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7/25/2019
A comparative evaluation of pre-emptive versus post-surgery intraperitoneal local anaesthetic instillation for postoperative pain relief…
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6423947/ 1/9
Indian J Anaesth. 2019 Mar; 63(3): 205–211.
doi: 10.4103/ija.IJA_767_18
PMCID: PMC6423947
PMID: 30988535
A comparative evaluation of pre-emptive versus post-surgery
intraperitoneal local anaesthetic instillation for postoperative pain relief
after laparoscopic cholecystectomy: A prospective, randomised, double
blind and placebo controlled study
Prabhu Gnapika Putta, Hemalatha Pasupuleti, Aloka Samantaray, Hemanth Natham, and
Mangu Hanumantha Rao
Department of Anaesthesiology and Critical Care, Sri Venkateswara Institute and Medical Sciences, SVIMS
University, Tirupati, Andhra Pradesh, India
Address for correspondence: Dr. Aloka Samantaray, Department of Anaesthesiology and Critical Care, Sri
Venkateswara Institute of Medical Sciences, SVIMS University, Tirupati - 517 507, Andhra Pradesh, India. E-
mail: aloksvims@gmail.com
Copyright : © 2019 Indian Journal of Anaesthesia
This is an open access journal, and articles are distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the
work non-commercially, as long as appropriate credit is given and the new creations are licensed under the
identical terms.
Abstract
Background and Aims:
Intraperitoneal local anaesthetic instillation (IPLAI) reduces postoperative pain and analgesic
consumption effectively but the timing of instillation remains debatable. This study aims at comparing
pre-emptive versus post-surgery IPLA in controlling postoperative pain after elective laparoscopic
cholecystectomy.
Methods:
Ninety patients belonging to American Society of Anesthesiologists physical status I or II were
randomly assigned to receive IPLAI of either 30 ml of normal saline (C) or 30 ml of 0.5% bupivacaine
at the beginning (PE) or at the end of the surgery (PS) using a double-dummy technique. The primary
outcome was the intensity of postoperative pain by visual analogue scale score (VAS) at 30 minute, 1,
2, 4, 6, 24 hours after surgery and time to the first request for analgesia. The secondary outcomes were
analgesic request rate in 24 hours; duration of hospital stay and time to return to normal activity. Data
were compared using analysis of variance, Kruskal-Wallis or Chi-square test.
Results:
For all predefined time points, VAS in group PE was significantly lower than that in groups C (P <
0.05). The time to first analgesic request was shortest in group C (238.0 ± 103.2 minutes) compared to
intervention group (PE, 409.2 ± 115.5 minutes; PS, 337.5 ± 97.5 minutes;P < 0.001). Time to attain
discharge criteria was not statistically different among groups.
Conclusion:
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Pre-emptive intraperitoneal local anaesthetic instillation resulted in better postoperative pain control
along with reduced incidence of shoulder pain and early resumption of normal activity in comparison
to post surgery IPLAI and control.
Key words: Analgesia, bupivacaine, cholecystectomy, intraperitoneal, laparoscopy
INTRODUCTION
The origin of pain after laparoscopic cholecystectomy is multifactorial -pain arising from incision sites
i.e., somatic pain, pain from gall bladder bed i.e., visceral pain and referred pain to shoulder.[1] The
most explainable cause for visceral and shoulder pain is peritoneal distension and visceral irritation
caused by the creation of capnoperitoneum and surgical handling. Intraperitoneal administration of
local anaesthetic agents alone or in combination with opioids has been found to reduce the
postoperative pain and analgesic consumption effectively following laparoscopic cholecystectomy.[2,3]
However, the timing remains debatable.[4] Recent advances suggest that an afferent block (with local
anaesthetics) achieved before nociceptive input can reduce or eliminate the onset of central neural
hyper excitability and can thus significantly reduce both intensity and duration of pain, while also
delaying its onset.[5] We hypothesised that local anaesthetic instillation into the peritoneal cavity
immediately after capnoperitoneum (equivalent to pre-emptive analgesia) would be more efficient than
at the end of the surgery (equivalent to post nociceptive analgesia) in controlling postoperative pain and
discomfort and thus lead to an earlier discharge from the hospital.
METHODS
This prospective randomised double blind, double dummy trial was conducted after obtaining approval
from Institutional Ethics committee and written informed consent from the study participants.
