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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 4  |  Page : 1943-1948

Postoperative pain relief after laparoscopic cholecystectomy using sodium bicarbonate irrigation: a comparative controlled study


Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission08-Feb-2022
Date of Decision26-May-2022
Date of Acceptance29-May-2022
Date of Web Publication04-Mar-2023

Correspondence Address:
Sarah M Al Feshawy
Sers Ellian, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_312_22

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  Abstract 


Objectives
The aim of this study was to assess the value of using irrigation with sodium bicarbonate in relieving pain after laparoscopic cholecystectomy.
Background
Laparoscopic cholecystectomy is considered as the treatment of choice for symptomatic cholelithiasis. Few studies reported about the clinical significance of pain control after laparoscopic surgery. This randomized clinical trial was designed to determine whether it is possible to reduce postlaparoscopic pain by neutralizing acidic peritoneal environment (created by CO2 insufflation) using peritoneal irrigation with sodium bicarbonate.
Patients and methods
This double-blinded randomized clinical trial was carried out on 32 patients undergoing elective laparoscopic cholecystectomy.
Results
The time of pneumoperitoneum in sodium bicarbonate group ranged from 27 to 67, with mean ± SD of 49.81 ± 11.55, whereas in the nonwashing group, the time of pneumoperitoneum ranged from 26 to 63, with mean ± SD of 45 ± 11.21, with no statistically significant difference (P = 0.241) between the two groups. Visual analog scale at 24 h in the sodium bicarbonate group ranged from 2 to 6, with mean ± SD of 3.56 ± 1.09, whereas in the nonwashing group, the visual analog scale score at 24 h ranged from 2 to 9 with mean ± SD of 5.81 ± 1.87, with a highly statistically significant difference (P ≤ 0.001) between the two groups. Regarding the sites of pain, there was no significant difference between the two studied groups (P = 0.858).
Conclusion
Intraperitoneal irrigation of sodium bicarbonate is a simple and safe method that provides pain relief in the postoperative period after laparoscopic cholecystectomy compared with nonwashing. Moreover, intraperitoneal irrigation of sodium bicarbonate was found to have a better pain relief profile compared with normal saline.

Keywords: irrigation, laparoscopic cholecystectomy, postoperative pain relief, sodium bicarbonate


How to cite this article:
Shahin MA, Al Feshawy SM, Zedan AS. Postoperative pain relief after laparoscopic cholecystectomy using sodium bicarbonate irrigation: a comparative controlled study. Menoufia Med J 2022;35:1943-8

How to cite this URL:
Shahin MA, Al Feshawy SM, Zedan AS. Postoperative pain relief after laparoscopic cholecystectomy using sodium bicarbonate irrigation: a comparative controlled study. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:1943-8. Available from: http://www.mmj.eg.net/text.asp?2022/35/4/1943/371027




  Introduction Top


Laparoscopic cholecystectomy is considered as the treatment of choice for symptomatic cholelithiasis. Laparoscopic surgery has displayed advantages over open surgery, including less postoperative pain, smaller incisions, shorter postoperative ileus, reduced blood loss, reduced length of hospital stay, faster recovery, as well as earlier return to preoperative activity and work [1].

The pH of peritoneal fluid ranges between 7.5 and 8.0 and contains significant buffering capacity [2].

In fact, reduced postoperative pain is one of the most important advantages of laparoscopic cholecystectomy compared with open surgery. However, postoperative pain is not completely absent and is still considerable [3].

Pain can increase morbidity and is the primary reason for prolonged hospitalization after laparoscopic cholecystectomy [4],[5]. Patients frequently complain of back and shoulder region pains and discomfort of port site incisions. Considerable shoulder and subdiaphragmatic pain occurs in ~ 12–60% of patients [6].

Peak of pain intensity is during the first few postoperative hours and usually declines after 2 or 3 days [7]. The etiology of pain after laparoscopic cholecystectomy is multifactorial [8]. One suggested cause of pain after laparoscopic cholecystectomy is the peritoneal insufflation with CO2 and phrenic nerve irritation in the abdominal side of the diaphragm [1].

In fact, the acid milieu created by the dissolution of CO2 gas causes peritoneal irritation and phrenic nerve stimulation in laparoscopic cholecystectomy [9].

To date, administration of NSAIDs and narcotics, gas drainages, intraperitoneal saline, TAP block, and intraperitoneal instillation of local anesthetics and opioids were carried out to reduce pain after a laparoscopic cholecystectomy [10]. However, use of these methods for pain relief after laparoscopic cholecystectomy had a lot of adverse effects or was not associated with a similar result; therefore, the clinical significance of pain control using the aforementioned technique after laparoscopic surgery remains controversial [1]. This randomized clinical trial was designed to determine whether it is possible to reduce postlaparoscopic pain by neutralizing acidic peritoneal environment (created by CO2 insufflation) using peritoneal washout with sodium bicarbonate (an alkaline solution).

