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intraperitoneal dissection10. Variable analgesic effects of fixed time interval at 6hrs, 12hrs, 24hrs, and 48hrs
periportal infiltration of local anesthetics, intraperitoneal respectively. Presence of shoulder pain was also assessed
spraying above the gall bladder, and instillation into the during the same interval.
subdiaphramatic space and into the subhepetic space
Patients were given narcotic analgesic intramuscularly
covering the area of the hepatoduodenal ligament have been
(pethidine 50mg+ phenargan 25mg) on requirement and the
reported. Some of them failed to show any benefit11.
total number of doses of narcotic analgesia used was
Our study is designed to evaluate the effect of combined recorded in a proforma. Statistical analysis of the data was
intraperitoneal and port site infiltration of bupivacaine for done using SPSS software programmed. Independent t
pain relief following laparoscopic cholecystectomy. test and chi square test were used for statistical analysis.
Differences were considered significant at a probability
Methodology:
level less than 0.05.
This is a prospective, consecutive study conducted in the
Results
General Surgery Unit-II of Dhaka Medical College Hospital
for six month. Patients scheduled to undergo elective A total of 50 patients participated in the study. The male to
laparoscopic cholecystectomy during March 2006 to August female ratio was 1: 4 in the study group and 1:4 in control
2006, were included in this study. There were fifty patients group. There were 80% of females in both study and control
who participated in this study, with twenty-five patients in group. Twenty-five patients (20 women & 5men) with mean
each arm. All the patients gave informed consent and met (SD) age 36.92(13.24) years received Bupivacaine. The
the following criteria: adult patient [above 16 years] with control group comprised 25 patients (20 women, 5 men)
ASA Class 1(a normally healthy individual) and 2(a patient with mean age 40.92 (13.11) years.
with mild to moderate systemic disease), who were
The gas pressure in the bupivacaine group was median
undergoing planned elective procedure for symptomatic gall
(SD) 12.12 mmHg (0.92) and that of control was 13.08
stone disease. Patient with choledocholithiasis, placement
mmHg (0.70) and was not found to be statistically
of drain intraoperatively and any previous upper abdominal
significant.
surgery were not included in the study. All patients were
explained about the basis of study and informed consent Intensity of pain was assessed at fixed time intervals at 6
was obtained. hrs, 12hrs, 24hrs and 48 hrs postoperatively. The Mean
(SD) score ranged from 2.68 (0.47) to 6.08 (0.40) for
All patients were screened preoperatively with the help of
the bupivacaine group and from 2.44 (0.51) to 8.44(0.51)
anesthetist and explained about the use of Numerical Rating
for the control group. (Table-I)
Scale (NRS) for pain employed in this study. The scale
ranged from 0-10, with 1 being the mildest pain the patient Table I: Mean pain Scores for study and control group
ever had and 10 being the most severe pain, zero counts for
Mean ( SD) Pain Scores* postoperatively for patients
no pain12.
given Bupivacaine compared with those not receiving
Patients were randomized into the study arm and control Bupivacaine (control)
arm using the random number table. In all cases induction,
maintain and reversal of anesthesia was achieved by Postop Assessment Bupivacaine Control p value
standard protocol. time group group
Pneumoperitoneum was produced by insufflations of carbon 6hrs 6.08(0.40) 8.44(0.51) <0.001*
dioxide with the method of open laparoscopes using Hassans 12hrs 4.72(0.61) 6.08(0.64) <0.001*
canula and port laparoscopes was carried out with carried out
24hrs 3.44(0.51) 3.40(0.50) 0.780
with gas pressure maintained between 12-14mm Hg.
48hrs 2.68(0.47) 2.44(0.51) 0.091
After delivery of the gall bladder 20 ml of 0.5% bupivacaine
solution was instilled in the right sub diaphragmatic space [Ranged from 0 (no pain) to 10 (severe pain) ]
and another 20ml was infiltrated into the port sites (6ml was * Highly significant
infiltrated through the abdominal wall around each midline At 6 hours postoperatively the Mean (SD) pain score of
port site and 4ml administered in the similar fashion at the Bupivacaine group was found to be 6.08(0.40) as
lateral port sites). compared to Control group 8.44(0.51) and it was found to
In all cases, residual carbon dioxide was evacuated at the be having p value of <0.001.
end of the procedure by compressing the abdomen before Therefore, Bupivacaine provided a substantial reduction of
closure of ports. pain intensity during the first 6 hours postoperatively and
The time of arrival in the postoperative ward was defined as this was found to be statistically highly significant. At 12
zero hour postoperatively. Pain intensity was measured at hours postoperatively, although the Mean (SD) was
Although we expected the effect of the local anesthetic to study of pain level and analgesic requirement after
wear off after the period of 6-8hours, there was no increase laparoscopic and open cholecystectomy. Surg Laparosc
in the pain score at the 3rd pain assessment at 24hours Endosc 1994;4:139-41.
postoperatively in the patients who received bupivacaine.
