SHORT COMMUNICATLONS 837
11 Dicket AL, Pierce MR, Munshi UK et al. Nitric oxide inhibition
causes growth retardation and hind-limb disruptions in rats. Am
J Obstet Gynecoll994; 171: 1243- 1250.
12 Nicolaides KH,Peters MT, Vyas S, Rabiniwitz R, Rosen DJD,
Campbell S. Relation of urine production to oxygen tension in
British Journal of Obstetrics and Gynaecology
August 1996, Vol. 103, pp. 837-839
An assessment of the value of intraperitoneal bupivacaine
for analgesia after laparoscopic sterilisation
M. C.Kelly Senior House Oficer
Department of Anaesthetics, Daisy Hill Hospital, Newry
Central to high quality day-case care is the
provision of good analgesia with minimal side
effects. The success of laparoscopic sterilisation as
a day case procedure may be hampered by severe
post-operative pain1. Opioid drugs have a poor
side effect profile; a reduction in their use should
contribute significantly to patient care. Local
anaesthetic blocks used to improve post-operative
pain relief after laparoscopic sterilisation include
combined rectus sheath and mesosalpinx block2,
but an extra surgical procedure is involved. Small
volumes of concentrated bupivacaine applied
directly to the fallopian tubes are safe and
effective3.
Since pain after laparoscopic sterilisation may
arise from manipulation of pelvic organs during
visualisation of the fallopian tubes, as well as from
the direct application of Filshie clips, this study
was designed to assess the analgesic effect, as
measured by visual analogue scores for pain and
post-operative analgesic requirements, of a large
volume of dilute bupivacaine instilled into the
pelvic peritoneal cavity.
Methods
Local medical ethics committee approval was
obtained prior to commencement of the study. On
the basis of a pilot study, it was determined that 58
women would be necessary to detect, with a 95 %
probability and 90% power, a 25% reduction in
visual analogue scores for pain at 2 h. The study
took place over six months in a district general
hospital. All women were of American Society of
Correspondence: Dr M. C. Kelly, Department of Anaesthetics,
The Queens University of Belfast, Whitla Medical Building, 97
Lisburn Road, Belfast BT9 7BL, UK.
0 RCOG 1996 Br J Obstet Gynaecol 103, 837-839
small for gestational age fetuses. Am J Ohster Gynecol1990;162:
387-391.
Received 31 May 1995
Accepted 8 January 1996
Anaesthesiologists grades 1 to 3 listed for elective
day-case laparoscopic sterilisation and gave in-
formed written consent. Women with known sensi-
tivity to local anaesthetics, morbid obesity and pre-
vious pelvic surgery were excluded. The study was
designed to be randomised, double-blind and
placebo-controlled. All solutions for instillation
were drawn up from ampoules which had been
blinded, prior to commencement of the study, in
accordance with a table of random numbers. The
ampoules contained 0.5 YO bupivacaine or 0 9 %
sodium chloride and were diluted fourfold with
0.9 % sodium chloride solution ; this was done by
the scrub nurse under aseptic conditions. The
bupivacaine group (Group B) received an intra-
peritoneal instillation of 0-75 ml/kg of 0-125YO
bupivacaine and the placebo group (Group P) an
instillation of 0.75 ml/kg of 0.9 % NaC1.
Prior to anaesthesia all the women were fami-
liarised with use of a 10 cm continuous unmarked
Visual Analogue Scale (VAS) for pain. No
premedication was given. Intra-operative moni-
toring consisted of electrocardiogram, oxygen
saturation, end-tidal carbon dioxide and non-
invasive blood pressure monitoring. Induction
was with propofol 2 to 3 mg/kg, intra-operative
analgesia provided by fentanyl 2 pg/kg; and
muscle relaxation was obtained using atracurium
0.3mg/kg. The women were intubated using a
cuffed endotracheal tube and ventilated to normo-
carbia using 33% oxygen in nitrous oxide and
1 % isoflurane. Surgery was conducted in the
combined lithotomy and Trendelenberg position.
