Efficacy of intraperitoneal Ropivacaine in decreasing postoperative pain after laparoscopic tubal sterilization
JMK Azhary *NM Adenan*A Rahman** S. Balakrishnan** SZ Omar*
*Department of Obstetrics and Gynecology University of Malaya**Department of Obstetrics sand Gynecology Penang General Hospital
8. Cruikshank DP, Laube DW, De Backer LJ. Intraperitoneal lidocaine anesthesia for postpartum tubal ligation. Obstet Gynaecol 1973;42:127–30.
9.Moiniche S, Jorgensen H, Wetterslev J, Berg J. Local anesthetic infiltration for postoperative pain relief after laparoscopy: a qualitative and quantitative systematic review of intraperitoneal, port-site infiltration and mesosalpinx block. Anesth Analg 2000; 90: 899±912
- The intervention group showed lower pain scores at each corresponding times but this are not statistically significant.
- There is also no significant differences in the mean change of pain score over time between the treatment groups. The mean change between t=15 and t=240, -1.56 and -2.30 respectively for the control and intervention group, p=0.481.
- The tubes were ligated either with the Filshie clips (Pic. 1) or the Fallop rings (Pic .2)
- At the end of the procedure, before the abdomen was deflated, 15mls of Ropivacaine (7.5mg/ml Ropivacaine without dilution) or placebo solution (normal saline) is splashed (7.5mls on each tube) on both the ligated tubes with a veress needle under direct vision via the 5mm port.
- Following skin closure (port skin), the remaining 5mls of Ropivacaine was infiltrated under skin in both study groups
- Once fully conscious, each patient informed the medical staff of the severity of her pain using a visual analogue score of 1 to 10 at 15, 60,120 and 240 minutes post operation.
- Need for additional pain relief was assessed and the administration of analgesia was noted (Rescue drug of intravenous Parecoxib 40mg).
- By 15th December 2010, 60 patients had been included in the study, in which 30 were allocated in each arm (Intervention and placebo).
- The demographic data are shown as in Table 1
- Method of ligation used were Filshie clips in 58.3% (35 out of 60) the patients.
- Laparoscopic sterilization is probably the most common laparoscopic surgery in the UK and gaining momentum in developing countries in Asia.
- Regional and general anesthesia are routinely used for this minor operation in most parts of the world including Malaysia.
- Intraperitoneal lidocaine instillation for postpartum tubal sterilization was first reported in 1973; however, it was limited due to small sample size.
- Several subsequent studies have proven its efficacy in reducing post operative pain and the need for opiates.
- The objective of this study are :-
- To assess the severity and the duration of pain following laparoscopic tubal sterilization.
- To assess the effectiveness of instillation of Ropivacaine into the peritoneal cavity for the relief of post operative pain
- To prove that combination of intraperitoneal instillation with port sites/skin infiltration of Ropivacaine is better in controlling postoperative pain
Pic. 1: Application of Filshie clips
- Intraperitoneal Ropivacaine moderately decreases postoperative pain after laparoscopic tubal sterilization with a pain score between 4 to 5.
- Our findings suggest that the treatment with intraperitoneal Ropivacaine is no more effective than placebo in reducing postoperative pain after laparoscopic tubal sterilization
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2. Ruminjo JK, Lynam PF. A fifteen-year review of female sterilization by minilaparotomy under local anesthesia in Kenya. Contraception 1997;55:249–60.
3. Cruikshank DP, Laube DW, De Backer LJ. Intraperitoneal lidocaine anesthesia for postpartum tubal ligation. Obstet Gynaecol 1973;42:127–30.
4. Moiniche S, Jorgensen H, Wetterslev J, Berg J. Local anesthetic infiltration for postoperative pain relief after laparoscopy: a systematic review of intraperitoneal, port-site infiltration and mesosalpinx block. Anesth Analg 2000; 90: 899±912
5.Goldstein A, Grimault P, Henique A,Keller M,Fortin A, Darai E. Preventing Postoperative Pain by Local AnestheticInstillation After Laparoscopic Gynecologic Surgery: A Placebo-Controlled Comparison of Bupivacaine and Ropivacaine. Anesth Analg 2000;91:403–7
- All patients for elective laparoscopic tubal sterilization with Filshie or Fallop ring between 15th January 2010 to 15th December 2010 in Penang general hospital were recruited.
- Exclusion criteria were patients with known drug allergies to substances contained in the local anaesthesia, Ropivacaine and Parecoxib
- A standard pre-operative questionnaire were filled up and no pre-medication or any form of analgesia was given prior to procedure.
- Close technique with veress needle was used at each laparoscopy with the standard insufflation
- A primary 5 mm port was inserted sub-umbilically as the optic trochar and subsequent 5mm secondary port was inserted into the right or left iliac fossa or suprapubic region under direct vision
Pic. 2: Application of Fallop clips
- With Ropivacaine, the mean pain score at 15 minutes were only 4.07 and 4.07 for patients in the placebo group.
- The mean pain scores in both the placebo and intervention groups showed decreasing trend with time, reaching about 50 to 60% by 120 minutes.