The study population comprised of 90 patients belonging to American Society of Anesthesiologists
physical status (ASA PS) I and II in the age group of 18–60 years of either sex posted for elective
laparoscopic cholecystectomy under general anaesthesia. Patients not willing to participate in the study,
pregnant or lactating mothers, allergic to study drugs, presented with acute cholecystitis, severe
cardiac, pulmonary and renal diseases were excluded from the study. Any patients who needed
conversion to open cholecystectomy or insertion of a drain at the end of the procedure were also
excluded from the study.
Ninety patients were randomised into three groups using computer generated random number table and
sealed opaque envelope technique. Each patient received intraperitoneal instillation of either 30 ml of
placebo or 0.5% bupivacaine at different timing as per their group allocation using double dummy
technique.
Patients in control group (C) received 30 ml normal saline at beginning of surgery (after creation of
capnoperitoneum) and at the end of the surgery (after removal of gall bladder). Patients from pre-
emptive group (PE) received 30 ml 0.5% bupivacaine at the beginning of surgery and 30 ml of saline at
the end of the surgery and patients from post-surgery group (PS) received 30 ml of saline at the
beginning of surgery and 30 ml of 0.5% bupivacaine at the end of the surgery. Blinding was ensured by
preparing the study drugs in a ready to inject coded 50 ml syringe by a trainee anaesthesia resident not
involved with the study protocol. The postoperative follow-up of the study participant was done by one
of the co-author blinded to the study drug administration and not involved with intraoperative
management of the case.
Preoperatively, all the patients were explained about the study protocol and how to use visual analogue
scale (VAS) to indicate their pain perception by identifying zero as no pain and 10 as worst imaginable
pain. On arrival to the operating room a peripheral 18 G intravenous cannula under local anaesthesia
was secured and standard monitoring like three lead electrocardiography, non-invasive blood pressure,
oxygen saturation and end tidal CO were connected and base line vital parameters noted. A standard
general endotracheal anaesthesia protocol comprising of intravenous (IV) fentanyl (2 μ/kg), midazolam
(0.04 mg/kg), thiopentone sodium titrated to sleep dose (4-7 mg/kg) for anaesthesia induction and
vecuronium bromide (0.1 mg/kg) IV to facilitate orotracheal intubation was followed in all patients. All
2
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patients were given 0.1 mg/kg of morphine IV after induction of anaesthesia but before incision for
trocar placement. Anaesthesia was maintained with 1–3% sevoflurane and 40% oxygen in air.
Intermittent positive-pressure ventilation was used to adjust minute ventilation for the desired
normocapnia (end tidal carbon dioxide between 34 and 38 mm Hg). During laparoscopy, intra-
abdominal pressure was limited to 12–14 mm Hg. At the end of surgery, residual neuromuscular
blockade was reversed with intravenous neostigmine and glycopyrrolate. The study drugs as per group
allocation were instilled in equal amounts into the hepatodiaphragmatic space, near and above the
hepatoduodenal ligament and above the gall bladder bed under direct vision in Trendelenburg's
position. All patients were operated by the same surgical team with standard number of port placement
and surgical steps. All patients received 4 mg dexamethasone IV after anaesthesia induction and 8 mg
ondansetron after deflation of capnoperitoneum as prophylaxis for post-operative nausea and vomiting.
The intensity of pain was recorded for all patients using visual analogue scale at 0.5, 1, 2, 4, 6, 24 hours
after surgery. Analgesia requirements were recorded for 24 h. If VAS score >3, patients were prescribed
paracetamol 1 g IV followed by additional doses if requested by patient after an interval of 6 h and pain
between 2 doses of paracetamol was treated with fentanyl 1 μg/kg IV (rescue analgesic). Time to
satisfy criteria for hospital discharge was assessed by modified post anaesthesia discharge scoring
system (PADSS) criteria[6] at 8.00 h and 18.00 h every day until they achieved a score of at least 9 out
of 10.
The primary outcome measure of the trial was total postoperative pain severity and time to the first
analgesic request in recovery room (considering time at extubation to be zero).
The secondary outcomes were analgesic request rate (number of doses of paracetamol in 24 hours);
number of patient using rescue fentanyl in 24 hours; duration of hospital stay (PADSS of 9/10),
incidence of shoulder pain and return to normal activity (obtained by telephonic interview).
Sample size was estimated from our pilot study which yielded a mean pain score of 4.6 with standard
deviation 2.7 at second hour after surgery measured with a visual analogue scale in 10 patients who
received normal saline. In order to demonstrate a 25 mm difference in VAS score 2 h after surgery
among the groups for an alpha-error of 0.05 and beta-error of 0.10, we needed 25 patients per group.
Assuming a dropout rate of 15%, 90 patients were required for this study.