The aim of this study was to assess the value of using irrigation with sodium bicarbonate in relieving pain after laparoscopic cholecystectomy.


  Patients and methods Top


This double-blinded randomized clinical trial was carried out on 32 patients undergoing elective laparoscopic cholecystectomy at the General Surgery Department of Menoufia University Hospital between May 2021 and May 2022. The study was done after being approved by the ethics committee, and informed written consent was obtained from all patients included by the author.

Sample size

According to previous studies at a power of 80%, 95% confidence interval sample size was calculated and was found to 16 participants in each group (total 32 participants).

Inclusion criteria were adult patients with no previous history of psychological medication.

Exclusion criteria were patients with a previous malignant disease, a history of severe and/or repeated postoperative nausea and vomiting after previous minor surgery, pregnant females, positive history of the use of opioids and alcohol, patients with acute cholecystitis, gangrene or empyema of the gallbladder, rupture of the gallbladder, and bile leakage at the site of surgery.

Ethical considerations

The protocol was approved by the Research Ethics Committee. Informed consent was obtained from the patients before enrollment of the study. All data were kept confidential, and all participants had the right to withdraw from the study without affecting their management.

Clinical data

Full clinical history was taken in detail. Patients' age and sex were documented. Smoking (whether negative, positive, light, or heavy smoker) assessment was done. History of present illness onset, course, and duration of venous ulcer was recorded. History of diabetes mellitus. was taken (period of disease, type of diabetes mellitus, controlled or not, treatment whether on oral hypoglycemics or insulin therapy). Moreover, history of any previous neurological manifestations, especially peripheral neuropathy, was taken. Family history of calcular diseases or any collagen diseases has been asked about.

Preoperative preparations

Physical examination of all patients was done. Vital signs were checked. General examination, including face and general appearance, cardiological examination, neurological examination, and abdominal examination, was performed. Abdominal examination was done to detect any surgical diseases, and hernia orifices were also detected.

Investigations

Routine laboratory test results were collected from the files and included complete blood picture, kidney and liver function tests (bilirubin, AST, ALT, and alkaline phosphatase), coagulation profile, blood glucose level, and the lipid profile. Routine radiological investigations such as chest radiograph and abdominal ultrasonography were done.

Operative preparations

The patients were classified into two groups: groups A and B. Group A was the sodium bicarbonate group, where 100 ml of sodium bicarbonate 7.5% at a temperature of 37°C using a thermometer was infused via a cannula inserted through midclavicular port in the surgical bed, superior surface of the liver, and under the right hemidiaphragm and was left for 5 min. Group B was the nonwashing group, where no intraperitoneal irrigation was applied. CO2 was evacuated at the end of the surgery through the epigastrium trocar. Drains were used.

All patients were referred to the operating room without analgesic medication. A standard anesthetic was used during the surgery. Nalbuphine with induction was used (half-life ranged from 4 to 6 h postoperatively).

All laparoscopic cholecystectomy was performed by a surgeon holding an MD degree. A standard operative method was used with a 4-trocar technique in all patients. The patient was placed in supine position with the surgeon standing to the left of the patient and first assistant standing on the patient's right side. The pneumoperitoneum was achieved by either closed Veress needle technique or open technique using a blunt trocar or a Hasson's trocar. A 10-mm telescope usually a 30° was used at the umbilicus either infraumbilical, intraumbilical, or supraumbilical depending on patient's habitus and surgeon's preference. Another 10-mm trocar was used in the epigastrium, which was the main right working port for the surgeon. One 5-mm trocar in the right lumbar region was used for gallbladder fundus traction, and another 5 mm trocar in the right hypochondrium was used as the left-hand working port for the surgeon.

Pneumoperitoneum was achieved with insufflations of CO2 through a periumbilical trocar and was maintained at 14 mmHg during the entire surgical procedure. After removal of the gallbladder, monopolar diathermy was used for hemostasis in the surgical bed, and patients were randomly assigned to each of the two groups of 16 patients in which all consideration was taken.

Pain was assessed during an interview with the patients using a visual analog scale (VAS) of 0–10 by a resident doctor.

Assessments were done at the patient's bedside at 6 and 24 h postoperatively, as well as 3 days after the surgery. Intensity of pain was recorded at five locations for assessment of right shoulder tip pain, back pain, the area between the shoulders, the tip of scapula, and deep seated intraabdominal pain. During the first 24 h after the surgery, all of the patients were allowed to receive paracetamol as analgesic (slow intravenous infusion of 100 mg).

Primary outcome

Postoperative pain was assessed by VAS at 6, 24 h, and 3 days after the surgery.

Secondary outcome

Time of pneumoperitoneum was the secondary outcome.

