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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 24-28

Difficult laparoscopic cholecystectomy and postoperative requirement of analgesics: An observational study


1 Department of Health and Family Welfare, SDH Chadoora, Kashmir Division, Jammu and Kashmir, India
2 Department of Surgery, GMC Srinagar, Jammu and Kashmir, India
3 Department of Pathology, GMC Srinagar, Jammu and Kashmir, India

Date of Submission23-Apr-2019
Date of Acceptance26-Apr-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Majid Mushtaque
J3, Jeelanabad Colony, Peerbagh, Airport Road, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJL.SJL_7_19

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  Abstract 

Context: Despite many advances in laparoscopic cholecystectomy (LC), postoperative pain is still a problem. Difficult and prolonged procedures may cause more postoperative pain. Operative difficulty scores in LC and their correlation with the postoperative visual analog scale (VAS) pain scores and postoperative analgesic requirements in these patients have not been studied before.
Aim: The aim of this study is to evaluate the requirement of postoperative analgesics in patients with different grades of intraoperative difficulties in elective LC.
Settings and Designs: This was an observational study conducted at two peripheral hospitals in Kashmir.
Materials and Methods: A total of 322 patients were scheduled for LC. Nassar scale (grades 1–5) was used to grade the operative difficulty. Postoperatively, intramuscular injection of diclofenac sodium 50 mg BD was used for analgesia. The data recorded were duration of surgery, postoperative VAS score (0–10), and requirement of additional postoperative rescue analgesic with reference to Nassar scale.
Statistical
Analysis:
Chi-square test/one-way ANOVA was used as a test of significance.
Results: Sixteen patients required conversion to open cholecystectomy and were excluded from the study. The final study group comprised of a total of 306 patients (112 males and 194 females). The age of the patients ranged between 16 and 60 years with a body mass index of <30. Nassar intraoperative difficulty grades of I, II, III, and IV were observed in 68.3%, 18.6%, 9.80%, and 3.26% of the patients, respectively. The mean operative time was longer with higher Nassar intraoperative grade (P < 0.05). The mean postoperative VAS was persistently higher in patients with Nassar grades of III and IV at different points of time but was statistically significant only at 3 h postoperatively (P < 0.05). Postoperative rescue analgesic was required by 0.95%, 7.01%, 50%, and 70% of patients with Nassar grade of I, II, III, and IV, respectively.
Conclusions: With increasing level of difficulty in LC, there is increased postoperative pain and requirement for additional analgesia.

Keywords: Laparoscopic cholecystectomy, Nassar scale, postoperative analgesia, visual analog scale score


How to cite this article:
Mushtaque M, Kema AR, Khanday SA, Bacha UQ. Difficult laparoscopic cholecystectomy and postoperative requirement of analgesics: An observational study. Saudi J Laparosc 2019;4:24-8

How to cite this URL:
Mushtaque M, Kema AR, Khanday SA, Bacha UQ. Difficult laparoscopic cholecystectomy and postoperative requirement of analgesics: An observational study. Saudi J Laparosc [serial online] 2019 [cited 2019 Nov 15];4:24-8. Available from: http://www.saudijl.org/text.asp?2019/4/1/24/267860

