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It is well established fact that laparoscopic cholecystectomy causes less postoperative pain as compared to open cholecystectomy.

However it is not completely painless. The accurate assessment of pain is difficult because of its individual threshold, subjectivity and difficulty in measurement. Various methods of analgesia including NSAIDS and opioids have been tried to reduce postoperative pain. However the prevention of pain with long acting local anaesthetic infiltration at port site achieves peripheral blockage of painful stimuli, which is more advantageous than treating pain after it occurs. It is postulated that this reduces postoperative pain and analgesic requirements. Periportal infiltration of bupivacaine and levobupivacaine has been used for relief of postoperative pain in laparoscopic cholecystectomy (Alexander DJ, Ngoi SS et al, 1996 and Louizos AA, Hadzilia SJ et al, 2005). Only few comparative studies are available for assessing early postoperative pain following laparoscopic cholecystectomy. Therefore, it has been proposed to do comparative clinical evaluation of early postoperative pain with or without port site infiltration with ropivacaine during laparoscopic cholecystectomy.


Half life of ropivacaine is 4. Periportal infiltration of Bupivacaine and levobupivacaine has been used for relief of postoperative pain in laparoscopic cholecystectomy (Alexander DJ. It produces surgical anaesthesia at high doses and analgesia (sensory block with limited and non-progressive motor block) at lower doses. Ropivacaine follows linear pharmacokinetics and the Cmax is proportional to the dose. Ropivacaine causes reversible blockade of impulse propagation along nerve fibers by preventing the inward movement of sodium ions through the cell membrane. in our study we will be using ropivacaine which is least cardiotoxic. this technique decreases anaesthetic and analgesic requirement during surgery as well as reduces the need for opioids postoperatively. 94% of plasma ropivacaine is bound to alpha-1 2 . It belongs to amide group. These agents are known to produce cardiac and nervous toxicities if inadvertently injected intravenously (especially bupivacaine).Port site infiltration with long acting local anaesthetics has been used as an adjuvant for the relief of postoperative pain in laparoscopic cholecystectomy.44L/min. chemically described as S-(-)-1-propyl-2’. Therefore. the route of administration.pipecoloxylidide hydrochloride monohydrate with molecular formula of C17H28N2O. When administered before surgery. Ngoi SS et al 1996).2hrs with clearance of o. and is a pure S-enatiomer. It has both anaesthetic and analgesic effects.HCL.H20. Time of onset of action is 4mins and effect lasts for 8-10hrs. The plasma concentration depends upon the dose. 6’. and the vascularity of the site of injection.

cardiovascular and central nervous system toxicities after systemic exposure to excessive quantities. 10(1%) mg/ml concentrations. 7. 3 . Ropivacaine is available in 2(0. It is to be stored at a temp.75%). Ropivacaine is extensively metabolised in the liver. Of 20-25 degree Celsius. 5(0. The major metabolite is 3-hydroxy-ropivacaine. about 37% of which is excreted in the urine. mainly conjugated.acid glycoprotein. Rare adverse effects associated with the use of ropivacaine include allergic reactions.2%). mainly by aromatic hydroxylation. Dose of ropivacaine for local infiltration is 2-5mg/kg body weight.5(0.5%).

E. Grecu I et al. Ropivacaine reduced overall pain the first 24 hrs and incisional pain for the first 3 postoperative hrs. Atmatzidis K.Nicolau A. and supplemental analgesic consumption were registered the first postoperative week. They concluded that a combination of incisional and intra-abdominal local anaesthetic treatment reduced incisional pain and incisional infiltration of local anaesthetic is recommended in patients undergoing laparoscopic cholecystectomy. During the first 3 postoperative hrs. The control group comprised 75 cases of laparoscopic cholecystectomy and 20 cases of laparoscopic inguinal 4 . (2003) conducted prospective randomised study comprising 190 al. and nausea was reduced in the ropivacaine group. Klarskov B. Kristiansan VB. morphine requirements were lower. (1990) conducted randomised double blind controlled trial comprising 60 patients assigned into four groups and concluded that ropivacaine shows significant favourable effects on postoperative pain after laparoscopic cholecystectomy when using both parietal and intraperitoneal instillation. pain localization. and pain and nausea were rated hourly. Daily pain intensity. the use of morphine and antiemetic was registered. et al (1999) They conducted a randomized trial comprising of 58 patients who received a total of 286mg(66ml) ropivacaine or 66ml of saline via periportal and intraportal infiltration.E.S. Bisgaard T. Pavlidis T. During first 3 postoperative hrs.

