Incidence Of Shoulder Tip Pain Research Articles

Comparative study of two thoracic segmental spinal anaesthesia techniques for laparoscopic cholecystectomy: low-dose hypobaric ropivacaine and isobaric ropivacaine at T10-11 intervertebral space vs. standard technique using isobaric levo bupivacaine at T8-T10 intervertebral space

Background: Many prior studies have utilized thoracic or lumbar spinal anesthesia with isobaric/hyperbaric bupivacaine or Ropivacaine and opioids for laparoscopic cholecystectomy and have reported variable results. our study is centered around addressing the occurrence of intraoperative right shoulder pain and its potential impact on the need for conversion to general anesthesia. Methods: This is a prospective comparative case series study in which 70 patients scheduled for elective laparoscopic cholecystectomy were. Patients in Group R received 1 ml (1 mg) of Hypobaric Ropivacaine 0.1% at T10-11 followed by 25 mcg fentanyl, and 5 mg Isobaric Ropivacaine 0.5% whereas patients in Group B received 1.5 ml (7.5 mg) Isobaric levo Bupivacaine 0.5% and 25 mcg fentanyl at T8-T10. Patients in both the groups were compared for incidence of shoulder tip pain and Hemodynamic stability. Results: Both techniques achieved satisfactory anaesthesia quality, with similar results in surgical anaesthesia onset. Average surgical duration was 45-75 minutes with average of 60 mins with longer durations in two cases common to both the groups. In group R there was there was no bradycardia or hypotension recorded more than 10% of preinduction vitals. Whereas in group B 2 patients had bradycardia and hypotension more than 10% of preinduction vitals. Conclusions: The T10-11 technique using low-dose (6 mg) hypobaric ropivacaine and isobaric Ropivacaine appears to be superior in terms of shoulder tip pain, and hemodynamic stability compared to the T8-T10 technique using isobaric levo-Bupivacaine alone in higher dose.

Shoulder tip pain after cesarean section: General versus spinal anesthesia

Shoulder tip pain is a common but overlooked complication during the postoperative cesarean section. In this study, we aimed to investigate the relationship between the anesthesia method and the incidence of shoulder tip pain. In this randomized clinical study, 117 patients who underwent cesarean section were divided into two groups as spinal anesthesia and general anesthesia. The demographic characteristics, the presence, the severity of shoulder tip pain, and also analgesic consumption in the first 24 hours were compared. The incidence of shoulder tip pain was significantly higher in the spinal anesthesia group than in the general anesthesia group (p = 0.032). While there was no statistically significant difference in terms of the number of patients who needed opioid treatment within the first 24 hours between patients with and without STP, a statistically significant difference was observed in terms of the use of nonsteroidal anti-inflammatory drugs (P < 0.001). This study shows that the frequency and severity of shoulder pain are higher in women who have had cesarean section under spinal anesthesia, compared to those who had received general anesthesia.

A FOLLOW-UP STUDY - LOW-PRESSURE PNEUMOPERITONEUM COMPARED TO STANDARD PNEUMOPERITONEUM IN LAPAROSCOPIC CHOLECYSTECTOMY

Introduction-: Post-laparoscopic pain syndrome is well conceded and characterized by abdominal and especially shoulder tip pain. It occurs frequently following laparoscopic cholecystectomy. The etiology of post-laparoscopic pain can be classied into three aspects visceral, incision, and shoulder. This study purposed to compare the frequency and strength of shoulder tip pain between low pressure (7 mmHg) and standard pressure (14 mmHg) in a prospective randomized clinical test. Methods-: One hundred forty successive patients undergoing elective laparoscopic cholecystectomy were randomized prospectively to either low or high-pressure pneumoperitoneum. The statistical analysis included mean age, weight, sex, duration of surgery, conversion rate, American Society of Anesthesiologists (ASA) grade, operative time, incidence and severity of shoulder tip pain, and post-operative hospital stay. Results -: The patient's quality was similar in the two groups except for the predominance of males in the standard-pressure group. The plan of action was successful in 68 of 70 patients in the low-pressure group. The number of analgesic injections, visual analog score, operative time, and length of post-operative days were the same in all groups. Occurence of shoulder tip pain was higher in the standard-pressure group, but not statistically signicantly so (p = 0.100) (27.9% versus 44.3%). Conclusions -: Low-pressure pneumoperitoneum tended to be better than standard-pressure pneumoperitoneum in a period of lower incidence of shoulder tip pain. Still, this difference did not reach statistical signicance following elective laparoscopic cholecystectomy

