Published: 2017-07-26

Intraperitoneal analgesia to reduce pain after laparoscopic hysterectomy

Amira Mohammed Badawy


Background: Laparoscopic hysterectomy is now an established operation, as it is less invasive and carries much less post-operative pain compared to open hysterectomy. However, post-laparoscopy analgesia is still a challenge. Intraperitoneal (IP) instillation of local anaesthetics has been shown to minimize postoperative pain after laparoscopic surgeries. This study was conducted to evaluate the efficacy of IP instillation of dilute analgesia prior the end of laparoscopic hysterectomy to reduce postoperative pain. The primary outcome was to assess postoperative pain scores. Secondary outcomes included assessment of postoperative analgesic requirements (type, amount, and timing), and frequency of nausea and vomiting.

Methods: 20 cases were enrolled for laparoscopic hysterectomy and were divided randomly into two groups, Group A: 10 cases, where IP analgesia (Bupivacaine and Magnesium Sulphate) was instilled -under vision- prior removal of trocars, and Group B: 10 cases, where no IP analgesia was used. After surgery, Visual Analogue Score (VAS) was recorded at 6, 12, 24 hours and 7 days. Postoperative analgesic requirements (type, amount, and timing), and frequency of nausea and vomiting were also recorded.

Results: The overall VAS during the first postoperative 24 hours was significantly lower in group A (P = 0.048, 0.049, and 0.003 at 6, 12, and 24 hours after surgery). Time to first of analgesia required (in hours) was longer (6.0±1.41 vs 3.20±1.48, P = 0.004) and total analgesic consumption (in mg) was lower (2.40±0.89 vs 3.30±0.67, P = 0.047) in group A compared to group B. The need for opioids was also significantly less in group A (3 cases vs 8 cases, P = 0.024). in group A, nausea and vomiting were less reported as well (P = 0.040).

Conclusions: The instillation of local IP dilute analgesia is an effective and safe method for reducing pain after laparoscopic hysterectomy.


Intra-peritoneal analgesia, Laparoscopic hysterectomy, Pain after laparoscopy

Full Text:



Kim TH, Kang HK, Park JS, Chang IT, Park SG. Intraperitoneal ropivacaine instillation for postoperative pain relief after laparoscopic cholecystectomy. J Korean Surg Soc. 2010;79:130-6.

Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG. Hysterectomy rates in the United States. Obstet Gynecol. 2003;2007:1091-5.

Kai-Yun Wu, Srithean Lertvikool, Kuan-Gen Huang, Hsuan Su, Chih-Feng Yen, Chyi-Long Lee. Laparoscopic hysterectomies for large uteri. Taiwanese J Obstet Gynecol. 2011;50:411-4.

El-Sherbiny W, Saber W, Askalany AN, El-Daly A, Sleem AA. Effect of intra-abdominal instillation of lidocaine during minor laparoscopic procedures. Int J Gynecol Obstet. 2009;106:213-5.

Pasqualucci A, de Angelis V, Contardo R, Colò F, Terrosu G, Donini A et al. Preemptive analgesia: Intraperitoneal local anesthetic in laparoscopic cholecystectomy. A randomized, double-blind, placebo-controlled study. Anesthesiology. 2000;85:11-20.

Bisgaard T, Kehlet H, Rosenberg J. Pain and convalescence after laparoscopic cholecystectomy. Eur J Surg. 2001;167:84-96.

Gottschalk A, Smith DS. New concepts in acute pain therapy: preemptive analgesia. Am Fam Physician. 2001;63:1979-84.

Miller, Eriksson, Fleisher, Wiener-Kronish, Cohen, Young. Miller's Anesthesia, 2-Volume Set, 8th Edition. Chapter 98. Acute Postoperative Pain. 8th Edition. Elsevier Health Sciences; 2010.

White PF. The role of non-opioid analgesic techniques in the management of postoperative pain. Anesth Analg. 2002;94:577-85.

Jiménez Cruz J, Diebolder H, Dogan A, Mothes A, Rengsberger M, Hartmann M et al. Combination of pre-emptive port-site and intraoperative intraperitoneal ropivacaine for reduction of postoperative pain: a prospective cohort study. Eur J Obstet Gynecol Reprod Biol. 2014;179:11-6.

