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The effects of adding upper and lower subcostal transversus abdominis plane blocks to a lateral transversus abdominis plane block after laparoscopic cholecystectomy

A randomised, double-blind clinical trial

Takimoto, Kayo; Sakai, Norihiro; Ono, Mayu

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European Journal of Anaesthesiology (EJA): November 2015 - Volume 32 - Issue 11 - p 819-820
doi: 10.1097/EJA.0000000000000305
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Editor,

Laparoscopic cholecystectomy facilitates early hospital discharge and fast recuperation by decreasing postoperative pain and risk of adverse events when compared with open cholecystectomy.1 However, laparoscopic cholecystectomy causes moderate to severe postoperative pain, particularly during the first 24 h.2 A transversus abdominis plane (TAP) block is an effective perioperative analgesic technique for patients undergoing laparoscopic cholecystectomy.3 A TAP block can be administered through five approaches: upper subcostal, which covers T7 and T8; lower subcostal, which covers T9 to T11; lateral, which covers T11 and T12; illio-inguinal, which covers T12 and L1; and posterior, which is a modified classical landmark-based approach.4 The effect of the respective TAP block depends on the pattern of local anaesthetic spread.4 No study has evaluated the effectiveness of a whole abdominal somatosensory blockade by upper subcostal, lower subcostal and lateral TAP blocks after laparoscopic cholecystectomy. In this prospective, double-blind, randomised controlled trial, we tested the hypothesis that the addition of upper and lower subcostal TAP blocks to a lateral TAP block provides better perioperative analgesia than a lateral TAP block alone in patients undergoing laparoscopic cholecystectomy.

This clinical trial was approved by the Institutional Review Board of Ikeda City Hospital (Chairperson: Dr T. Kobayashi, Ethical Committee No 3174) on 5 September 2012 and was prospectively registered with the UMIN Clinical Trials Registry (JPRN-UMIN000008877, 10 September 2012). All patients provided signed informed consent to participate. Seventy-two patients, aged 20 to 80 years, of American Society of Anesthesiologists physical status 1 or 2 and scheduled for laparoscopic cholecystectomy were included in this study. The exclusion criteria were blood coagulopathies, needle insertion site infection, allergy to any drug used in this trial, daily opioid intake, requirement of single port laparoscopic or open cholecystectomy, emergency surgery and an inability to understand the trial protocol. A research pharmacologist who was not involved in the study prepared the randomisation sequence using cards sealed in opaque envelopes before starting the study. The participants were randomly allocated to receive upper and lower subcostal TAP blocks added to a lateral TAP block (subcostal group) or a lateral TAP block alone (lateral group). Patients, surgeons and data collectors were blinded to the group assignments. Patients received a standardised anaesthetic regimen. After endotracheal intubation, bilateral ultrasound-guided TAP blocks were performed in-plane with a 22-gauge, 80 mm needle (Plexufix, B. Braun; Melsungen AG, Melsungen, Germany) using the M-Turbo System (SonoSite Inc., Bothwell, Washington, USA). Ropivacaine 2.9 mg kg−1 was diluted with saline 0.9% to a volume of 60 ml with 30 ml being injected on each side. In the subcostal group, 5 ml injections were performed at upper subcostal, semilunar line and lower subcostal sites. The remaining 15 ml was injected midway between the costal margin and iliac crest at the mid-clavicular line. In the lateral group, 30 ml was injected at the mid-clavicular line. Similarly, contralateral TAP blocks were performed. For the first 12 h postoperatively, we provided intravenous fentanyl by a patient-controlled analgesia (PCA) device. The primary outcome was visual analogue pain scale (VAPS, 0 to 100 mm; 0, no pain, 100, worst possible pain) while coughing, estimated as the area under the curve for the first 24 postoperative hours (AUC24 h) based on VAPS at 2, 4, 6, 12 and 24 h postoperatively. Secondary outcomes included VAPS AUC24 h at rest, VAPS AUC6 h, postoperative fentanyl consumption, additional analgesic requirements and postoperative nausea and vomiting (PONV). Mann–Whitney U-test, Student's t-test and Fisher exact tests were used as appropriate. Two-sided P value less than 0.05 was considered to be statistically significant. Statistical analyses were conducted using R for Windows version 2.13.1 (R Foundation for Statistical computing, Vienna, Austria).

Patient characteristics, baseline VAPS and surgical durations were similar in groups. VAPS AUC24 h while coughing was not significantly different (P = 0.16) between groups (Table 1). VAPS AUC6 h (P = 0.02) and fentanyl consumption (P = 0.04) were significantly lower in the subcostal group (Table 1). There was no significant difference between the groups in other secondary outcomes. No adverse effects were observed.

Table 1
Table 1:
Postoperative visual analogue pain scale estimated as the area under the curve for the first 24 and 6 postoperative hours (AUC24 h and AUC6 h)

The marginal reductions in VAPS AUC6 h and fentanyl consumption may be attributable to better spread of multiple injections in the subcostal group; however, the duration of a single-injection TAP block did not continue beyond the initial few hours. Two trials have recently described that upper and lower subcostal TAP blocks significantly decreased pain scores compared with a lateral TAP block.5,6 As the largest incision is usually at the umbilicus, it may be that subcostal TAP blocks, which are effective in the T7 to T11 region, may have the largest analgesic effect. The arbitrary selections of local anaesthetic solution and volume may be a limitation of our study because of the sparse published data for TAP block during laparoscopic cholecystectomy.7 In conclusion, we found that patients who received upper and lower subcostal in addition to lateral TAP blocks had only marginal short-term analgesic benefits compared with lateral TAP block alone after laparoscopic cholecystectomy.

Acknowledgements relating to this article

Assistance with the study: we wish to acknowledge Dr Kohei Takimoto for his assistance with this article.

Financial support and sponsorship: none.

Conflict of interest: none.

References

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7. Abdallah FW, Chan VW, Brull R. Transversus abdominis plane block: a systematic review. Reg Anesth Pain Med 2012; 37:193–209.
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