A Randomized Trial of Low-Pressure (08–10 mm Hg) vs. Standard-Pressure (13–15 mm Hg) Pneumoperitoneum in Laparoscopic Cholecystectomy

The reported incidence of shoulder tip pain after laparoscopic cholecystectomy was 30%–50%. The aim of the present randomized controlled study was to compare the effects of low-pressure (08–10 mm Hg) vs. standard-pressure (13–15 mm Hg) pneumoperitoneum in patients undergoing laparoscopic cholecystectomy. One hundred patients between 18 and 70 years undergoing laparoscopic cholecystectomy were included. Group A and group B patients underwent low-pressure and standard-pressure pneumoperitoneum laparoscopic cholecystectomy respectively. Post-operative shoulder tip pain and post-operative abdominal pain were measured using visual analogue scale score at 2 h, 8 h, 24 h and 48 h after surgery. The primary outcome measures were the incidence and severity of post-operative shoulder tip pain, whereas secondary outcome measures were the incidence and severity of abdominal pain. Intergroup comparison of categorical and continuous variables was done using the chi-square test/Fisher’s exact test and unpaired ‘t’ test respectively. The incidence and severity of post-operative shoulder tip pain at 2 h, 8 h, 24 h and 48 h was significantly higher in group B as compared to group A. The incidence of post-operative abdominal pain at 48 h was significantly higher in group B as compared to group A. The severity of post-operative abdominal pain at 24 h and 48 h was significantly higher in group B as compared to group A. Low-pressure laparoscopic cholecystectomy significantly decreases the incidence and severity of post-operative shoulder tip and abdominal pain. Routine use of low-pressure pneumoperitoneum for the alleviation of post-operative pain following laparoscopic cholecystectomy is recommended.

A Study to Evaluate Role of Intraperitoneal Saline Wash for Shoulder Tip Pain Reduction after Laparoscopic Cholecystectomy

Background: Shoulder tip pain after laparoscopic procedures is common leading to patient’s distress, delayed discharge. Objective: To evaluate simple and effective intervention to reduce incidence of shoulder tip pain after laparoscopic cholecystectomy. Setting: Tertiary care medical college. Materials and methods: Eighty patients of cholelithiasis were included in study and aim of study will compare incidence of shoulder tip pain in two groups of 40 each. Group A (Study group) received thorough intraperitoneal saline wash and in Group B (Control group), no saline wash will be done. We intend to thoroughly wash the peritoneal cavity after the removing all blood clots and debris with 0.9% normal saline till clear fluid is seen in the cavity. Postoperative pain was assessed by visual analogue scale at fixed time intervals. Results: When VAS score was analysed in two groups. Study group add less score as compared to control group, though statistically insignificant (P>0.05), reduction of incidence of shoulder tip pain was found within 24 hours post-operatively. This shows that incidence of shoulder tip pain after laparoscopic cholecystectomy was reduced by intraperitoneal wash. Additional analgesic requirement was significantly less in study group (P=0.005) at 1 hour after surgery, highly significant (p=0.000) up to 6 hours and again significant at 6-12 hours post-operatively (p=0.005). Analgesic requirement though reduced in study group at 12-24 hours but not statistically significant (p=0.338). Conclusion: Intraperitoneal saline wash was effective in decreasing shoulder tip pain after laparoscopic cholecystectomy.

