Effect of active gas suctioning in postoperative pain after laparoscopic cholecystectomy

SK Pavan Kumar; OP Pathania; Nain Singh; SK Ramesh Kumar

doi:10.4103/sjl.sjl_1_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 6 | Issue : 1 | Page : 17-22

Effect of active gas suctioning in postoperative pain after laparoscopic cholecystectomy

SK Pavan Kumar¹, OP Pathania², Nain Singh², SK Ramesh Kumar²
¹ Department of Urology, King George's Medical University, Lucknow, Uttar Pradesh, India
² Department of Surgery, Lady Harding Medical College, Delhi, India

Date of Submission	19-Jan-2021
Date of Acceptance	02-May-2021
Date of Web Publication	14-Jun-2022

Correspondence Address:
Dr. S K Pavan Kumar
Department of Urology, King George’s Medical University, Lucknow, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/sjl.sjl_1_21

Abstract

Introduction: Abdominal pain and shoulder pain after laparoscopic cholecystectomy (LC) is most likely a combination of direct stretching of the diaphragm caused by insufflation and the release of hydrogen ions. Reducing postoperative discomfort after LC is an area of active research. Many methods such as low pressure pneumoperitoneum and intraperitoneal instillation of drugs (local anesthetic, saline) to reduce pain have been carried out. Drainage of gas after elective LC reduces early postoperative abdominal pain including shoulder pain. Materials and Methods: Seventy-five adult female patients with symptomatic gall stones were worked up on the outpatient department basis. After detailed history and physical examination, patient underwent elective surgery. After elective laparoscopic cholecystectomy, active suction was performed by inserting the laparoscopic suction irrigation device through a 5-mm trocar. Continuous suction will be applied for 60 s. In all the patients, port sites were closed in the standard manner. Postoperative pain, residual gas volume, and analgesic requirement were assessed and analyzed. Results: The median patient age was 32 years, median duration of surgery being 40 min. Residual gas volume (gas under diaphragm) was present in 22 patients out of 75 patients which accounts for 29.3% of the study population. The median amount of residual gas calculated using the formula was 7.3 ml (4.9–16.10 ml). Out of 75 patients studied, about eight patients developed shoulder pain and the rest of the patients complained of abdominal pain. Out of 75 patients studied, one patient developed gall bladder fossa collection. Conclusion: Active gas suction is a very simple procedure that is safe and feasible. Performing this procedure signiﬁcantly decreases the residual intraperitoneal gas volume and postoperative pain after laparoscopic surgery and our surgeons should pay more attention in active aspiration of carbon dioxide at the end of laparoscopic operation.

Keywords: Abdominal pain, residual gas, shoulder pain

How to cite this article:
Pavan Kumar S K, Pathania O P, Singh N, Ramesh Kumar S K. Effect of active gas suctioning in postoperative pain after laparoscopic cholecystectomy. Saudi J Laparosc 2021;6:17-22

How to cite this URL:
Pavan Kumar S K, Pathania O P, Singh N, Ramesh Kumar S K. Effect of active gas suctioning in postoperative pain after laparoscopic cholecystectomy. Saudi J Laparosc [serial online] 2021 [cited 2023 Mar 23];6:17-22. Available from: https://www.saudijl.org/text.asp?2021/6/1/17/347473

Introduction

The introduction of laparoscopic technique to general surgery has dramatically changed view to the postoperative course of patients after cholecystectomy. Laparoscopic cholecystectomy (LC) has many proven advantages compared with the conventional open method, including shorter hospital stay, less pain, and quicker convalescence. LC is a safer procedure with lower chances of destroying natural layers of anterior abdominal wall, less traumatizing, less pain after procedure, better cosmetic effect, and earlier recovery back to physical activity. It also allows shorter hospitalization period and decreased costs of hospitalization.^[1],[2]