right and left sub diaphragmatic areas and onto visceral peritoneum. 24hrs after the surgery. In control group in 20% of laparoscopic cholecystectomy cases and 44% of laparoscopic inguinal hernia repair cases no analgesia was required. Memedov C. They concluded wound infiltration with ropivacaine provide satisfactory postoperative analgesia and reducing need for opioids. only saline was used. after laparoscopic cholecystectomy is a non-invasive. The study group comprised 75 cases of laparoscopic cholecystectomy and 20 cases of laparoscopic inguinal hernia repair with preincisional periportal infiltration with 20ml of ropivacaine (10mg/ml). safe and simple technique that reduces pain and postoperative tramadol consumption. No analgesia was required in 41% of laparoscopic cholecystectomy cases and 85% of laparoscopic inguinal hernia repair cases in study group. 4. a long acting local anaesthetic. et al (2008) they conducted a prospective randomized study over 45 patients. The patients were randomized into 3 groups to receive either a total of 150mg(80ml) ropivacaine or a mixture of 400mg(20ml) prilocaine(80ml) or placebo (80ml saline). and 20ml. 12.hernia repair without use of local anaesthesia. The same effect was not observed with prilocaine administration. 18. They concluded that multiregional intraperitoneal instillation and port site infiltration of ropivacaine.80ml were injected into gallbladder. were injected around entry of 4 port sites. 5 . 5ml each. Mentes O. Visual analogue scale was used for postoperative pain assessment at 2. Simsek A. They used visual analogue scale for assessment of postoperative pain. 8.

In group B. In all patients. Baek CW. pre-incisional local infiltration of ropivacaine around the trocar wound was performed. Visual analogue scale was used to assess pain score. They observed significant lower pain scores in single incision laparoscopic cholecystectomy group and also less requirements for analgesics. Liu Y.Y. (2008) conducted randomised double blind controlled trial comprising 120 patients assigned in 6 groups and concluded preincisional local infiltration and intraperitoneal infusion of ropivacaine at the beginning of laparoscopic cholecystectomy is safe and valid method for reducing pain after laparoscopic cholecystectomy. 6 . 4 port classic laparoscopic cholecystectomy was performed. Tsimoyiannis EC.L et al. Cha SM. Farantos C. intraperitoneal. Tsimogiannis KE. et al (2010) conducted a randomized controlled trial involving 40 patients who were randomly assigned into 2 groups.N. Nicolas Z et al. Postoperative pain was assessed by visual analogue scale. In group A. single incision laparoscopic cholecystectomy was performed. (2009) randomised 72 patients into 2 groups.George P.G. Lee H. Yeh C. Kang H. et al (2011) they conducted a randomized double blind control trial to evaluate the effect of peritrocal. One group received port site ropivacaine at the end of laparoscopic cholecystectomy and the other group received normal saline. They concluded port site pain and requirement of opioids was lower in study group with shorter hospital stay as compared to control group.

visceral and shoulder tip pain after laparoscopic cholecystectomy. Group A received peritrocal and intraperitoneal saline. 4. El-labban MA. 24 and 48 hrs following surgery. 8. They concluded that peritrocal infiltration of ropivacaine significantly decreases parietal pain and intraperitoneal instillation of ropivacaine significantly decreases the visceral and shoulder pain.25% levobupivacaine and group III received 20ml solution of 0. Group I who didn’t received either intraperitoneal or intraincisional levobupivacaine. They divided patients into 3 groups. 7 . They concluded intraincisional infiltration of levobupivacaine is more effective than intraperitoneal route in controlling post operative pain and reduced need for analgesics. 12. Hokkam EN. Group II received local infiltration of 0. Group B received peritrocal saline and intraperitoneal ropivacaine. El-labban GM. Postoperative pain was recorded for first 24hrs using visual analogue scale. Postoperative pain was assessed by visual analogue scale at 2. (2011) they conducted a randomized controlled study involving 189 patients who underwent laparoscopic cholecystectomy. et al.combined peritrocal-intraperitoneal ropivacaine on the parietal. They randomly assigned 80 patients into 4 groups. Group C received peritrocal ropivacaine and intraperitoneal saline. Group D received peritrocal and intraperitoneal ropivacaine.25% levobupivacaine intraperitoneally.