Aerosolized intraperitoneal local anesthetic for laparoscopic surgery: a randomized, double-blinded, placebo-controlled trial.

Postoperative pain remains a significant challenge following laparoscopy. Aerosolized intraperitoneal local anesthetic (AILA) is a novel method to deliver local anesthetic. The aim was to evaluate aerosolized ropivacaine in pain management following laparoscopic Nissen fundoplication (LNF) and cholecystectomy (LC). This prospective randomized double-blinded placebo-controlled trial enrolled consecutive patients undergoing LNF and LC. The treatment group (TG) received intraperitoneal ropivacaine (5 mL 1 % Naropin(®)) at CO2 insufflation via the AeroSurge(®) aerosolizer device through the camera port. The control group (CG) received 5 mL of saline in the same manner. Postoperative shoulder tip pain at rest 6 h postoperatively was the primary study endpoint, with secondary endpoints of shoulder and abdominal pain within the first 24 h, recovery room stay, hospital stay, and postoperative analgesia use. Pain scores were collected using the Verbal Rating Score. Eighty-seven patients were included in the final analysis (TG n = 40, CG n = 47). There was no significant difference between CG and TG at the primary endpoint. In the LC group, AILA significantly reduced shoulder tip pain at rest at 10 (p = 0.030) and 30 min (p = 0.040) and shoulder tip pain on movement at 10 (p = 0.030) and 30 min (p = 0.037). In the LNF group, AILA significantly reduced postoperative abdominal pain at rest at 6 h (p = 0.009). AILA reduced overall incidence of shoulder tip pain in the LC group (11.8 vs. 57.9 %, p = 0.004). This study did not demonstrate a significant difference between TG and CG in the primary endpoint, pain at 6 h postoperatively.

Shoulder Tip Pain After Cesarean Section.

The aim of this study was to investigate the frequency of postoperative shoulder tip pain (STP) after cesarean section and compare spinal and general anaesthesia with respect to STP. Three hundred patients who underwent cesarean section were randomly assigned to either spinal anaesthesia group (Group SA, n=143) or general anaesthesia group (Group GA, n=157). Postoperative STP was assessed at 8 hours and 24 hours after operation by Visual Analogue Scale of Pain (VAS). There were no statistically significant difference between the groups in terms of demographic data, operative findings, and clinical outcomes. The overall incidence of STP in study population was 35.7%. The incidence of STP in group SA (26.6%) was lower than that in group GA (43.9%)(p=0.005). Moreover VAS scores for STP at 6 hours and 24 hours were significantly lower in Group SA (p=0.001 and p<0.001, respectively). Shoulder tip pain is a common complaint after cesarean section, which is more prevalent in general anaesthesia.

Shoulder Tip Pain Following Laparoscopic Cholecystectomy-a Randomized Control Study to Determine the Cause.

The aim of this study was to determine the effect of low-pressure pneumoperitoneum and duration of surgery in laparoscopic cholecystectomy on postoperative shoulder tip pain. A total of 100 patients were assigned into two groups depending on the intraperitoneal pressure during laparoscopic cholecystectomy. Group A included patients in whom the intraperitoneal pressure was 13-15mm of Hg and group B included patients who underwent surgery at 10-12mmHg. Each group was then subdivided into two subgroups depending on the duration of surgery. In the first subgroup, the duration of surgery was less than 1h and the next subgroup included patients who took more than 1h. Presence or absence of shoulder tip pain was recorded within 4h, at 24h, and at 48h. Total number of patients having shoulder tip pain in the lower pneumoperitoneal group was more than the higher pneumoperitoneal group in both subgroups, P values >0.05. More patients in the <1h subgroup had shoulder tip pain as compared to the >1h group at both pneumoperitoneal groups, P values >0.05. Shoulder tip pain was most at 24h and gradually decreased thereafter. In our study, intra-abdominal pressures and shorter duration of surgery were factors unrelated to incidence of shoulder tip pain after laparoscopic cholecystectomy.