Statistical analysis

Statistical analysis was done by SPSS, v27 (IBM, Chicago, Illinois, USA). Shapiro–Wilk test and histograms were used to evaluate the normality of the distribution of data. Quantitative parametric data were presented as mean and SD and were analyzed by unpaired Student t test. Quantitative nonparametric data were presented as median and interquartile range and were analyzed by Mann–Whitney test. Qualitative variables were presented as frequency and percentage and were analyzed using the χ2 test or Fisher's exact test when appropriate. A two-tailed P value less than 0.05 was considered statistically significant.


  Results Top


Demographic and medical characteristics among the study population are shown in [Table 1].
Table 1: Demographic characteristics and medical characteristics among the study population

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Smoking history was insignificantly different between both studied groups [Table 2].
Table 2: Smoking history among the study population

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Time of pneumoperitoneum in the sodium bicarbonate group ranged from 27 to 67, with mean ± SD of 49.81 ± 11.55, whereas in the nonwashing group, the time of pneumoperitoneum ranged from 26 to 63, with mean ± SD of 45 ± 11.21, with no statistically significant difference (P = 0.241) between the two groups. VAS score at 6 h in the sodium bicarbonate group ranged from 4 to 8, with mean ± SD of 5.5 ± 1.26, whereas in the nonwashing group, the VAS score at 6 h ranged from 4 to 10, with mean ± SD of 8.56 ± 1.63, with a highly statistically significant difference (P ≤ 0.001) between the two groups. There was no statistically significant difference between the male and female population in the two groups [Table 3].
Table 3: Time of pneumoperitoneum among the study population

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VAS score at 24 h in the sodium bicarbonate group ranged from 2 to 6, with mean ± SD of 3.56 ± 1.09, whereas in the nonwashing group, the VAS score at 24 h ranged from 2 to 9, with mean ± SD of 5.81 ± 1.87, with a highly statistically significant difference (P ≤ 0.001) between the two groups. VAS score at 3 days in the sodium bicarbonate group ranged from 0 to 3, with mean ± SD of 1.44 ± 0.73, whereas in the nonwashing group, the VAS score at 3 days ranged from 1 to 4, with mean ± SD of 1.94 ± 0.85, with no statistically significant difference (P = 0.085) between the two groups. Regarding sites of pain, there was no significant difference between the two studied groups (P = 0.858) [Table 4] and [Figure 1].
Table 4: Visual analog scale score at 24 h among the study population

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Figure 1: Boxplot showing difference between the study groups regarding VAS score at 6 h. VAS, visual analog scale.

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  Discussion Top


In previous studies that used subdiaphragmatic washout with sodium bicarbonate solution, a significant decrease in postoperative pain intensity has been reported. In previous studies that used intraperitoneal bupivacaine washout for reduction of pain after laparoscopic cholecystectomy, the effect was short-lived and did not exceed 6–12 h after the surgery [1],[8],[11].

In our study, there was a highly statistically significant difference (P ≤ 0.001) between the two groups regarding VAS score in 6 and 24 h postoperatively; however, there was no statistically significant difference (P = 0.085) between the two groups regarding VAS score after 3 days.

In a study by Vijayaraghavalu and Bharthi Sekar [10], shoulder pain intensity measured by VAS after surgery was significantly lower in lidocaine and nalbuphine groups in comparison with the intraperitoneal normal saline group at first 8 h [10].

Our results align with study done by Saadati et al.[1] who evaluated the efficacy of sodium bicarbonate irrigation to relieve postoperative pain after laparoscopic cholecystectomy compared with saline irrigation. Patients in group B showed no significant difference in terms of age, sex, past medical history, and smoking history (P > 0.05). Right shoulder tip pain was significantly lower only between the sodium bicarbonate group and nonwashing group at 6, 18, and 24 h postoperatively (P = 0.04, 0.02, and 0.009, respectively). There was no significant difference among the three treatment groups in right shoulder tip pain, back pain, and port site incisional pain [1].

Our result is nearly similar to these results, which leads us to state that in laparoscopic cholecystectomy, peritoneal irrigation with sodium bicarbonate may reduce the intensity of postoperative shoulder tip pain and is an effective method for improving the quality of life within the early recovery period.

Another randomized double-blinded trial was done by Liu et al.[11], where the incidence of postoperative pain in the intervention group was significantly lower than that in the control group (P < 0.05). Contrarily, incisional and visceral pain was similar in both groups (P = 0.1). The consumption of rescue analgesics in the intervention group was lower than that in the control group. Adverse effects were comparable in both study groups [11].

Subdiaphragmatic irrigation with sodium bicarbonate could effectively reduce shoulder pain, but not abdominal incisional and visceral pain, in patients undergoing laparoscopic cholecystectomy without an increase in adverse effects [12].

