Effectiveness of Intraperitoneal Bupivacaine in General Anesthesia for Laparoscopic Appendectomy

Introduction: Appendicitis is an inflammation of vermiform appendix organ. It is a medical emergency case and one of the most common acute abdominal cases. The removal of acute appendix with minimally invasive surgery, laparoscopic procedure, is associated with shortened recovery time and length of stay in hospital, reduced risk of postoperative wound infections, also improved cosmetic outcomes. Anesthesia procedure for laparoscopic in Indonesia is usually performed under general anesthesia (GA) which has effective and safe form of sedation. One local anesthesia agent that often used in laparoscopic procedure is bupivacaine. Studies have shown that intraperitoneal bupivacaine as analgesia after laparoscopy can reduce postoperative pain, such as visceral pain associated with tissue injury and the stretching of nerve endings in the peritoneal cavity, parietal pain related to the incisional trauma at the port sites, and shoulder pain referred by stretching of the diaphragm. Case


INTRODUCTION
The vermiform appendix is inflamed in appendicitis.Appendix is a hollow organ found near the cecum's tip, generally in the right bottom quadrant of the abdomen.Appendicitis most commonly affects people between the ages of 5 and 45, with a mean age of 28.
The incidence is around 233 per 100,000 people.Men are somewhat more likely than women to have acute appendicitis, with lifetime incidence rates of 8.6% and 6.7%, respectively.In the United States, around 300,000 hospital visits are made each year for appendicitis-related complications 1,2 .
An appendectomy is the gold standard therapy for acute appendicitis.The result of the NRS (Numeric Rating Scale) after 2 hours of the laparoscopic procedure was 0, after 6 hours was 2, after 12 hours was 3, after 18 hours was 1, and after 24 hours of the laparoscopic procedure was 0. There was also a graph which explained the NRS (Numeric Rating Scale) from the patient in this case after the laparoscopic procedure.Appendicitis is most common at the age of 10-20 years.The ratio of men to women ratio is 1.4:1.Studies in the United States showed the lifetime risk of developing appendicitis was 8.6% for men and 6.7% for women.Complicated appendicitis was reported in 16.5% to 24.4% of cases 2,7 .Thus, it can be concluded that although the dose was smaller, the effectiveness of pain prevention was better and also the cost was low with or without the using of opioid 18 .In this case, 40 cc of bupivacaine was administered because the patient was obese so it was expected with 40 cc dose, the effect of bupivacaine would remain optimal.However, this case report has some limitations because it was performed only in one patient and it did not record the need for opioid use.

CONCLUSION
It has been reported that a patient underwent laparoscopic appendicitis procedure using general anesthesia (GA).In this case, the patient received intraperitoneal bupivacaine as a postoperative analgesia.Therefore, intraperitoneal bupivacaine has been shown to be very useful in laparoscopic appendicitis procedure under general anesthesia (GA).
It has been reported that a patient underwent laparoscopic appendicitis procedure received intraperitoneal bupivacaine as a postoperative analgesia which provided quicker recovery and good improvement of pain control for the patient without any significant negative consequences.
However, the laparoscopic procedure is favoured over the open approach for appendectomy.Several studies have compared the results of laparoscopic appendectomy patients to those of open appendectomy patients.The findings implied that the patients who received laparoscopic procedure can be associated with a shortened recovery time and length of stay in the hospital, reduced risk of postoperative wound infections, also improved cosmetic outcomes.However, pain is one of the complication of laparoscopic procedure that must be treated.Several methods have been tried for controlling postoperative pain after laparoscopic, including the procedure of anesthesia that acted as analgesia 1,3 .Anesthesia procedure for laparoscopic is usually performed under general anesthesia (GA).General anesthesia (GA) helps to alleviate respiratory distress and cardiovascular alterations caused by laparoscopy's pneumoperitoneum induction.Therefore, general anesthesia (GA) is an effective and safe form of sedation for laparoscopic procedure.Besides, local anesthesia can be used to reduce postoperative pain without producing any side effects.The local anesthesia agents provide antinociception by affecting nerve membrane associated proteins and by inhibiting the release and action of prostaglandins that stimulates the nociceptors and causes inflammation.One agent of local anesthesia that often used is bupivacaine with intraperitoneal administration 4,5 .Thus, this case report aimed to explain the anaesthetic management of a patient who underwent laparoscopic appendicitis procedure, specifically to Effectiveness of Intraperitoneal Bupivacaine in General Anesthesia for Laparoscopic Appendectomy Sarah Lorenza Caverina, Fanda Ayyu Rindiati, F.X. Andhi Haris Respati investigate the use of intraperitoneal bupivacaine as analgesic for the patient under general anesthesia (GA).CASE Anamnesis Mr. TA, 27 years old, working as a police officer, unmarried, and lived in East Jakarta, came to ER Bhayangkara TK I R. Said Sukanto Jakarta Hospital.He complained of pain in the lower right abdomen since 1 day ago.He said that at first, he felt pain in the middle of abdomen around the umbilical since 3 days ago.Then at night, abdominal pain was felt to migrate from the middle of abdomen to the lower right abdomen.Abdominal pain felt worse since 2 days ago, especially with changing positions from lying to sitting or when doing activities.Pain also persisted in the lower right abdomen.Other complaints experienced by him were fever, nausea, and vomiting 3 times containing food and water.The pain in the lower right abdomen was unbearable accompanied with lost of appetite since 1 day ago.He claimed that he felt weak since he threw up all of the meal.He can still fart, has no difficulty defecating, and did not experience liquid, mucus, or bloody stools.During urination and after urination, the patient did not feel pain, did not need to strain before urination, and the bladder was not gritty or bloody.Then, the patient was brought by family to ER Bhayangkara TK I R. Said Sukanto Jakarta Hospital for further treatment.