Narchi P, Benhamou D, Fernandez H. Intraperitoneal local anaesthetic for shoulder pain after day-case laparoscopy. Lancet. 1991;338:1569-70.

Huang S, Mi S, He Y, Li Y, Wang S. Analgesic efficacy of trocar sites local anesthetic infiltration with and without transversus abdominis plane block after laparoscopic hysterectomy: a randomized trial. Int J Clin Exp Med. 2016;9(3):6518-24.

Joris J, Thiry E, Paris P, Weerts J, Lamy M. Pain after laparoscopic cholecystectomy: characteristics and effect of intraperitoneal bupivacaine. Anesth Analg. 1995;81:379-84.

Marks JL, Ata B, Tulandi T. Systematic review and metaanalysis of intraperitoneal instillation of local anesthetics for reduction of pain after gynecologic laparoscopy. J Minim Invasive Gynecol. 2012;19:545-53.

Shoeibi G, Sadegi M, Firozian A, Tabassomi F. The additional effect of magnesium sulphate to lidocaine in spinal anaesthesia for caesarean section. Int J Pharmacol. 2007;3:425-7.

Bisgaard T, Klarskov B, Kristiansen VB, Callesen T, Schulze S, Kehlet H et al. Multi-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi modal analgesia: A randomized, double-blinded, placebo-controlled study. Anesth Analg. 2009;89:1017-24.

Labaille T, Mazoit JX, Paqueron X, Franco D, Benhamou D. The clinical efficacy and pharmacokinetics of intraperitoneal ropivacaine for laparoscopic cholecystectomy. Anesth Analg. 2002;94:100-5.

Goldstein A, Grimault P, Henique A, Keller M, Fortin A, Darai E. Preventing postoperative pain by local anesthetic instillation after laparoscopic gynecologic surgery: A placebo-controlled comparison of bupivacaine and ropivacaine. Anesth Analg. 2000;91:403-7.

Callesen T, Hjort D, Mogensen T, Schouenborg L, Nielsen D, Reventlid H, et al. Combined field block and i.p. instillation of ropivacaine for pain management after laparoscopic sterilization. Br J Anaesth. 1999;82:586-90.

Arden D, Seifert E, Donnellan N, et al. Intraperitoneal instillation of bupivacaine for reduction of postoperative pain after laparoscopic hysterectomy: a double-blind randomized controlled trial. J Minim Invasive Gynecol. 2013;20:620-6.

Andrews V, Wright JT, Zakaria F, Banerjee S, Ballard K. Continuous infusion of local anaesthetic following laparoscopic hysterectomy - a randomized controlled trial. Br J Obstet Gynecol. 2014;121:755-61.

Rivard C, Vogel RI, Teoh D. Effect of Intraperitoneal Bupivacaine on Postoperative Pain in the Gynecologic Oncology Patient. J Minim Invasive Gynecol. 2015;22(7):1260-5.

Saccardi C, Gizzo S, Vitagliano A, Noventa M, Micaglio M, Parotto M et al. Peri-incisional and intraperitoneal ropivacaine administration: a new effective tool in pain control after laparoscopic surgery in gynecology: a randomized controlled clinical trial. Surg Endosc. 2016;30(12):5310-8.

Ranjita A, Daisy K, Megha K. Postoperative analgesia with intraperitoneal, ropivacaine with and without dexamedetomidine after total laparoscopic hysterectomy: Asian J Pharmaceu Clin Res. 2016;9:1-4.

Abdel-Raof NM, El-Refaei N, El-Shazly I. Does intraperitoneal magnesium work peripherally in patients undergoing laparoscopic cholecystectomy? Egypt J Anaesth. 2005;21:307-10.

Yadava A, Rajput SK, Katiyar S, Jain RK. A comparison of intraperitoneal bupivacaine - tramadol with bupivacaine – magnesium sulphate for pain relief after laparoscopic cholecystectomy: prospective, randomised study. Indian J Anaesth. 2016; 60(10):757-62.