Intraperitoneal and intravenous lidocaine for effective pain relief after laparoscopic appendectomy: a prospective, randomized, double-blind, placebo-controlled study

The preemptive intravenous and intraperitoneal application of local anesthetics is known to improve the postoperative outcome in abdominal surgery. The aim of this study was to compare the analgesic effect of intravenous lidocaine injection to that of intraperitoneal lidocaine instillation in patients who were undergoing laparoscopic appendectomy (LA). Sixty-eight patients who were undergoing LA for unperforated appendicitis were randomly divided into three groups. Group IP (the intraperitoneal instillation group) received intraperitoneal instillation of lidocaine and intravenous normal saline injection. Group IV (the intravenous injection group) received intravenous lidocaine injection and intraperitoneal instillation of normal saline. In group C (the placebo control group), normal saline was given both intravenously and intraperitoneally. The visual analog scale (VAS) of pain scores was measured after surgery. The needs for additional intravenous fentanyl were evaluated and the integrated fentanyl consumption (PCA delivered + additional fentanyl) was assessed. The incidence of shoulder tip pain and postoperative nausea and vomiting (PONV) were noted. Reduction of the VAS score and of fentanyl consumption was noted in the IV and IP groups and compared to that of group C (P < 0.05). The shoulder tip pain and PONV were reduced in groups IP and IV compared to that in group C (P < 0.05). However, no significant differences were found between the IP and IV groups for all the studied variables. There was no adverse effect from intravenous lidocaine throughout the study. Intravenous lidocaine injection is as effective as intraperitoneal instillation for reducing pain and fentanyl consumption. The major benefit of intravenous injection is that this is an easily and universally applicable procedure compared to that of intraperitoneal instillation. Lidocaine intravenous administration is a better alternative for reducing the pain of patients who are undergoing laparoscopic surgery.

Systematic review and meta-analysis of intraperitoneal local anaesthetic for pain reduction after laparoscopic gastric procedures

With the advent of minimally invasive gastric surgery, visceral nociception has become an important area of investigation as a potential cause of postoperative pain. A systematic review and meta-analysis was carried out to investigate the clinical effects of intraperitoneal local anaesthetic (IPLA) in laparoscopic gastric procedures. Comprehensive searches were conducted independently without language restriction. Studies were identified from the following databases from inception to February 2010: Cochrane Central Register of Controlled Trials, the Cochrane Library, MEDLINE, PubMed, Embase and CINAHL. Relevant meeting abstracts and reference lists were searched manually. Appropriate methodology according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was adhered to. Five randomized controlled trials in laparoscopic gastric procedures were identified for review. There was no significant heterogeneity between the trials (χ(2) = 10·27, 10 d.f., P = 0·42, I(2) = 3 per cent). Based on meta-analysis of trials, there appeared to be reduced abdominal pain intensity (overall mean difference in pain score -1·64, 95 per cent confidence interval (c.i.) -2·09 to -1·19; P < 0·001), incidence of shoulder tip pain (overall odds ratio 0·15, 95 per cent c.i. 0·05 to 0·44; P < 0·001) and opioid use (overall mean difference -3·23, -4·81 to -1·66; P < 0·001). There is evidence in favour of IPLA in laparoscopic gastric procedures for reduction of abdominal pain intensity, incidence of shoulder pain and postoperative opioid consumption.