Address for correspondence: Dr. Majid Mushtaque,


  Introduction Top


Laparoscopic cholecystectomy (LC) is the current gold standard for the treatment of gallstone disease.[1] It has been observed that surgeons encountered difficulty while LC when there were dense adhesions at Calot's triangle, fibrotic and contracted gallbladder, acutely inflamed or gangrenous gallbladder, and cholecystoenteric fistula.[2] Number of preoperative scoring systems[3],[4] as well as operative classification of findings at LC[5],[6] has been reported to predict difficult LC. Despite many advances in LC, postoperative pain is still a problem, and in most reports, up to 80% of patients ask for analgesics after LC.[7] Different treatments have been proposed to relieve pain after laparoscopy. The choice of different drugs, the timing and route of their administration, as well as the dosages are variable. Opioids and nonsteroidal anti-inflammatory drugs are generally used for the management of postoperative pain after LC. Use of port-site and intraperitoneal local anesthesia has also been used for postoperative pain relief.[8] Postoperative pain in LC has been studied with reference to size and number of ports used[9],[10] as well as whether drains were used or not.[11] Difficult and prolonged laparoscopic procedures may cause more postoperative pain, and to our knowledge, there has been no study which has studied the operative difficulty scores in LC and their correlation with the postoperative visual analog scale (VAS) pain scores. The present study aims at studying the same as well as the postoperative analgesic requirements in these patients.


  Materials and Methods Top


The prospective study was conducted at Sub District Hospital Chadoora and DH Budgam, Kashmir, Jammu and Kashmir, India, from July 2014 to February 2019 and included a total of 322 patients, including 124 males and 198 females, scheduled for elective LC under general anesthesia (GA). The age of the patients ranged between 16 and 60 years with a body mass index (BMI) of <30. Exclusion criteria included ASA Grade III and above, history of acute cholecystitis within previous 8 weeks, previous history of upper abdominal surgery, associated cardiovascular or pulmonary illnesses, gallbladder mass, and symptoms or investigations, suggestive of common bile duct stones. Patients who required conversion to open surgery were also excluded from the study. After obtaining written and informed consent from the patients and a formal approval from the institutional ethical committee, all the eligible patients were evaluated thoroughly with complete relevant history and examination – complete blood count, kidney function test, liver function test, international normalized ratio, chest X-ray, electrocardiography, serology, ultrasound abdomen, and preanesthetic checkup. LC was planned using a standard four-port technique. Gallbladder was extracted via the epigastric or umbilical ports. A small 14 Fr tube drain was placed in the subhepatic region in all the patients. Ports were removed under vision and port sites closed. Postoperatively, intramuscular injection of diclofenac sodium 50 mg BD was used for analgesia. Intra-operatively, Nassar scale (grades 1–5) was used to grade operative findings from the gallbladder, cystic pedicle, and associated adhesions [Table 1]. Other data recorded were duration of surgery, postoperative VAS score (0–10), and requirement of additional postoperative rescue analgesic (tramadol 50 mg intravenous in 100 ml normal saline) when VAS was 4 or above.
Table 1: Nassar scale (grade) of operative findings at laparoscopic cholecystectomy

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Chi-square test/one-way ANOVA was used as a test of significance for data, and a P < 0.05 was considered statistically significant.


  Results Top


In the present study, 322 patients were scheduled for elective LC under GA. The age of the patients ranged between 16 and 60 years (mean 43.5 years) with a BMI of <30 (19.5–28.6 kg/m2). Sixteen patients (12 males and 4 females) required conversion to open cholecystectomy and were excluded from the study. Most of these patients (n = 13, 81.25%) had Nassar grades of III or higher [Table 2]. The final study group therefore comprised of a total of 306 patients including 112 males and 194 females.
Table 2: Nassar grade and mean duration of surgery

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Among the study sample, Nassar intraoperative difficulty grades of I [Figure 1], II [Figure 2], III [Figure 3], and IV [Figure 4] were observed in 209 (68.3%), 57 (18.6%), 30 (9.80%), and 10 (3.26%) of the patients, respectively. The mean operative time was longer with higher Nassar intraoperative grade with one-way ANOVA revealed a P < 0.05, which was statistically significant [Table 2].
Figure 1: Nassar grade I

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Figure 2: Nassar grade II

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Figure 3: Nassar grade III

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Figure 4: Nassar grade IV

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The mean postoperative VAS in relation to Nassar Grade is shown in [Table 3]. It was found to be persistently higher in patients with higher Nassar grades (III and IV) at different points of time but was statistically significant only at 3 h postoperatively (P < 0.05).
Table 3: Mean postoperative visual analogue scale in relation to Nassar grade

