Pain After Laparoscopic Cholecystectomy: Characteristics

and Effect of Intraperitoneal Bupivacaine

J. Joris, MD*, E. Thiry, MD*, I?. Paris, MDt, J. Weerts, MD*, and M. Lamy, MD*
*Department of Anesthesia and Intensive Care Medicine, University Hospital of Liege, Domaine du Sart Tilman, Liege,
Belgium, and Departments of tAnesthesia and Intensive Care Medicine and SAbdominal Surgery, Clinique Saint Joseph,
Liege, Belgium

Although pain after laparoscopic cholecystectomy is
less intense than after open cholecystectomy, some pa-
tients still experience considerable discomfort. Further-
more, the characteristics of postlaparoscopy pain differ
considerably from those seen after laparotomy. There-
fore, we investigated the time course of different pain
components after laparoscopic cholecystectomy and
the effects of intraperitoneal bupivacaine on these dif-
ferent components. Forty ASA physical status grade
I-II patients were randomly assigned to receive either
80 mL of bupivacaine 0.125% with epinephrine
l/200,000 (n = 20) or the same volume of saline (n = 20)
instilled under the right hemidiaphragm at the end of
surgery. Intensity of total pain, visceral pain, parietal
pain, and shoulder pain was assessed 1,2,4,6,8,24, and
48 h after surgery. Analgesic consumption was also re-
corded. Patient data were similar in the two groups. In
the saline group, visceral pain was significantly more
intense than parietal pain at each time point; visceral
and parietal pain were greater than shoulder pain dur-
ing the first 8 h postoperatively. Intraperitoneal bupiva-
Caine did not significantly affect any of the different
components of postoperative pain. Analgesic con-
sumption was similar in the two groups. This study
demonstrates that visceral pain accounts for most of the
pain experienced after laparoscopic cholecystectomy.
Intraperitoneal bupivacaine is not effective for treating
any type of pain after laparoscopic cholecystectomy.
(Anesth Analg 1995;81:379-84)

T
he many benefits reported after laparoscopic inflammation after CO, pneumoperitoneum provides
surgery explain its increasing success (l-4). a rationale for the use of nonsteroidal antiinflamma-
Laparoscopic cholecystectomy results in less tory drugs (NSAIDs) (8). However, treatment of post-
postoperative pain and/or reduced analgesic con- laparoscopy pain with NSAIDs yields controversial
sumption as compared with open cholecystectomy results (7,9-12). Moreover, because of the pathophys-
(1,3,5). Nonetheless, pain after laparoscopy may be iologic changes of renal blood flow induced by pneu-
moderate or even severe for some patients, and may moperitoneum, the safety of preoperative administra-
require opioid treatment. Interestingly, the type of tion of NSAIDs may be questionable (13). Recently,
pain after laparoscopy differs considerably from that instillation of local anesthetic (80 mL of bupivacaine
seen after laparotomy. Indeed, whereas laparotomy 0.125%, epinephrine l/200,000) under the right dia-
results mainly in parietal pain (abdominal wall), pa- phragm was reported to reduce shoulder pain after
minor gynecologic laparoscopy (14). This technique,
tients complain more of visceral pain after operative
however, seems to be ineffective in relieving pain after
laparoscopy (3). Finally, shoulder pain secondary to
laparoscopic cholecystectomy (15,16). This discrep-
diaphragmatic irritation as a result of CO, pneumo-
ancy may be due to differences in study protocol
peritoneum is a frequent postoperative observation
[volume and concentration of local anesthetic instilled:
after laparoscopy (35% to 60%) (6,7).
20 mL of bupivacaine 0.25% (15) and 100 mL of bupi-
Different treatments have been proposed to relieve vacaine 0.15%, epinephrine l/150,000 (1611, and/or
pain after laparoscopy. The observation of peritoneal the use of two different laparoscopic procedures.
These may result in different profiles of pain charac-
This work was presented at the 1994 annual meeting of the teristics. Therefore, we performed this study to define
European Society of Anaesthesiologists in Brussels, Belgium. the different components of pain after laparoscopic
Accepted for publication April 4, 1995.
Address correspondence and reprint. requests to J. Joris, MD,
cholecystectomy, to plot their time course, and to as-
Department of Anesthesia and Intensive Care Medicine, CHU of sess the effect of intraperitoneal administration of
Liege, Domaine du Sart Tilman, B-4000 Liege, Belgium. bupivacaine on these pain components. We used the

