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Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 5-10

Evaluation of intraperitoneal and preincisional port site local anesthetic use in laparoscopic cholecystectomy

1 Department of General and Laparoscopic Surgery, Faculty of Medicine, El-Menoufia University, El-Menoufia, Egypt
2 Department of General and Vascular Surgery, Faculty of Medicine, El-Menoufia University, El-Menoufia, Egypt

Date of Submission24-Mar-2014
Date of Acceptance22-Jul-2014
Date of Web Publication29-Apr-2015

Correspondence Address:
Ahmed Essam AlKafrawy
46 Hegazi Street, El-Mesaha, Tanta 31111
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-2098.155900

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The aim of the study was to evaluate the role of intraperitoneal and port site use of local anesthetic in laparoscopic cholecystectomy in postoperative pain relief.
Laparoscopic strategies for managing intra-abdominal pathologies offer significant benefits compared with conventional approaches. Of interest are reports of decreased postoperative pain, resulting in shorter hospitalization and earlier return to normal activity. However, many patients still require strong analgesia postoperatively. This study analyzed the intraperitoneal and port site use of local anesthetic and its ability to reduce postoperative pain.
Patients and methods
For this study, 60 patients undergoing laparoscopic cholecystectomy were recruited and divided randomly into three groups: control (n = 20), intraperitoneal local anesthetic irrigation of bladder bed (n = 20), intraperitoneal and port site local anesthetic (n = 20). All patients had standard preoperative, intraoperative, and postoperative care. Pain scores were recorded by the physician after 1, 2, 4, 6, 8, 10, and 12 h postoperatively using a standard 0-10 pain scoring scale. In addition, peristalsis auscultation, passing flatus, and movement from bed were recorded.
Intraperitoneal and port site local anesthetic use significantly reduced postoperative pain in comparison with all other treatments (P < 0.05).
Intraperitoneal and port site local anesthetic is an effective method for controlling postoperative pain. It significantly helped to reduce opiate use and contributed to rapid mobilization, leading to short hospitalization and possible reduction in treatment cost.

Keywords: Cholecystectomy, intraperitoneal, laparoscopic, preincisional

How to cite this article:
Sultan HM, Zaid NA, AlKafrawy AE. Evaluation of intraperitoneal and preincisional port site local anesthetic use in laparoscopic cholecystectomy. Menoufia Med J 2015;28:5-10

How to cite this URL:
Sultan HM, Zaid NA, AlKafrawy AE. Evaluation of intraperitoneal and preincisional port site local anesthetic use in laparoscopic cholecystectomy. Menoufia Med J [serial online] 2015 [cited 2020 Feb 24];28:5-10. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/5/155900

  Introduction Top

Laparoscopic operative procedures have revolutionized surgery with many advantages: a smaller and more cosmetic incision, reduced blood loss, and reduced postoperative stay and pain, which cut down on hospital cost [1].

However, patients undergoing laparoscopic procedures do experience postoperative pain, especially in the upper and lower abdomen, back, and shoulder region. Pain intensity usually peaks during the first postoperative hours and usually declines over the following 2-3 days [1]. Pain after laparoscopy results from the stretching of the intra-abdominal cavity, peritoneal inflammation, and phrenic nerve irritation caused by residual CO 2 in the peritoneal cavity [2].

Intraperitoneal injection of local anesthetic (LA) has been proposed to minimize postoperative pain after laparoscopic cholecystectomy (LC). Several reports are available on the efficacy of intraperitoneal administration of LA for analgesia after laparoscopic surgery [3].

The exact etiology of postlaparoscopic pain remains unclear. However, it appears to be multifactorial, and treatment of any one factor in isolation will not achieve the desired outcome. The causes include initiation of pneumoperitoneum, type of insufflated gas and intra-abdominal pH, residual intraperitoneal gas, gas temperature, humidity, and the use of certain anesthetic and anti-inflammatory drugs. Additional contributing factors include access-related pain, sociocultural status, and individual factors [4].

The ease of use and safety of LA is well recognized, and collectively they serve as one of the most important classes of drugs in perioperative care. The main advantage of LA agents is that they do not have the adverse effects of systemically administered opioids, such as postoperative sedation, nausea, gastrointestinal paralysis, and respiratory suppression, and they act directly on the tissue that they are applied to [5].

Pain after LC is considered to arise from three main sources: the incision sites, the pneumoperitoneum in association with both local (peritoneal and diaphragmatic stretching, ischemia, acidosis) and systemic (hypercarbia causing sympathetic nervous system excitation resulting in amplification of the local tissue inflammatory response) changes, and the postcholecystectomy wound within the liver. Total abdominal pain after LC covers all these aspects, with the largest component (50-70%) arising from the incision sites, followed by the pneumoperitoneum (20-30%) and cholecystectomy (10-20%) [6].