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A total of 28 patients required single additional analgesic postoperatively [Table 4]. Postoperative rescue analgesic at 1 and 12 h was required in one each of the patients with Nassar grades III and IV (P < 0.05). At 3 h, it was required by 1, 2, 7, and 3 patients with Nassar difficulty grades of I, II, III, and IV, respectively (P < 0.05). Rescue analgesia was also required at 6 h in 1, 2, 6, and 2 patients with Nassar intraoperative grades of I, II, III, and IV, respectively (P < 0.05). None of the patients irrespective of Nassar intraoperative grade required any additional analgesic at 24 h.
Table 4: Number of patients requiring rescue drug during each period with reference to Nassar grade

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In terms of patients requiring rescue analgesic, it was observed that 0.95%, 7.01%, 50%, and 70% of patients with Nassar grade of I, II, III, and IV, respectively, did so at different points of time postoperatively [Table 4].

None of the patients had any significant complications or experienced any untoward side effects of diclofenac or tramadol in this study. Histopathological examination of the specimen revealed normal gallbladder in 221 patients, evidence of chronic cholecystitis in 49, acute cholecystitis with mucocele in 27, acute cholecystitis with empyema in 5, chronic cholecystitis associated with poly in 3, and adenocarcinoma in 1 of the patients.


  Discussion Top


Despite rapid progress in LC, postoperative pain continues to be a serious problem and up to 80% of patients demand analgesics after LC. Pain intensity peaks over the first 12 postoperative hours and then gradually decreases.[12] The common sites of pain are the shoulder tip and epigastric and subcostal port sites.[6] Pain can increase morbidity and is the primary reason for prolonged hospitalization after LC.[12] Efficient pain control permits early mobilization, decreases the postoperative complication rate, and allows early hospital discharge.

Not only can the natural history of gallbladder disease vary with patient cohorts, but surgical findings can also be surprising, with somewhat unexpected degrees of surgical difficulty. In the presence of intraoperative difficulty in LC, a surgeon struggles. To determine whether this intraoperative struggle of the surgeon translates into the postoperative struggle of the patient in terms of pain was the main idea of this study. Many studies have been conducted to evaluate the pre- and intra-operative difficulty levels of LC.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] To the best of our knowledge, this is the first prospective study evaluating the difficulty level of cholecystectomy vis-à-vis postoperative pain.

The etiology of pain after LC is multifactorial. It arises from the skin, fascia, peritoneum, and tissues around the surgical site of dissection.[8],[9],[10],[11],[12],[13],[14] As carbon dioxide (CO2) is used for the creation of pneumoperitoneum during laparoscopy, this leads to peritoneal acidosis and has been proposed as one of the possible mechanisms for damaging the mesothelial lining of the peritoneum and consequent pain. It is also possible that the phrenic nerve could be damaged directly by the acidic environment created by CO2.[12] In one of the studies aimed at calculating the level of acidosis caused by CO2 insufflation, it was found out that the intraperitoneal pH was 6.0 immediately after the operation and raised to 6.4–6.7 and 6.8–6.9 on the 1 and 2 postoperative days, respectively.[13]

Other major causes of postoperative pain are the stretching of the wound during surgery and the length of the fascial incision.[14] Our concern was that the longer operative time of higher Nassar grade group might translate into more stretching of the port sites and subsequently more postoperative pain, which was indeed the case. A significant difference was found between the groups in terms of mean VAS and the requirement of analgesics. It is logical to expect that epigastric and subcostal port sites were most painful as they were subjected to most stretching during surgery. It has not escaped our mind that additional modes of analgesia such as transversus abdominis plane block,[15] subphrenic and liver bed saline, and bicarbonate instillation[12] might be employed to alleviate the postoperative pain in higher Nassar group; however, it was not done in our study as it was outside the protocol. The maximum scores of pains were observed at 6 h postoperatively in all the groups, presumably due to exhaustion of the effects of analgesia and anesthesia, as reported elsewhere.[14]

We acknowledge the fact that patients with difficult cholecystectomies might have had more severe inflammation that could influence their pain-bearing threshold; however, we tried to arrive at the relationship between postoperative pain and level of difficulty as per the objective assessment of VAS and analgesic requirement. The strength of our study is that it was a blinded one as the nurse who was not aware of the operative findings, and consequently, Nassar group determined the postoperative pain scores.


