Cunniffe M G, McAnena O J, Dar M A, Calleary J, Flynn N
Department of Surgery, University College Hospital, Galway, Ireland.
Am J Surg. 1998 Sep;176(3):258-61. doi: 10.1016/s0002-9610(98)00150-0.
Postoperative shoulder-tip pain (STP) frequently occurs following laparoscopic surgery. In an attempt to abrogate this complication we prospectively evaluated the efficacy of intraoperative irrigation of the diaphragm with bupivacaine.
One hundred and five consecutive patients undergoing laparoscopic surgery were prospectively randomized to treatment or control groups. Treatment group (B, n = 55) received irrigation with 10 mL 0.5% bupivacaine in 500 mL saline and control group (A, n = 50) received an equal volume of normal saline. Each dome of the diaphragm was irrigated with 250 mL of either solution at the end of surgery. Laparoscopic procedures performed included cholecystectomy (n = 63), Nissen fundoplication (n = 21), appendicectomy (n = 7), hernia repair (n = 4), and diagnostic laparoscopy (n = 10). Patients' anesthesia and perioperative analgesia were standardized. STP was recorded on a visual analogue pain scale (VAPS) in the recovery room immediately following surgery and at 4, 10, and 24 hours thereafter.
The overall incidence of STP in patients undergoing laparoscopic procedures was approximately 24%. Twenty-one patients (42%) in the control group and 4 patients (7%) in the treatment group complained of shoulder pain during the recording period (P = 0.003). Mean STP scores as recorded on VAPS were significantly lower in the bupivacaine group than in the control group from 4 to 24 hours after surgery (P < 0.01). Postoperative analgesia requirements were also significantly reduced in those patients receiving bupivacaine irrigation (P < 0.04).
Intraperitoneal irrigation with bupivacaine to both hemidiaphragms at the end of surgery significantly reduces both frequency and intensity of STP following laparoscopic procedures thus reducing patient morbidity.
腹腔镜手术后经常会出现肩尖痛（STP）。为了消除这种并发症，我们前瞻性地评估了术中用布比卡因冲洗膈肌的疗效。
105例连续接受腹腔镜手术的患者被前瞻性地随机分为治疗组和对照组。治疗组（B组，n = 55）接受在500 mL盐水中加入10 mL 0.5%布比卡因的冲洗液，对照组（A组，n = 50）接受等体积的生理盐水。手术结束时，用250 mL上述两种溶液中的任何一种冲洗膈肌的每个穹窿。所进行的腹腔镜手术包括胆囊切除术（n = 63）、nissen胃底折叠术（n = 21）、阑尾切除术（n = 7）、疝修补术（n = 4）和诊断性腹腔镜检查（n = 10）。患者的麻醉和围手术期镇痛均标准化。术后立即在恢复室以及术后4、10和24小时，采用视觉模拟疼痛量表（VAPS）记录肩尖痛情况。
接受腹腔镜手术患者的肩尖痛总体发生率约为24%。在记录期内，对照组有21例患者（42%）、治疗组有4例患者（7%）主诉肩部疼痛（P = 0.003）。术后4至24小时，布比卡因组VAPS记录的平均肩尖痛评分显著低于对照组（P < 0.01）。接受布比卡因冲洗的患者术后镇痛需求也显著减少（P < 0.04）。
手术结束时用布比卡因对双侧膈肌进行腹腔内冲洗，可显著降低腹腔镜手术后肩尖痛的发生率和强度，从而降低患者的发病率。
