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

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

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

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

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

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

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. 1995 Aug;81(2):379-84 Br J Surg. 2000 Mar;87(3):273-84 Surg Endosc. 1999 May;13(5):445-8

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

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. 2006 Nov;22(9):799-804

Medication COX-2 inhibitor IV Lower Pain intensity score Better satisfaction in global evaluation Anesth Analg. 2004 Feb;98(2):336-42

Medication Dexmedetomidine Painkiller, analgesics oral Dose dependent analgesic effect Indian J Anaesth. 2014 Nov-Dec; 58(6): 726–731

Medication Gabapentin/Tramadol Painkiller, analgesics oral Lower mean VAS score Lower mean fentanyl consumption Can J Aaesth. 2004 Apr;51(4):358-63

Medication Pregabalin Painkiller, analgesics oral Lower mean VAS score Lower pethidine consumption Can J Aaesth. 2004 Apr;51(4):358-63

Procedure Low-pressure pneumoperitoneum 13 mmHg CO2 9 mmHg CO2 Lower pain intensity score Decreased shoulder-tip pain Br J Surg. 2000 Sep;87(9):1161-5

Procedure Single incision Lower VAS score Significant lower pain (Post op. 6hrs) Chin Med J. 2015 Dec;128(24):3310-6

Procedure Single incision ? Lower VAS score Significant lower pain (Post op. 6hrs) Chin Med J. 2015 Dec;128(24):3310-6

Procedure Local anesthesia (LA)

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

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

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

Trial 1 Peritrocal (PT) & Intraperitoneal (IP) injection Ropivacaine Minimal side effect Longer duration  Considered to offer advantage in postop. pain J Surg Res. 2012 Jun 15;175(2):251-8

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. 2012 Jun 15;175(2):251-8

Intraperitoneal (IP) for visceral pain immediately after pneumoperitoneum 100 mL of ropivacaine solution (2 mg/kg) J Surg Res. 2012 Jun 15;175(2):251-8

Treatment Group A (n = 20) Group B (n = 20) Group C (n = 20) Group D (n = 20) Peritrocal Saline Ropivacaine Intraperitoneal J Surg Res. 2012 Jun 15;175(2):251-8

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. 2012 Jun 15;175(2):251-8

Total postoperative pain severity (TPPS) in control group Visceral: deep breathing Parietal: wound를 누르거나 moving, coughing 시 유발되는 통증 J Surg Res. 2012 Jun 15;175(2):251-8

Total postoperative pain severity (TPPS) in control group Parietal P. > shoulder tip P. J Surg Res. 2012 Jun 15;175(2):251-8

Total postoperative pain severity (TPPS) in control group Parietal P. > shoulder tip P. Visceral P. > parietal P. J Surg Res. 2012 Jun 15;175(2):251-8

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. 2012 Jun 15;175(2):251-8

Total fentanyl consumption (TFC) Frequency push the button (FPB) Lock out, infusion rate:설정가능 누른 횟수와 소모양 J Surg Res. 2012 Jun 15;175(2):251-8

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. 2012 Jun 15;175(2):251-8

Total fentanyl consumption (TFC) Frequency push the button (FPB) IP < C PT < C PT Peritrocal injection IP Intraperitoneal injection C Control J Surg Res. 2012 Jun 15;175(2):251-8

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. 2012 Jun 15;175(2):251-8

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

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

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

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

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

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

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

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