Shoulder Pain Following Laparoscopic Cholecystectomy: Factors Affecting the Incidence and Severity

Laparoscopic cholecystectomy (LC) has become the standard treatment for gall bladder disease. However, despite its low degree of invasiveness, many patients complain of postoperative pain and postoperative nausea/vomiting. This study was planned to evaluate different factors affecting the incidence and severity of postoperative shoulder-tip pain after LC. One hundred consecutive patients who were treated for gall bladder stone by LC at the Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt, during the period from October 2008 to January 2010, were randomized according to different pnemoperitonum pressures (8, 10, 12, and 14 mm Hg). Each group comprises 25 patients. There were 62 patients reported to have postoperative shoulder-tip pain during the first 12 hours after operation, which decreased to 9 patients on the 10th postoperative day. A significant difference was observed in the prevalence of pain at different pressures, 11% with low pressure and increased to 20% with high pressure. The incidence of shoulder-tip pain was significantly more in patients with a longer duration of the operation of >45 minutes at 12 hours (23 [76.7%] versus 39 [55.7%]; P = 0.04), at 24 hours (23 [76.7%] versus 29 [41.4%]; P = 0.009), and at 3 days postoperatively (19 [63.3%] versus 20 [28.6%]; P = 0.01). The volume of used gases during the operation had no effect on the incidence or severity of shoulder-tip pain after LC. Also, the use of intraoperative analgesics had no effect on the incidence or severity of shoulder-tip pain after LC. The origin of pain after LC is multifactorial. We recommend the use of the lower pressure technique during LC, and as patients with and without drains have similar incidence of postoperative shoulder pain, drains should not be used with the intention of preventing shoulder pain.

Low-pressure pneumoperitoneum versus standard pneumoperitoneum in laparoscopic cholecystectomy, a prospective randomized clinical trial

Post-laparoscopic pain syndrome is well recognized and characterized by abdominal and particularly shoulder tip pain; it occurs frequently following laparoscopic cholecystectomy. The etiology of post-laparoscopic pain can be classified into three aspects: visceral, incision, and shoulder. The origin of shoulder pain is only partly understood, but it is commonly assumed that the cause is overstretching of the diaphragmatic muscle fibers owing to a high rate of insufflations. This study aimed to compare the frequency and intensity of shoulder tip pain between low-pressure (7 mmHg) and standard-pressure (14 mmHg) in a prospective randomized clinical trial. One hundred and forty consecutive patients undergoing elective laparoscopic cholecystectomy were randomized prospectively to either high- or low-pressure pneumoperitoneum and blinded by research nurses who assessed the patients during the postoperative period. The statistical analysis included sex, mean age, weight, American Society of Anesthesiologists (ASA) grade, operative time, complication rate, duration of surgery, conversion rate, postoperative pain by using visual analogue scale, number of analgesic injections, incidence and severity of shoulder tip pain, and postoperative hospital stay. p < 0.05 was considered indicative of significance. The characteristics of the patients were similar in the two groups except for the predominance of males in the standard-pressure group (controls). The procedure was successful in 68 of 70 patients in the low-pressure group compared with in 70 patients in the standard group. Operative time, number of analgesic injections, visual analogue score, and length of postoperative days were similar in both groups. Incidence of shoulder tip pain was higher in the standard-pressure group, but not statistically significantly so (27.9% versus 44.3%) (p = 0.100). Low-pressure pneumoperitoneum tended to be better than standard-pressure pneumoperitoneum in terms of lower incidence of shoulder tip pain, but this difference did not reach statistical significance following elective laparoscopic cholecystectomy.