8 . 2. To compare the clinical outcome in these two groups of patients. To evaluate and compare early postoperative pain following laparoscopic cholecystectomy with or without port site local anaesthetic infiltration.1.

9 . An observation will be made at the injected site after 20 min. Development of erythema or wheel of >5mm will be considered positive and patient will be excluded from the study. 0.Patients in group I will be subjected to local anaesthesia with 0. Body mass index and co morbid conditions.75% ropivacaine before making skin incision. Patients with hypersensitivity to ropivacaine. Group II.1ml of 0. verapamil and fluvoxamine (Drug interactions). Government Medical College. Jammu from December 2011 to December 2012. Pregnancy. 4. Group I. Patients in group I will be subjected to hypersensitivity test one day before surgery.Patients without port site infiltration of local anaesthetic.All patients who will be subjected to laparoscopic cholecystectomy will be included in the study which shall be conducted in post graduate Department of surgery. Children < 14yrs of age. Patients taking theophylline. EXCLUSION CRITERIA 1. Patients will be divided into two groups after matching age group. SENSITIVITY TEST FOR ROPIVACAINE. 3.75% ropivacaine will be injected intradermally(using insulin syringe) into flexor aspect of left forearm. 2.

injection Glycopyrrolate. Local anaesthetic-0. Post operatively pain will be assessed in first 24hrs with the help of visual analogue scale at 3rd. METHOD OF INFILTRATION Before making skin incision for introducing port. Routine pre-anaesthetic check up of every patient will be performed. Insulin syringe for sensitivity test. 3.MATERIAL 1. 3rd generation cephalosporin. Before injecting ropivacaine it will be made sure that it will not enter any vessel and during surgery monitoring will be done for any side effects like hypotension.75% ropivacaine (maximum of 40 ml). shoulder pain or pain at any other site. Patient will be administered general anaesthesia. Patients will be examined as per the proforma attached. If visual analogue scale will be above 3 at rest. 12th and 24hrs after surgery. the proposed port site will be infiltrated throughout all layers with 20ml of 0. Pain will be assessed at rest. 2.75% ropivacaine. an intramuscular injection of diclofenac 75mg will be given. 6th. on coughing and on walking. All patients will be given premedication including injection Diclofenac 75 mg intramuscular. Scale of 10cm for assessment of pain. Post operative pain assessment will include pain at port site. If pain still persists injection nalbuphine 10mg will be 10 . Dose 2-5mg/kg body weight.

The post operative analgesia requirement will be assessed in both the groups and the difference will be assessed statistically at 3rd. 12th and 24hrs following laparoscopic cholecystectomy. These injections will be repeated at in minimum interval of 8hrs if required. 6th.administered slowly intravenously. 11 .

Ngoi SS. Br J Surg 1996. Klarskov B.7:173-7. placebo-controlled study. intraperitoneal infiltration of local anaesthetic for controlling early postlaparoscopic cholecystectomy pain. El-labban MA. The use of intraoperative topical bupivacaine in the control of post operative pain folloeing laparoscopic cholecystectomy. 7. et al. Alexander DJ. Bilge O. et al.83:1123-5.13:349-53. Cha SM. et al. 4. Minerva Chir. et al.1. Bisgaard T. El-labban GM. Kristiansan VB. Anesth Analg 1999. double-blind. J Surg Res 2011. 21658722. The effect of post incisional injection of bupivacaine on post-operative pain in laparoscopic cholecystectomy: a prospective randomized study. 5. 1996. J Min Access Surg2011. Yavru A. 2. et al. Casati A. Randomized trial of periportal bupivacaine for pain relief after laparoscopic cholecystectomy. A prospective randomized double-blind control trial. Bupivacaine. Hokkam EN. Ulusal Cerrahl Dergisi (Turkish J Surg) 1997. Multiregional local anaesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized. levobupivacaine and ropivacavine: are they clinically different. Peritrocal and intraperitoneal ropivacaine for laparoscopic cholecystectomy. Miglietta C. 3. Lee L. Intraincisional vs. Di Gioia S. Garrone C. 6. 12 . Tekant Y. Kang H. Best practice clinical anaesthesia. Morino M.51:881-885. Forani M. Putzu M. 89: 1017-24. BaekCW.

