Evolution of Various Components of Pain After Laparoscopic Cholecystectomy: Importance of Its Prognostication for Effective Pain Control Using a Local Anesthetic and for Making a Valid Practical "Discharge Criteria" Model Predicting Early Discharge of Patients.

Objectives: Pain continues to be the most important limiting factor affecting the early discharge of patients after laparoscopic cholecystectomy (LC). Our aim was to conduct a randomized case controlled study to predict the evolution of various components of postoperative pain by using ropivacaine 0.2% at intraperitoneal and intraincisional locations; and to further use this information to make a model predicting early discharge of patients.

Methods: Two hundred forty-four patients underwent elective four-port LC. Patients were triple blindly randomized. All patients received ∼23 mL of solution, of which 20 mL was given intraperitoneally and ∼3 mL was given intraincisionally. Solution was either normal saline or drug (0.2% ropivacaine) depending on the group (controls [n = 77], intraperitoneal group [n = 80], and intraincisional group [n = 87]). Five different pain scales were used for assessment of overall pain. Only those patients with a Visual Analog Scale (VAS) ≤3, Numeric Rating Scale (NRS) ≤3, Visual Descriptor Scale (VDS) ≤ "Slight Pain," Faces Pain Scale-Revised (FPS-R) ≤2, and Activity Tolerance Scale (ATS) ≤ "Can Be Ignored" along with absence of use of rescue analgesia and shoulder pain were considered for "Discharge Criteria."

Results: Incisional component of pain was found to be the main component of pain that predominated in the immediate postoperative period. However, it declined rapidly over 12 hours and was then dominated by the visceral component. Shoulder component peaked around the eighth postoperative hour. Seven percent of patients in controls could be discharged at the 12th postoperative hour and 18% at the 24th hour. In the intraperitoneal group, 18% and 61% patients could be discharged at the 12th and 24th hour, respectively, as compared with 57% and 78% in the intraincisional group using the "Discharge Criteria." "Discharge Criteria" was 100% effective in predicting patients' acceptance to go home.

Conclusion: The effect of local anesthetic at intraincisional and intraperitoneal sites is additive with drug catering to different components of pain. We recommend using the "Abbreviated Discharge Criteria" routinely in practice to check for patients' eligibility to be discharged.