A periumbilical cannula was used for carbon
dioxide insufflation and the laparoscope subse-
quently inserted in the same place. The single
operating instrument port was inserted in the right
838 SHORT COMMUNICATIONS

iliac fossa. Tuba1 occlusion was with Filshie clips.
In the supine horizontal position, immediately
prior to closure of the umbilical port, an instillation
of the blinded test solution was directed into the
pelvis. At the end of the operation anaesthesia
was discontinued and neuromuscular blockade
reversed with neostigmine 005 mg/kg accom-
panied by 0.01 mg/kg glycopyrrolate.
In the recovery ward an initial assessment of
pain on wakening was made by trained nurses on
a four-point scale of none, mild, moderate or
severe pain. Post-operative analgesia of morphine
(0.125 mg/kg intramuscularly) 4 to 6 hourly as
required, or two capsules each of 500mg para-
cetamol and 30mg codeine 4 to 6 hourly as
required, was ordered to be given at the recovery
nurses discretion. Severe breakthrough pain was
treated with intravenous morphine, administered
by the anaesthetist as soon as it was reported.
Visual analogue scale assessments of pain were
made by the patients at 1 h, 2 h and 4 h after
awakening. Each VAS assessment was made with
the previous recordings covered to ensure that the
measurements were independent. The time to, and
nature of, the first analgesia was noted. The total
analgesic requirement and a VAS on discharge
were noted. Ages and weights were compared
using Students t test; pain on wakening and
numbers needing postoperative morphine using
the x2 test for trend; and the Mann-Whitney U test
was used for pain scores, analgesic requirements
and times to first analgesia and discharge. A P
value of less than 0.05 was taken as significant.
Results
Thirty women were randomised to Group P and
28 to Group B. One woman in Group B was
excluded from the study as one of the blinded
ampoules was broken; this patient was not
replaced. In Group P the women were of mean
(SD) age 35 (4.9) years and in Group B 34 (48)
years. In Group P the women weighed 64 (12.5) kg
and in Group B 67 (11.1) kg. These differences
were not significant. Pain on wakening was non-
existent in twelve patients (40 %) in Group P and
eleven (40.7 YO)in Group B; mild in eight (26.7 %)
in Group P and twelve (44.4%) in Group B;
moderate in eight (26.7%) in Group P and three
(1 1-7%) in Group B ; and severe in two (6-7YO)in
Group P and one (3.7%) in Group B. These
results failed to reach statistical significance with a
x2 test for trend value greater than 0 1.
Visual analogue scores for pain were lower in
the bupivacaine group at 1, 2, and 4 h but this
reached statistical significance only at 2 h (Table
1). At discharge the VAS score for the bupivacaine
group was 0.1 point higher on the scale; this was
not significant.
The mean time to first analgesia was longer in
the bupivacaine group (96 vs 46 min; P = 0-168),
but this difference failed to reach statistical
significance. The mean dose of morphine required
in the bupivacaine group was 0-073mg/kg, while
in the placebo group it was 0*105mg/kg; again
this difference was not significant. However, in the
placebo group eight women (27%) required no
post-operative morphine while in the bupivacaine
group 22 women (73%) needed no morphine
(xz= 10.89; P < O*OOl). There was a significant
difference in the amount of oral analgesia needed.
The time to discharge was 20 min longer in the
bupivacaine group.
Discussion
The main findings of this study were that an intra-
peritoneal instillation of 0.75 ml/kg of 0.125 YO
bupivacaine, when used as an adjuvant technique

Table 1. Post-operativevisual analogue scores (VAS) for pain, analgesic requirementsand duration of surgery and post-operativestay.
n = no. of patients. VAS are expressed as median (interquartile range). Other variables are expressed as mean (standard error of
the mean).
