Restricted accessResearch articleFirst published online 2021-08
Intraperitoneal Subdiaphragmatic Ropivacaine Instillation for Prevention of Shoulder Tip Pain After Laparoscopic Surgery in High-Risk Patients: A Randomized Controlled Trial
To evaluate the efficacy of intraperitoneal subdiaphragmatic instillation of ropivacaine on shoulder tip pain (STP) or upper abdominal pain postoperatively after gynecological laparoscopic surgery.
Design:
It was a parallel-arm randomized controlled trial conducted in a private tertiary care center between October 2017 and January 2020. A total of 118 participants in two study groups were analyzed.
Materials and Methods:
Women in the study group (Group A) received 40 mL of 0.2% ropivacaine, sprayed under the diaphragm immediately after the creation of pneumoperitoneum. Women in the control group (Group B) did not. Postoperative STP was assessed by using the visual analogue scale at 1, 4, 12, and 20 hours after surgery. The pain scores and requirement of postoperative analgesia were compared between the two groups.
Results:
Incidence of STP or upper abdominal pain was significantly higher in the control arm at 12 hours (Intervention arm: 7.4% vs. Control arm: 21.9%; p = 0.039) and at 20 hours (Intervention arm: 3.7% vs. Control arm: 17.2%; p = 0.035) post-surgery. Number needed to treat was calculated as 6.9. An individual in the intervention arm was found to be 75% more protected from the incidence of pain after adjusting for time and individual level clustering (adjusted incidence rate ratio: 0.25, 95% confidence interval: 0.10–0.68, p = 0.006) than the control arm.
Conclusion:
Intraperitoneal subdiaphragmatic instillation of ropivacaine in fertility-preserving laparoscopic surgeries among high-risk patients reduces the incidence of postoperative STP or upper abdominal pain. (J GYNECOL SURG 37:315)
Get full access to this article
View all access options for this article.
References
1.
EdwardsND, BarclayK, CatlingSJ, MartinDG, MorganRH. Day case laparoscopy: A survey of post-operative pain and an assessment of the value of diclofenac. Anaesthesia, 1991; 46:1077–1080.
KehletH, DahlJB. Anaesthesia, surgery, and challenges in post-operative recovery. Lancet Lond Engl, 2003; 362:1921–1928.
4.
TsaiHW, WangPH, YenMS, ChaoK-C, HsuT-F, ChenY-J. Prevention of postlaparoscopic shoulder and upper abdominal pain: A randomized controlled trial. Obstet Gynecol, 2013; 121:526–531.
5.
DonatskyAM, BjerrumF, GögenurI. Surgical techniques to minimize shoulder pain after laparoscopic cholecystectomy. A systematic review. Surg Endosc, 2013; 27:2275–2282.
6.
KandilTS, El HefnawyE. Shoulder pain following laparoscopic cholecystectomy: Factors affecting the incidence and severity. J Laparoendosc Adv Surg Tech A, 2020; 20:677–682.
7.
DeyA, MalikVK. Shoulder Tip Pain Following Laparoscopic Cholecystectomy—A randomized control study to determine the cause. Indian J Surg, 2015; 77(Suppl. 2):381–384.
8.
YasirM, MehtaKS, BandayVH, AimanA, MasoodI, IqbalB. Evaluation of post-operative shoulder tip pain in low pressure versus standard pressure pneumoperitoneum during laparoscopic cholecystectomy. Surg J R Coll Surg Edinb Irel, 2012; 10:71–74.
9.
GoelA, GuptaS, BhagatTS, GargP. Comparative analysis of hemodynamic changes and shoulder tip pain under standard pressure versus low-pressure pneumoperitoneum in laparoscopic cholecystectomy. Euroasian J Hepato-Gastroenterol, 2019; 9:5–8.
10.
SinglaS, MittalG, Raghav, MittalRK. Pain management after laparoscopic cholecystectomy-a randomized prospective trial of low pressure and standard pressure pneumoperitoneum. J Clin Diagn Res JCDR, 2014; 8:92–94.
11.
AliIS, ShahMF, FarazA, KhanM. Effect of intraabdominal pressure on post-laparoscopic cholecystectomy shoulder tip pain: A randomized control trial. JPMA J Pak Med Assoc, 2016; 66(Suppl. 3):S45–S49.
12.
EsmatME, ElsebaeMMA, NasrMMA, ElsebaieSB. Combined low pressure pneumoperitoneum and intraperitoneal infusion of normal saline for reducing shoulder tip pain following laparoscopic cholecystectomy. World J Surg, 2006; 30:1969–1973.
13.
SeoYK, LeeHJ, HaTK, LeeKG. Effect of normal saline irrigation on attenuation of shoulder tip pain and on β-endorphin levels after laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A, 2012; 22:311–314.
14.
TsaiHW, ChenYJ, HoCM, et al.Maneuvers to decrease laparoscopy-induced shoulder and upper abdominal pain: A randomized controlled study. Arch Surg, 2011; 146:1360–1366.
15.
WongCS, CousinsG, DuddyJC, WalshSR. Intra-abdominal drainage for laparoscopic cholecystectomy: A systematic review and meta-analysis. Int J Surg Lond Engl, 2015; 23(Pt A):87–96.
16.