01995 by the International Anesthesia Research Society

0003-2999/95/$5.00 Anesth Analg 1995;81:379-84 379
380 JORIS ET AL ANESTH ANALG
PAIN AFTER LAI’AROSCOPIC CHOLECYSTECTOMY 1995;81:379-84

same dose and protocol as Narchi et al. who reported

beneficial results (14).

Methods
After approval of the local ethics committee, and con-
sent of the involved patients, 40 ASA physical status
I-II patients scheduled for laparoscopic cholecystec-
tomy were informed about the different components
of postoperative pain they would experience, and
were selected by the same investigator for their ability
to differentiate these pain components and to use the
visual analog scale. No patient had acute cholecystitis.
I ,
All patients received the same anesthetic technique. lh 2h 4h 6h 8h 24h 48h
They were premeditated with hydroxyzine 50-75 mg TIME A-El3 SURGERY
and alprazolam 1 mg orally 1 h before surgery. Gen-
Figure 1. Total pain after laparoscopic cholecystectomy measured
eral anesthesia was induced intravenously with sufen- at rest using a loo-mm visual analog scale (VAS). Data are median,
tanil 15-20 pg, and propofol 2 mg/kg. Orotracheal lOth, and 90th percentiles; boxes = 25th and 75th percentiles. Circles
intubation was facilitated by 0.1 mg/kg vecuronium. indicate data outside the lo-90 percentile interval.
Anesthesia was maintained with isoflurane in 60%
N,O/O,. Vecuronium was administered as repeated more difficult to localize, inside the abdomen, or re-
boluses to assure one response on train-of-four testing. sembling biliary colic), and shoulder-tip pain were
Minute ventilation was controlled (Servo 900C; Sie- assessed.The intensity of the different postoperative
mens Elema, Solma, Sweden) and adjusted to keep the pain components was recorded on a loo-mm visual
end-tidal Pco, between 30 and 40 mm Hg. During analog scale at rest, during mobilization (patients
laparoscopy, intraabdominal pressure was automati- were asked to move from the supine to the sitting
cally maintained at 14 mm Hg by a CO, insufflator. position), and on coughing. Pain intensity was meas-
After surgery, patients were randomly assigned in a ured 1, 2, 4, 6, 8, 24, and 48 h after surgery. Daily
double-blind fashion to one of two treatments (n = 20 analgesic consumption was also recorded.
in each group). In the control group, 80 mL of saline Results are reported as mean ? SEM. Data were
was injected under direct vision by the surgeon into analyzed by two-way analysis of variance. Pain scores
the right subdiaphragmatic area at the end of the for the different pain components, and for the saline
procedure. Similarly, in the other group, 80 mL of and bupivacaine groups, were compared using the
bupivacaine 0.125% plus epinephrine l/200,000 was Mann-Whitney U-test. Student’s t-test was used to
instilled under the right diaphragm. CO, was evacu- compare demographic data of the two groups. Results
ated carefully from the peritoneal cavity at the end of were considered to be statistically significant at the
surgery. Surgical wounds were not infiltrated with 5% critical level. Correlations between the duration
local anesthetic. In the two groups, postoperative pain of pneumoperitoneum and the highest score of each
treatment was provided on the same nursing unit with pain component were tested for significance by linear
identical standardized protocol. During the first 24 h regression.
postoperatively, alternate intravenous administration
(up to every 6 h) of 1 g metamizol (Novalginem;
Hoechst, Brussels, Belgium) and 2 g propacetamol, a Results
precursor of paracetamol (Pro-Dafalgan@; UPSA Med-
ica, Brussels, Belgium: 2 g propacetamol = 1 g parac- For defining the characteristics of pain after laparo-
etamol Jparacetamol = acetaminophen in the United scopic cholecystectomy, only data from the control
States]), were given as necessary. On the second day, group were considered. Interindividual variations
500 mg metamizol and 500 mg paracetamol orally were substantial (Figure 1). The time course and in-
were administered alternately. If pain relief was con- tensity of the different components of pain after lapa-
sidered insufficient after these treatments (pain score roscopic cholecystectomy appeared to differ signifi-
>40 mm on a loo-mm visual analog scale at rest), 0.2 cantly. Visceral pain was significantly more severe
mg/kg piritramide (Dipidolor@; Janssen Pharmaceu- than parietal pain at each time point. Visceral and
tica, Beerse, Belgium), a synthetic opioid, was admin- parietal pain were both significantly greater than
istered intramuscularly. Total pain, parietal pain (su- shoulder pain during the first 8 h postoperatively.
perficial pain, located in the abdominal wall, pain that Interestingly, shoulder-tip pain, which was slight dur-
you can “touch”), visceral pain (defined as deep, dull, ing the first postoperative hour, tended to become
ANESTH ANALG JORIS ET AL. 381
1995,81 379-84 PAIN AFTER LAI’AROSCOl’IC CHOLECYSTECTOMY

