GastrointestinalPeritrocal and Intraperitoneal Ropivacaine for Laparoscopic Cholecystectomy: A Prospective, Randomized, Double-Blind Controlled Trial1
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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Ropivacaine wound infiltration: a fast-track approach in patients undergoing thoracotomy surgery
2017, Journal of Surgical ResearchCitation Excerpt :Perioperative pain management has become an important fast-track approach.5 Of the multimodal pain management techniques, wound infiltration with a local anesthetic, has now been used worldwide in various surgeries, including but not limited to thoracic and abdominal surgeries and cesarean deliveries.6-10 Ropivacaine is a local anesthetic agent (Fig. 1) that blocks the generation and conduction of nerve impulses by increasing the electrical excitation threshold, slowing nerve impulse propagation, and reducing the rate of rise of the action potential.
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This trial is registered with ANZCTR (ACTRN12610000910000).