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

This study aimed to evaluate the optimal timing of preemptive analgesia with bupivacaine peritoneal instillation in a prospective, randomized, double-blind, placebo-controlled trial. In this study, 120 patients qualified for laparoscopic cholecystectomy were randomized to four groups. Group A received 2 mg/kg of bupivacaine in 200 ml of normal saline before creation of pneumoperitoneum. Group B received 2 mg/kg of bupivacaine in 200 ml of normal saline after creation of pneumoperitoneum. Group C received 200 ml of normal saline before creation of pneumoperitoneum. Group D received 200 ml of normal saline after creation of pneumoperitoneum. Local wound infiltration with bupivacaine was used before skin incisions. The primary end points of the study were postoperative pain intensity on a visual analog scale and incidence of shoulder tip pain. The secondary end points included the latency of nurse-controlled analgesia activation, the analgesia request rate, and analgesic consumption. Significantly lower visual analog scores were observed in group A versus groups C and B versus group D during the initial 48 and 24 h, respectively. The patients in group A versus group B reported significantly lower pain at 4 h (p < 0.001) and 8 h (p = 0.003) postoperatively, but the difference was not significant after 12, 24, and 48 h. None of the group A patients reported shoulder tip pain, whereas it was reported by 3 patients in group B, 6 patients in group C, and 7 patients in group D (p < 0.01). The latency of nurse-controlled analgesia activation was 426.8 +/-57.2 min in group A, as compared with 307 +/- 39.8 min in group B, 109.3 +/- 51 min in group C, and 109 +/- 46.5 min in group D (p < 0.001). A significantly lower analgesia request rate was observed in group A versus C, as compared with group B versus D, throughout the entire study period (p < 0.05). Preemptive analgesia with bupivacaine peritoneal instillation is much more effective for pain relief if used before creation of pneumoperitoneum. Although the effect of bupivacaine peritoneal instillation is also noticeable when used after creation of pneumoperitoneum, it confers significantly lower benefits.

Preemptive analgesia installation during gynecologic laparoscopy: A randomized trial

Study objective To evaluate the efficacy of intraoperative infusion of bupivacaine solution for the relief of pain after operative gynecologic laparoscopy. Design Prospective, double-blind, randomized, controlled trial (Canadian Task Force classification I4). Setting Tertiary teaching hospital. Patients Ninety-one women aged 16 to 69 years who underwent gynecologic laparoscopic surgery from November 2002 through November 2003. Interventions Group A (n = 30): intraperitoneal infusion of a mixture of 10 mL of 0.5% bupivacaine (50 mg) with epinephrine (1:500) in 40 mL of Ringer’s lactate solution postoperatively. Group B (n = 30): the same mixture solution infusion preoperatively and postoperatively (total 100 mg bupivacaine). Group C (n = 31): placebo. Measurements and main results Shoulder tip pain (STP), abdominal parietal pain (APP), and abdominal visceral pain (AVP) were recorded on a visual analog scale at 2, 4, 8, 16, and 24 hours postoperatively. A total of 79 patients fulfilled the study criteria. The overall incidence of STP was 60.8%. Abdominal visceral pain in group B was significantly less than in group C at 2 and 4 hours postoperatively (p = .011 and p = .010, respectively). No statistically significant difference was found in length of hospital stay, postoperative meperidine consumption, or side effects. Conclusion Intraperitoneal bupivacaine administration both immediately after placement of trocars and at the end of surgery was found to be effective in reducing the intensity of AVP but not in reducing STP, APP, or postoperative analgesia consumption after nonadvanced gynecologic laparoscopic procedures. The duration of the analgesic effect of bupivacaine instilled into the peritoneal cavity did not exceed 8 hours and probably was not dose related.

Suprascapular nerve block or a piroxicam patch for shoulder tip pain after day case laparoscopic surgery

The reported incidence of shoulder tip pain following laparoscopic surgery varies from 35 to 63%. This study evaluated the analgesic efficacy of either performing a prophylactic suprascapular nerve block with bupivacaine or applying a piroxicam patch to the skin over both shoulders for the relief of shoulder tip pain after laparoscopy. Sixty healthy informed female patients were randomly assigned to one of three groups: (a) a control group (n = 20), no treatment; (b) a suprascapular nerve block group (n = 20) in which a bilateral suprascapular nerve block was performed before induction of anaesthesia with 5 mL 0.5% bupivacaine with epinephrine; and (c) a piroxicam patch group (n = 20) in which a 48 mg piroxicam patch on the skin of each shoulder was applied before induction of anaesthesia. All patients received a total intravenous anaesthesia technique with propofol, fentanyl and vecuronium. Shoulder tip and wound pain were recorded on a visual analogue pain scale at five time intervals for 24 h after surgery. A total of 80% of patients in the control group, 75% in the suprascapular nerve block group and 45% in the piroxicam patch group complained of shoulder tip pain during the recording period (P < 0.05). The scores for shoulder tip pain in the piroxicam patch group were significantly lower compared with the control group at 3, 6 and 12 h, and compared with the suprascapular nerve block group at 6 and 12 h. The need for analgesics was also significantly lower in the piroxicam patch group compared with the other two groups. Prophylactic piroxicam patches are effective and safe for the relief of shoulder tip pain after laparoscopy. Bilateral suprascapular nerve block is not effective in this setting.

