|Year : 2018 | Volume
| Issue : 2 | Page : 73-77
Efficacy of ultrasound-guided subcostal transversus abdominis plane block for analgesia after laparoscopic cholecystectomy
Prashant Bhalekar1, Rajendra Gosavi1, Sandeep Mutha1, Vaibhav Mahajan1, Deepak Phalgune2
1 Department of Anesthesia, Poona Hospital and Research Centre, Pune, Maharashtra, India
2 Department of Research, Poona Hospital and Research Centre, Pune, Maharashtra, India
|Date of Submission||20-Feb-2018|
|Date of Acceptance||02-Aug-2018|
|Date of Web Publication||15-Nov-2018|
Dr. Deepak Phalgune
18/27, Bharat Kunj - 1, Erandawane, Pune - 411 038, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Subcostal transversus abdominis plane (TAP) block involves nerves of anterior abdominal wall. In the present study, the primary objective was to find out whether subcostal TAP block reduces the requirement of rescue analgesics following laparoscopic cholecystectomy.
Materials and Methods: Fifty patients scheduled for laparoscopic cholecystectomy under general anesthesia were randomly divided into two groups. Twenty-five patients in Group B received subcostal TAP block with 0.25% bupivacaine 20 mL on each side and 25 patients in Group A received 0.9% normal saline 20 mL on each side after completion of surgery. Each patient's pain was assessed using visual analog scale (VAS) score at 0, 2, 4, 8, 16, and 24 h. The primary outcome measure was to compare the requirement of rescue analgesia, whereas secondary outcome measure was to compare satisfaction grades between the two groups. Comparison of quantitative and qualitative variables between groups was done using unpaired student's t-test and Chi-square test, respectively, using Statistical Package for the Social Sciences.
Results: Percentage of patients who required paracetamol (P < 0.002) and nalbuphine (P < 0.001) as rescue analgesic was significantly less in Group B as compared to Group A. In all, 92% of Group B and 4% of Group A patients had a satisfactory overall quality of postoperative analgesia which was statistically significant (P < 0.002).
Conclusion: Subcostal TAP block is an effective method of providing postoperative analgesia in patients undergoing laparoscopic cholecystectomy.
Keywords: Laparoscopic cholecystectomy, postoperative analgesia, rescue analgesia, subcostal transversus abdominis plane block, visual analog scale score
|How to cite this article:|
Bhalekar P, Gosavi R, Mutha S, Mahajan V, Phalgune D. Efficacy of ultrasound-guided subcostal transversus abdominis plane block for analgesia after laparoscopic cholecystectomy. Indian Anaesth Forum 2018;19:73-7
|How to cite this URL:|
Bhalekar P, Gosavi R, Mutha S, Mahajan V, Phalgune D. Efficacy of ultrasound-guided subcostal transversus abdominis plane block for analgesia after laparoscopic cholecystectomy. Indian Anaesth Forum [serial online] 2018 [cited 2023 Jun 7];19:73-7. Available from: http://www.theiaforum.org/text.asp?2018/19/2/73/245534
| Introduction|| |
Despite its minimally invasive nature, pain can be moderate to severe in the immediate postoperative period, in laparoscopic cholecystectomy. Hence, provision of effective postoperative analgesia is of key importance to facilitate early ambulation and prevent postoperative morbidity. When laparoscopic cholecystectomy is performed as a day-care procedure, pain is the primary reason for delayed discharge after the procedure.,
Use of peripheral nerve blocks has become increasingly popular in the past two decades. Subcostal transversus abdominis plane (TAP) is a newly developed block involving nerves of the anterior abdominal wall from T6 to T10 dermatomes. Recent articles report promising results of subcostal TAP block in postoperative pain management., We hypothesized that a subcostal TAP block would reduce the requirement of rescue analgesia. In the present study, the primary objective was to find out whether subcostal TAP block reduces the requirement of rescue analgesics following laparoscopic cholecystectomy, whereas the secondary objective was to compare satisfaction grades between the two groups.
| Materials and Methods|| |
This prospective, randomized, double-blind placebo-controlled study was conducted between April 2016 and September 2016. After approval from the Scientific Advisory Committee and Institutional Ethics Committee, written informed consent was obtained from all patients. Patients aged 18–65 years of either sex scheduled for laparoscopic cholecystectomy under general anesthesia, belonging to American Society of Anesthesiologist (ASA) Grade I and II were included in the study. Pregnant or lactating women, patients having papillotomy by endoscopic retrograde cholangiopancreatography 1 month before operation, patients with diabetes mellitus, body mass index (BMI) over 30, severe kidney or liver disease, patients using regular analgesic medication for chronic pain, any contraindication to nonsteroid anti-inflammatory drugs, and patients in whom surgical procedure was converted to open cholecystectomy were excluded from this study.