The data obtained were evaluated for normality using the Shapiro–Wilk test. Normally distributed data
were presented as mean (SD). Comparison of three groups for continuous variables were done by using
analysis of variance followed by a post hoc Tukey test to find out the significance between pairs. Non-
normally distributed continuous variables were expressed as a median value (inter quartile range 25–
75) and was analysed using Kruskal–Wallis test with Bonferroni's correction. Descriptive variables
were presented as frequency of occurrence, percentage or number and compared using Chi-square test
or Fisher's exact test, as appropriate; P values <0.05 was considered statistically significant. All the
data were checked twice. All statistical analysis were done using SPSS version 19 (IBM Inc. Chicago
IL, USA, 2010).
RESULTS
In total 134 patients were screened for the study and 90 patients meeting the inclusion and not having
any exclusion criteria were randomised into three groups. There were six dropouts after randomisation,
two from each group as they needed drain insertion at the end of surgery for suspected bile spillage [
Figure 1]. There were no significant differences among the three treatment groups in terms of patient
demographics and risk stratification except that patients from control group underwent longer duration
of surgery [Table 1].
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A comparative evaluation of pre-emptive versus post-surgery intraperitoneal local anaesthetic instillation for postoperative pain relief…
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Open in a separate window
Figure 1
CONSORT Flow Diagram
Table 1
Patients’ baseline and intraoperative characteristics
Variable Control (C) n=30 Pre-emptive (PE) n=30 Post-surgery (PS) n=30 P
Age (yrs.) 41.0 (9.0) 46.7 (8.7) 41.6 (12.7) 0.080
Sex (Male/Female) (n) 13/15 11/17 9/19 0.540
Weight (kgs) 61 (11) 63.2 (10.7) 60.17 (8.8) 0.520
BMI (kg/m ) 24.2 (3.2) 25.0 (4.0) 24.2 (3.2) 0.660
ASA PS I/II (n) 23/5 18/10 21/7 0.310
Duration of surgery (min) 106.6 (18.8) 87.1 (22.9) 92.6 (26.7) 0.007
Data presented as mean (SD); n – Number of patients; BMI – Body mass index; ASAPS – American Society of
Anesthesiologists Physical Status
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None of the patients complained pain in the first 30 minutes after surgery and there after a significant
difference in pain perception was found among groups.
All patients from control group had a higher pain score compared to intervention group (PE and PS)
from 1 hour onward till the completion of the study period for all predefined time points.
In our study, PE group achieved a statistically significant lower VAS score for all time points over
control whereas for PS group it reached statistical significance only at 4 and 24 hour [Table 2]. The
time to first analgesic request was shortest in group C (238.0 ± 103.2 minutes) compared to
intervention group (PE, 409.2 ± 115.5 minutes; PS, 337.5 ± 97.5 minutes; P < 0.001). However, the PE
group fairs better than PS group in delaying the time to first analgesic request by about 20% over the
post-surgery group (P = 0.039 by post-hoc test) [Table 2]. A statistically significant, reduction of
incidence of shoulder tip pain was found at 24 hour post operatively in intervention groups compared
to group C (P < 0.001). Maximum number of patients (18 out of 28, 64%) from control group
experienced shoulder tip pain in the postoperative period in contrast to only 7% (2 out of 28) from PE
and 21% (6 out of 28) from PS [Table 3].