Six gases have been used for abdominal insufflation during laparoscopy: Carbon dioxide, nitrous oxide, helium, air, nitrogen, and argon. Carbon dioxide is the most widely used gas for insufflation. In addition and most importantly, CO₂ is unique in its quality of suppressing combustion, and it is highly soluble in water. The hemoglobin has higher affinity for CO₂, adding a higher safety margin in the rare event of gas embolism.^[3]

Abdominal pain and shoulder pain after laparoscopic cholecystectomy are most likely a combination of direct stretching of the diaphragm caused by insufflation and the release of hydrogen ions as a consequence of the reaction between CO₂ and water: CO₂+H₂0>H₂CO₃>H⁺+HCO₃⁻. The free radical H+ acid may irritate the phrenic nerve.^[4]

One of the unpleasant postsurgical symptoms is abdominal pain and shoulder pain initially being recognized by gynecologist during experience with laparoscopic sterilization. A considerable number of patients undergoing laparoscopic surgery experiences shoulder pain. Occasionally, it is so strong that the patient needs analgesia and is forced to lie in bed for some time. The incidence of shoulder pain varies from 35% to 80% and ranges from mild to severe. In some cases, it has been reported to last more than 72 h after surgery.^[5],[6],[7]

After laparoscopic cholecystectomy, many patients complain of pain at the shoulder, back, and abdomen. Reducing postoperative discomfort after LC is an area of active research. Many methods such as low pressure pneumoperitoneum and intraperitoneal instillation of drugs (local anesthetic, saline) to reduce pain. Drainage after elective LC reduces early postoperative abdominal pain including shoulder pain. A correlation between residual intraperitoneal carbon dioxide and postoperative pain after LC has been reported. Based on these results, several authors have suggested a method of active gas suction. However, in these studies, amount of residual intraperitoneal carbon dioxide after gas suctioning was not measured and only pain scores of the patient compared. In this context, a prospective study in the Indian population with the aim to directly investigate whether active gas suctioning reduces intraperitoneal residual carbon dioxide and to analyze the effect of active gas suctioning on postoperative pain has been planned

Materials and Methods

It is a prospective, observational study. The study was conducted from November 1, 2015 to March 2017 at the department of surgery of our institution. The study population comprised of female patients of symptomatic cholelithiasis who underwent elective laparoscopic cholecystectomy. The sample size was calculated after applying inclusion and exclusion criteria, a minimum of 75 patients of symptomatic cholelithiasis were enrolled in the study

Inclusion criteria

All female patients of more than 18 years of age and less than 65 years of age
Patients with symptomatic gall stones, gall bladder polyp, adenomyomatosis, or porcelain gall bladder
Patients with gall stones and common bile duct (CBD) stones where CBD stones have been cleared by Department of Medical Gastroenterology ERCP
Only those patients who provide written and informed consent in English or Hindi should be included in the study.

Exclusion criteria

Patients with complications of gall stone disease (acute cholecystitis, empyema, and obstructive jaundice)
Patients converted to open cholecystectomy
Patients with coagulopathy, portal hypertension, pregnancy, those unfit for general anesthesia, and patients with abnormal liver function tests
A history of upper abdominal surgery
Patient requiring drain insertion after laparoscopic cholecystectomy.

Seventy-five adult female patients with symptomatic gall stones were worked up on outpatient department basis. After detailed history and physical examination, all patients were subjected to laboratory tests including complete blood count, renal function tests, liver function tests, serum electrolytes, coagulation profile, and abdominal sonography. After preanesthetic clearance, they were admitted and informed consent taken from each patients for laparoscopic cholecystectomy under general anesthesia. Details of the study explained to each patient, and written informed consent was obtained.

Technique of laparoscopic cholecystectomy

Under general anesthesia, after nasogastric intubation and emptying of urinary bladder, abdomen was prepared with antisepsis and then draped. Access to peritoneal cavity was obtained by Verre's needle or open Hasson technique. Pneumoperitoneum created by using carbon dioxide till a pressure of 10–15 mm Hg reached, standard 4 port of American cholecystectomy is used. After grasper inserted in the third trocar, the infundibulum was grasped and retracted laterally and upward to expose Calot's triangle. The Calot's triangle carefully dissected to visualize cystic duct and cystic artery, ligated using clips, and divided using laparoscopic scissors. The gall bladder then dissected off the liver bed and removed through 10 mm port.