Out of 65 patients assessed for eligibility, after exclusion, fifty patients were randomly divided into two equal groups of 25 each, using computer-generated randomization code [Figure 1]. We used sealed envelope for randomization with block size 4. Group A patients received 40 mL of 0.9% normal saline 20 mL on each side after completion of surgery, whereas Group B patients received subcostal TAP block with 40 mL of 0.25% bupivacaine 20 mL on each side after completion of surgery. All the patients were given intravenous (IV) paracetamol infusion 1 g and intramuscular diclofenac 75 mg just after induction of anesthesia. An operation theater nurse prepared syringes with bupivacaine or normal saline in 40 mL volume and put them into concealed envelopes according to the allocation orders. This was done under the supervision of a senior anesthesiologist. Researcher and patients were blind as to their group assignment.
Preanesthesia checkup was done 1 day before surgery. The patients were evaluated for any systemic diseases, and laboratory investigations were recorded. Details of the procedure were explained to the patients. The patients were educated about the visual analog scale (VAS).
In the operation theater, adequate IV access was confirmed. Standard monitors were attached. Noninvasive blood pressure, pulse oximeter, electrocardiogram, and end-tidal CO2 (ETCO2) were monitored after intubation. Before induction of anesthesia, all patients were given IV glycopyrrolate 0.2 mg, IV ondansetron 4 mg, and IV ranitidine 50 mg. In all patients, anesthesia was induced with IV fentanyl 2 μg/kg, IV propofol 2–2.5 mg/kg followed by IV atracurium 0.5 mg/kg. Intubation was done with appropriate sized cuffed oral endotracheal tube (ETT). ETT placement was confirmed. Orogastric tube was placed for deflating the stomach. This was removed at the end of surgery.
Anesthesia was maintained with a total 1 L of gas in equal air and O2 ratio and sevoflurane 1.5%–2.5% with controlled ventilation. ETCO2 was maintained between 30 and 35 mmHg. Supplemental doses of IV atracurium were 0.1 mg/kg. To minimize hemodynamic and respiratory effects, abdominal pressure was maintained at 12 mmHg. All patients received local anesthetic infiltration at four trocar sites using 5 mL for each port and a total of 20 mL solution of 1% lignocaine just before the surgery. One percent of lignocaine was made by diluting 10 mL of 2% lignocaine with 10 mL of normal saline.
Subcostal TAP block was performed at the end of surgery following all aseptic precautions using SonoSite portable ultrasound machine (made in Japan)-guided technique. The puncture area and the ultrasound probe were prepared in an aseptic manner. The rectus abdominis and underlying transversus abdominis muscles were identified near the costal margin and xiphoid process. An in-plane image was obtained, and a 22-gauge 6” blunted StimuplexR needle attached with flexible tubing to a syringe filled with study solution was used under ultrasound guidance after visualization of the fascial extensions of the abdominal wall muscles. The skin over the abdominal wall was pierced with the needle held at right angles to the coronal plane and was inserted through the rectus muscle 2–3 cm medial to the probe. The needle was stabilized and advanced at right angles to the skin in a coronal plane under direct visualization by ultrasound. The tip of the needle was visualized in the plane. Aspiration was done to ascertain that any vessel was not punctured. A test dose of 1 mL bupivacaine was injected between fascial planes. After a negative test dose, the study solution (Group A: 20 mL saline and Group B: 20 mL of 0.25% bupivacaine) was then injected through the needle, observing closely for the separation of the fascial plane between internal oblique and transversus abdominis muscle. Subcostal TAP block was then given on the opposite side using an identical technique. When the patient's spontaneous respiratory efforts appeared, muscle relaxation was reversed with IV neostigmine 50 μg/kg and IV glycopyrrolate 0.004 mg/kg. Each patient was further observed for 15 min and shifted to the postanesthesia care unit (PACU).
Pain was assessed using VAS score at rest and on coughing during the following: on arrival in the PACU when the patient was awake and oriented (0 h); thereafter, 2, 4, 8, 16, and 24 h. At any time, if pain was ≥4 on VAS, rescue analgesic nalbuphine 10 mg/70 kg IV was given. A further dose of 5 mg/kg was repeated as required. Rescue analgesic requirement was noted. Injection paracetamol 1 g IV was repeated 8 hourly as required. After 24 h, patients were asked to state their satisfaction about the overall postoperative pain relief as good/fair/poor.
Primary outcome measures were requirement of rescue analgesia (paracetamol and/or nalbuphine), whereas secondary outcome measures were satisfaction grade regarding quality of postoperative analgesia. On the basis of a previously published study, a sample size of 25 patients in each group was calculated by a formula with 80% power and 5% probability of type I error to reject null hypothesis.