Table 2
Primary outcome measures
Primary Outcome variables Control (C)
n=28
Pre-emptive (PE)
n=28
Post-surgery (PS)
n=28
P
VAS 30 min 0 (0) 0 (0) 0 (0)
VAS 1 h 0 (0-2) 0 (0-0) 0 (0-2) 0.004
VAS 2 h 2.3 (1.4) 1.5 (1.3) 1.7 (0.9) 0.049
VAS 4 h 3.8 (1.3) 2.4 (1.3) 2.9 (1.2) <0.001
VAS 6 h 4.2 (1.3) 3.2 (0.7) 3.7 (1.4) 0.016
VAS 24 h 4.6 (1.0) 3.9 (0.8) 3.8 (0.9) 0.005
Time to the first request of analgesia
(min)
238.0 (103.2) 409.2 (115.5) 337.5 (97.5) <0.001
Data are presented as mean (SD) or median (Inter quartile range 25-75); n – Number of patients; VAS – Visual
analogue score (0-100 mm); Data analysed using Kruskal-Wallis test; P<0.05 versus control group; P<0.05
versus PS
st
th th
a b
b
b b
b
b b
b,c b
a b c
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Table 3
Secondary Outcome measures
Secondary outcome variables Control (C)
n=28
Pre-emptive (PE)
n=28
Post-surgery (PS)
n=28
P
Number of doses of paracetamol
required
3.7 (0.5) 2.2 (0.8) 2.8 (0.7) <0.001
Need for rescue analgesics, n (%) 16 (57%) 2 (7%) 7 (25%) <0.001
Incidence of shoulder pain, n18 (64%) 2 (7%) 6 (21%) <0.001
Time to satisfy modified PADSS
criteria (min)
1096 (114) 1140 (181) 1088 (127) 0.357
Time to return to normal activity
(days)
6.2 (0.8) 4.7 (0.6) 5.5 (0.6) <0.001
Data presented as mean (SD) or median (quartile 1-3); n – Number of patients. Paracetamol 1 gm IV; P<0.05
versus control; P<0.05 versus PS; PADSS – Post Anaesthetic Discharge Scoring System
The control group needed a significantly more number of paracetamol in contrast to patients from
intervention group (PE and PS). Comparison among the groups revealed that, pre-emptive group
consumed least number of doses of paracetamol (2.2 ± 0.8)) versus PS group (PS, 2.8 ± 0.7; P = 0.007)
and control group (C, 3.7 ± 0.5; P < 0.001) [Table 3]. The number of patient requiring rescue fentanyl
was significantly higher in the control group compared to intervention groups (PE and PS). Sixteen
patients from control group, two patients from pre-emptive group and seven patients from post-surgery
group required rescue fentanyl for pain relief (P < 0.001) [Table 3].
The time to achieve a score of ≥9 in PADSS was comparable among the three groups. However, the
patients from control group took longer time to resume their normal activity after discharge in
comparison to other two pre-emptive and post-surgery group (C, 6.2 ± 0.8 days; PE, 4.7 ± 0.6 days; PS,
5.5 ± 0.6 days; P < 0.001). Further post hoc analysis revealed that pre-emptive group patients returned
to their normal activity significantly much earlier compared to post surgery (PE, 4.7 ± 0.6 day; PS, 5.5
± 0.6 day; P = 0.001) and control group (PE, 4.7 ± 0.6 days C, 6.2 ± 0.8 days; P < 0.001). A similar
trend was also observed between post-surgery versus control group (PS, 5.5 ± 0.6 days; C, 6.2 ± 0.8
days P = 0.003) [Table 3].
DISCUSSION
Even today the postoperative pain after laparoscopic cholecystectomy remains one of the major
concerns while considering early discharge of patients from hospital and resumption of daily normal
activity after discharge.
The primary findings of the studies are Intraperitoneal local anaesthetic instillation (IPLAI) of
bupivacaine after creation of capnoperitoneum not only reduce the postoperative pain intensity in the
first 24 h effectively but also result in early return to normal routine activity and reduce incidence of
shoulder tip pain significantly. However, intraperitoneal infiltration of bupivacaine does not lead to
early discharge from the hospital.
Two successive Cochrane review published in the same year opined that IPLAI reduces the intensity of
pain perception in ASA PS I or II patients undergoing elective laparoscopic cholecystectomy.[3,7] The
second Cochrane review[3] did not find enough evidence to determine conclusively the effects of
timing of IPLAI or different drugs on postoperative pain. However, both the review suggested that,
a
b,c b
b,c b
a b
c
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there is a need to link the clinical relevance of this reduction in pain with IPLAI to clinical outcomes in
terms of attaining early discharge criteria and time to return to routine activity. Few recent studies also
not analysed the effects of improved pain relief on attaining early discharge criteria or resumption of
daily routine activity.[8,9,10]
Our study was designed to overcome few of the shortcoming of the trials included in the previous
systemic meta-analysis. We have prospectively studied not only the effects of timings of IPLAI on pain
score but also the effect of improved pain relief on the clinical outcome in terms of attaining early
discharge criteria and time to resume normal activity. In our study, pre-emptive group achieved a
statistically significant lower VAS score at all-time points over control whereas for PS group it reached
statistical significance only at 4 and 24 hour. Nevertheless, the VAS always remained numerically
lower in PS group compared to control group. However, we did not find any significant difference in
VAS score between PE versus PS group at any time points. This improved quality of analgesia resulted
in prolongation of time to first analgesic request in the pre-emptive group by 70% over control group
and 20% over PS group [Table 2]. As a consequence of this improved duration of analgesia PE group
not only consumed less paracetamol but also less rescue analgesics compared to group C and group PS.
