it is well known that laparoscopy causes less postoperative pain than does open cholecystectomy , as do other laparoscopic procedures , eg , inguinal hernia repair . however , it is not completely painless . this pain is thought to be multifactorial in nature and severity , and various methods of analgesia have been introduced . they aim at avoidance of opioids and include nonsteroidal antiinflammatory drugs ( nsaids ) , intraperitoneal local anesthesia , local anesthetic infiltration of the wound , intraperitoneal saline , adequate removal of the insufflation gas , heated gas , low pressure gas , and nitrous oxide pneumoperitoneum . the combination of techniques that have parietal , diaphragmatic , and visceral components may reduce pain after laparoscopy . the accurate assessment of pain is difficult because of its individual threshold , subjectivity , and difficulty in measurement . however , most of all , the prevention of pain should be directed peripherally at inputs along sensory axons or central neurons . preincisional or preemptive analgesia with long - acting local anesthesia theoretically achieves peripheral blockage of pain stimuli , which is more advantageous than treating pain after it occurs . bupivacaine has been used recently for somatovisceral blockage with satisfactory results . in this prospective , randomized trial , we chose ropivacaine , a long - acting ( duration 8 to 10 hours ) local anesthetic , because of its postulated safety and theoretical improved efficacy . the purpose was to evaluate the analgesic effect of preincisional port - site wound infiltration in reducing postoperative pain after laparoscopic procedures in comparison with placebo use . this prospective , randomized trial was designed to include 190 laparoscopic procedures ( 150 cholecystectomies and 40 inguinal hernia repairs ) carried out by the same surgeon . it conforms to consort guidelines for the reporting of clinical trials . ethical approval by the scientific committee of our hospital was achieved as was written consent from the patients . the randomization was conducted by sealed envelope on the patient 's arrival at the operating theater until the planned number of equivalent groups was reached . an independent surgeon was responsible for the randomization as well as for the preparation of an unmarked syringe containing 20 ml of ropivacaine or saline . the operating surgeon , the staff , and the patients were blinded to this procedure . in the control group including 75 cases of lc and 20 cases of lihr , wound infiltration with local anesthetic was not used ; only saline was used . in the study group including 75 cases of lc and 20 cases of lihr , preincisional periportal infiltration with ropivacaine was applied . the patients belonged to asa ii or i , according to the classification of the american society of anesthesiologists . patients with a previous upper abdominal operation or suspected bile duct stones by ultrasonography and liver function tests were excluded from laparoscopic cholecystectomy ; those with a previous lower abdominal operation , except of appendectomy , were excluded from laparoscopic hernia repair . patients were premedicated with oral diazepam 0.15 mg / kg 1 hour before the operation . all patients received an intravenous injection of midazolam 2 mg and ondansetron 4 mg just before the anesthesia . general anesthesia with an endotracheal tube was achieved by using fentanyl 3 to 5 g / kg and propofol 2 to 3 mg / kg followed by cisatracurium 0.1 mg / kg and sevoflurane to maintain it . pneumoperitoneum was achieved by insertion under direct vision of a special cone - shaped trocar 10 to 12 mm ( ethicon , cincinnati , oh , usa ) through the infraumbilical region ( hasson open method ) and insufflation of warmed carbon dioxide . this first trocar was used for the introduction of an optic direct view 0 for cholecystectomy and oblique view 30 for hernia repair . intraabdominal pressure was maintained at 12 mm hg for cholecystectomy and at 16 mm hg for hernia repair . before the skin incision and trocar placement , local infiltration of the port sites throughout all layers with 20 ml ropivacaine ( astra , sdertlje , sweden ) containing 10 mg / ml ( study group ) or saline ( control group ) was equally allocated according to the diameter of the trocar ; 7 ml for 10 to 12 mm and 3 ml for 5 mm . laparoscopic cholecystectomy was performed with the patient in a slight reverse trendelenburg position with a 4-trocar technique , according to the  american  variable . hernia repair was performed with the patient in the opposite position ( slight trendelenburg ) with a 3-trocar technique . the hernia repair was achieved by a transabdominal preperitoneal ( tapp ) approach and placement of a 6  11-cm polypropylene mesh ( prolene , ethicon , cincinnati , oh , usa ) under the transversalis fascia to reinforce the posterior wall . an independent nurse recorded the postoperative pain at the 3rd , 6th , 12th , and 24th hour after the operation according to patient 's perception . pain assessment was based on a 0 to 10 visual analogue scale ( vas , 0 : no pain , 10 : the worst imaginable pain ) . preoperatively , the nurse introduced patients