the comparisons of intra-peritoneal bupivacaine instillation versus trendelenburg position and valsalva maneuver on the laparoscopic cholecystectomy-induced abdominal and shoulder pain

background :although  laparoscopic   cholecystectomy  is   associated  with  less   post-operative  pain compared  to   open  cholecystectomy,  diffuse  shoulder  and  abdominal  pain  is   one    of   the    main postoperative complications in  this technique. the  aim  of this study was  to  compare the  abdominal and shoulder pain after laparoscopic cholecystectomy by  applying intra-abdominal  bupivacaine instillation versus the  trendelenburg position and valsalva maneuver. methods :a double blind randomized clinical trial was  conducted in the  university hospital. 120  patients aged 25-55  years were scheduled for  elective laparoscopic cholecystectomy and without any  history of previous surgery, pregnancy or acute abdomen were enrolled. patients were allocated into 4 groups (each30 cases)group 1 received just intra-peritoneal normal saline (ns).  group 2 patients who were placed intrendelenburg  position  plus valsalva maneuver  and  received intra-peritoneal  ns.  for   group 3,  intra- peritoneal bupivacaine instillation was  done. patients in group 4 received intra-peritoneal bupivacaine as well  as  were placed in  trendelenburg position plus valsalva maneuver. post-operative pain severity using visual analog scale, analgesic requirement and nausea and vomiting were recorded in all patients. results :total mean pain score at 24 hours was  3.55±0.47 in group 1, 1.08  ±0.85  in group 2, 0.33  ±0.14  in group 3, and 0.20  ±0.59  in group 4 (p= 0.001). mean total score of shoulder pain was  4.70  ±2.18  in group1, 1.23  ±0.11  in group 2, 1.18  ±0.11  in group 3, and 0.70  ±0.12  in group 4 (p= 0.001). conclusion : combined  intra-peritoneal   bupivacaine  with trendelenburg   positioning  and   valsalva maneuver   was    superior   to either one alone in decreasing pain severity after laparoscopic cholecystectomy.