Low-pressure pneumoperitoneum combined with intraperitoneal saline washout for reduction of pain after laparoscopic cholecystectomy: a prospective randomized study

We designed a prospective randomized clinical trial to investigate whether intraperitoneal saline washout combined with a low-pressure pneumoperitoneum (LPSW) was superior to low-pressure pneumoperitoneum (LP) alone as a means of reducing postoperative pain and analgesic consumption in the early recovery period after laparoscopic cholecystectomy (LC). A total of 124 consecutive patients undergoing LC due to uncomplicated symptomatic gallstones were randomized to the LP or LPSW group. In the LPSW group, normal saline at body temperature (25 ml/kg of body weight) was irrigated under the diaphragm. The fluid was evacuated via the passive-flow method through a 16-F closed drain left under the liver for 24 h. We then assessed the intensity of total abdominal postoperative pain using the Visual Analogue Scale (VAS), including the incidence of shoulder-tip pain (STP), total daily analgesia demand rate, analgesic consumption. Quality of life (QOL) within 7 days after the operation was assessed using the Medical Outcomes Study Short Form 36 Health Survey (SF-36). A p value of <0.05 was considered significant. The mean postoperative pain score was lower by 2.64 +/- 0.86 in the LPSW; the difference equaled 9.64% (p < 0.05). The incidence of STP was lower in the LPSW group (LP 11.29% vs LPSW 1.6%; p = 0.028). The analgesia demand rate was remarkably lower in LPSW vs LP within 24 and 48 h postoperatively (70.96% vs 90.32%; p = 0.006 and 64.51% vs. 83.87%; p = 0.013, respectively). After LPSW vs LP, QOL was better in terms of physical functioning, role limitations due to physical problems, and bodily pain (90.32% vs 77.42%; p = 0.05, 90.32% vs 75.8%; p = 0.03, 91.93% vs 74.19%; p = 0.008, respectively). In terms of lower postoperative pain and a better QOL within the early recovery period, LPSW is superior to LP alone. The saline washout procedure should be recommended during LC because it is a simple way to reduce pain intensity, even after LP operations.

Suprascapular nerve block or a piroxicam patch for shoulder tip pain after day case laparoscopic surgery

Background and objective: The reported incidence of shoulder tip pain following laparoscopic surgery varies from 35 to 63%. This study evaluated the analgesic efficacy of either performing a prophylactic suprascapular nerve block with bupivacaine or applying a piroxicam patch to the skin over both shoulders for the relief of shoulder tip pain after laparoscopy. Methods: Sixty healthy informed female patients were randomly assigned to one of three groups: (a) a control group (n = 20), no treatment; (b) a suprascapular nerve block group (n = 20) in which a bilateral suprascapular nerve block was performed before induction of anaesthesia with 5 mL 0.5% bupivacaine with epinephrine; and (c) a piroxicam patch group (n = 20) in which a 48 mg piroxicam patch on the skin of each shoulder was applied before induction of anaesthesia. All patients received a total intravenous anaesthesia technique with propofol, fentanyl and vecuronium. Shoulder tip and wound pain were recorded on a visual analogue pain scale at five time intervals for 24 h after surgery. Results: A total of 80% of patients in the control group, 75% in the suprascapular nerve block group and 45% in the piroxicam patch group complained of shoulder tip pain during the recording period (P < 0.05). The scores for shoulder tip pain in the piroxicam patch group were significantly lower compared with the control group at 3, 6 and 12 h, and compared with the suprascapular nerve block group at 6 and 12 h. The need for analgesics was also significantly lower in the piroxicam patch group compared with the other two groups. Conclusions: Prophylactic piroxicam patches are effective and safe for the relief of shoulder tip pain after laparoscopy. Bilateral suprascapular nerve block is not effective in this setting.