to the concept of a vas scale . if the vas score was above 3 , an intramuscular ( i m ) injection of diclofenac 75 mg was applied . if pain was persistent , an i m injection of dextropropoxyphene 75 mg at first , and then if this was inadequate meperidine 50 mg was administered . the nausea was assessed by the patient 's complaint and the need for the use of an antiemetic drug . parametric data were compared between groups by analysis of variances ( anova ) and post - hoc testing . statistical significance was assumed if p<0.05 . the analysis was performed with the statistical package for the social sciences ( spss , inc . , cholecystectomy was performed in the control group in 14 men and 61 women with a mean age of 55 years ( range 22 to 82 ) and in the study group in 16 men and 59 women with a mean age of 56 years ( range 17 to 88 ) , suffering from symptomatic cholelithiasis . inguinal hernia repair was performed in the control group in 16 patients including 14 men and 2 women with a mean age of 58 years ( range 33 to 71 ) , in which the hernia was bilateral in 4 cases and recurrent in 5 cases . it was performed in the study group in 14 patients including 13 men and 1 woman with a mean age of 60 years ( range 35 to 72 ) , in which the hernia was bilateral in 6 cases and recurrent in 6 cases . the laparoscopic procedure was completed successfully in all cases without any intraoperative complications or need of conversion to an open operation . the mean duration of the operation was 47 minutes ( range 25 to 90 ) for cholecystectomy and 40 minutes ( range 25 to 65 ) for hernia repair in the study group . it was 50 minutes ( range 35 to 85 ) for lc and 45 minutes ( range 30 to 90 ) for lihr in the control group . no cardiotoxicity , neurotoxicity or any other toxic effect was associated with the local use of ropivacaine . all but 4 patients recovered well and had an uneventful postoperative course without any complications or death . in 3 cases ( 2 in the study and 1 in the control group ) , after laparoscopic cholecystectomy ( morbidity 1.5% ) , an ultrasound revealed mild infrahepatic bile collection ( biloma ) manifested by persistent right upper quadrant pain , fever , and leukocytosis . it was managed successfully by drainage under ultrasound guidance and antibiotics . in 1 case in the study group , after laparoscopic bilateral repair of a large recurrent inguinal hernia , moderate scrotal swelling was seen due to right spermatic cord edema . postoperative analgesia was not required in the study group in 31 patients after lc ( 41% ) and in 12 patients after lihr ( 85% ) ; in the control group in 15 patients after lc ( 20% ) and in 7 patients after lihr ( 44% ) . the vas scores in the study group were significantly lower than those in the control group at the 3rd and 6th hours ( p<0.01 ) , whereas they did not differ significantly at the 12th and 24th hours ( p>0.05 ) ( figures 1 and 2 ) . postoperative visual analogue scale ( vas ) scores in the patients of the study group and control group after laparoscopic cholecystectomy ( lc ) . postoperative visual analogue scale ( vas ) scores in the patients of the study group and control group after laparoscopic inguinal hernia repair ( lihr ) . shoulder pain was experienced in the study group in 20 patients after lc ( 27% ) and in 1 patient after lihr ( 7% ) ; in the control group in 22 patients after lc ( 30% ) and in 2 patients after lihr ( 12% ) . opioids were used in the study group in 24 patients after lc ( 32% ) and in 1 patient after lihr ( 7% ) ; in the control group in 36 patients after lc ( 51% ) and in 8 patients after lihr ( 50% ) . the differences were statistically significant ( p<0.05 ) . they include 8 doses of meperidine ( 50 mg each ) after lc and 40 doses of dextropropoxyphene ( 75 mg each ) in the study group and 20 doses of meperidine and 80 doses of dextropropoxyphene in the control group . after lihr , 0 doses of meperidine and 2 doses of dextropropoxyphene were administered in the study group , and 3 doses of meperidine and 12 doses of dextropropoxyphene were administered in the control group . postoperative nausea was experienced in the study group in 18 patients after lc ( 24% ) and in 1 patient after lihr ( 7% ) ; in the control group in 11 patients after lc ( 25% ) and in 2 patients after lihr ( 12% ) . the differences were not statistically significant ( p>0.05 ) . the mean duration of hospital stay was 2.1 days ( range 1 to 7 ) for cholecystectomy and 1.4 days ( range 1 to 4 ) for hernia repair in the study group . it was 1.9 days ( range 1 to 4 ) for lc and 1.5 days ( range 1 to 3 ) for lihr in the control group . the mean time of return to normal activity was 5.1 days ( range 4 to 10 ) after lc and 6.2 days ( range 5 to 14 ) after lihr in the study group . it was 5.3 days ( range 4 to 9 ) for lc and 6.4 days ( range 4 to 10 ) for lihr in the control group . laparoscopic cholecystectomy reduces the incidence of postoperative right upper quadrant pain seen after open procedures . it has been reported that after laparoscopic cholecystectomy no analgesia was required by 26% of patients , nonnarcotic analgesia by 42% , and narcotic analgesia by 32% . our results