3. Kunz R, Berger D, Berger HG.Laparoscopic
For the control group pain scores peaked immediately and cholecystectomy versus mini-lap cholecystectomy: a
were maximum during the first 6-8hours after the surgical prospective randomized trial.Surg Endosc 1994;8:504.
procedure and there after declined to the level comparable to
4. Mjaland O, Reader J, Aesboe V, Trondsen E, Buanes
that for the bupivacaine group by the third assessment at
T. Out patient laparoscopic cholecystectomy. Br J Surg
24hours postoperatively. Therefore, the main effect of
1997;84:958-961.
bupivacaine in this study seems to have been in amelioration
of pain peak occurring during the initial 6 hours after the 5. KeulmansY, Eshuis J,de Haes H, de Wit LT, Gouma
surgical procedure. We did find an appreciable difference in DJ:Laparoscopic cholecystectomy:daycare versus
total narcotic analgesics requirement between the control clinical observation.Ann Surg1998;228:734-740.
and bupivacaine group and this was consistent with the
6. Spittal MJ, Hunter SJ. A comparison of bupivacaine
findings that of Bisgaard22 in a randomized control study.
instillation and inguinal field block for pain control
If laparoscopic cholecystectomy is to be a routine after herniorrhaphy. Ann R Coll Surg Engl 1992;74:85-
ambulatory surgical procedure, the pain experienced by the 88.
patients during early postoperative period must be
7. Bays RA, Barry L. The use of bupivacaine in elective
addressed. Our study showed that Infiltration of bupivacaine
inguinal herniorrhaphy as a fast and safe technique for
into the port site and intraperitoneal instillation diminishes
relief of postoperative pain. Surg Gynecol Obstetric
the peak of pain occurring during the first 6 hours after the
1991;57:548-52.
surgical procedure and significantly reduces the need for
narcotic analgesics. 8. Thomas DF, Lambert WG. The direct perfusion of
surgical wounds with local anesthetics solution: an
Any reduction in such pain is relevant, particularly if it is
approach to postoperative pain. Ann R Coll Surg Engl
statistically significant, whether the lower pain score
1983;65,226-9.
translated into increased patients comfort and compliance is
questionable. However, at whatever level they functioned 9. Szem JW, Hydo L A double blind evaluation of
they did so more comfortably. intraperitoneal bupivacaine vs saline for the
reduction of postoperative pain and nausea after
Thus, this simple, inexpensive, effective technique improves
laparoscopic cholecystectomy. Surg Endos 1996;
the postoperative period in-hospital course and can be 10:44-48.
practiced routinely in all elective laparoscopic
cholecystectomy. 10. Rademaker BM, Kalkman CJ.Intraperitoneal local
anesthetics after laparoscopic cholecystectomy:
Conclusion effects on postoperative pain, metabolic responses and
lung function. Br J Anaes 1994;72:263-6.
Laparoscopic cholecystectomy in now the gold standard for
the treatment of gall stones disease when a careful, correct 11. Mouret P. from the first laparoscopic cholecystectomy
technique is employed, though pain after laparoscopic to the frontiers of laparoscopic surgery, the future
cholecystectomy is multifactorial; our study showed port prospectives. Dig Surg 1991;81:124-125
site, intraperitoneal infiltration of local anesthetics for post
12. Mouton WG, Bessell JR Pain after laparoscopy. Surg
operative pain relief is, in this context, an effective
Endoscopy; 1999;13:106-108.
alternative method for early pain control and minimize the
need of opoid analgesics and the technique is very simple, 13. Alexander JI, Hull MGR. Adbominal pain after
easily applicable. laproscopy: the value of a gas drain. Br J Obstet
Gynaecol 1987;94:26-269.
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