Comparative Evaluation of 0.5% Hyperbaric Levobupivacaine versus 0.75% Hyperbaric Ropivacaine for Elective Infraumbilical Surgeries Under Spinal Anesthesia: A Randomized, Double-Blind Study

doi:10.61336/jccp/25-10-111

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Abstract
Keywords
Introduction
Materials And Methods
Results
Discussion
Conclusion
References

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Research Article | Volume 11 Issue 10 (October, 2025) | Pages 823 - 829

Comparative Evaluation of 0.5% Hyperbaric Levobupivacaine versus 0.75% Hyperbaric Ropivacaine for Elective Infraumbilical Surgeries Under Spinal Anesthesia: A Randomized, Double-Blind Study

Ajanth Singaravelu

Manikandan Ravi

Pughal vendan Gnanaprkasam

Soma Sundaram Annamalai

Assistant professor, Department of Anaesthesiology, Sri Muthukumaran Medical College and Research institute, Chennai, TN, India

Associate professor, Department of Anaesthesiology, Sri Muthukumaran Medical College and Research institute, Chennai, TN, India.

Post graduate resident, Department of Anaesthesiology, Sri Muthukumaran Medical College and Research institute, Chennai, TN, India

Under a Creative Commons license

Open Access

DOI : 10.61336/jccp/25-10-111

Received

Sept. 10, 2025

Revised

Sept. 25, 2025

Accepted

Oct. 13, 2025

Published

Oct. 31, 2025

Abstract

Background: Spinal anesthesia with levobupivacaine and ropivacaine is widely used for infraumbilical surgeries, but comparative data on their efficacy and safety remain limited. Objectives: To compare block characteristics, hemodynamic stability, and perioperative safety of 0.5% hyperbaric levobupivacaine versus 0.75% hyperbaric ropivacaine in elective infraumbilical procedures. Methods: In this prospective, randomized, double-blind study, 80 adult ASA I-II patients scheduled for elective infraumbilical surgeries were allocated to receive 3 mL of either 0.5% hyperbaric levobupivacaine or 0.75% hyperbaric ropivacaine intrathecally. Onset and duration of sensory and motor block, hemodynamic parameters, and adverse events were recorded and analyzed. Results: Levobupivacaine showed significantly faster onset of sensory (2.64 vs. 3.35 min, p=0.011) and motor block (6.88 vs. 9.60 min, p=0.004), and longer duration of analgesia (220.4 vs. 154.2 min, p<0.001) and motor block (189.1 vs. 129.3 min, p<0.001). Ropivacaine group had greater hemodynamic stability with fewer hypotensive episodes (8% vs. 20%, p=0.048). Both drugs were well tolerated with minimal adverse events. Conclusions: Both levobupivacaine and ropivacaine provide effective spinal anesthesia for infraumbilical surgeries. Levobupivacaine offers rapid onset and prolonged analgesia, suitable for longer surgeries, while ropivacaine provides better hemodynamic stability and faster recovery, favoring hemodynamically vulnerable patients.

Keywords

Spinal anesthesia

Levobupivacaine

Ropivacaine

Infraumbilical surgery

Sensory block

Motor block

Hemodynamic stability

Randomized controlled trial

INTRODUCTION

Subarachnoid block (SAB), commonly referred to as spinal anesthesia, is widely recognized for its reliability, rapid onset, and potent sensory and motor blockade in lower abdominal and lower limb surgeries. Compared to general anesthesia, SAB offers a favorable safety profile and is considered the technique of choice in many elective infraumbilical procedures due to relatively simple administration, lower systemic toxicity, and reduced postoperative morbidity. The pharmacological basis of SAB lies in the reversible inhibition of voltage-gated sodium channels by local anesthetics, preventing nerve impulse propagation and achieving a dense neuroaxial block. Amide-type local anesthetics—including bupivacaine, levobupivacaine, and ropivacaine—are predominantly utilized due to their chemical stability and low incidence of hypersensitivity reactions. Racemic bupivacaine has long served as the standard for intrathecal anesthesia given its long duration and depth of block, but its use is limited by dose-dependent cardiovascular and central nervous system toxicity, especially in high-risk patients. This has led to the development and increasing use of the S-enantiomers, levobupivacaine and ropivacaine, which feature reduced toxicity while maintaining robust anesthetic efficacy. Multiple clinical trials and meta-analyses have shown that levobupivacaine and ropivacaine offer equivalent clinical success to racemic bupivacaine in SAB, with levobupivacaine providing prolonged sensory and motor block, and ropivacaine enabling faster postoperative mobilization due to a shorter block duration. Notably, hyperbaric preparations of ropivacaine and levobupivacaine allow predictable spread and reliable block characteristics, making them suitable alternatives for major infraumbilical surgeries. A recent randomized controlled trial reported comparable hemodynamic stability and block quality between hyperbaric 0.5% levobupivacaine and 0.75% ropivacaine in lower limb and abdominal procedures, emphasizing the clinical interchangeability of these agents at equipotent doses. Despite SAB's safety, complications such as hypotension, transient neurologic symptoms, and rare instances of hematoma or nerve injury underscore the need for careful patient selection and vigilance. Improved understanding of drug pharmacodynamics, patient factors, and refined administration techniques continue to enhance the risk–benefit profile of SAB in contemporary surgical practice. Given these advances, the present study was designed to comparatively evaluate hyperbaric 0.5% levobupivacaine and 0.75% ropivacaine for elective infraumbilical surgeries, focusing on block characteristics, hemodynamic stability, and perioperative safety.

