Elsevier

Journal of Clinical Anesthesia

Volume 34, November 2016, Pages 72-78
Journal of Clinical Anesthesia

Original Contribution
Transversus abdominis plane block as a component of multimodal analgesia for laparoscopic cholecystectomy,☆☆

https://doi.org/10.1016/j.jclinane.2016.03.033Get rights and content

Highlights

  • TAP and OSTAP blocks were used as components of postoperative multimodal analgesia.

  • TAP and OSTAP block groups required less analgesia than did the control group.

  • TAP and OSTAP block groups required less PCA tramadol than did the control group.

  • VAS scores were lower in the OSTAP group than in the TAP and control groups.

  • VAS scores, PCA demand, and total PCA received were correlated during the first 6 hours postoperatively.

Abstract

Objective

To evaluate and compare intercostal-iliac transversus abdominis plane (TAP) and oblique subcostal TAP (OSTAP) blocks for multimodal analgesia in patients receiving laparoscopic cholecystectomy.

Design

A prospective, randomized, double-blinded clinical study.

Setting

Operating room, postoperative recovery area, and ward.

Patients

In total, 60 laparoscopic cholecystectomy patients (43 women, 17 men, American Society of Anesthesiologists grades I-II) were enrolled from the general surgery department of our tertiary care center.

Intervention

The patients were assigned to 1 of the 3 groups. Group 1 received TAP blocks (n = 20), group 2 received OSTAP blocks (n = 20), and group 3 patients were used as controls and received patient-controlled analgesia (PCA) only (n = 20). After the induction of anesthesia, blocks were performed bilaterally in study groups 1 and 2, using 20 mL of lidocaine (5 mg/mL). PCA with intravenous tramadol was routinely provided for all patients during the first 24 hours.

Measurements

The intraoperative use of remifentanil, postoperative visual analog scale (VAS) scores, demand for PCA, and total analgesic consumption were recorded.

Main Results

The patients in the control group had greater analgesic demands and analgesic consumption than did those in groups 1 and 2. However, patients in the OSTAP group had lower VAS scores than did those in groups 1 and 3.

Results

The demand for analgesia was greater in the control group than in groups 1 and 2. Moreover, lower VAS scores were recorded in the OSTAP group than in groups 1 and 3 and were positively correlated with total PCA consumption among all patients. However, postoperative VAS scores were negatively correlated with the total intraoperative consumption of remifentanil at 24 hours.

Conclusions

TAP and OSTAP blocks improved postoperative analgesia in patients receiving laparoscopic cholecystectomy, which resulted in lower VAS scores and reduction in total analgesic consumption.

Introduction

Transversus abdominis plane (TAP) block involves the blockade of sensory nerve signals to the anterolateral abdominal wall. Recognized indications for TAP block consist of cesarean delivery, bowel surgery, laparoscopic cholecystectomy, and retropubic prostatectomy [1], [2], and blocks are performed in the anatomical area of Petit's triangle, which is located between the iliac crest and latissimus dorsi and external oblique abdominal muscles. However, improper positioning of the needle can be associated with severe complications [3], [4]. During this procedure, local anesthetic is injected into the area between the internal oblique abdominal and transverse abdominal muscles, which are innervated by T7-12 intercostal nerves, ilioinguinal and iliohypogastric nerves, and lateral cutaneous branches of the dorsal rami of L1-3. Despite promising results of block techniques in recent trials, the success rates of blocks and contributions to postoperative analgesia are not well described in the literature, to the best of our knowledge.

Ultrasound guidance for TAP block was previously described [5], and oblique subcostal access was recently investigated with the probe positioned directly parallel to the costal margin and the needle introduced near the xiphisternum. This access strategy was designed to optimize analgesia of the supraumbilical abdominal area [6]. Recent data demonstrate the efficacy of this approach for providing postoperative analgesia after upper abdominal surgery [7], [8]. Thus, the oblique subcostal TAP (OSTAP) block, superior and inferior to the umbilicus, is suitable for surgery [6], [7].

Laparoscopic cholecystectomy is a minimally invasive surgical procedure that results in lower perioperative pain scores than open procedures; however, it can be associated with significant postoperative pain. In the present prospective, randomized, double-blinded clinical study, we evaluated ultrasound-guided TAP and OSTAP blocks and compared their efficacy during pain management after laparoscopic cholecystectomy.

Section snippets

Study design

This study was approved by the local institutional review board (2011/09/93), and written informed consent was obtained from all participants. In total, 60 patients were prospectively enrolled (43 women and 17 men) with the American Society of Anesthesiologists physical status grade I or II, and laparoscopic cholecystectomy was performed between May 2012 and August 2013 in the general surgery department of our tertiary care center. Patients with a history of opioid analgesic abuse, sensitivity

Discussion

The use of neuraxial or local intraperitoneal anesthesia, as well as standard general anesthesia, may increase the efficacy of perioperative pain management and reduce opioid requirements in patients receiving laparoscopic cholecystectomy [8], [9], [10]. Here, we evaluated the TAP and OSTAP blocks and compared their efficacies as components of analgesia in laparoscopic cholecystectomy. We demonstrated that although the TAP and OSTAP groups received effective postoperative analgesia as compared

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Department to which the work is attributed: Mustafa Kemal University Medical School, Anesthesiology and Reanimation Department, Hatay, Turkey.

☆☆

Disclosure of acknowledgments, grants, sponsors, and funding sources: None.

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