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Randomized controlled study of intraincisional infiltration versus intraperitoneal instillation of standardized dose of ropivacaine 0.2% in post-laparoscopic cholecystectomy pain: Do we really need high doses of local anesthetics—time to rethink!

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Abstract

Background

Earlier studies done to compare the efficacy of use of local anesthetics at intraperitoneal location versus intraincisional use had utilized equal amount of drugs at the two locations, usually 10–20 ml. Using this large amount of drug in the small space of intraincisional location as compared to similar amount of drug in large intraperitoneal space created an inadvertent bias in favor of patients receiving the drug intraincisionally so these patients naturally experienced less pain.

Aims and objectives

To conduct a randomized, triple-blind, placebo-controlled study by standardizing dose of local anesthetic, to compare the effectiveness of intraperitoneal against intraincisional use of ropivacaine 0.2% for post-laparoscopic cholecystectomy pain relief.

Materials and methods

294 patients underwent elective 4-port laparoscopic cholecystectomy. Patients were triple blindly randomized. All patients received ~ 23 ml of solution, of which 20 ml was given intraperitoneally (1 ml/cm; 16 ml along right hemi-dome and 4 ml in gall bladder fossa) and ~ 3 ml intraincisionally (1 ml/cm of length of incision). Solution was either normal saline or drug (0.2% ropivacaine) depending on the group [controls (n = 86), intraperitoneal group (n = 100), and intraincisional group (n = 108)]. 5 different pain scales were used for assessment of overall pain. Pain scores were assessed at 5 points of time.

Results

Patients in intraincisional group showed significantly less overall pain and rescue analgesia requirement (p < 0.05). Intraincisional group showed significantly less overall pain (p < 0.05) as compared to intraperitoneal group; however, use of rescue analgesia was comparable in the two groups (p > 0.05); and shoulder pain was significantly less in intraperitoneal group (p < 0.05).

Conclusion

The intraincisional use of injection ropivacaine at its minimum concentration of 0.2% in minimal doses of 1 ml/cm at the end of procedure provides significantly more post-operative analgesia as compared to intraperitoneal group and controls. However, for controlling shoulder pain, the use of intraperitoneal ropivacaine is desirable.

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Acknowledgements

Professor Ramesh Chand Goel, Department of Statistics, PGIMER, Chandigarh helped in conducting the statistical analysis comprehensively. Department of English, Faculty of Arts, Aligarh Muslim University helped in critically revising the manuscript for English language corrections and grammatical mistakes.

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Authors and Affiliations

  1. Department of Surgery, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, 202002, India

    Singh Mathuria Kaushal-Deep, Afzal Anees, Shehtaj Khan & Mohammad Amanullah Khan

  2. Department of Anesthesia, Institute of Medical Science, Banaras Hindu University, Varanasi, 22100, India

    Mehershree Lodhi

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  1. Singh Mathuria Kaushal-Deep
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  2. Afzal Anees
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Correspondence to Singh Mathuria Kaushal-Deep.

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Disclosures

The authors have been associated with the same institution in the time period of 36 months while this study was conducted and no corporate/commercial relationships existed in relation to this study or any other during this time duration. This study received no funding in any form, from any other source whether inside or outside the institution. No financial or any form of vested interest exists between the authors and the manufacturers of Injection Ropin 0.2% marketed by Neon Laboratories Ltd., Mumbai, India. The drug brand was chosen because of its easy and free availability through the hospital drug section. Drs. Singh Mathuria Kaushal-Deep, Afzal Anees, Shehtaj Khan, Mohammad Amanullah Khan, and Mehershree Lodhi have no conflicts of interest or financial ties to disclose

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Kaushal-Deep, S.M., Anees, A., Khan, S. et al. Randomized controlled study of intraincisional infiltration versus intraperitoneal instillation of standardized dose of ropivacaine 0.2% in post-laparoscopic cholecystectomy pain: Do we really need high doses of local anesthetics—time to rethink!. Surg Endosc 32, 3321–3341 (2018). https://doi.org/10.1007/s00464-018-6053-z

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