A prospective randomized trial of intraoperative bupivacaine irrigation for management of shoulder-tip pain following laparoscopy

Background: Postoperative shoulder-tip pain (STP) frequently occurs following laparoscopic surgery. In an attempt to abrogate this complication we prospectively evaluated the efficacy of intraoperative irrigation of the diaphragm with bupivacaine. Methods: One hundred and five consecutive patients undergoing laparoscopic surgery were prospectively randomized to treatment or control groups. Treatment group (B, n = 55) received irrigation with 10 mL 0.5% bupivacaine in 500 mL saline and control group (A, n = 50) received an equal volume of normal saline. Each dome of the diaphragm was irrigated with 250 mL of either solution at the end of surgery. Laparoscopic procedures performed included cholecystectomy (n = 63), Nissen fundoplication (n = 21), appendicectomy (n = 7), hernia repair (n = 4), and diagnostic laparoscopy (n = 10). Patients’ anesthesia and perioperative analgesia were standardized. STP was recorded on a visual analogue pain scale (VAPS) in the recovery room immediately following surgery and at 4, 10, and 24 hours thereafter. Results: The overall incidence of STP in patients undergoing laparoscopic procedures was approximately 24%. Twenty-one patients (42%) in the control group and 4 patients (7%) in the treatment group complained of shoulder pain during the recording period ( P = 0.003). Mean STP scores as recorded on VAPS were significantly lower in the bupivacaine group than in the control group from 4 to 24 hours after surgery ( P <0.01). Postoperative analgesia requirements were also significantly reduced in those patients receiving bupivacaine irrigation ( P <0.04). Conclusion: Intraperitoneal irrigation with bupivacaine to both hemidiaphragms at the end of surgery significantly reduces both frequency and intensity of STP following laparoscopic procedures thus reducing patient morbidity.

Port Site and Intraperitoneal Infiltration of Local Anesthetics in Reduction of Postoperative Pain after Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is now the gold standard technique for the treatment of gallstones disease. Although pain after laparoscopic cholecystectomy is less intense than after open cholecystectomy, some patients still experience considerable discomfort during the first 24 to 72 postoperative hours. The aim of this study is to evaluate the effect of intraperitoneal and port site instillation of local anaesthetics on pain relief in early postoperative period following laparoscopic cholecystectomy. Fifty patients undergoing elective laparoscopic cholecystectomy were consecutively included in this study and sample was divided into two groups. Following removal of gallbladder, Group A received 20 ml of 0.25% bupivacaine instilled in the right sub diaphragmatic space and 20 ml of 0.25% bupivacaine in divided doses at the trocar sites. The evaluation of postoperative pain was done at fixed time interval according to the numerical verbal scale and the dosage of narcotic analgesics consumed was also recorded. Mean pain scores at 6 hours and at 12 hours after surgery were 6.02 and 4.72 respectively, in the bupivacaine group compared with 8.44 and 6.08 respectively in the control group (p= &lt;0.001 and &lt;0.001). However, pain scores at 24 hours and 48 hours postoperatively and incidence of shoulder tip pain did not differ significantly between the two groups. The mean total narcotic analgesics used in study group was 1.91 as compared to 2.50 in the control group respectively and was found to be statistically significant (p= &lt;0.001). Infiltration of bupivacaine in to port site and intraperitoneal space is simple, inexpensive and effective technique to minimize early postoperative pain and can be practiced for elective laparoscopic cholecystectomy. DOI: 10.3329/medtoday.v22i1.5601 Medicine Today Vol.22(1) 2010. 24-28