Data collected were entered in Excel 2007 and analysis of data was done using Statistical Package for the Social Sciences (SPSS) version 20, IBM, USA. The comparison of quantitative variables between the groups such as mean age, mean weight, mean duration of surgery, and mean VAS score was done using unpaired student's t-test, whereas comparison of qualitative variables such as gender, ASA grade, percentage of patients who required paracetamol/nalbuphine, and patient satisfaction was done using Chi-square test or Fisher's exact test. The confidence limit for significance was fixed at 95% level with P < 0.05.
| Results|| |
Out of 65 patients assessed for eligibility, 10 were excluded because of diabetes mellitus (4), BMI >30 (4), refused to participate (2). Five patients were further excluded (three patients from the study group and two patients from the control group) from analysis because these patients were converted to open cholecystectomy. Fifty patients were randomly allotted [Figure 1]. In all, data for fifty patients (25 patients in each group) were analyzed and compared.
Both groups were comparable with respect to mean age, sex distribution, mean weight, ASA physical status, and duration of surgery [Table 1]. Throughout the 24 h after surgery, mean VAS score at rest and on coughing was significantly less in patients of Group B as compared to Group A [Figure 2]. As depicted in [Table 2], the percentage of patients requiring paracetamol as rescue analgesic was significantly lower in Group B (17/25–68%) compared to Group A (25/25–100.0%) and the percentage of patients requiring nalbuphine as rescue analgesic was significantly lower in Group B (2/25–8%) as compared to Group A (24/25–96.0%).
|Figure 2: Line diagram showing visual analog scale score at rest and on coughing between Group A and Group B|
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|Table 2: Total requirement of paracetamol and nalbuphine in 24 h postoperatively|
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Patient feedback about the overall quality of postoperative analgesia showed that 23/25 (92.0%) patients from Group B had good satisfaction, whereas 1/25 (4.0%) patients from Group A had good satisfaction which was statistically significant (P < 0.002) [Table 3].
| Discussion|| |
In the present study, the percentage of patients who required paracetamol and/or nalbuphine as rescue analgesic in 24 h after surgery was significantly less in Group B compared to Group A. Higher percentage of patients in Group B had good satisfaction than in Group A regarding the overall quality of postoperative analgesia.
El-Dawlatly et al. reported that 76% patients of subcostal TAP group required a significantly lower amount of opiates compared with the control group. Seventy-six percent of patients given subcostal TAP group received only the induction dose of sufentanil, whereas all patients in the control group required additional intraoperative sufentanil (P < 0.01). Ra et al. reported that 4/18 (22.2%) and 17/18 (94.4%) patients of subcostal TAP and control group, respectively, required ketorolac as a postoperative rescue analgesic. They further stated that no patient from the subcostal TAP group required fentanyl, whereas 4/18 (22.2%) patients from the control group required fentanyl which was statistically significant. The findings of the present study are similar, in which the percentage of patients in the subcostal TAP group required significantly less postoperative rescue analgesia compared with those in the control group. Tolchard et al. reported that patients in the subcostal TAP group required morphine and tramadol in 1/21 (4.8%) and 6/21 (28.6%) patients, respectively, whereas the control group required morphine and tramadol in 3/22 (13.6%) and 8/22 (36.4%) patients postoperatively which was not statistically significant. These results are contrary to our study.
In the study conducted by Petersen et al. in 2012 about the beneficial effect of TAP block after laparoscopic cholecystectomy in day-care surgery, VAS pain score (while coughing) was significantly reduced in the subcostal TAP as compared to the placebo group (2.6 vs. 3.4). These results are similar to our study. VAS pain scores at rest showed no significant difference between the two groups in their study, whereas VAS pain scores at rest were significantly less in the subcostal TAP group in our study. Saliminia et al. reported lower VAS score in the subcostal TAP group than the control group at 1 h (3.44 vs. 5.17), 6 h (3.94 vs. 6.44), 12 h (1.94 vs. 3.39), and 24 h (0.83 vs. 1.44). Basaran et al. also reported lower VAS scores in the subcostal TAP group than in the placebo groups at PACU (2.4 vs. 6.5), 2 h (2.3 vs. 4.0), and 24 h (2.1 vs. 3.0) postoperatively. These findings are similar to the present study.
A review by Petersen et al. stated that the results of subcostal TAP block as postoperative anesthesia were encouraging and most studies have demonstrated clinically significant reductions of postoperative opioid requirements and pain. The present study substantiated the above findings.
The limitations of the research were the duration of the study which was only 24 h. The number of patients included in the study was less and patient satisfaction score tool was not validated. Other aspects of recovery such as postoperative nausea and vomiting, fatigue, and resumption of normal activity were not included in our study. The results of the present study are only valid for relatively healthy patients undergoing laparoscopic cholecystectomy. Hence, generalization of the results to ASA III and IV patients requires further studies. Further studies are warranted with other local anesthetics, in varying concentrations, doses, or additives, with ultrasound-guided technique in other surgical procedures.
| Conclusion|| |
This randomized, double-blind controlled study demonstrated that supplementing a standard multimodal analgesic regimen with a subcostal TAP block with bupivacaine provided superior analgesia up to 24 h postoperatively after laparoscopic cholecystectomy compared with administration of the placebo.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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