predominant after 24 h, while parietal pain and vis- Subdiaphragmatic administration of 80 mL bupiva-
ceral pain rapidly decreased (Figure 2). Visceral and Caine 0.125% plus epinephrine l/200,000 had no sig-
parietal pain were significantly worsened by cough- nificant effect on total pain, parietal pain, visceral
ing, whereas mobilization did not significantly in- pain, or shoulder-tip pain as compared with saline
crease these two components. Shoulder pain was not (Figure 3).
significantly affected by mobilization and coughing
(Table 1). Finally, there was no correlation between the
duration of pneumoperitoneum and the intensity of Discussion
any pain component.
When determining the effect of intraperitoneal This study demonstrates that pain after laparoscopic
bupivacaine on postoperative pain, there were no sig- cholecystectomy can be subdivided into several com-
nificant differences between the two groups with re- ponents (parietal, visceral, and shoulder pain) that
gard to age, sex, weight, height, and duration of pneu- have different intensities and their own time courses.
moperiteum (Table 2). None of these components is effectively treated by
Analgesic consumption was similar in the two instillation of 80 mL bupivacaine 0.125% plus epi-
groups during the first 48 h postoperatively (Table 3). nephrine l/200,000 under the right diaphragm.
This work highlights the characteristics of pain after
laparoscopic cholecystectomy. Visceral pain accounts
for most of the discomfort experienced in the early
postoperative period. Its intensity quickly decreases
80
after the first 24 h postoperatively. Whereas visceral
F ! pain developing after laparoscopic cholecystectomy is
5
O-J 60
I
.
I
T* I* not affected by mobilization, coughing increases its
intensity. Indeed, our mobilization test required only
T
contraction of the abdominal muscles, and did not
involve movement of the intraabdominal viscera. On
the other hand, cough produces a brusque displace-
ment of the liver, and consequently results in stimu-
lation of the inflamed cholecystectomy wound. Pari-
eta1 pain is less intense than visceral pain, owing to
1 I I I I I I the small abdominal incisions and the limited damage
Ih 2h 4h 6h 8h 24h 46h to the abdominal wall. For the same reasons, and
TtME AFTER SURGERY in contrast to pain after laparotomy, parietal pain
Figure 2. Parletal pain (open bars), visceral pain (striped bars), and after laparoscopic cholecystectomy requires intense
shoulder pain (gray bars) measured at rest using a loo-mm visual abdominal muscle contraction to be increased and,
analog scale WAS). Data are median, IOth, and 90th percentiles;
boxes = 25th and 75th percentiles. * P < 0.05 was considered a consequently, is worsened only by coughing but
slgmflcant difference as compared with visceral pam. not by mobilization. Shoulder-tip pain, insignificant

