Preperitoneal wound infusion

Tagged Analgesia, epidural, preperitoneal catheters; Posted 12 years ago

I realise that in general gynaecology we hardly need to do laparotomies any more except for very big and complex cases. Even in gynaecological oncology most of our work has become laparoscopic in recent years. Virtually all hysterectomies for uterine cancer and surgery for virtually all benign gynaecological conditions, such as adenomyosis, fibroids, adnexal masses is done laaproscopically these days. 

However, a few laparotomies are still required and they come with challenges. They are the most complicated of all cases, and we discussed problems around postoperative analgesia and its association with surgical complications previously.

In particular some of my colleagues and I noted that clinical outcomes (including surgical complications) are worse with epidural compared to non-epidural, other postoperative pain control. In a manuscript that we have submitted this week, we prove that epidural analgesia is associated with a higher incidence of postoperative complications. I will expand on it once it has been accepted for publication.

However, there is another high-quality paper that one of our anaesthetists kindly forwarded to me. The authors from Genova, Italy completed a randomised controlled trial comparing continuous wound infusion with local anaesthetics and epidural analgesia. They randomised 108 patients who required surgery for colorectal cancer. In addition to either epidural analgesia or wound infusion, all patients also received a Morphine PCA. Study outcomes included i.v. Morphine consumption, time to first flatus and time to first bowel movement, duration of hospital stay, quality of night sleep, patient satisfaction with the quality of postoperative analgesia and the usual surgical complications after surgery.

Half of patients received a wound infusion system that delivers local anaesthetic into the wound for 3 days. The catheter of the wound infusion was placed preperitoneally, within the muscle layer and a continuous rate of ropivacaine was delivered at a rate of 10ml/hr was delivered over 72 hours. The other half of the patients received an epidural also for 3 days.

Characteristics of surgery were similar between the two groups at baseline. While total Morphine consumption was similar across both groups, pain control was superior with the wound infusion at 48 and 72 hours postoperatively. Postoperative nausea and vomiting was significantly increased in the epidural group on day 1, 2, and 3 after surgery. Time to first flatus and time to first bowel movements was shorter in the wound infusion group. Length of hospital stay was 8 days in the epidural group and 7 days in the wound infusion group (not significant). Quality of night sleep was better in the wound infusion group at 3 days post surgery. Surgical and anaesthetic complications were also similar when compared both groups.

For more than 6 months I use preperitoneal wound catheters for postoperative pain control in those patients who require a laparotomy through a midline incision. Leaving the epidural path has been the best thing I could have done for my patients and for me. Analgesia is better, patients are happier, I mobilise them earlier, they can eat earlier, etc.

In the public hospital where we get anaesthetists randomly assigned and where there is very little continuity of anaesthetic/analgesic care, I found it difficult to establish preperitoneal wound catheters. However, in the private sector, I was able to speak to my anaesthetists (even before this paper was published) and they are very happy for me to insert the wound catheters and abstain from inserting an epidural.

I normally, close one half of the rectus sheath first. Then I insert the catheter through an introducer, peel-away needle. I always use two catheters, one on either side of the wound. My right hand manipulates the needle, while my left hand feels the needle/introducer and makes sure it nicely runs along the peritoneum, where I can feel it.  Once the needle is in, I close the remainder of the sheath. Once the wound is closed, I insert the infusion catheters and peel away the introducer. Only then we close the skin and make sure a dressing covers the wound catheters.

I can’t recall any problems with that approach. Certainly I had no issues with wound infections, etc. Once the catheter was caught up in the abdominal suture and I had to free it.

The time of epidural has passed. While I realise that there might be the odd indication for an epidural, there is no way I could go back and request epidurals for all patients who require a laparotomy.

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