Gastrointestinal
Peritrocal and Intraperitoneal Ropivacaine for Laparoscopic Cholecystectomy: A Prospective, Randomized, Double-Blind Controlled Trial1

https://doi.org/10.1016/j.jss.2011.04.033Get rights and content

Background

The goal of this study was to evaluate the effect of peritrocal, intraperitoneal, or combined peritrocal-intraperitoneal ropivacaine on the parietal, visceral, and shoulder tip pain after laparoscopic cholecystectomy.

Methods

Eighty patients were randomly assigned to four groups. Group A received peritrocal and intraperitoneal saline. Group B received peritrocal saline and intraperitoneal ropivacaine. Group C received peritrocal ropivacaine and intraperitoneal saline. Group D received peritrocal and intraperitoneal ropivacaine. The parietal, visceral, and shoulder tip pain were assessed at 2, 4, 8, 12, 24, and 48 h postoperatively using a visual analog scale (VAS). The frequency of the patient pushing the button of the PCA and fentanyl use were also recorded.

Results

In visceral pain, significantly lower VAS scores were observed in Group B from 2 to 4 h and in Group D from 2 to 8 h. In parietal pain, significantly lower VAS scores were observed in Group C from 4 to 24 h and in Group D from 2 to 12 h. In shoulder tip pain, significantly lower VAS scores were observed in Group B from 4 to 48 h and in Group D from 2 to 12 h. The fentanyl use and the frequency to push the button of the PCA were the highest in Group A and the lowest in Group D at every time point.

Conclusions

We conclude that peritrocal infiltration of ropivacaine significantly decreases parietal pain and intraperitoneal instillation of ropivacaine significantly decreases the visceral and shoulder tip pain. Their effects are additive with respect to the total pain.

Introduction

Despite the markedly reduced postoperative pain after laparoscopic cholecystectomy (LC) than that after open traditional cholecystectomy [1], the early pain after LC is still considered a significant issue [2]. The pain after LC is thought to have a multifactorial origin 3, 4, 5, 6: incisional trauma at the port site 7, 8, the pneumoperitoneum in association with both the local changes (peritoneal and diaphragmatic stretching, ischemia, acidosis), and the systemic changes (hypercarbia causing sympathetic nervous system excitation that results in amplification of the local tissue inflammatory response), and the postcholecystectomy wound within the liver [9]. Pain after LC has three major main components; parietal pain caused by incisional trauma at the port site 7, 8, visceral pain related to pneumoperitoneum-induced local and systemic changes and the postcholecystectomy wound within the liver 9, 10, 11, and shoulder tip pain that occurs due to diaphragmatic stretching with phrenic nerve neuropraxia 4, 12. These components have different intensities and their own time course [5].

Various studies have been performed for reducing the pain after LC by blocking these sites using local anesthetics: peritrocal infiltration of local anesthetics 7, 8, diffuse instillation of local anesthetics into the entire peritoneal space [13], intraperitoneal spraying above the gall bladder [11], instillation into the subdiaphragmatic area 5, 11, or a combination of peritrocal and peritoneal blocks 14, 15. However, there is controversy about the characteristics and intensity among these components that cause the pain after LC 3, 5, 15, 16, 17 and also about the pain-reducing effects of intraperitoneal or peritrocal local anesthetics 5, 15, 16, 17.

The aim of our prospective, randomized, double-blind study was to evaluate the intensity of the parietal, visceral and shoulder tip pain and to determine the efficacy of peritrocal injection and intraperitoneal instillation of ropivacaine on each of these pain components.

Section snippets

Materials and Methods

This study was approved by the Institutional Review Board of the College of Medicine of Chung-Ang University (c2009014 (201)) and was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12610000910000). This study was carried out according to the principles of the Declaration of Helsinki, 2000.

We performed a prospective, randomized, double-blind, controlled study, and informed written consent was obtained from each patient before inclusion in the study.

Results

There were no significant differences among the groups with respect to age, height, weight, gender, the ASA class, the duration of anesthesia, and operation (Table 2).

Five patients were excluded from this study at the conclusion of the operation because of conversion to open surgery, iatrogenic gall bladder perforation, drain placement, and extension of the umbilical incision. Subsequently, five patients who fit our inclusion criteria replaced these excluded patients.

Discussion

In our Group A (the control group), the VAS of the visceral component was higher than the VAS of the parietal component at each time point, and VAS of each component peaked at the first 2 h and declined over the following 2 d. These findings are in close agreement with those of the previous study, which reported the dominant source of pain after laparoscopy was the visceral component rather than the parietal component 5, 19. In our study, the fact that fentanyl use and the frequency to push the

Acknowledgment

This study was supported by a grant of the Korea Healthcare Technology R&D Project, Ministry of Health and Welfare, Republic of Korea. (A100054).

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    1

    This trial is registered with ANZCTR (ACTRN12610000910000).

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