Intraperitoneal vs Intraincisional Bupivacaine for Post Operative Pain Relief in Laparoscopic Cholecystectomy
Authors: Saldanha N. , D’Souza A. , Rudresh M. 
Published: November 2024

Introduction: Laparoscopic cholecystectomy has become the standard technique for gall bladder surgeries1. Given the expanding role of ambulatory surgery, effective post operative pain relief has become a greater challenge for Anaesthesiologists. New insights into our knowledge of the origins of abdominal and shoulder pain after laparoscopic procedures lead to the increasing use of intra peritoneal and port site instillation of local anesthetic for pain relief2.
Methods: Patients fulfilling the inclusion criteria, followed a prospective randomized double blinded study in 100 patients, divided into 2 groups of 50 each; by Anaesthetist I: Group A-Bupivacaine (0.25%) 20ml intra-incisional. Group B- Bupivacaine (0.25%) 20ml intraperitoneal. After a thorough pre-anesthetic evaluation and obtaining an informed consent, the patient was made familiar with the 10-point visual analogue scale (VAS) and visual rating scale (VRS). All patients were asked to keep NPO as per guidelines. Premedicated with Tab Alprazolam 0.5mg and Tab Pantoprazole 40 mg orally the previous night of the surgery. After connecting monitors (ASA standard), an 18G peripheral cannula was secured and Lactated Ringer’s solution initiated. Standard General Anesthesia with intubation and positive pressure ventilation was administered. After completion of surgery Bupivacaine was injected at: Group A: Intra-incisional (fascia, muscle and preperitoneal space); 5ml for each port (infiltration of four trocar sites, total- 20ml). Group B: Intraperitoneal, 10ml in hepato-diaphragmatic space, 5ml in gall bladder bed, 5ml into space between liver and kidney, in Trendelenburg position of 20 degree to facilitate dispersion of drug solution in sub hepatic region. All the operations were performed by the same team of laparoscopic surgeons. Patients were reversed adequately and extubated at the end of the procedure. Post operatively, pain using VAS & VRS was assessed by anesthetist II- blinded to the study groups; at first hour of surgery, hourly till four hours, 6, 8, 12 and 24 hours after the surgery. Shoulder tip pain, nausea, vomiting, need for rescue analgesia, any voiding problems, respiratory difficulties if any, was documented. Rescue analgesia was administered to a goal of VAS score ≤ 4.
Results: There was a statistically significant reduction in VAS and VRS scores at all time frames postoperatively in Group B (p value - ≤0.001), as compared to Group A. A reduction in heart rate was noted at all time frames in Group B, of which heart rate from 0 till 8 hours postoperatively was statistically significant (p value ≤0.001). There was also a statistically significant reduction in systolic blood pressure across all time frames in Group B which received intraperitoneal Bupivacaine instillation. Diastolic blood pressure showed no statistical significance between the two groups. We also noted a statistically significant reduction in shoulder tip pain in Group B which received intraperitoneal Bupivacaine. The requirement for post operative pain relief rescue analgesia Inj. Diclofenac 75mg IV, was significantly higher in the patients who received intra-incisional local anaesthetic.
Conclusion: We conclude that intraperitoneal Bupivacaine 0.25% (20mls) instilled into the peritoneal cavity at the end of procedure, with the patient in Trendelenburg position is an effective way to alleviate post operative pain in laparoscopic cholecystectomy procedures up to 24 hours. It reduces shoulder tip pain, with a considerable reduction in rescue analgesic requirement as well. Effective analgesia also reduced post operative duration of hospital stay, having no adverse effect like nausea and vomiting, local anesthetic toxicity.

Key words: Intraperitoneal, Local anaesthesia, pain relief, Bupivacaine, shoulder tip pain