  Conclusion Top


We conclude that with increasing level of difficulty in LC, the postoperative pain increases and appropriate additional methods of postoperative analgesia must be employed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sain AH. Laparoscopic cholecystectomy is the current “gold standard” for the treatment of gallstone disease. Ann Surg 1996;224:689-90.  Back to cited text no. 1
    
2.
Singh K, Ohri A. Difficult laparoscopic cholecystectomy: A large series from North India. Indian J Surg 2006;68:205-8.  Back to cited text no. 2
    
3.
Gupta N, Ranjan G, Arora MP, Goswami B, Chaudhary P, Kapur A, et al. Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg 2013;11:1002-6.  Back to cited text no. 3
    
4.
Vivek MA, Augustine AJ, Rao R. A comprehensive predictive scoring method for difficult laparoscopic cholecystectomy. J Minim Access Surg 2014;10:62-7.  Back to cited text no. 4
    
5.
Sugrue M, Sahebally SM, Ansaloni L, Zielinski MD. Grading operative findings at laparoscopic cholecystectomy – A new scoring system. World J Emerg Surg 2015;10:14.  Back to cited text no. 5
    
6.
Nassar AH, Ashkar KA, Mohamed AY, Hafiz AA. Is laparoscopic cholecystectomy possible without video technology? Minim Invasive Ther Allied Technol 1995;4:63-5.  Back to cited text no. 6
    
7.
Madsen MR, Jensen KE. Postoperative pain and nausea after laparoscopic cholecystectomy. Surg Laparosc Endosc 1992;2:303-5.  Back to cited text no. 7
    
8.
Lepner U, Goroshina J, Samarütel J. Postoperative pain relief after laparoscopic cholecystectomy: A randomised prospective double-blind clinical trial. Scand J Surg 2003;92:121-4.  Back to cited text no. 8
    
9.
Wani M, Wani H, Shahdhar M, Hameed S, Mir S, Magray M. Two-port and four-port laparoscopic cholecystectomy: Differences in outcome. Arch Int Surg 2014;4:72-7.  Back to cited text no. 9
  [Full text]  
10.
Umemura A, Suto T, Nakamura S, Fujiwara H, Endo F, Nitta H, et al. Comparison of single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy: A Single institutional randomized clinical trial. Dig Surg 2019;36:53-8.  Back to cited text no. 10
    
11.
Qiu J, Li M. Nondrainage after laparoscopic cholecystectomy for acute calculous cholecystitis does not increase the postoperative morbidity. Biomed Res Int 2018;2018:8436749.  Back to cited text no. 11
    
12.
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;9:189-96.  Back to cited text no. 12
    
13.
Pier A, Benedic M, Mann B, Buck V. Postlaparoscopic pain syndrome. Results of a prospective, randomized study. Chirurg 1994;65:200-8.  Back to cited text no. 13
    
14.
Rashid A, Nazir S, Kakroo SM, Chalkoo MA, Razvi SA, Wani AA. Laparoscopic interval appendectomy versus open interval appendectomy: A prospective randomized controlled trial. Surg Laparosc Endosc Percutan Tech 2013;23:93-6.  Back to cited text no. 14
    
15.
Krishna Prasad G V, Bansal M. Transverse abdominis plane (TAP) block by POP method: A novel technique of postop-analgesia method in lap cholecystectomy in a secondary care peripheral hospital. Int J Contemp Med Res 2017;4:16-9.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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



 

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