Intraperitoneal Levobupivacaine Instillation ImprovesOutcome of Laparoscopic Cholecystectomy: A Comparative Study of Preemptive versus Postoperative Instillation

Objectives: The present study aimed at investigating the postoperative (PO) analgesicefficacy of intra-peritoneal (IP) levobupivacaine instillation on the frequency and intensity of shoulder tip pain (STP) and its impact on duration of hospital stay in patients assigned for laparoscopic cholecystectomy (LC) comparing preemptive (PE) versus postoperative instillation. Patients Methods: The study comprised 80 patients, 71 ASA I and 9 ASA II, assigned to undergo elective laparoscopic cholecystectomy (LC). Patients were randomly allocated into 4 equal groups according to timing of IP instillation: Group PE received PE instillation; Group PO received PO continuous installation of levobupivacaine at rate of 12.5 mg/h and Group PE+PO received both PE instillation and PO continuous installation; control group receive PE+PO instillation of saline only (placebo) (Group C). No local anesthetic infiltration of wound site was applied. The intensity of postoperative STP Was assessed using a visual analogue scale (VAS) ranging from 0 (no pain) to 10 (unbearable pain). Pain assessment was conducted hourly for 12 hours and 2-hourly for another 12 hours. The duration of analgesia; defined as the time elapsed from patient arrival to the recovery room till the first request of rescue analgesia that was given when patient has VAS score of 4 was determined. Results: Intraperitoneal LA instillation provided significantly longer duration of analgesia, significantly lower pain VAS score and significantly less consumption of PO rescue analgesia compared to control group. Patients enrolled in PE+PO group showed superior outcomes compared to both PE and PO groups with significant difference in favor of PE group. Ten patients 7 in PE+PO and 3 in PE groups did not request rescue analgesia for STP with postoperative rescue analgesic sparing effect of 12.5%. Patients received levobupivacaine IP instillation had significantly shorter PO hospital stay compared to control group and those received combined PE and PO instillation had significantly shorter postoperative hospital stay compared those received PE or PO instillation with a non-significant difference between both modalities despite being in favor of PE instillation. Conclusion: It could be concluded that IP levobupivacaine instillation provided profound PO analgesia with rescue analgesia sparing effect of 12.5% and significantly reduced PO hospital stay. Combined PE and PO instillation provided superior outcome compared to either PE or PO instillation and is advocated as therapeutic modality for pain management after LC.