Page 26 - Journal of Laparoscopic Surgery - WALS Journal

Mahmoud AL Bahram et al
Table 4: Postoperative complications in both groups immediately postoperative and remained significant up
Group I Group II p-value to 4 hours postoperative. However, the difference was not
Nausea 27 105 S significant between both groups after 6 hours; this may
Vomiting 4 56 S be due to the rescue analgesia doses of NSAIDs given to
Bradycardia 0 3 NS patients in group II. The results in this study conform
Respiratory depression 0 2 NS with the results in the study done by Singh et al and
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Hospital stay 1 ± 0.12 days 1 ± 0.42 days NS Golubovi et al. 2
Intra-abdominal infection 1 0 NS 10
S: Significant; NS: Nonsignificant A study done by Gupta et al also showed that intra-
peritoneal instillation of fentanyl (100 μg) along with
bupivacaine (0.5% 20 ml) significantly reduces immediate
During hospital stay and early postoperative follow-
up, the incidence of nausea and vomiting was signifi- postoperative pain. It also reduces intensity of pain even
after 24 hours.
cantly lower in group I than in group II. There was no
In group II, about two-thirds of the patients required
significant difference between both groups regarding a first dose of rescue analgesia immediately postopera-
complications and hospital stay (Table 4).
tively and the remaining third of the patients required
this dose within the next 6 hours, whereas in patients
DISCUSSION
in group I receiving ropivacaine, 25% of the patients
The establishment of laparoscopic cholecystectomy as required the first dose immediate postoperatively and
an outpatient procedure has accentuated the clinical the remaining 75% of patients required analgesia within
importance of reducing early postoperative pain and 24 hours postoperatively. There was a significant differ-
nausea as both are the most common complications ence between both groups regarding timing of first dose
of laparoscopic surgery, including cholecystectomy. of rescue analgesia. Further requirement of rescue doses
Both, particularly pain, prolong recovery and discharge of analgesia was significantly lower in group I than in
times and contribute to unanticipated admission group II.
after ambulatory surgery. Pain also contributes to Shoulder pain is a common outcome after laparo-
postoperative nausea and vomiting. 1 scopic cholecystectomy and can delay return to normal
Interestingly, the type of pain after laparoscopy differs activities. The proposed mechanism of shoulder pain
considerably from that seen after laparotomy. Although seems to be a diaphragmatic stretching with phrenic
it is the belief of patients that laparoscopy has ushered nerve neuropraxia, which is possibly due to increased
a pain-free era, the fact remains that patients complain concavity of diaphragm induced by pneumoperitoneum
more of visceral pain after laparoscopy in contrast to and reference of pain from the traumatized area. 10
parietal pain experienced in laparotomy. 5 Shoulder pain was significantly lower in group I than
Visceral pain is caused by inflammation or local in group II early in the postoperative period, but was
irritation around the gallbladder bed, liver, diaphragm, not significant after 6 hours postoperatively. The reason
or peritoneum. Also, the incidence of postoperative could be the blocking of nociceptive inputs generated by
shoulder pain due to diaphragmatic irritation by residual inflamed diaphragm peritoneum caused by instillation
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carbon dioxide following laparoscopic surgery may reach of ropivacaine. Joris et al obtained similar results
up to 80%. 6 using ropivacaine and showed that use of ropivacaine
Intraoperative use of large bolus doses or continu- decreased incidence of shoulder pain even after 24 hours
ous infusions of potent opioid analgesics may actually postoperatively.
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increase postoperative pain as a result of their rapid Studies by Gupta et al using bupivacaine and Kim
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elimination and/or the development of acute tolerance. et al using ropivacaine showed similar results, which
Also, opioid analgesics are associated with a variety of further supports these results.
perioperative side effects, such as respiratory depres- In this study, the incidence of nausea, vomiting,
sion, drowsiness, bradycardia, postoperative nausea, bradycardia, respiratory depression, and intra-abdominal
and vomiting. 7 infection was recorded in both groups. There was a
Therefore, anesthesiologists and surgeons are significantly lower incidence of postoperative nausea and
increasingly turning to nonopioid analgesic techniques vomiting in group I than in group II, but no significant
as adjuvant for managing pain during the perioperative difference between both groups as regarding bradycardia,
period to minimize the adverse effects of analgesic respiratory depression, or postoperative intra-abdominal
opioids. 8 infection. This shows ropivacaine instillation reduces
This study showed that VAS scores are highly sig- the incidence of nausea and vomiting. The cause could
nificantly lower in group I in comparison to group II be lower incidence of pain and avoiding the side effect
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