Table 1. Effects of Mobilization and Coughing on the Different Components of Pain After Laparoscopic
Cholecystectomy
1 11 2h 4h 6h 8h 24 h 48 h
Parietal
Rest 11 i2 17 i 4 21 I 4 17 -f 5 13 F 4 812 5i2
Mobilization 15 i 4 21 i 4 22 t 4 24 i 5 171-4 13 i 4 6i3
Coughing 23 i 5* 30 i 5% 24 t 5 24 I 7 21 t 6 19 i 5” 6i2
Visceral
Rest 27 I 5 28 I 4 27 i- 5 26 I 5 20 t- 4 13 i 4 St3
Mobilization 24 k 5 33 i- 4 25 -t 5 28 i 6 25 +- 5 21 i 4 8i3
Coughing 36 i- 6 36 i- 5’ 29 -c 5 30 i 7 27 t- 6” 24 i 5” 13 i 3
Shoulder
Rest 5i2 71-3 14 -f- 5 13 i 6 7-c3 12 -+ 5 9t3
Mobilization 6il 1113 10 t4 15 i 6 9+4 12 I 3 411
Coughing 4il 813 924 925 St-4 11 i4 512
Data are mean i SEM
Each component of pan (pm&al, visceral, and shoulder pm) after laparoscopy cholecy+xtomy wa\ asessed at reit, durmg mob~hmtmn (from the wpme
to sitting posltlon), and on coughing I, 2, 4, 6, 8, 24, and 48 h after the end of surgery Only visual analog scale xores from the control group were cmmdered
*P i 0 05 was considered a slgmfmnt difference as compared wth pan, at rest
382 JORIS ET AL. ANESTH ANALG
PAIN AFTER LAPAROSCOPIC CHOLECYSTECTOMY 1995;81:379-84

Table 2. Patient Data

PARIETAL PAIN
Saline Bupivacaine
n 20 20
--)- PLA
Age (yr) 49.0 i 10.9 47.7 -t 15.2
Sex (M/F) 7/13 4/16 + BUPI

Weight (kg) 71.6 t 16.5 67.0 + 10.0

Height (cm) 166.3 ? 9.6 163.2 i- 8.6
Duration of 33.9 i 13.5 28.6 i 10.4
pneumoperitoneum
(min)
Data are mean i SD.
There were no significant differences between the two groups with regard
to age, sex, weight, height, and duration of pneumoperitoneum. VISCERAL PAIN

Table 3. Number of Requests for Analgesic Drugs

Saline Bupivacaine
Metamizol
POD1 1 (O-3) 1 (O-4)
POD2 0 (O-2) 0 (O-3)
Paracetamol
POD1 1 (O-1) 1 (O-2)
POD2 0 (O-3) 0 (O-3)
Piritramide SHOULDER PAIN
POD1 0 0 (0-l)
POD2 0 0 (O-l)
Data are medmn (range)
Analgesic (metamizol, paracetamol, and pmtramide) consumption was
smular m the two groups
POD1 = the first 2.4 h postoperatwely, POD2 = from 24 to 48 h postop-
eratwely.

