1. Chung-Ang Univ. Yoo Shin Choi
Multimodal practices to reduce pain after LC : How can we do better? & personal experience
Chung-Ang Univ.
Yoo Shin Choi

2. Systemic changes -hypercarbia --causing sympathetic nervous
system excitation that results in amplification of the local tissue inflammatory response

3. Systemic changes -hypercarbia --causing sympathetic nervous
system excitation that results in amplification of the local tissue inflammatory response

4. Laparoscopic Cholecystectomy (LC)
World widely common & simple op.
 Outpatient setting
Systemic changes -hypercarbia --causing sympathetic nervous
system excitation that results in amplification of the local tissue inflammatory response

5. Laparoscopic Cholecystectomy (LC)
World widely common & simple op.
 Outpatient setting
But, early pain after LC: still problem
Systemic changes -hypercarbia --causing sympathetic nervous
system excitation that results in amplification of the local tissue inflammatory response

6. 3 main Components of Pain after LC
Parietal pain
Incisional trauma at port site
Visceral pain
Pneumoperitoneum (local & systemic changes)
Postcholecystectomy wound within liver
Shoulder tip pain (by diaphragmatic stretching)
Tearing of blood vessels
Traumatic traction of the nerves
Release of inflammatory mediators
Phrenic nerve neuropraxia

7. 3 main Components of Pain after LC
Parietal pain
Incisional trauma at port site
Visceral pain
Pneumoperitoneum (local & systemic changes)
Postcholecystectomy wound within liver
Shoulder tip pain (by diaphragmatic stretching)
Tearing of blood vessels
Traumatic traction of the nerves
Release of inflammatory mediators
Phrenic nerve neuropraxia
Anesth Analg Aug;81(2):379-84
Br J Surg Mar;87(3):273-84
Surg Endosc May;13(5):445-8

8. Various methods/studies for reducing pain
Medications
Prophylactic or perioperative use of
NSAIDs/COX-2 inhibitors/dexmedetomidine
Other medication (tramadol/gabapentin/pregabalin)
Procedures
Low pressure pneumoperitoneum
Local anesthesia
Local wound anesthetic infiltration
Instillation of intraperitoneal local anesthetics
Multimodal analgesic treatment

9. Medication Dextro-methorphan (IM) & ketorolac (IV)
C- control
DM - dextro-methorphan
K - ketorolac
DM+K - dextro-methorphan
+ketorolac
NMDA antagonist
NSAID
preoperative
Best pain relief: DM+K group
Clin J Pain Nov;22(9):

10. Medication COX-2 inhibitorIV
Lower Pain intensity score
Better satisfaction in global evaluation
Anesth Analg Feb;98(2):336-42

11. Medication Dexmedetomidine
Painkiller, analgesics
oral
Dose dependent analgesic effect
Indian J Anaesth Nov-Dec; 58(6): 726–731

12. Medication Gabapentin/Tramadol
Painkiller, analgesics
oral
Lower mean VAS score
Lower mean fentanyl consumption
Can J Aaesth Apr;51(4):358-63

13. Medication Pregabalin
Painkiller, analgesics
oral
Lower mean VAS score
Lower pethidine consumption
Can J Aaesth Apr;51(4):358-63

14. Procedure Low-pressure pneumoperitoneum
13 mmHg CO2
9 mmHg CO2
Lower pain intensity score
Decreased shoulder-tip pain
Br J Surg Sep;87(9):1161-5

15. Procedure Single incision
Lower VAS score
Significant lower pain (Post op. 6hrs)
Chin Med J Dec;128(24):3310-6

16. Procedure Single incision?
Lower VAS score
Significant lower pain (Post op. 6hrs)
Chin Med J Dec;128(24):3310-6

17. Procedure Local anesthesia (LA)

18. Procedure Local anesthesia (LA)
Type of LA
Ropivacaine
Lidocaine
Levobupivacaine
Type of injection
Intraperitoneal
Peritrocal
Intravenous
Various methods
Concentration
Total contents
Total volume
Timing & site of instillation
 Different results

19. 2 trial for pain relief after LC
Personal experience of LA
2 trial for pain relief after LC

20. 2 trial for pain relief after LC
Personal experience of LA
2 trial for pain relief after LC
prospective, randomized, double-blind controlled
Trial 1 (May 2008 ~ May 2009)
Ropivacaine: Peritrocal vs. Intraperitoneal
Trial 2 (May 2011 ~ May 2012)
Lidocaine: Intraperitoneal vs. intravenous

21. Trial 1 Peritrocal (PT) & Intraperitoneal (IP) injection Ropivacaine
Minimal side effect
Longer duration
 Considered to offer advantage in postop. pain
J Surg Res Jun 15;175(2):251-8

22. Peritrocal (PT) for parietal pain
before insertion of the trocar
16 mL (ropivacaine-2 mg/mL)
6 mL for the umbilical port
6 mL for the epigastric port
4 mL for RUQ working port
J Surg Res Jun 15;175(2):251-8

23. Intraperitoneal (IP) for visceral pain
immediately after pneumoperitoneum
100 mL of ropivacaine solution (2 mg/kg)
J Surg Res Jun 15;175(2):251-8

24. Treatment
Group A (n = 20)
Group B (n = 20)
Group C (n = 20)
Group D (n = 20)
Peritrocal
Saline
Ropivacaine
Intraperitoneal
J Surg Res Jun 15;175(2):251-8

