Pain reduction by continuous intraperitoneal nebulization of ropivacaine during gynecological laparoscopic surgery

Gynecol Surg (2013) 10:51–56 DOI 10.1007/s10397-012-0761-5 ORIGINAL ARTICLE Pain reduction by continuous intraperitoneal nebulization of ropivacaine during gynecological laparoscopic surgery Y. Kaufman & L. Ostrovsky & O. Klein & I. Hirsh & R. Auslander & R. Pizov & A. Lissak Received: 15 May 2012 / Accepted: 28 July 2012 / Published online: 24 August 2012 # Springer-Verlag 2012 Abstract The objective of this study was to examine the analgesic effect of intraperitoneal nebulization of ropivacaine during gynecological laparoscopic procedures for patients anesthetized with an ultrashort-acting opiate. The study was a double-blinded placebo-controlled randomized trial (Canadian Task Force classification I) and involved 40 patients (20 patients in each arm) undergoing elective gynecological same-day outpatient laparoscopic surgery including unilateral/bilateral salpingo-oophorectomy or unilateral/ bilateral ovarian cystectomy at the University Hospital Ambulatory Gynecological Endoscopic Unit. The study group received 10 ml of 1 % ropivacaine, and the control group received 10 ml of sterile water by intraperitoneal nebulization. Vital signs were recorded and summarized. Postoperatively, patients were followed up for 24 h including visual analogue scale (VAS) scores and analgesic usage. Results showed no significant differences between the two groups in terms of patient characteristics and surgical data. There were no significant differences between the groups in postoperative VAS scores at rest at the different time intervals. VAS scores during strain showed significantly decreased pain at the postoperative 2-h interval (p<0.05). Postoperative opiate and nonopiate analgesia consumption was similar for Y. Kaufman (*) : L. Ostrovsky : O. Klein : I. Hirsh : R. Auslander : A. Lissak Department of Obstetrics and Gynecology, The Lady Davis Carmel Medical Center, Technion Institute of Technology Medical School, 7 Michal Street, Haifa 34362, Israel e-mail: R. Pizov Department of Anesthesiology and Critical Care, The Lady Davis Carmel Medical Center, Technion Institute of Technology Medical School, Haifa, Israel both groups. Patients in the study groups required more antiemetic agents compared to the control group patients (p<0.05). There were no reported side effects related to ropivacaine. Intraperitoneal nebulization of 100 mg of ropivacaine during gynecological laparoscopy under general anesthesia with an ultrashort-acting opiate does not reduce postoperative pain and it does not reduce postoperative opiate and nonopiate analgesia consumption. Keywords Pain . Intraperitoneal . Nebulization . Ropivacaine . Gynecology . Laparoscopy . Visual analog scale (VAS) score . Opiates . Remifentanil Background Laparoscopic surgery has been clearly proven to have significant advantages over open surgery in many aspects including decreased postoperative pain. This has allowed many of the laparoscopic procedures to be performed on an outpatient basis. Pain control and reduction of postoperative nausea and vomiting (PONV) are essential for the patient’s well-being and adamant for ambulatory surgery. Good postoperative pain relief has been advocated by the Joint Commission on Accreditation of Healthcare Organizations as a patient’s right [1]. Pain during and after laparoscopy is multifactorial. This includes factors related to the procedure such as the type and duration of the procedure; factors related to the CO2 gas including the total volume, pressure, and humidity of the delivered gas as well as the amount of residual gas within the peritoneum at the end of the procedure; and factors related to the intraoperative anesthetic protocol and the postoperative pain control protocol [2–4]. Improvements in postoperative pain may be achieved by reducing the CO2 pressure, increasing humidity of the gas, and changing the 52 Gynecol Surg (2013) 10:51–56 intraoperative as well as postoperative use of anesthetics and analgesics. Postoperative pain is mostly visceral [5]. Pain control is usually done using opiates and opiate derivatives as well as local anesthetics (LA) and nonsteroidal anti-inflammatory drugs. Opiates are effective in pain control but at the price of causing PONV and drowsiness which are counterproductive for outpatient treatment. Reducing the negative effects of the opiates can be done by using short-acting opiates and intraperitoneal local anesthetics during laparoscopy. There are conflicting results regarding the effectiveness of intraperitoneal local anesthetics. Studies on this subject vary in terms of the timing for administration of the local anesthetic in relation to the procedure (i.e., beginning of insufflation, end of insufflation, end of the procedure), location of distribution within the peritoneal cavity, dosage, and the addition of adrenaline, which lowers peak plasma volume of the anesthetic [3]. Previously, we have published a study on continuous intraperitoneal nebulization of ropivacaine throughout gynecological laparoscopic procedures [6]. Ropivacaine pharmacodynamics depend on the method of administration. An animal study has shown that ropivacaine reaches peak concentrations after 1 h from administration, has a half-life of 2 h, and is excreted after approximately 6 h [7]. Our results showed no significant reduction in postoperative pain or in the use of postoperative analgesics. We assumed that residual effects of opiates given during the laparoscopic procedure have a prolonged postoperative effect which might be masking a possible potential paindecreasing benefit of ropivacaine after surgery. Therefore, we decided to perform a follow-up study using the same technique of intraperitoneal nebulization but with a different anesthetic protocol which is based on ultrashort-acting opiates. Remifentanil is an ultrashort-acting opiate with an onset of action around 1 min and a half-life of 2–3 min which is rapidly eliminated from the body [8]. The objective of our study was to examine the effect of intraperitoneal nebulization of ropivacaine during gynecological laparoscopic procedures under an ultrashort-acting opiate anesthetic protocol on postoperative pain and analgesic consumption. Methods The study was a double-blinded placebo-controlled randomized trial approved by the Carmel Medical Center Helsinki Ethics Committee. We included 40 patients (20 patients in each arm), ages 18–70, with an American Society of Anesthesiologists physical status grade I or II, undergoing elective gynecological laparoscopic surgery at our Ambulatory Gynecoendoscopic Unit. All operations were performed by two senior consultants. After signing a consent form, patients who were candidates for a same-day outpatient laparoscopy including unilateral/bilateral salpingooophorectomy or unilateral/bilateral ovarian cystectomy randomly received either 10 ml of 1 % ropivacaine to a total of 100 mg (Naropin, 100 mg/10 ml, AstraZeneca, UK) or 10 ml of sterile water. The ampoules were prepa (...truncated)