Active suction will be performed by inserting the laparoscopic suction irrigation device through a 5mm trocar. Continuous suction will be applied for 60 s. In all the patients, port sites were closed in the standard manner. That is umbilical and epigastric port will be closed in two layers (fascia and skin subcutaneous layer) and other ports to be closed by single layer (skin and subcutaneous layer) using ethilon 2–0.

Assessment of postoperative pain (abdominal pain and shoulder pain)

Postoperative pain assessed using the Visual Analog Scale score of from 0 to 10 is used as the pain score with 0 measuring “no pain” and 10 measuring 'worst possible pain [Figure 1]. The pain score will be measured three times; 6 h after surgery, in the morning on postoperative day 1 and while discharging the patient.

Figure 1: Visual analog scale

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Measurement of residual intraperitoneal gas volume

The total residual intraabdominal gas will be measured by the method as described by Jackson et al.^[6] from the chest X-ray taken on postoperative day I, gas volume will be calculated using the formula as shown in figure.

Measurement of analgesic requirement

The total amount of analgesic requirement is calculated on patients demand basis. Amount measured in mg/kg body weight/day. The standard analgesic used is injection diclofenac sodium given Intramuscular (IM). The dose is calculated on the basis number of injections required by the patient.

Aims and objectives

To study the decrease in postoperative pain scores of the patient undergoing active gas suctioning after laparoscopic cholecystectomy
To document the relationship between the residual intraperitoneal residual carbon dioxide and postoperative pain score.

Results

The age of patients studied varied from 19 to 65 years. Median patient age was 32 years [Table 1]. The maximum number of patients (n = 30) out of 75 patients were in the age range of 31 to 40 years accounting 40% of the study population. The duration of surgery varied from minimum of 20 min to maximum of 75 min with median duration being 40 min. Nearly 56 patients out of 75 underwent laparoscopic cholecystectomy with duration of 30–50 min accounting for nearly 74.6%. Residual gas volume (gas under diaphragm) was present in 22 patients out of 75 patients which accounts for 29.3% of the study population. It was absent in the rest of the patients. The amount calculated using the formula varied from minimum of 4.9 ml to maximum of 16.10 ml with the median of 7.3 ml. Out of 75 patients studied, about 8 patients developed shoulder pain and the rest of the patients complained of abdominal pain. All patients were discharged at the evening of postoperative day 1 except 2 patients which were put on drain were discharged on the postoperative day 2. Out of 75 patients studied, one patient developed gall bladder fossa collection

Table 1: Age Distributions

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Pain scores

All the patients in the study underwent laparoscopic cholecystectomy. Pain on an average after first 6 h is 5.31 ± 0.99 and on postoperative day 1 is 2.17 ± 0.66 accordingly with the Visual Analog Scale, as shown in [Table 2].

Table 2: Pain scores

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Analgesic requirement

All patients in the study population received injection voveran as the pain medication. The dose of injection voveran received by the patient varied from 50 to 200 mg with the median of 75 mg. About 31 patients required 75 mg for their pain relief and 24 patients required about 50 mg and one patient required 200 mg for pain relief [Table 3].

Table 3: Analgesic Requirement

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Pain scores comparison with residual gas volume

About 22 patients who had residual intraperitoneal gas received pain scores of 6.14 ± 0.77 and 2.32 ± 0.48 after 6 h and on postoperative day 1, respectively. Fifty-three patients who did not had residual gas received pain scores of 4.96 ± 0.85 and 2.11 ± 0.73 after 6 h and on postoperative day 1 of laparoscopic cholecystectomy, respectively [Table 4].