MATERIALS AND METHODS

Study Design and Setting This comparative, prospective, randomized, double-blind study was conducted at Sri Muthukumaran Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India, over 18 months (August 2023–December 2024). The study received institutional ethics committee approval and was registered in the Clinical Trials Registry of India (CTRI/2023/12/060908). Informed written consent was obtained from all participants. Participants Eighty adult patients (18–65 years), American Society of Anesthesiologists (ASA) physical status I and II, scheduled for elective infraumbilical surgeries, were enrolled. Exclusion criteria included ASA class III and IV, emergency surgery, patient refusal, local infection, coagulopathy, pregnancy, allergy to the study drugs, and BMI ≥30 kg/m². Patients were randomly allocated (shuffled sealed envelope method) into two equal groups of 40 each. Interventions Group A: Received 3 mL of 0.75% hyperbaric ropivacaine intrathecally. Group B: Received 3 mL of 0.5% hyperbaric levobupivacaine intrathecally. All procedures were conducted under strict aseptic precautions at the L3–L4 interspace using a 25G Quincke spinal needle. Drug preparation was performed by a senior anesthesiologist not otherwise involved in the study to ensure blinding. The intraoperative parameters were observed by an investigator blinded to group allocation. Preoperative and Intraoperative Management All patients underwent a detailed pre-anesthetic evaluation and were advised nil per oral status (6 hours for solids, 2 hours for liquids) preoperatively. Alprazolam 0.5 mg and pantoprazole 40 mg were administered on the night prior. Standard ASA monitoring (ECG, heart rate, pulse oximetry, noninvasive BP) was used throughout the procedure. Study Measurements The study systematically collected comprehensive data to evaluate and compare the effects of hyperbaric levobupivacaine and ropivacaine in spinal anesthesia. Patient demographics including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status, and co-morbidities were recorded to ensure baseline comparability. Sensory blockade characteristics were assessed using the pinprick method, noting the onset time to achieve anesthesia at the T10 dermatome as well as the duration of sensory blockade. Motor blockade was evaluated using the Modified Bromage scale, with data collected on both onset and duration. Additionally, the time to reach maximum sensory blockade and the duration of analgesia and motor blockade were documented. Intraoperative vital parameters, specifically heart rate (HR), mean arterial pressure (MAP), and oxygen saturation (SpO₂), were continuously monitored and recorded at regular intervals of 2, 4, 6, 8, 10, 15, 30, 45, 60, 75, 90, and 120 minutes after the administration of the spinal block. This systematic approach allowed for a detailed comparison of anesthetic efficacy, hemodynamic stability, and safety profiles between the two study drugs. Adverse events and complications. Statistical Analysis Sample size (n=80, 40 per group) was determined based on previous studies and statistical power calculations. Data were analyzed using IBM SPSS v22. Quantitative data were summarized as mean and SD, and compared using independent sample t-tests or ANOVA as appropriate. Categorical data were examined with chi-square tests. Statistical significance was considered at p < 0.05. Results are presented with corresponding 95% confidence intervals. Ethical Considerations Confidentiality and anonymity were maintained throughout the study. Participation was voluntary, with the right to withdraw at any time. Data were used solely for research purposes, accessible only to the study investigator, and all procedures followed the Helsinki Declaration and institutional guidelines.

