use of the prophylactic analgesia is based on local infiltration anesthesia (LIA) subcutaneous in the area planned for the surgical incision or for instance in the area of the abdominal wall.

LIA implies blocking incoming nerve paths prior to the onset of pain sensitivity due to incision of the skin and subcutaneous tissue, as well as contact with abdominal wall muscles, thereby preventing or reducing the level of pain occurring due to terminating paths of the nervous system between surgically sensitive organs and the brain [9].

The positive effects of a well-planned preemptive analgesia during a surgical procedure can be well utilized for the general well-being, meaning primarily for the patient, and then also for institutions in which the procedures are undertaken, because possible harmful effects can be well supervised and prevented under controlled conditions. Anesthesiologists in collaboration with surgeons determine the most effective preemptive analgesic regime for limiting sensibility of the nervous system throughout the entire perioperative period.

The concept of preemptive analgesia is based on advancements and research in the science of pain, as well as on clinically proven research. It has been shown that a surgical incision is not the only catalyst for central sensitivity of the nervous system, and accordingly, preemptive analgesia is further profiled and developed [10].

Regardless of the results obtained and proven in clinical research on animals, in clinical practice not only in Croatia but throughout the world, controversies do exist in terms of administering preventive analgesia. The reason for this is the general consensus that there is insufficient evidence as to the one-hundred-percent effectiveness of this manner of preventing postoperative pain. The recommendation is, therefore, to expand antinociceptive protection during the postoperative period, which ensures preventing analgesic infiltration, in order to include the most effective possible treatment for the inflammatory phase in the location of the operative area. Some studies on animals have shown that anesthesia techniques that deeply reduce the amount of information on pain reaching the spinal cord and brain may prevent central sensitivity and reduce pain-linked behavior when given prior to the onset of pain [11].

#### **5. Description of analgesia applied to the abdominal wall**

As we have previously described in the anatomy section, it is clear that there is a nerve supply in the area of the abdominal wall from T7–11 intercostal nerves and the T12 subcostal nerve, leading to the anterior and lateral segments, as well as the iliohypogastric and ilioinguinal nerves and their branches. Based on the actual procedure and experience, painful stimuli of the abdominal wall are certainly caused by liposuction, plication of the abdominal wall, lower fixation of the lateral scar,

and closing of wounds. This is the main reason why, in the earlier stages of general analgesia and liposuction, the decision to administer additional analgesia into the abdominal wall with 40 mL of levobupivacaine or bupivacaine (0.5%) is used. This step is very important, depending on the availability of local long-lasting anesthetics and analgesics [9].

The pattern of administering the local anesthetic is radial, in the form of a fanshape. It is applied with a G23 needle, administered centrally, toward the sides, and in the region of the horizontal incision, approximately 40 injections on each side, using 40 ml of the solution. Each jab provides 0.5 ml of local anesthetics.

Levobupivacaine, as opposed to lidocaine, is a long-lasting local anesthetic, providing significantly more than 2–3 h of anesthesia (>9 h) and up to 24 h as analgesia [6, 7]. It acts by blocking transmission in sensory and motor nerves through sodium channels on the cell membrane, but also by blocking potassium and calcium channels. It is far less systemically toxic than lidocaine. It is used as an anesthetic in larger surgical procedures, for instance as an epidural during a cesarean section, as well as an anesthetic in smaller surgical procedures, like those done on the eye. It is used as an analgesic for epidural infusion in treating postoperative pain or as an analgesic during labor. It is contraindicated for patients with known sensitivities against levobupivacaine and bupivacaine, or some of the auxiliary substances, as an intravenous regional anesthesia, and in patients with cardiovascular shock due to serious hypotension.

Due to its known interaction with some drugs, an important factor in the proper and quality administering of levobupivacaine is the experience of the operator.

The most often recorded adverse side effects are mostly related to the side effects based on the group of drugs to which it belongs, which includes hypotension, nausea and vomiting, anemia, dizziness, headache, pyrexia, and fetal distress syndrome. Compared to bupivacaine, levobupivacaine has been shown to have a long-lasting effect, less indirect toxicity, reduced cardiac effect in terms of bradycardia, and a weaker depressive effect on the CNS **Figure 8**.

#### **Figure 8.**

*A. Plan of application of local abdominal wall analgesia on the skin. B. Long-lasting local infiltration prepared for application. C. Plan for application of local infiltration analgesia in the abdominal wall, and D. application of long-lasting local anesthetic in the abdominal wall.*

*Fan-Shaped Application of Local Abdominal Wall Analgesia in Abdominoplasty Patients… DOI: http://dx.doi.org/10.5772/intechopen.100235*