Table 4: pain scores relation with residual gas volume

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Residual gas volume with shoulder pain

Out of 22 patients who had residual intraperitoneal gas, eight patients developed shoulder pain and the rest not. All patients with no residual gas volume did not experience shoulder pain [Table 5].

Table 5: relation residual gas volume with shoulder pain

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Residual gas with analgesic requirement

Twenty-two patients with residual gas volume required a median of 100 mg of injection diclofenac as compared with 51 patients with no residual gas required 75 mg of injection diclofenac. Two patients with drain inserted required a median dose 175 mg of injection [Table 6].

Table 6: Relation of residual gas volume with analgesic requirement

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Postoperative nausea and vomiting

Out of 75 patients about 19 patients had nausea and vomiting varying to 1 episode to 3 episodes in the postoperative period.

Out of 75 patients in the study, about 13 had comorbidities, hypertension, and diabetes. About seven patients were diabetic and four were hypertensive and two patients were both diabetic and hypertensive.

Mean pain scores are 5.23 and 2.31 after 6 h of surgery and postoperative day 1, respectively, which did not show significant difference. Out of 75 patients, about seven patients had intraoperative bile spillage accounting for 9.3%. Out of 75 patients, about seven patients had intraoperative bile spillage. Mean pain scores are 6.00 and 2.71 after 6 h of surgery and postoperative day 1, respectively.

Discussion

LC has become one of the most commonly performed operations in the ﬁeld of general surgery. Although LC has many proven advantages over open surgery, pneumoperitoneum-related complications have been reported. Serious complications such as pneumothorax or gas embolism are rare;^[8],[9] however, shoulder pain, which is thought to result from stimulation of the phrenic nerve, is very common after laparoscopic surgery. Provision of adequate postoperative pain relief is of considerable importance following day-care laparoscopic cholecystectomy. It is suggested that postlaparoscopic cholecystectomy pain have multiple factors and methods for short-term analgesia cannot improve postoperative functions or hospitalization stay.^[10] Several factors, including patient demographic factors, underlying disease, surgical factors, volume of residual gas, type of gas used for pneumoperitoneum, and the pressure created by the pneumoperitoneum, affect post laparoscopic cholecystectomy pain.^{[11],[12],[13],[14],[15]}

Various methods have been investigated with the aim of decreasing shoulder pain. One of the methods that have been studied is active gas suction. Jorgensen et al.^[16] studied the effect of applying suction on the suprahepatic drain after LC and concluded that this procedure significantly reduced shoulder pain as reported by the patient. Jackson et al. studied 20 patients who received gynecological laparoscopic surgery and reported that there was a correlation between residual intraperitoneal gas volume and pain score. Based on these findings, Atak et al.^[17] investigated the effect of active gas suction after LC. After completion of cholecystectomy, a cannula was placed in the subdiaphragmatic space, and active suction was performed to decrease residual gas. The pain scores of the patients and the analgesic requirements were signiﬁcantly decreased. Das et al.^[18] performed a similar study and also reported decreased pain scores. Pain scores are a subjective parameter because the amount of residual intraperitoneal air is an objective parameter; the present study was designed to directly investigate whether active suction decreases residual intraperitoneal gas, with the secondary aim of investigating whether active suction decreases pain score. No previous studies have investigated whether residual gas decreases after active suction. The active suction procedure was very easy to perform. There were no special instruments required, and suction was applied for only 60 s. As a result of this procedure, the residual gas volume decreased to less than half.

Relation of pain scores with residual gas volume

In our study, out of 75 patients who underwent LC and active gas suctioning, 22 patients had residual intraperitoneal gas. The mean pain experienced by patients with residual gas was 6.14 ± 0.77 and 4.96 ± 0.85 for patients who did not have residual gas. Hence, the pain experienced by patients with residual gas is more when compared to patients who did not had residual gas with the significant P value of < 0.001

Relation of shoulder pain with residual gas volume

The mechanism of shoulder tip pain and diaphragmatic irritation has not been fully explained and is felt to be multifactorial. The duration of pneumoperitoneum, the rate of gas insufflations, the peak intraperitoneal pressure, the temperature of gas, and the presence or absence of nitrous oxide in the anesthetic gases have all been investigated. It would seem that the common factor is stimulation of intraperitoneal nerve endings, either through distension, acidiﬁcation of the intra-abdominal environment, or changes in temperature. In our study, out of 22 patients who had residual gas volume, eight patients developed shoulder pain. Rest of the patients did not experience shoulder pain with significant P < 0.001.

