A Comparative Study of Pre-emptive versus Post Surgery Intraperitoneal Instillation of Bupivacaine for Postoperative Pain Relief after Laparoscopic Cholecystectomy: A Prospective, Randomized, Double blind and Placebo Controlled Study.

BACKGROUND AND AIMS: Laparoscopic cholecystectomy (LC) is the preferred treatment for cholelithiasis due to its minimally invasive approach and faster recovery compared to open surgery. However, postoperative pain remains a significant challenge, impacting patient recovery. Various pain management strategies, including intravenous nonsteroidal anti-inflammatory drugs, local anesthetic (LA) infiltration, intrapleural and intercostal nerve blocks, and epidural opioids, have been explored. While studies support the efficacy of intraperitoneal LA instillation for pain relief, few compare preemptive versus postsurgery administration. This study evaluates the effectiveness of 30 ml of 0.25% bupivacaine instilled intraperitoneally preemptively and post the gallbladder removal, in controlling postoperative pain following elective LC.

METHODS

After obtaining ethical committee approval and informed patient consent, 134 subjects were screened, and 90 patients (American Society of Anesthesiologists I-II, aged 18-70 years, both sexes) meeting the strict inclusion criteria were randomized into three groups. Each group received 60 ml of solution (30 ml 0.25% bupivacaine + 30 ml normal saline) instilled intraperitoneally by the surgeon on the gallbladder bed at distinct surgical stages. Postoperative pain intensity was measured using the Numerical Rating Scale (NRS) at 0.5, 1, 2, 4, 6, 12, and 24 h. Additional outcomes included the time to first rescue analgesic and the total number of rescue analgesic doses required within 24 h postsurgery.

RESULTS

Patients receiving 30 ml of 0.25% bupivacaine immediately after capnoperitoneum creation exhibited significantly lower NRS scores over 24 h compared to those receiving it post the gallbladder removal. Preemptive administration also significantly prolonged the time to first rescue analgesic, reduced the need for additional analgesics, and facilitated earlier resumption of normal activity.

CONCLUSION

Intraperitoneal instillation of 0.25% bupivacaine immediately after creation of capnoperitoneum effectively reduces postoperative pain, delays the need for rescue analgesia, and supports faster recovery compared to administration after gallbladder removal, as evidenced by NRS scores over 24 h.