Quadratus Lumborum Block vs Erector Spinae Plane Block in Laparoscopic Hysterectomy
Condition: Gynecologic Disease
MeSH terms: Genital Diseases, Female
Study type: Interventional

Summary: 
      Postoperative pain following laparoscopic hysterectomy is a challenging concern as some
      patients suffer acute pain that could let to chronic pain over time following the surgery.

      Epidural analgesia which is the gold standard for postoperative pain management in abdominal
      surgeries including laparoscopic hysterectomy has side effects such as hypotension, hematoma,
      motor weakness of lower limbs, paresthesia, intrathecal placement of the epidural catheter
      and urinary retention that could prolong hospital stay.

      Since high frequency ultrasound machines' usage has increased in postoperative analgesia
      management, ultrasound guided fascial plane blocks has been performed by clinicians with high
      success rate. To avoid possible complications of epidural catheter placement and epidural
      analgesia, various techniques has been applying for an analgesic effect close to the
      effectiveness of epidural analgesia. These techniques include transversus abdominis plane
      block, rectus sheath block, wound infiltration of local anesthetics, erector spinae plane
      block and quadratus lumborum plane block . However, each of the plane blocks has limitations
      individually which prevent them to be the unique analgesic technique for postoperative
      analgesia following abdominal surgery.

      As far as the authors knowledge, there's no reported study which compares ultrasound guided
      erector spinae plane block versus ultrasound guided quadratus lumborum type III block
      (anterior quadratus lumborum block) as a preemptive analgesia technique in patients
      undergoing laparoscopic hysterectomy.
    

Detailed description: 
      Total laparoscopic hysterectomy is the most preferred technique for hysterectomy in obstetric
      and gynecology clinics (1). The management of postoperative pain in gynecologic laparoscopic
      surgery is challenging (2, 3). Due to side effects of opioids such as nausea and vomiting,
      titration of opioid dosage for postoperative pain is difficult and effective postoperative
      analgesic regimes is needed (3-5).

      Ultrasound guided regional anesthesia techniques such as erector spinae plane block and
      quadratus lumborum block for postoperative pain management has an acceleration in usage as
      ultrasound guidance makes the interventions safer and easier to perform, and they contribute
      to better pain control and pain experience (6).

      Ultrasound guided quadratus lumborum block for postoperative pain management after abdominal
      surgery was firstly conceived by Blanco in 26th European Society of Regional Anesthesia
      Congress in 2007 as a variant of transversus abdominis plane (TAP) block (7). Later on he
      reported posterior quadratus lumborum block (QLB) in 2013 which is known as QLB II (8).
      Børglum et. al described the transmuscular quadratus lumborum block (TQL or QLB III) in 2013
      which is frequently performed in abdominal wall surgeries (9). QLB III, transmuscular
      quadratus lumborum block (TQL) and anterior quadratus lumborum block; these are all synonyms
      and refers to injection of local anesthetic into the anterior thoracolumbar fascia (TLF)
      which lays between quadratus lumborum muscle and psoas major muscle (10).

      Erector spinae plane block has being performed by clinicians for abdominal and thoracic
      surgeries since it was firstly described by Forero et al. in 2016 for analgesia in thoracic
      neuropathic pain (11-13). In this ultrasound guided technique local anesthetic is applied
      between the transverse process of the relevant thoracic or lumbar vertebrae and the erector
      spinae muscle which leads to the spread of the local anesthetic cephalad, caudally and
      through the paravertebral space (14, 15).

      The investigators hypothesize that performing ultrasound-guided quadratus lumborum block will
      be more superior or equal to erector spinae plane block in providing postoperative analgesia
      for patients undergoing laparoscopic hysterectomy under general anesthesia.
    

Intervention name(s): Quadratus Lumborum Block Type III; Erector Spinae Plane Block; No Block
Intervention type(s): Procedure; Procedure; Other
Intervention description(s): Patients will receive ultrasound-guided quadratus lumborum block type III with 60 ml of bupivacaine 0.25% followed by general anesthesia.; Patients will receive ultrasound-guided erector spinae plane block type III with 60 ml of bupivacaine 0.25% followed by general anesthesia.; The patients will receive general anesthesia.
Other intervention name(s): QLB III; ESPB; Control Group
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: The patients will be divided randomly by a computer-generated randomization table into three equal groups.
Masking: Double (Care Provider, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Erector Spinae Plane Block; Quadratus Lumborum Block; Analgesia; Laparoscopic Hysterectomy; Ultrasound Guidance