~~~~ ~

Placebo Bupivacaine
n = 30 n = 27 P

VAS at 1 h 63 (4.1-8.0) 57 (3-2-7.9) 0.498

VAS at 2 h 5.4 (3.8 -6.9) 3.0 (2.8-4.2) 0*006*
VAS at 4 h 2.1 (1.1-3.5) 1.9 (1.1-28) 0.35
{AS at discharge 1.0 (0.8-1.8) 1.0 (07-1.8) 0.779
rime to first analgesia (min) 46 (8.4) 96 (21) 0.168
rime to discharge 344 (6.8) 364 (9.9) 0.220
vlorphine (mg/kg) 0.105 (0.016) 0073 (0.015) 0146
\lo. of paracetamol (0.5 g) & codeine (30 mg) tablets 1.9 (0.23) 1.2 (022) 0.043*
._ ___
.P= < 005.

0 RCOG 1996 Br J Obstet GynaecollO3, 837-839


for analgesia after laparoscopic sterilisation, sig-
nificantly reduced the numbers ofpatients requiring
post-operative morphine. However, over the total
study population this technique failed to reduce
significantly morphine consumption and had only
a very marginal and transient analgesic effect.
The search for effective analgesia after lapa-
roscopic sterilisation has largely focused on the
peri-operative use of local anaesthetic techniques.
Smith et a1.' has assessed a combined technique of
rectus sheath block with a mesosalpinx block for
laparoscopic sterilisation and found this to be an
effective method of reducing post-operative pain,
but mesosalpinx block carries the risk of broad
ligament haematoma. The application of small
volumes of concentrated bupivacaine directly onto
the fallopian tubes has been found to be effective
in reducing post-operative pain3.
In this study a large volume of dilute local
anaesthetic was used with the aim of not only
anaesthetising the area of the fallopian tube to be
clipped but also to percolate around all the pelvic
organs because manipulation of the uterus, ovaries
and tubes may cause pain additional to that from
local spasm due to tubal occlusion4. The use of
17 ml 025 % bupivacaine (42 mg bupivacaine)
instilled into the pelvis has been found to be of
significant benefit after diagnostic laparoscopy5,
but our technique using a mean dose of 61 mg
bupivacaine failed to provide satisfactory analgesia
for laparoscopic sterilisation. This failure of a
higher dose of analgesia to provide significant
analgesia for laparoscopic sterilisation concurs
with previous findings' that laparoscopic
0 RCOG 1996 Br J Obstet GynaecollO3, 837-839
SHORT COMMUNICATIONS 839
sterilisation is more painful than diagnostic
laparoscopy .
The reduction of post-operative pain achieved
by the method we describe was modest, although
significantly more patients in the active treatment
group needed no post-operative opioids. The
technique was devoid of complications.
Acknowledgements
The author would like to thank the nursing staff,
anaesthetists and gynaecologists of Daisy Hill
Hospital for their help, and Dr C. Patterson and
Dr K. Wilson-Davis, Queen's University, Belfast
for statistical advice.
References
I Collins KM, Docherty PW, Plantevin OM. Post-operative
morbidity following gynaecological outpatient laparoscopy. A
reappraisal of the service. Anoesthesia 1984; 39: 819-822.
2 Smith BE, McPherson GH, De Jonge M et al. Rectus sheath and
mesosalphinx block for laparoscopic sterilisation. Anaesthesia
1991; 46:875-877.
3 Wheatley SA, Millar JM, Jadad AR. Reduction of pain after
laparoscopic sterilisation with local bupivacaine: a randomised,
parallel, double-blind trial. Br J Obsfef Gynaecol 1994; 101:
443-446.
4 Speilman FJ, Hulka JF, Ostheimer GW e f al. Pharmacokinetics
and pharmacodynamics of local analgesia for laparoscopic tubal
ligation. Am J Obstet Gynecol 1983; 146: 821-824.
5 Loughney AD, Sarma V, Ryall EA. Intraperitoneal bupivacaine
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1988; 43: 796-797.
Received 24 July 1995
Accepted 8 January 1996