during the first postoperative hours, increases there-

after to become the main complaint on the second day I I I I I I I I I I I I I

postoperatively. 0 4 8 24 48
These data confirm the results of a previous study Time after surgery(h)
where laparoscopic cholecystectomy was compared to Figure 3. Effect of intraperitoneal administration of bupivacaine on
open cholecystectomy (3). Whereas patients com- the different components of pain after laparoscoprc cholecystec-
plained more of parietal pain after laparotomy, after tomy. Pain was measured at rest with a loo-mm vrsual analog scale
(VAS). Eighty milliliters of bupjvacaine 0.125% plus epinephrine
laparoscopy patients reported mainly visceral pain. l/200,000 (BUPI) (0) or the same volume of saline Cm) (placebo
Pain after laparoscopy was also much more short- [PLAI) were Instilled into the right subdiaphragmatic area. Data are
lived than after laparotomy. Indeed, whereas the inci- mean. SEM, omitted for clarity, ranged from 2 to 6 mm and were
sion of the abdominal wall, which is repeatedly stim- similar in the two groups. For each pain component, between times
comparrsons revealed significant differences (omitted in the figure
ulated by mobilization and coughing, is responsible for clarity). Parietal pain: 1 h vs 4 and 48 h; 2 h vs 4 and 48 h; 4 h vs
for persistent pain after laparotomy, parietal pain is 8,24 and 48 h; 6 h vs 48 h; 8 h vs 48 1~. Visceral pain: 1 h vs 8,24 and
limited after laparoscopy, which does not involve 48 h; 2 h vs 24 and 48 h; 4 h vs 8,24,48 h; 6 h vs 48 h. Shoulder pam:
1 h vs 6,24 and 48 h; 2 h vs 24 h.
large surgical incisions and spares the abdominal wall
the trauma of surgical retractors. Similarly, in this
study, while parietal pain after laparoscopic cholecys- operative laparoscopies, such as laparoscopic chole-
tectomy is expectedly increased by coughing, it re- cystectomy, result in significant visceral inflammation,
mains, however, less intense than visceral pain. responsible for postoperative visceral pain. Visceral
The intensity of shoulder pain reported in our study pain being more intense, the shoulder pain component
is markedly less than in other studies after day-case may be minimized or even ignored by the patients.
gynecologic laparoscopy (6,7,14). These authors inves- Furthermore, residual intraperitoneal CO,, which con-
tigated pain after minor gynecologic laparoscopy, in- tributes to postoperative pain after laparoscopy
cluding diagnostic laparoscopy and tubal ligation, (17,181, was emptied carefully by our surgeon. The
which results in, at most, only minor visceral trauma. extent of CO, evacuation was, however, not men-
In the absence of visceral pain, shoulder-tip pain im- tioned in these studies reporting significant shoulder
mediately becomes predominant. On the other hand, pain (6,7,14).
ANESTH ANALG JORIS ET AL. 383
1995;81:379-84 PAIN AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Marked interindividual variability is another char- shoulder-tip pain, negligible in the early postoperative
acteristic of pain after laparoscopic cholecystectomy period, may be literally ignored by patients who there-
(3). These variations are greater than after open cho- fore will not notice any reduction after intraperitoneal
lecystectomy. The reasons for this significant variabil- bupivacaine.
ity are not clear. The same surgeon performed all the In summary, this study characterized pain and its
surgical procedures. Residual intraperitoneal CO, was various components after laparoscopic cholecystec-
evacuated carefully using the same technique. Finally, tomy. Visceral pain is predominant during the first
we were unable to find any correlation between pain 24 h postoperatively, is short-lived, is unaffected by
intensity and duration of pneumoperitoneum. mobilization, and increased by coughing. Shoulder
The existence of several components of postopera- pain, minor during the early postoperative period,
tive pain after laparoscopic cholecystectomy raises increases and becomes significant on the second post-
several issues. Since these pain components have dif- operative day. Instillation of 80 mL bupivacaine
ferent intensities, time courses, and pathophysiologic 0.125% plus epinephrine l/200,000 was ineffective in
mechanisms, studies on pain relief after laparoscopy treating any of the different components of pain after
should investigate the effects of analgesic therapies on laparoscopic cholecystectomy. Finally, this study em-
each of these components. Pain patterns may differ phasizes the need for future studies on analgesia after
markedly depending upon the laparoscopic proce- laparoscopy, to analyze pain into its different compo-
dure, as mentioned above, for tubal ligation and lapa- nents, and to investigate the effects of treatment on
roscopic cholecystectomy. These differences may ex- these different pain components.
plain discrepancies in the literature with regard to the
effectiveness of a given therapeutic. Extension and
generalization of results obtained with one type of
laparoscopy to all laparoscopies therefore should be
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