A meta-analysis from United Kingdom favoured use of IPLAI to reduce early postoperative pain after
laparoscopic cholecystectomy.[2] However, most of the studies included in this meta-analysis failed to
document the effect of intraperitoneal local anaesthetic instillation on postoperative shoulder pain
which is a well-recognised disturbing element with incidence of 30–50% in the postoperative period
following laparoscopic cholecystectomy. The other strong point in our study is that the incidence of
shoulder pain significantly reduced in intervention group (PE and PS) in comparison to control group.
Such high incidence of shoulder pain in control group can be partly explained by the relatively
prolonged duration of surgery and partly by the absence of IPLA instillation.
In concordance with ours study, other investigators have also confirmed the superiority of pre-emptive
analgesia in controlling post-operative pain.[5,11] Several researchers used trocar site local anaesthetic
infiltration as a form of pre-emptive analgesia. An American study concluded that a simple
combination of an oral nonsteroidal anti-inflammatory pain medication and preincision local
anaesthetic infiltration is no better than placebo in controlling postoperative pain after elective
laparoscopic cholecystectomy.[12] However, other studies using trocar site infiltration along with
IPLAI concluded favourably for pre-emptive analgesia. A Turkish study demonstrated that, trocar site
local anaesthetic infiltration is more effective then IPLA instillation for postoperative analgesia and
reduction in incidence of shoulder pain.[8] The authors explained that, higher incidence of shoulder
pain in IPLA group could be because of dilution of IPLAI with placement of a routine drain to observe
potential bile leakages. The incidence of shoulder tip pain in our study is around 7–21% with IPLAI
and very similar to the Turkish study (20%). This can be explained by the fact that unlike the Turkish
study, we have excluded all the cases requiring insertion of a drain at the end of the surgery with a
suspected spillage of bile or blood. Moreover, we have used a higher dose of IPLA (30 ml of 0.5%
bupivacaine) in contrast to Turkish study (20 mL of 0.5% bupivacaine). A Canadian randomised
control trial opined that a combination of pre-emptive periportal (20 mL) and intraperitoneal (40 mL of
0.25% bupivacaine with 1:200,000 epinephrine) infiltration provides superior quality analgesia
compared to only post-operative IPLA or incisional local anaesthesia (LA) infiltration.[13] The recent
Turkish[14] and Polish study[15] also emphasised the superiority of pre-emptive analgesia with
intraperitoneal instillation of bupivacaine. In our study, we have used additional morphine (0.1 mg per
kg) before incision as an alternative to periportal infiltration of LA in other studies to provide pre-
emptive analgesia followed by IPLA instillation after creation of capnoperitoneum. Yet, our results are
similar to their findings and suggest that a single dose of morphine before incision along with 30 mL of
0.5%bupivacaine IPLA instillation offers the same benefit of combined periportal and IPLA
infiltration.
In our study, the superior quality and prolonged duration of postoperative analgesia does not got
translated to attainment of early discharge criteria (modified PADSS 9/10) and time to attain this is
comparable among our study cohort. This could be because the time to satisfy modified PADSS criteria
was assessed only at two time points (8 AM and 6 PM) every day and not continually every hour.
th th
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Hence, we might have missed few patients who have achieved the discharge criteria much earlier
between 8 AM and 6 PM. However, on telephonic interview, the patients from pre-emptive group
reported an early resumption to their daily activity in comparison to post surgery and control group.
Although we have taken care to standardise various factors (dose/concentration/site/position during
IPLA instillation, volume of residual CO ) except timing of instillation that might influence the
benefits of IPLA instillation, one of the major limitation to this study is failure to differentiate and
characterise the type of pain experienced by the patient while obtaining VAS score. Keeping in mind
the multifactorial nature of pain after laparoscopic cholecystectomy, a nuanced analysis could have
thrown some light on differential effect of pre-emptive and post-surgery IPLA instillation on different
types of pain perception. The second limitation is we neither warmed the CO nor measured the
residual CO volume at the end. However we have taken care to maintain intra-abdominal pressure
between 12-14 mm Hg during laparoscopy and end-tidal carbon dioxide between 34-38 mm Hg just
before extubation.
CONCLUSION
To conclude intra peritoneal local anaesthetic instillation immediately after creation of
capnoperitoneum reduces the magnitude of postoperative pain, prolongs the duration of first analgesic
request, reduces analgesic consumption, reduces incidence of shoulder pain in the postoperative period
and facilitates early resumption of normal activity. The current regimen of IPLA instillation appears to
be safe but warrant further study to ascertain plasma drug concentration before making its routine use
as a part of multimodal approach to pain management.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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