15(19):2376-2380. Nicolaos Z.Y. et al.22:2036-2045. 13 . LeeH. Kong MH. Can J Anaesth. World J Gastroenterol 2009 May 21. Mazoit JX. Yeh C. Anesth Analg 2002. et al.8. Kucuk C.L. Liu Y. Goerge P.25%. Labille T. et al. Kim SH. Benhamou D. Surg Endosc2005. Paqueron X. Local anaesthesia with ropivacaine for patients undergoing laparoscopic cholecystectomy.19:1503-6. Savli S.A randomized double blind control trial. Louizos AA.48:545-550.G.37:396-400. 11. Surg Endsc 2008. Kadiogullari N. Surg Today 2007. Franco D. Canoler O. 2001. Preincisional and intraperitoneal ropivacaine plus normal saline infusion for post operative pain relief after laparoscopic cholecystectomy. 9.94: 100-5. 12. A placebo controlled double blind randomized trial of preincisional infiltration and intraperitoneal instillation of levobupivacaine 0. Pain after laparoscopic cholecystectomy: the effect and timing of incisional and intraperitoneal bupivacaine. et al. 13.N. A placebo controlled comparison of bupivacaine and ropivacaine instillation for preventing postoperative pain after laparoscopic cholecystectomy. Konstantinos N. The clinical efficacy and pharmacokinetics of intraperitoneal ropivacaine for laparoscopic cholecystectomy. Lee IO. 10. Hadzilia SJ.

7(4):305-310.17:1961-4. Shrestha S. Sarac AM.G et al. Chirurgia 1990. Tsimoyiannis EC. Simsek A. Papaziogas B. Pavlidis T. Different pain scores in single transumblical incision laparoscopic cholecystectomy versus 14 . JSLS 2003.S. Baykan N. 18. 1996.A double blind randomized control trial.E. Intraperitoneal and periportal injection of bupivacaine for pain after laparoscopic cholecystectomy. 16. Atmatzidis K. Maharjan SK. Yegen C. Surg Endosc 2003. Surg Laparosc Endosc. Memedov C.14. Papagiannopoulou P. Gulhane Med J 2008.6:362-366. Farantos C. Kathmandu University Medical Journal 2009.E. 20. The effect of preincisional periportal infiltration with ropivacaine in pain relief after laparoscopic procedures. Yalin R. Mentes O. 17. Makris J.103(5):547-551. The effect and timing of local anaesthesia in laparoscopic cholecystectomy. 19. 50(2): 84-90. Micu B. et al. Aktan AO. Nicolau A. Multimodal analgesia in elective laparoscopic cholecystectomy. et al.Tsimogiannis KE.7:50-53. Grecu I. 15.T. Preincisional local infiltration of levobupivacaine vs ropivacaine for pain control after laparoscopic cholecystectomy. Argiriadou H. [Multiregional local anaesthetic administration for the prevention of postoperative pain after laparoscopic cholecystectomy: placebo controlled comparison of ropivacaine and prilocaine]. et al.

Surg Endosc 1993. 21. Surg Endosc. 15 . 24(8): 1842-8.7:482-88. Preincisional local anaesthesia with bupivacaine and pain after laparoscopic cholecystectomy. 2010. Troidl H. Spangenberger W et al. Ure BM.classic laparoscopic cholecystectomy: a randomized controlled trail.

Date of admission Date of discharge Date of surgery HISTORY Chief complaints Past history Personal history Family history Drug history EXAMINATION Pulse Blood pressure Pallor Icterus Cyanosis Oedema 16 .Name of patient Age Sex MRD No.

Rh grouping. Platelet counts. Liver function tests. DLC.Respiratory system Cardiovascular system Abdomen INVESTIGATIONS ABO. BT. CT. TLC. PTI. 17 . X-ray chest-PA view. ECG all leads. Hb. Renal function tests. Blood sugar. USG abdomen.

diclofenac required in 24 hrs No. nalbuphine required in 24hrs 18 . of doses of inj.Assessment of early postoperative pain 3 hrs- 6 hrs- 12 hrs- 24 hrs- Group I Group II No. of doses of inj.