Often the pain following LC can arise from the incision site (incisional pain), visceral structures (abdominal pain), or referred from the subdiaphragmatic region as shoulder pain. Shoulder pain is often mild in intensity and can remain for 24 h [7].

Incisional pain is usually mild to moderate in intensity and maximal immediately postoperatively, subsiding with time 10. Abdominal pain following LC can occur for a number of reasons: stretching of the parietal peritoneum from the insufflations of gas intraperitoneally, release of inflammatory mediators of the soft tissue, or dissection of the gallbladder of the liver bed. The reason for the marked variation of pain between individuals remains unclear but could be due to multiple factors, including the size of the incisions, the duration of surgery, blood, bile, or insufflated gas at the end of surgery. It could also be influenced by the length of surgery, experience of the surgeon, total amount of blood loss, as well as by instillation of normal saline to 'dilute' any local pain mediators [8].

  Patients and methods Top

This prospective study was carried out on 60 patients; all of them were subjected to LC. Cases were accepted at the Department of General Surgery, El-Menoufia University Hospitals; informed consents were obtained from all patients included in the study, which are approved by the local ethics committee. The inclusion criteria for the cases were patients undergoing laparoscopic cholecystectomy with American Society of Anesthesia (ASA) 1 and 2 and who were above 18 years and younger than 70 years. The exclusion criteria were any patients with ASA 3 and 4, presented with acute cholecystitis, patients with allergy to NSAIDs or LA, patients younger than 18 years and above 70 years, patients with significant cardiac, respiratory, hepatic, renal, or hematologic disorders, patients with history of gastrointestinal bleeding, if the operation is converted from LC to open cholecystectomy, or patients receiving regular NSAIDs.

All included patients were subjected preoperatively to medical history including personal, present illness, past and family history, followed by physical examination including general and local (inspection, palpation, percussion, and auscultation), then preoperative investigations such as complete blood count (CBC), liver function, kidney function, prothrombin time and activity, direct and indirect bilirubin, ECG, and chest radiograph; thereafter, informed consent was taken from each case according to ethical and legal research guidelines at El-Menoufia University Hospitals.

Thereafter, cases were divided randomly into three groups: group A (20 patients), the control group; group B (20 patients) undergoing LC with intraperitoneal injection of local anesthetic (IPLA); and group C (20 patients) undergoing LC with preincisional subcutaneous infiltration with LA at port sites in addition to IPLA.

Operative technique used is consisted of the following steps: first, the patient was placed in the supine position; then, peripheral intravenous lines were placed along with ECG, pulse oximetry, and blood pressure monitors; after that the patient was intubated and general anesthesia was initiated; and then the patient's arms were abducted or tucked comfortably at his sides. The two laparoscopic towers were placed on either side of the patient's trunk, toward the head. The surgeon stands on the patient's left and the assistant stands on the right. The skin was initially prepared with chlorhexidine from just below the nipple line to the inguinal ligaments and laterally to the anterior superior iliac spine. Thereafter, the operative field was draped with sterile drapes.

In group C only, preincisional subcutaneous injection of Xylocaine (lidocaine HCl) was given 1 cm at each port site.

Thereafter, a 1.5-cm transverse incision was made at the inferior aspect of the umbilicus and deepened it through the subcutaneous fat to the anterior rectus sheath. With a Kocher clamp, the reflection of the linea alba onto the umbilicus was grasped and elevated it cephalad; the peritoneum between two straight clamps were elevated and incised, affording safe entry into the abdominal cavity. An 11-mm blunt Hasson trocar was placed into the abdominal cavity and CO 2 insufflation was initiated to a maximum pressure of 15 mmHg; the laparoscope was white balanced and advanced it slowly into the abdominal cavity. A 1.2-cm incision was made three-finger breadths below the xiphoid process and deepened it into the subcutaneous fat. An 11-mm trocar into the abdominal cavity (under direct vision) was advanced in the direction of the gallbladder through the abdominal wall, making sure to enter just to the right of the falciform ligament. Thereafter, the table was placed in reverse Trendelenburg position with the right side up to allow the small bowel and colon to fall away from the operative field.