Relation of residual gas volume with analgesic requirement

Millitz et al. in 1994^[19] showed no pneumoperitoneum in 30 (60%) of patients in the day after operation. Fourteen patients (28%) had <5 mm pneumoperitoneum and 6 (12%) had 6–10 mm pneumoperitoneum, while they expelled carbon dioxide at the end of surgery through the ports by opening the cannulas and removing the instruments. Fredman et al.^[20] showed patients in whom the pneumoperitoneum gas was actively aspirated at the end of surgery during the first postoperative hour (AA group) made significantly fewer demands for patient-controlled analgesia (PCA) morphine and received less intravenous morphine from their PCA devices compared with those patients in whom no attempt was made to remove residual pneumoperitoneum. Perhaps, the deep abdominal and referred shoulder pain experienced by patients after laparoscopic cholecystectomy is aggravated by the continual stretching and irritation of the peritoneum by free residual carbon dioxide (CO2). In our study, patients who had no residual pneumoperitoneum volume had lower analgesic requirement compared with patients having residual pneumoperitoneum, 22 patients with residual gas volume required a median of 100 mg of injection diclofenac compared with 51 patients with no residual gas required 75 mg of injection diclofenac with significant P value of <0.001. Two patients with drain inserted required a median dose 175 mg of injection.

The incidence of postoperative nausea and vomiting after laparoscopic procedures ranges from 10% to 60%.^[21] The pathogenesis of postoperative nausea and vomiting is multifactorial, depending on anesthesia, surgery, and gender and perioperative administration of opioids.^[22] Frequency of nausea and vomiting in our study (33.6%), despite differences in residual pneumoperitoneum and postoperative pain, did not have any significant difference (P = 0.51). It shows that other factors more than pain and residual pneumoperitoneum have effects on the frequency of nausea and vomiting. Das et al.^[18] compared postoperative pain and recovery variables between active gas reduction group (Group 1, n = 105) and the control group (Group 2, n = 95). They showed no difference in recovery variables despite differences of postoperative pain between two groups. There was not any difference in recovery variables including time of unassisted ambulation, time of oral intake, and time of return of bowel function between groups despite differences in other variables such as postoperative pain and analgesic requirements. Therefore, factors affecting pain and analgesics requirements have no effect on recovery variables.

Limitations

Like any other study, this one also suffers from certain limitations. Owing to the relatively small sample size (n = 75) and the fact that an ever-increasing number of patients is undergoing LC with every passing day, all patients underwent active gas suctioning and all of them did not have residual gas under diaphragm and all patients those with residual gas did not develop shoulder pain. Hence, further prospective studies and meta-analysis involving greater number of patients are needed to draw definitive conclusions about the residual gas volume relation with pain scores and in turn analgesic requirement.

conclusions

The results of this study show that this procedure did not influence operation time or complication rates. Leaving a suprahepatic drain or placing a cannula in the subdiaphragmatic space to apply active suction may be unnecessary, as the results of this study show that using a laparoscopic suction irrigation device is sufficient to decrease residual intra peritoneal gas. Moreover, pain scores were significantly decreased after this procedure. Correlation analysis showed that there was a correlation between gas volume and pain score, which is in line with previous findings in the literature.^[6] In conclusion, active gas suction is a very simple procedure that is safe and feasible. Performing this procedure significantly decreases the residual intraperitoneal gas volume and postoperative pain after laparoscopic surgery and our surgeons should pay more attention in active aspiration of carbon dioxide at the end of laparoscopic operation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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