Surgical Endoscopy (2018) 32:3321–3341
Randomized controlled study of intraincisional inﬁltration
versus intraperitoneal instillation of standardized dose of ropivacaine
0.2% in post-laparoscopic cholecystectomy pain: Do we really need
high doses of local anesthetics—time to rethink!
Singh Mathuria Kaushal‑Deep
· Afzal Anees
· Shehtaj Khan
· Mohammad Amanullah Khan
· Mehershree Lodhi
Received: 25 August 2017 / Accepted: 11 January 2018 / Published online: 16 January 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018
Background Earlier studies done to compare the eﬃcacy of use of local anesthetics at intraperitoneal location versus intrain-
cisional use had utilized equal amount of drugs at the two locations, usually 10–20 ml. Using this large amount of drug in
the small space of intraincisional location as compared to similar amount of drug in large intraperitoneal space created an
inadvertent bias in favor of patients receiving the drug intraincisionally so these patients naturally experienced less pain.
Aims and objectives To conduct a randomized, triple-blind, placebo-controlled study by standardizing dose of local anes-
thetic, to compare the eﬀectiveness of intraperitoneal against intraincisional use of ropivacaine 0.2% for post-laparoscopic
cholecystectomy pain relief.
Materials and methods 294 patients underwent elective 4-port laparoscopic cholecystectomy. Patients were triple blindly
randomized. All patients received ~ 23 ml of solution, of which 20 ml was given intraperitoneally (1 ml/cm; 16 ml along right
hemi-dome and 4 ml in gall bladder fossa) and ~ 3 ml intraincisionally (1 ml/cm of length of incision). Solution was either
normal saline or drug (0.2% ropivacaine) depending on the group [controls (n = 86), intraperitoneal group (n = 100), and
intraincisional group (n = 108)]. 5 diﬀerent pain scales were used for assessment of overall pain. Pain scores were assessed
at 5 points of time.
Results Patients in intraincisional group showed signiﬁcantly less overall pain and rescue analgesia requirement (p < 0.05).
Intraincisional group showed signiﬁcantly less overall pain (p < 0.05) as compared to intraperitoneal group; however, use
of rescue analgesia was comparable in the two groups (p > 0.05); and shoulder pain was signiﬁcantly less in intraperitoneal
group (p < 0.05).
Conclusion The intraincisional use of injection ropivacaine at its minimum concentration of 0.2% in minimal doses of 1 ml/
cm at the end of procedure provides signiﬁcantly more post-operative analgesia as compared to intraperitoneal group and
controls. However, for controlling shoulder pain, the use of intraperitoneal ropivacaine is desirable.
Keywords Ropivacaine · Local anesthesia · Intraincisional inﬁltration · Intraperitoneal instillation · Post-laparoscopic
cholecystectomy pain · Shoulder pain · Rescue analgesia
and Other Interventional Techniques
* Singh Mathuria Kaushal-Deep
Mohammad Amanullah Khan
Department of Surgery, Jawaharlal Nehru Medical College
and Hospital, Aligarh Muslim University, Aligarh,
Uttar Pradesh 202002, India
Department of Anesthesia, Institute of Medical Science,
Banaras Hindu University, Varanasi 22100, India