RESULTS

The results of this study provide a detailed comparative evaluation of spinal anesthesia using 0.75% hyperbaric ropivacaine (Group A) and 0.5% hyperbaric levobupivacaine (Group B) in elective infraumbilical surgeries. An in-depth analysis of six key tables elucidates significant clinical and statistical differences relevant to anesthetic efficacy, onset, duration, hemodynamic profile, and safety. Patient demographic data indicated both groups were comparable at baseline, with no significant differences in age, weight, height, gender distribution, or ASA status. This ensured a balanced comparison and minimized bias from confounding factors [Table-1]. Table 1: Patient Demographics and Baseline Characteristics thesis Parameter Group A: Ropivacaine (n=40) Group B: Levobupivacaine (n=40) p-value Age (years, mean ± SD) 39.90 ± 11.98 41.48 ± 12.35 0.126 Weight (kg, mean ± SD) 63.00 ± 10.16 63.58 ± 8.54 0.9918 Height (cm, mean ± SD) 160.1 ± 8.85 161.4 ± 7.45 0.9252 Gender (M/F) 29/11 22/18 0.7641 ASA I/II (%) 60/40 35/65 — Regarding anesthetic block characteristics, levobupivacaine demonstrated a significantly faster onset of sensory blockade to the T10 dermatome, with mean onset times of 2.64 minutes versus 3.35 minutes for ropivacaine (p=0.0112). The time to achieve maximum sensory block was also notably shorter with levobupivacaine (4.58 minutes compared to 6.18 minutes, p<0.001). These findings align with published literature showing levobupivacaine's relatively rapid onset profile. Motor block onset occurred earlier in the levobupivacaine group (6.88 minutes versus 9.6 minutes, p=0.004), indicating its potential for more rapid motor blockade initiation [Table-2]. In terms of block duration, levobupivacaine provided prolonged motor block (189.1 minutes) and analgesia (220.4 minutes) compared to shorter durations with ropivacaine (129.3 and 154.2 minutes, respectively, both p<0.0001). This prolonged effect could benefit longer surgical procedures requiring extended anesthesia but may limit early postoperative mobilization. The statistically significant longer block durations reinforce levobupivacaine's utility in providing sustained analgesia [Table-2]. Table 2: Onset and Duration of Blocks Parameter Group A: Ropivacaine Group B: Levobupivacaine P value Onset to sensory block at T10 (min, mean ± SD) 3.35 ± 1.01 2.64 ± 1.08 0.0112 Onset to max. sensory block (min, mean ± SD) 6.18 ± 1.26 4.58 ± 1.15 0.0001 Onset to motor block (min, mean ± SD) 9.60 ± 3.98 6.88 ± 2.98 0.0040 Duration of motor block (min, mean ± SD) 129.3 ± 8.6 189.1 ± 8.1 0.0001 Duration of analgesia (min, mean ± SD) 154.2 ± 6.2 220.4 ± 6.8 0.0001 Table 3: Hemodynamic Parameters Comparison Time point (min) Heart Rate (bpm) A/B MAP (mmHg) A/B SpO₂ (%) A/B p-value (MAP) Pre-op 85.2 / 85.7 92.2 / 79.8 99 / 99 0.0001 15 92.8 / 90.3 90.2 / 78.0 99 / 99 0.0001 30 93.4 / 90.9 87.2 / 94.3 99 / 99 0.0001 (A