have been compared separately for 2 different laparoscopic procedures , ie , cholecystectomy and inguinal hernia repair . the results are reported here in the same article , and both evaluate the relief of pain coming from the port - site wounds . more specifically , in our study the use of ropivacaine increased the rate of no analgesia required from 20% to 41% after laparoscopic cholecystectomy and from 44% to 85% after laparoscopic tapp inguinal hernia repair . likewise , it decreased the rate of opioid requirement and the quantity , from 51% to 32% after laparoscopic cholecystectomy and from 50% to 7% after laparoscopic tapp inguinal hernia repair . however , it is important to note that in this study after laparoscopic cholecystectomy , one third of our patients with ropivacaine infiltration still required opium analgesia ; this indicates perhaps that the origin of pain may have been other than at the port site . the port - site wounds consist of the most usual cause of pain in the immediate postoperative hours ; other less common sources of distress are visceral mainly from cholecystectomy and shoulder tip pain attributed to diaphragmatic stretching . periportal peritoneal injection of a long - acting local anesthetic reduces immediate postoperative pain after laparoscopic cholecystectomy . in a recent review article , it was affirmed that regarding pre- or postoperative wound injection , one is not more effective than the other . however , sarac et al suggested that preemptive injection is not as effective as postoperative injection . , we preferred the preincisional use to block sensory inflow at the periphery , preventing the pain stimuli . intraperitoneal use of bupivacaine alone or in combination with normal saline in pain control after laparoscopic cholecystectomy has not gained wide acceptance . also , instilling bupivacaine into the confined preperitoneal space has no effect on postoperative pain after tapp laparoscopic hernia repair , and its routine use can not be recommended . some refinements in laparoscopic cholecystectomy techniques have been made , but the use of the open hasson 's method for the initial peritoneal access has not been widely accepted . half of the bowel injury during laparoscopic cholecystectomy has happened as a result of a blind insertion of the veress needle or the first trocar placement . we now routinely use the open method under direct vision to avoid this and other rare inadvertent visceral or vessel injuries . however , this approach using sutures for fascial repair may be a further source of pain . also , the local anesthetic can be infused into a surgical wound in day surgery inguinal hernia repair for pain relief . ropivacaine is a recently introduced long - acting local anesthetic with lower toxicity , fewer side effects , and is longer - lasting than bupivacaine . preoperative local infiltration of the inguinal wound for pain relief after open tension - free hernia repair is an effective and safe method . the addition of other drugs ( ketorolac or clonidine ) to the local anesthetic to increase the duration of their postoperative analgesic effect is debatable . despite pain control , postoperative nausea and vomiting are common side effects after general anesthesia and surgery , especially in patients undergoing laparoscopic procedures . the intravenous administration of metoclopramide or especially ondansetron , as in our experience , may be beneficial . our study suggests that preincisional periportal infiltration by ropivacaine is a safe , effective , and affordable method for pain relief after laparoscopic cholecystectomy or laparoscopic inguinal hernia repair .
background and objectives : it is essential to minimize pain after laparoscopic surgery . 
 this study examined the effect of wound infiltration by a long - acting local anesthetic.methods:this prospective , randomized study includes 190 laparoscopic procedures carried out by the same surgeon . 
 the patients were randomly allocated into 2 groups . 
 the control group comprised 75 cases of laparoscopic cholecystectomy ( lc ) and 20 cases of laparoscopic inguinal hernia repair ( lihr ) without the use of a local anesthetic ; only saline was used . 
 the study group comprised 75 cases of lc and 20 cases of lihr with preincisional periportal infiltration with 20 ml of ropivacaine ( 10 mg / ml ) . 
 the postoperative pain scores at 3 , 6 , 12 , and 24 hours determined with a visual analogue scale ( vas ) , nausea , and the kind and amount of analgesic drugs were assessed.results:in the study group in 41% of lc cases and 85% of lihr cases , no analgesia was required at all ; likewise , in the control group in 20% of lc cases and 44% of lihr cases , no analgesia was required . 
 the difference was statistically significant ( p<0.05 ) . in the remainder , 
 pain at 3 and 6 hours and total analgesic requirements in the study group were less than that in the control group ( p<0.05 ) . 
 the postoperative nausea and shoulder pain remained statistically unchanged ( p>0.05).conclusions : it seems that wound infiltration with ropivacaine in laparoscopy provides satisfactory postoperative analgesia , diminishing or reducing the need for opioids .