Case Scenario

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Sreekumar Kunnumpurath, MBBS, MD, FCARCSI, FRCA, FFPMRCA

Anita is a 28-year-old model with a very successful career. She has been living with her boyfriend, Leonardo, for the past 5 years. Through Leonardo, Anita has found the ultimate happiness in life and she is keen to keep this relationship forever. She decides to undergo laparoscopic-assisted tubal ligation. After careful evaluation and counseling, the surgeon decides to comply with Anita's wish and perform the procedure. You are the attending anesthesiologist involved with the case. The operation goes on without any glitch and completed in half an hour. You administer ketorolac and fentanyl as analgesics. At the end of the operation, the surgeon infiltrates abdominal incisions with bupivacaine at your request. You transfer Anita to the recovery room and hand her over to the recovery staff. Half an hour later you are called back to recovery: Anita is fully awake and in agony. When you see her in the PACU, she is thrashing about in her bed and screaming. She says that her pain is coming from her "tummy and chest."

What is your impression of Anitas pain?

She could be suffering from pain in three different anatomical locations due to three different physiological mechanisms. The pain might be coming from (1) visceral pain from the pelvics and from organs such as uterus, tubes, ovaries, or peritoneum; (2) somatic pain from the abdominal wound; (3) shoulder pain that is most likely a referred pain from the diaphragm due to distension from the collected CO2 gas during laparoscopy.

Sometimes the diaphragmatic pain may be felt in the sub-phrenic region. It is also very important to make sure that the pain is not due to a serious complication of surgery such as injury to the internal organs or a major blood vessel.

How will you distinguish between these different types of pain?

Somatic pain is localized around the site of injury; visceral pain is poorly localized, cramp-like, or colicky in nature and could be associated with nausea and vomiting; diaphragmatic pain is characterized by its location and radiation to the shoulder.

A thorough clinical assessment could indicate the source of the pain. If you suspect visceral injury, you may have to order appropriate investigations such as a CT scan.

Somatic pain will respond to simple analgesics such as NSAIDS, and visceral pain responds well to appropriate dosing with opioids. Pain due to collections of gas under the diaphragm is common, and is best treated by implementing preventive measures such as completely suctioning out CO2 at the end of the procedure, heating and humidifying the CO2, or spraying local anesthetic aerosol inside the abdomen. Analgesia also can be provided by blocking nerve conduction using various local anesthetic agents alone or in combination with other pharmacological agents, and can be undertaken at various levels of the pain pathway. This involves a range of techniques from local infiltration to neu-raxial blockade depending on the invasiveness of surgery performed. Pain is mediated by various physiologically active substances and pharmacological agents are available to counteract their effects, culminating in pain relief. The final perception of pain occurs at the cortical level and this is what ultimately matters in your final management of pain. It is essential to apply logic and knowledge in optimal proportions for successful, safe, and effective management of pain.

The pain from laparoscopic tubal ligation is usually of moderate intensity and Anita responds to further doses of opioid and ketorolac. She is discharged 2 days later. Three months after her surgery Anita is back to see you in the pain clinic. She has been referred to you by her primary care physician for the evaluation of a tender scar above the belly button. She tells you that the scar sometimes "burns". She mentions that ever since the laparoscopic her surgery, she has been suffering from severe and unbearable colicky pelvic pain radiating to her lower back. The pain comes during her mid-menstrual cycle. Anita is convinced that it is related to her ovulation. Her primary care physician has tried various analgesics and antidepressants without any benefit. Anita is concerned that her relationship with Leonardo is on the verge of breaking up. On examination you find that she has a very tender mass in the left iliac fossa.

What is your analgesic of choice for Anita? Since the pain is colicky in nature, would you prescribe an antispasmodic to treat the pain or would you inject her scar straight away? You probably would not consider the last two options at this point. The clinical assessment is suggestive of a pelvic pathology. The presence of a possible organic intraabdominal lesion may warrant an immediate surgical referral. So you refer Anita to the surgeon who decides to do a diagnostic laparoscopy, which reveals a clip that had been applied onto the left ovary and which is now interfering with ovulation. There is also scarring and inflammation of this ovary. The surgeon removes the clip, releases the adhesions around the ovary, and performs the necessary repair. A few months later you inject the scar with local anesthetic and steroid with very good results. In about 6 months, Anita is pain-free.

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