The fundus was grasped of the gallbladder with a 5-mm grasper placed through the 11-mm subxiphoid port. The gallbladder was elevated cephalad over the dome of the liver to aid in choosing the best lateral 5-mm port positions; after appropriate sites are chosen, skin incisions were made and two 5-mm lateral trocars was placed into the peritoneal cavity under direct vision. Two 5-mm graspers were placed with locking mechanisms through each of these lateral ports; the lateral grasper was used to grasp the fundus and held it cephalad over the dome of the liver. The medial grasper was used to retract the infundibulum of the gallbladder in a caudolateral direction. This maneuver straightens the cystic duct - that is, retracts it at a 90° angle from the common bile duct (CBD) - and is a key safety move integral in protecting the CBD from inadvertent injury. In contrast, retraction of the infundibulum cephalad tends to bring the cystic duct in line with the CBD, making the CBD more prone to injury.

Occasionally, adhesions between the gallbladder and omentum or duodenum may be encountered. These can be lysed using careful hook cautery. The authors prefer to use the L hook electrocautery, which allows for a very clean and delicate dissection, but any electrosurgical device can be used for this dissection; once the area of the hilum of the gallbladder has been reached, the importance of exposure and delicate dissection cannot be overemphasized. Carefully dissect and identify the cystic duct and artery in the triangle of Calot to obtain the critical view. The critical view is achieved when one can see only two structures entering directly into the gallbladder. This view must be obtained before the clipping and transection of any structures; the key to obtaining the critical view is complete clearance of the areolar tissue in the subhepatic space. The infundibulum caudolaterally was held and used the hook to score the anterior peritoneum overlying the infundibulum-cystic duct junction. Thereafter, the peritoneum was incised along the medial aspect all the way to within 1 cm of the liver, and then continued cephalad toward the fundus of the gallbladder.

Thereafter, the gallbladder was retracted caudomedially and a similar dissection was repeated on the lateral surface. This technique is sometimes called the flag technique; an endopeanut or dissector can be of great help in better defining these structures. At this point, one should be able to identify the cystic duct and artery entering directly into the gallbladder (this is the critical view); the structures can be clipped and divided. An endoscopic clip applier was used to place clips on the artery and duct (two proximally and one distally), followed by division with endoshears; once the cystic structures have been clipped and divided, retract the gallbladder infundibulum cephalad. A hook or spatula was used to develop a plane in the areolar tissue between the gallbladder and liver with smooth sweeping movements from right to left and back again. As with any surgery, the rule of traction-countertraction is essential. As one marches up the gallbladder bed, the assistant should reposition his graspers to ensure optimal tension on the areolar tissue between the gallbladder and its liver bed.

Before dividing the last strands connecting the gallbladder to the liver, a final inspection of the gallbladder fossa and the clipped cystic structures was made. Any bleeding points in the gallbladder fossa should be controlled at this time, before the gallbladder is completely separated from the liver. This is the last opportunity to visualize these areas well; the gallbladder was grasped with both 5-mm graspers and held it over the right upper quadrant. The laparoscope was transferred to the subxiphoid port. The gallbladder was taken out through the umbilical trocer and the final inspection and washout was performed.

In group B and C only, intraperitoneal irrigation of Xylocaine (lidocaine HCl, Astra Zeneca, Egypt) was used 4 mg/kg at bladder bed.

Thereafter, the table was returned to neutral position, followed by closure of all skin incisions, extubation of the patient, and transferring him to the postanesthesia care unit.

In postoperative evaluation, we measured postoperative pain through postoperative meticulous observation (after 1, 2, 4, 6, 8, 10, 12 h postoperatively), vital signs (arterial blood pressure, pulse, temperature, respiratory rate), pain rating scale, visual analog scale by doctor's notes, peristalsis auscultation, movement from bed, and passing flatus.

  Results Top

Statistical presentation and analysis of the present study were conducted using the mean, SD, and c2 -test by SPSS (V.16; SPSS Inc., Chicago, Illinois, USA).

Mean value (c- ): it is the sum of all observations divided by the number of observation

where å is the sum and n is the number of observations.

SD: it measures the degree of scatter of individual varieties around their mean

Analysis of variance tests: according to the computer program SPSS for Windows, analysis of variance test was used for comparison among different times in the same group in quantitative data.

The c2 -test was used to test the hypothesis that the row and column variables are independent, without indicating strength or direction of the relationship. Pearson's c2 and likelihood-ratio c2 , Fisher's exact test, and Yates' corrected c2 are computed for 2 × 2 tables.