25. Assessment of pain after treatment
Group A (n = 20)
Group B (n = 20)
Group C (n = 20)
Group D (n = 20)
Peritrocal
Saline
Ropivacaine
Intraperitoneal
Assessment of pain after treatment
Total postoperative pain severity (TPPS) by VAS
II. Frequency pushed the button (FPB) of PCA
III. Total fentanyl consumption (TFC) of PCA
Continuous + Additional
J Surg Res Jun 15;175(2):251-8

26. Total postoperative pain severity (TPPS)
in control group
Visceral: deep breathing
Parietal: wound를 누르거나 moving, coughing 시 유발되는 통증
J Surg Res Jun 15;175(2):251-8

27. Total postoperative pain severity (TPPS)
in control group
Parietal P. > shoulder tip P.
J Surg Res Jun 15;175(2):251-8

28. Total postoperative pain severity (TPPS)
in control group
Parietal P. > shoulder tip P.
Visceral P. > parietal P.
J Surg Res Jun 15;175(2):251-8

29. Total postoperative pain severity (TPPS)
Visceral pain
Parietal pain
Shoulder tip pain
IP & IP+PT< C
PT & IP+PT < C
IP & IP+PT < C PT
Peritrocal injection IP
Intraperitoneal injection C
Control
J Surg Res Jun 15;175(2):251-8

30. Total fentanyl consumption (TFC) Frequency push the button (FPB)
Lock out, infusion rate:설정가능
누른 횟수와 소모양
J Surg Res Jun 15;175(2):251-8

31. Total fentanyl consumption (TFC) Frequency push the button (FPB)
Highest in C
Lowest in IP+PT PT
Peritrocal injection IP
Intraperitoneal injection C
Control
J Surg Res Jun 15;175(2):251-8

32. Total fentanyl consumption (TFC) Frequency push the button (FPB)
IP < C
PT < C PT
Peritrocal injection IP
Intraperitoneal injection C
Control
J Surg Res Jun 15;175(2):251-8

33. Total fentanyl consumption (TFC) Frequency push the button (FPB)
IP < C
PT < C
IP+PT < C & IP & PT PT
Peritrocal injection IP
Intraperitoneal injection C
Control
J Surg Res Jun 15;175(2):251-8

34. Trial 2 Intraperitoneal (IP) & Intravenous (IV) Lidocaine
Neural response by
Blocking nerve conduction suppressing central sensitization
Inhibiting spinal visceromotor neurons
Reducing inflammation to postoperative pain
J Int Med Res 2014 Apr;42(2):307-19

35. Intraperitoneal (IP) Intravenous (IV)
100 mL of lidocaine solution (3.5 mg/kg)
Intravenous (IV)
Bolus 1.5 mg/kg  continuous IV of 2 mg/kg/h of lidocaine
during operation
Continuous till end surgery
J Int Med Res 2014 Apr;42(2):307-19

36. Assessment of pain after treatment
Group C (n = 24)
Group IP (n = 22)
Group IV (n = 26) IV
Saline
lidocaine IP
Assessment of pain after treatment
Total postoperative pain severity (TPPS) by VAS
II. Frequency pushed the button (FPB) of PCA
III. Total fentanyl consumption (TFC) of PCA
Continuous + Additional
J Int Med Res 2014 Apr;42(2):307-19

37. Total postoperative pain severity (TPPS)
in group C was >3 until 12 h after surgery. TPSS were significantly lower between 2 and 24 h in group IP compared with group C (P<0.05) and between 2 and12 h in group IV compared with group C (P<0.05). TPPS values were significantly lower in group IP than in group IV at 2 h (P<0.05). In all groups, the severity of pain gradually diminished over the course of the study
IP < C
IV < C IV
Intravenous injection IP
Intraperitoneal injection C
Control
J Int Med Res 2014 Apr;42(2):307-19

38. Total postoperative pain severity (TPPS)
in group C was >3 until 12 h after surgery. TPSS were significantly lower between 2 and 24 h in group IP compared with group C (P<0.05) and between 2 and12 h in group IV compared with group C (P<0.05). TPPS values were significantly lower in group IP than in group IV at 2 h (P<0.05). In all groups, the severity of pain gradually diminished over the course of the study
IP < IV
IP < C
IV < C IV
Intravenous injection IP
Intraperitoneal injection C
Control
J Int Med Res 2014 Apr;42(2):307-19

39. Total fentanyl consumption (TFC) Frequency push the button (FPB)
significantly higher in group C than in groups IP and IV, until 24 h after surgery (Figures 3 and 4). The difference between the IP and IV groups for TFC was not significant (Figure 3). The FPB was significantly lower in group IP than group IV at the 0–2 h interval (Figure 4).
IV & IP < C IV
Intravenous injection IP
Intraperitoneal injection C
Control
J Int Med Res 2014 Apr;42(2):307-19

40. Total fentanyl consumption (TFC) Frequency push the button (FPB)
significantly higher in group C than in groups IP and IV, until 24 h after surgery (Figures 3 and 4). The difference between the IP and IV groups for TFC was not significant (Figure 3). The FPB was significantly lower in group IP than group IV at the 0–2 h interval (Figure 4).
No difference between IV & IP
IP < IV IV
Intravenous injection IP
Intraperitoneal injection C
Control
J Int Med Res 2014 Apr;42(2):307-19

41. Summary 3 main components of pain after LC
Visceral, parietal, shoulder tip pain
How to reduce pain after LC
Medications
Procedures
Multimodal practices:
maybe helpful for soothing pain after LC