Intraperitoneal Normal Saline Infusion for Postoperative Pain after Laparoscopic Cholecystectomy

Abstract

After laparoscopic surgery carbon dioxide remains within the peritoneal cavity for a few days, commonly causing pain. This prospective randomized study was performed to determine the efficacy of intraperitoneal infusion of normal saline on postoperative pain after laparoscopic cholecystectomy. Altogether 300 patients were randomly assigned to one of five groups of 60 patients each. Group A: control group, no peritoneal infusion, no subhepatic drain. Group B: no peritoneal infusion but a subhepatic closed brain was left for 24 hours. Group C: normal saline 25 to 30 ml/kg body weight at a temperature of 37 degrees C was infused under the right hemidiaphragm and left in the peritoneal cavity. Group D: normal saline in a room temperature was infused under the right hemidiaphragm and suctioned after the pneumoperitoneum was deflated. Group E: normal saline was infused and suctioned as in group D, but a subhepatic closed drain was left for 24 hours. Postoperatively, analgesic medication usage, nausea, vomiting, and pain scores were determined at 2, 6, 12, 24, 48, and 72 hours (during hospitalization and at home). Postoperative pain was reduced significantly (p < 0.001) in the patients of groups C, D, and E versus controls, whereas no difference was observed between groups A and B. Among groups C < D and E, group E (p < 0.01) had the best results followed by group D and then group C. Intraperitoneal normal saline offered a detectable benefit to patients undergoing laparoscopic cholecystectomy. The beneficial effect was better when the fluid was suctioned after deflation of the pneumoperitoneum and even better when a subhepatic closed drain continued fluid suction during the first postoperative hours.

Acute postoperative pain relief, by intraperitoneal application of local anesthetics, during laparoscopic cholecystectomy

“…Our data also showed a signifi cant decrease in supplemental ketorolak in patients given morphine intraperitoneal. We used bupivacaine and low doses of morphine, intraperitoneally to achieve the additional analgesic benefi t from the combined eff ect of a local anesthetic with an opioid agonist (25)(26)(27)(28)(29). Intraperitoneal local anesthetics would be expected to be useful for treating visceral pain.…”

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

“…Though statistically not significant, reduction of incidence of shoulder tip pain was found at 24 hour post operatively. This shows that incidence of post-operative shoulder tip pain was reduced by intraperitoneal saline wash as compared to no wash (Table 1 then these results were confirmed by Duchene [38] with encouraging results.Tsionoyiannis et al [22] studies confirmed that saline wash at body temperature reduce post laparoscopy abdominal and shoulder tip pain with or without suctioning out of saline and keeping sub hepatic drains offered no benefit over saline wash for reduction of shoulder tip pain though may offer some benefit for reduction of abdominal pain. Tas B et al [28] evaluated techniques to reduce shoulder pain after laparoscopic surgery for benign gynaecological diseases, concluded that pulmonary recruitment manoeuvre and intraperitoneal drainage were found to reduce the incidence and severity of shoulder pain.…”

“…Use of N 2 O, Helium or Argon in place of CO 2 [26] bupivacaine infusion under right hemidiaphragm [27] warm and humified gasless laparoscopy [34]. And in intraperitoneal instillation of normal saline [22,35,36] are some methods that have been studied for reduction of abdominal and shoulder pain after laparoscopic cholecystectomy. For relief of shoulder tip pain, intraperitoneal infusion of normal saline at body temperature until the liver is submerged without fluid suction after deflation of pneumoperitoneum was first reported by Perry and Trambello [37] and Pearson Chi-Square, P Value=0.000, Highly Significant …”

“…In present era of day care surgery, shoulder tip pain may delay discharge in 10-20% of patients which is attributed to stretching of subdiaphragmatic fibres of phrenic nerve by increase concavity of diaphragm, which is induced by pneumoperitoneum and the resulting loss of visceral surface tension [22]. Pressure for creation of pneumoperitoneum is usually about 12-16 mmHg.…”

“…So different postoperative pain management protocols can reduce the opiates administration in such cases [20,21]. Tsimoyiannis et al [22] showed beneficial effect of intraperitoneal saline wash with suction and sub-hepatic drain to reduce incidence of postoperative shoulder pain. As CO 2 retention is a key factor in abdominal and shoulder tip pain in laparoscopy, removing or washing out residual CO 2 might help to reduce the severity of pain in both shoulder and upper abdomen .There are different methodologies to reduce this pain in addition to NSAIDS/Opioids, like port site infiltration of local anaesthesia, suprascapular blocks or piroxicam patch [23].…”