Kour et al.[13] showed that sodium bicarbonate without bupivacaine showed systemic acidosis higher than the placebo group (n = 30) which received 20 ml sodium bicarbonate without bupivacaine. A significant difference (P = 0.018) was observed in pain levels between both groups at 6 h postoperatively. The average analgesic requirement was lower in the bupivacaine group, but this did not reach statistical significance [13].

The use of bupivacaine irrigated over the surgical bed was an effective method for reducing pain during the first postoperative hours after laparoscopic cholecystectomy [14],[15].

These results are against the results achieved by our study, as all of our patients did not complain of any systemic acidosis and the pain was obviously decreased. The studies either with or against our results still vary broadly in different methods to decrease postoperative pain after laparoscopic cholecystectomy. Difference between other study and our study results was owing to various factors, including difference in sample size, demographic data, medical and clinical history, and different period of follow-up.


  Conclusion Top


Intraperitoneal irrigation of sodium bicarbonate is a simple and safe method that provides pain relief in the postoperative period after laparoscopic cholecystectomy compared with nonwashing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Saadati K, Razavi MR, Nazemi Salman D, Izadi S. Postoperative pain relief after laparoscopic cholecystectomy: intraperitoneal sodium bicarbonate versus normal saline. Gastroenterol Hepatol Bed Bench 2016; 9:189–196.  Back to cited text no. 1
    
2.
Al Shoyaib A, Archie SR, Karamyan VT. Intraperitoneal route of drug administration: should it be used in experimental animal studies? Pharm Res 2019; 37:12.  Back to cited text no. 2
    
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Akyurek N, Salman B, Irkorucu O, Tascilar O, Yuksel O, Sare M. Laparoscopic cholecystectomy in patients with previous abdominal surgery. JSLS 2005; 9:178–183.  Back to cited text no. 3
    
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Van Goor H. Consequences and complications of peritoneal adhesions. Colorect Dis 2007; 9:25–34.  Back to cited text no. 4
    
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Tiryaki C, Bayhan Z, Kargi E, Alponat A. Ambulatory laparoscopic cholecystectomy: a single center experience. J Minim Access Surg 2016; 12:47.  Back to cited text no. 5
    
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Kandil T, El Hefnawy E Shoulder pain following laparoscopic cholecystectomy: factors affecting the incidence and severity. J Laparoendosc Adv Surg Tech A 2010; 20:677–682.  Back to cited text no. 6
    
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Gupta V, Jain G Safe laparoscopic cholecystectomy: adoption of universal culture of safety in cholecystectomy. World J Gastrointest Surg 2019; 11:62.  Back to cited text no. 7
    
8.
Wills VL, Hunt DR Pain after laparoscopic cholecystectomy. Br J Surg 2000; 87:273–284.  Back to cited text no. 8
    
9.
Yang X, Cheng Y, Cheng N, Gong J, Bai L, Zhao L, Deng Y Gases for establishing pneumoperitoneum during laparoscopic abdominal surgery. Cochrane Database Syst Rev 2022; 3:31–35.  Back to cited text no. 9
    
10.
Vijayaraghavalu S, Bharthi Sekar E A comparative study on the postoperative analgesic effects of the intraperitoneal instillation of bupivacaine versus normal saline following laparoscopic cholecystectomy. Cureus 2021; 13:14–16.  Back to cited text no. 10
    
11.
Liu L, Xia T, Ji H, Guo Y, Liu J, Du L, et al. Sodium bicarbonate sub-diaphragmatic irrigation relieves shoulder pain after total laparoscopic hysterectomy: a randomized controlled trial. J Pain Res 2021; 14:3615–3622.  Back to cited text no. 11
    
12.
An Y, Zhao L, Wang T, Huang J, Xiao W, Wang P, et al. Preemptive oxycodone is superior to equal dose of sufentanil to reduce visceral pain and inflammatory markers after surgery: a randomized controlled trail. BMC Anesthesiol 2019; 19:1–7.  Back to cited text no. 12
    
13.
Kour L, Sharma G, Tantray SH Evaluation of addition of sodium bicarbonate to dexamethasone and ropivacaine in supraclavicular brachial plexus block for upper limb orthopedic procedures. Anesth Essays Res 2021; 15:26–31.  Back to cited text no. 13
    
14.
Castillo-Garza G, Díaz-Elizondo JA, Cuello-García CA, Villegas-Cabello O. Irrigation with bupivacaine at the surgical bed for postoperative pain relief after laparoscopic cholecystectomy. JSLS 2012; 16:105–111.  Back to cited text no. 14
    
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Ahmad A, Faridi S, Siddiqui F, Edhi MM, Khan M. Effect of bupivacaine soaked gauze in postoperative pain relief in laparoscopic cholecystectomy: a prospective observational controlled trial in 120 patients. Patient Saf Surg 2015; 9:31.  Back to cited text no. 15
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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