DISCUSSION

This comparative study evaluated the efficacy and safety of 0.5% hyperbaric levobupivacaine versus 0.75% hyperbaric ropivacaine in patients undergoing elective infraumbilical surgeries under spinal anesthesia. The results demonstrated distinct differences in block characteristics, duration, and hemodynamic effects, enriching the existing literature on safer and more effective local anesthetics for neuraxial blockade. The significantly faster onset of sensory and motor blockade observed with levobupivacaine in our study aligns with earlier investigations. For instance, Athar et al. reported faster sensory and motor block onset times with levobupivacaine compared to ropivacaine in lower limb orthopedic surgeries, corroborating our findings of onset times of 2.64 and 6.88 minutes, respectively, for levobupivacaine versus 3.35 and 9.60 minutes for ropivacaine [Table-2]. The rapid onset enhances operating room efficiency by shortening anesthesia induction time, particularly beneficial in settings with high surgical turnover. Prolongation of sensory and motor block duration as well as postoperative analgesia with levobupivacaine was one of the most clinically significant outcomes. Our data showed levobupivacaine’s motor block duration at 189 minutes and analgesia at 220 minutes, significantly longer than ropivacaine's 129 and 154 minutes, respectively [Table-2]. This extended duration is consistent with Malav et al.'s findings in sciatic nerve blocks, where levobupivacaine provided a longer postoperative analgesic period with reduced opioid consumption. These results suggest levobupivacaine’s higher lipophilicity and greater vasoconstrictive properties slow its systemic absorption, thereby prolonging effect duration and enhancing postoperative pain control. Notably, the longer block duration with levobupivacaine must be balanced with clinical contexts requiring rapid recovery and early mobilization. Ropivacaine’s shorter motor block and sensory block regression can be advantageous in ambulatory procedures, truncating hospital stay length without compromising anesthesia quality. This dual profile enables tailored anesthetic selection based on surgery duration and patient recovery priorities. Hemodynamic stability is paramount in spinal anesthesia. Although both agents demonstrated stable heart rate and oxygen saturation profiles, levobupivacaine was associated with a higher incidence of hypotension (20% vs. 8%, p=0.0478) [Table-5]. This finding resonates with broader literature acknowledging sympathetic blockade-induced vasodilation as a common cause of spinal anesthesia-associated hypotension. Ropivacaine may confer an advantage in patients at risk for cardiovascular compromise or those with limited physiological reserves, reflecting its lower propensity to cause hypotension. Clinicians should weigh this when applying levobupivacaine especially in elderly or hemodynamically unstable patients. Surgical duration was significantly longer in the levobupivacaine group (87 minutes vs. 57 minutes for ropivacaine) [Table-4], likely a consequence of the extended anesthetic effect facilitating longer intraoperative analgesia. This feature supports levobupivacaine’s use in more prolonged surgeries, reducing the need for supplemental anesthetic interventions. Adverse event profiles were mild and comparable except for hypotension, with no serious complications reported. This safety profile aligns with previous investigations endorsing the relatively favorable toxicity spectrum of both drugs compared to racemic bupivacaine, which carries higher cardiotoxic and CNS risks. Our findings bolster the clinical acceptability of levobupivacaine and ropivacaine as safer intrathecal local anesthetics. This study has some limitations. First, sample size was modest, which may limit the generalizability of results across diverse populations and surgical procedures. Second, the study was conducted in a single center, introducing potential institutional biases. Third, we did not include subpopulations such as elderly or patients with significant cardiac or neurological comorbidities, where differential drug effects may be accentuated. Fourth, the study did not assess long-term outcomes like chronic pain or postoperative functional recovery. Finally, hemodynamic monitoring was non-invasive, which may not capture subtle cardiovascular shifts compared to invasive methods. Our findings provide evidence supporting levobupivacaine's use when rapid onset and prolonged anesthesia are desired, such as in longer infraumbilical surgeries or when sustained postoperative analgesia is anticipated, contributing to decreased opioid requirements and improved pain control. Conversely, ropivacaine's more favorable hemodynamic profile and shorter block duration make it a compelling choice for patients requiring swift recovery or those at cardiovascular risk. Future studies could expand upon our findings by incorporating larger multicentric trials, including high-risk patient cohorts, and evaluating functional outcomes related to postoperative mobilization and quality of recovery. The integration of novel techniques such as ultrasound-guided regional anesthesia may also refine drug delivery and improve safety. Levobupivacaine and ropivacaine both serve as effective and safe alternatives for spinal anesthesia, each with characteristic advantages. Understanding their distinct pharmacodynamic and clinical profiles facilitates informed anesthetic choice tailored to surgical demands and individual patient risk profiles, optimizing outcomes in infraumbilical surgeries.

CONCLUSION

Spinal anaesthesia with hyperbaric 0.5% levobupivacaine and 0.75% ropivacaine both provide effective sensory and motor blockade for elective infraumbilical surgeries. Levobupivacaine offers faster onset and longer duration of anesthesia and postoperative analgesia, suitable for prolonged surgical procedures. Conversely, ropivacaine demonstrates superior hemodynamic stability with fewer episodes of hypotension, favouring patients at cardiovascular risk or requiring rapid recovery. Clinicians should individualize anesthetic choice based on surgical duration, patient health status, and recovery goals to optimize outcomes.

REFERENCES

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