KalooP, ArmstrongS, KalooC, JordanV. Interventions to reduce shoulder pain following gynaecological laparoscopic procedures. Cochrane Database Syst Rev, 2019; 1:CD011101.
17.
SaccardiC, GizzoS, VitaglianoA, et al.Peri-incisional and intraperitoneal ropivacaine administration: A new effective tool in pain control after laparoscopic surgery in gynecology: A randomized controlled clinical trial. Surg Endosc, 2016; 30:5310–5318.
18.
AllegriM, OrnaghiM, FerlandCE, et al.Peritoneal nebulization of ropivacaine during laparoscopic cholecystectomy: Dose finding and pharmacokinetic study. Pain Res Manag, 2017; 2017:4260702.
19.
Pappas-GogosG, TsimogiannisKE, ZikosN, NikasK, ManatakiA, TsimoyiannisEC. Preincisional and intraperitoneal ropivacaine plus normal saline infusion for post-operative pain relief after laparoscopic cholecystectomy: A randomized double-blind controlled trial. Surg Endosc, 2008; 22:2036–2045.
20.
SullivanKM, DeanA, SoeMM. OpenEpi: A web-based epidemiologic and statistical calculator for public health. Public Health Rep, 2009; 124:471–474.
21.
PaulPG, GargR, KhurdAS, et al.Should we use visual entry techniques in patients with previous laparotomies?. Gynecol Surg, 2016; 13:387–393.
22.
McCormackHM, HorneDJ, SheatherS. Clinical applications of visual analogue scales: A critical review. Psychol Med, 1988; 18:1007–1019.
23.
BurckhardtCS, JonesKD. Adult measures of pain: The McGill Pain Questionnaire (MPQ), Rheumatoid Arthritis Pain Scale (RAPS), ShortForm McGill Pain Questionnaire (SF-MPQ), Verbal Descriptive Scale (VDS), Visual Analog Scale (VAS), and West Haven-Yale Multidisciplinary Pain Inventory (WHYMPI). Arthritis Rheum, 2003; 49:96–104.
24.
NiknamF, SaxenaA, NilesN, BudakUU, MekisicA. Does irrigation of the subdiaphragmatic region with ropivacaine reduce the incidence of right shoulder tip pain after laparoscopic cholecystectomy? A prospective randomized, double-blind, controlled study. Am Surg, 2014; 80:E17–E18.
25.
IngelmoPM, BuccieroM, SomainiM, et al.Intraperitoneal nebulization of ropivacaine for pain control after laparoscopic cholecystectomy: A double-blind, randomized, placebo-controlled trial. Br J Anaesth, 2013; 110:800–806.
26.
LepnerU, GoroshinaJ, SamarütelJ. Post-operative pain relief after laparoscopic cholecystectomy: A randomized prospective double-blind clinical trial. Scand J Surg SJS Off Organ Finn Surg Soc Scand Surg Soc, 2003; 92:121–124.
27.
JorisJ, ThiryE, ParisP, WeertsJ, LamyM. Pain after laparoscopic cholecystectomy: Characteristics and effect of intraperitoneal bupivacaine. Anesth Analg, 1995; 81:379–384.
28.
ChoiGJ, KangH, BaekCW, JungYH, KimDR. Effect of intraperitoneal local anesthetic on pain characteristics after laparoscopic cholecystectomy. World J Gastroenterol, 2015; 21:13386–13395.
29.
McDermottAM, ChangKH, MieskeK, et al.Aerosolized intraperitoneal local anesthetic for laparoscopic surgery: A randomized, double-blinded, placebo-controlled trial. World J Surg, 2015; 39:1681–1689.
30.
BisgaardT, KlarskovB, KristiansenVB, et al.Multi-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: A randomized, double-blinded, placebo-controlled study. Anesth Analg, 1999; 89:1017–1024.
31.
PhelpsP, CakmakkayaOS, ApfelCC, RadkeOC. A simple clinical maneuver to reduce laparoscopy-induced shoulder pain: A randomized controlled trial. Obstet Gynecol, 2008; 111:1155–1160.
32.
SaoC-H, Chan-TiopiancoM, ChungK-C, et al.Pain after laparoscopic surgery: Focus on shoulder-tip pain after gynecological laparoscopic surgery. J Chin Med Assoc JCMA, 2019; 82:819–826.
33.
BarczyńskiM, KonturekA, HermanRM. Superiority of preemptive analgesia with intraperitoneal instillation of bupivacaine before rather than after the creation of pneumoperitoneum for laparoscopic cholecystectomy: A randomized, double-blind, placebo-controlled study. Surg Endosc, 2006; 20:1088–1093.
34.
PasqualucciA, de AngelisV, ContardoR, et al.Preemptive analgesia: Intraperitoneal local anesthetic in laparoscopic cholecystectomy. A randomized, double-blind, placebo-controlled study. Anesthesiology, 1996; 85:11–20.
35.
KaraaslanD, RemziyeGS, AkbulutG, DilekON. Preemptive analgesia in laparoscopic cholecystectomy: A randomized controlled study. Pain Pract, 2006; 6:237–241.
36.
Ruiz-TovarJ, GonzalezJ, GarciaA, et al.Intraperitoneal ropivacaine irrigation in patients undergoing bariatric surgery: A prospective randomized clinical trial. Obes Surg, 2016; 26:2616–2621.