The c2 -test was performed for comparison between two groups with respect to qualitative data

where å is the summation, O is the observed value, E is the expected value,

In the first hour, the P value of the visual analog scale was 0.001, which means highly significant difference between the three groups; in the second hour, P value was 0.002, which is also significant; in the fourth hour, P value was 0.006, which is significant; in the sixth hour, P value was 0.001, which is highly significant as well; in the eighth hour, P value was 0.012, which is significant; and in the 10 th and 12 th hours, P values were 1, which was insignificant [Table 1].
Table 1: The ranges, means, SDs, f-test, and P values of visual analog scale of the three groups at 1, 2, 4, 6, 8, 10, 12 h postoperatively

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The intraperitoneal and port site use of LA showed significant effect in the first, second, fourth, sixth, and eighth hours on reducing postoperative pain, whereas it showed no significant effect in the 10 th and 12 th hours postoperatively [Figure 1].{Figure 1.}

In group A, the mean of positive peristalsis auscultation was 6; in group B, the mean was 1.35; and in group C, the mean was 1.25, with P value of 0.001, which is highly significant [Table 2] and [Figure 2].
Figure 2: The mean values of peristalsis auscultation of the three groups.

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Table 2: The peristalsis auscultation of the three groups at 1, 2, 4, 6, 8, 10, 12 h postoperatively

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Using Scheffe's test, there was significant difference between the three groups, indicating the effect of use of LA both intraperitoneal and at port site.

Hence, the end result is that usage of LA both intraperitoneal and subcutaneous is significantly effective on reducing postoperative pain in the first eight hours, early intestinal movement, early passing flatus, and early postoperative ambulation.

  Discussion Top

LA prevent transmission of nerve signals from the trauma site to the spinal cord and reduce neurogenic local inflammation at the trauma site [9].

The total pain of laparoscopy can be reduced by application of LA under the diaphragm under direct vision, through an irrigation device or through a subphrenic catheter [10].

Pain after cholecystectomy is thought to be multidimensional in nature. With the advent of minimally invasive techniques including single-port laparoscopy and transluminal endoscopic surgery, there is potential to bypass the abdominal wall altogether for visceral access and resection. Although greatly reducing the need for analgesia, these advances in technique still cause visceral nociception, through disruption of the peritoneum and dissection of viscera [11].

Visceral pain is a distinctly separate form of pain compared to somatic pain. Visceral signaling occurs through the enteric nervous system, which is complex and partly independent of the central nervous system, with a vast network of distinct, and functionally diverse, neuronal subtypes. Viscera such as the gallbladder and covering peritoneum convey unpleasant sensations and autonomic reactions to injury through afferents in the vagus nerve. These so-called 'silent nociceptors' are activated by intraperitoneal inflammation and injury, giving rise to both painful and nonpainful sensations that influence feeding and illness behaviors [12].

The ease of use and safety of LA is well recognized, and collectively they serve as one of the most important classes of drugs in perioperative care. The main advantage of LA agents is that they do not have the adverse effects of systemically administered opioids, such as postoperative sedation, nausea, gastrointestinal paralysis, and respiratory suppression, and they act directly on the tissue that they are applied to. LA are commonly administered in abdominal surgery by skin infiltration or epidural administration, blocking somatic afferents and providing significant benefits in reducing postoperative pain and improving recovery. It is also possible, however, to instill LA solutions into the peritoneal cavity, thereby blocking visceral afferent signaling and potentially modifying visceral nociception and downstream illness responses. LA applied to the peritoneal cavity have been used as 'field blocks' from as early as 1950. Tubal ligation has been performed effectively and safely under abdominal wall and IPLA alone. Peripheral techniques of using LA also seem to be gaining popularity. However, the practice of IPLA is not routine in modern-day LC [13].

A significant number of papers have examined the IPLA in laparoscopic cholecystectomies according to the abdominal postoperative pain and narcotic analgesic consumption, with promising results [14],[15],[16],[17],[18]. However, other studies indicate that the postoperative analgesia [19-21] and narcotic usage were not significantly different in the groups that received LA [22],[23]. Some of these studies examined the timing of the administration of the LA during surgery, with controversial results because some showed no statistical difference regarding the postoperative pain and time of discharge of the patients [24],[25], whereas others support the belief that the timing of IPLA is very important [26].

  Conclusion Top

Preincisional and intraperitoneal infiltration of LA is an easy, safe, inexpensive, and noninvasive method that provides good analgesia during the early postoperative period and also provides early peristalsis resulting in the following effects: early regaining of intestinal movement and early passing flatus, leading to early oral feeding avoiding the complications of parenteral nutrition, early ambulation, avoiding the complications of long recumbency, patient returns to his normal life earlier, calm and painless postoperative recovery, avoiding complications of postoperative anxiety and agitation, minimizing usage of NSAIDs, avoiding their systemic side effects, and decreasing the length of postoperative stay at hospital. Hence, we advocate to use intraperitoneal and port site LA as a routine procedure of LC.

  Acknowledgements Top

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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