Comparison of Oblique Subcostal, Posterior or Dual Transversus Abdominis Plane Block in Laparoscopic Cholecystectomy
Condition: Laparoscopic Cholecystectomy; Cholelithiasis; Postoperative Analgesia
MeSH terms: Cholelithiasis; Cholecystolithiasis; Gallstones
Study type: Interventional

Summary: 
      The aim of the study is to evaluate the difference of postoperative analgesic effects and
      opioid consumption between ultrasound-guided unilateral oblique subcostal, posterior, or dual
      TAP blocks in patients undergoing laparoscopic cholecystectomy for cholelithiasis.
    

Detailed description: 
      Laparoscopic cholecystectomy is one of the most frequent operations. Laparoscopic
      cholecystectomy is a less invasive technic that provides early mobilization and reduces
      hospitalization time thus preferred to laparotomy often. There is a minimum of 4 trochar
      incisions on the right side of the abdomen at epigastric, umbilical, midclavicular subcostal,
      and anterior axillary subcostal regions in laparoscopic cholecystectomy. Some patients have a
      drainage tube at the middle/lower right abdomen. Thus the right side of the abdomen is the
      target side for abdominal wall blocks.

      Most patients complain of moderate pain after surgery which requiring opioids, mostly in the
      upper abdomen, lower abdomen, and shoulder. The pain has three components; somatic pain at
      the anterior abdominal wall, visceral pain caused by pneumoperitoneum and referred shoulder
      pain. Preventing postoperative pain is important for reducing respiratory complications and
      hospitalization time also improve patient satisfaction. Opioids are preferred less due to
      their side effects like nausea-vomiting and respiratory depression although which is
      preferable for moderate and severe pain. Transversus abdominis plane (TAP) block is the most
      preferred abdominal wall block to provide effective postoperative pain control for reducing
      perioperative analgesic requirements like opioids.

      TAP block was first described by Rafi by anatomic landmark technic then by Hebbard with
      ultrasonographic guidance. TAP block is a regional technic and a plan block that blocks the
      thoracolumbar nerves that innervate the anterior and lateral abdominal wall and passes in
      between the muscles' internal oblique and transversus abdominis. External oblique, internal
      oblique, and transversus abdominis muscles are displayed sequentially by ultrasonography. A
      hypoechoic, spindle-shaped separation of the fascia by hydrodissection technic is performed
      by local anesthetic injection in between the internal oblique muscle (or rectus abdominis)
      and transversus abdominis muscle. Dermatomal spread is differentiated with subcostal, oblique
      subcostal, and posterior approaches.

      In oblique subcostal TAP block, anesthetic solution spreads across the location of T6-L1
      nerves thus suitable for surgeries at both superior and inferior the umbilicus. Some other
      studies show that posterior TAP block can block the T5 to L1 thoracolumbar nerves thereby
      spreading into paravertebral space. The paravertebral spread of the posterior TAP block
      suggests that the analgesic efficacy will be long-lasting by blocking the thoracolumbar
      sympathetic chain and will spread to a wider dermatomal area. In this study, the
      investigators aimed to compare the analgesic efficacy and opioid-sparing effects of oblique
      subcostal, posterior, and dual TAP blocks in patients undergoing laparoscopic
      cholecystectomy. Taking the advantage of the paravertebral extension of the posterior
      approach and the wide spread of the oblique subcostal approach on the anterior abdominal
      wall, it's supposed to be the dual TAP block will result in lower pain scores.

      All patients will have general anesthesia. For premedication midazolam 0.03mg/kg will be used
      for all patients. At the induction of the anesthesia, patients will receive propofol 2 mg/
      kg, fentanyl 2 μg/kg, and rocuronium 0.6 mg/ kg IV. After enough muscle relaxation patients
      will be orotracheally intubated. General anesthesia will be maintained with sevoflurane and
      air/O2 mixture. The end-tidal carbon dioxide partial pressure will be maintained between 32
      and 36 mmHg by adjusting the pressure-controlled mechanical ventilation. All patients will
      receive tramadol 1mg/kg, paracetamol 1gr, and ondansetron 8mg intravenously before skin
      closure. Postoperatively ultrasound-guided right oblique subcostal and posterior TAP blocks
      will be performed on all patients. Postoperatively starting from at the postoperative care
      unit (0th hour) then 2nd,4th, 6th, 8th, 12th and 24th hours pain intensity by numerical
      rating scale (NRS) at rest and with motion, sensory dermatomal involvement by pinprick test,
      Ramsey sedation scales, nausea and vomiting scores, and rescue analgesic medication
      requirements will be recorded. Besides heart rate, blood pressure, respiratory rate,
      peripheric oxygen saturation, mobilization time, side effects if there are any will be
      recorded at the aforementioned hours. Patients with NRS≥4 will receive dexketoprofen 50mg as
      rescue analgesic medication. If NRS≥7 tramadol 100mg will be administered.

      The study will start after getting written informed consent from patients who are informed
      about the study and potential risks. The study is a prospective, clinical, randomized
      controlled, quadruple-blinded, and monocenter study. Participation of the 60 patients
      undergoing laparoscopic cholecystectomy had been planned. Patients will be randomized into
      three groups of 20 patients each.
    

Intervention name(s): unilateral ultrasound-guided oblique subcostal TAP block with %0.5 Bupivacaine 10ml + %1 Prilocaine 10ml + %0.9 NaCl 10ml; unilateral ultrasound-guided oblique subcostal TAP block with %0.9 NaCl 30ml; unilateral ultrasound-guided posterior TAP block with %0.5 Bupivacaine 10ml + %1 Prilocaine 10ml + %0.9 NaCl 10ml; unilateral ultrasound-guided posterior TAP block with %0.9 NaCl 30ml
Intervention type(s): Procedure; Procedure; Procedure; Procedure
Intervention description(s): In the supine position, after the skin sterilization, ultrasound with a high-frequency linear probe will be placed subcostally and from the xiphoid to the right iliac crest obliquely. The rectus abdominis and underlying transversus abdominis muscles will be identified. The local anesthetic solution (%0.5 Bupivacaine 10ml + %1 Prilocaine 10ml + %0.9 NaCl 10ml) will be injected after negative aspiration to the transversus abdominis plane between the rectus abdominis and transversus abdominis muscles along the oblique subcostal line.; In the supine position, after the skin sterilization, ultrasound with a high-frequency linear probe will be placed subcostally and from the xiphoid to the right iliac crest obliquely. %0.9 NaCl 30ml will be injected after negative aspiration to the transversus abdominis plane between the rectus abdominis and transversus abdominis muscles along the oblique subcostal line.; After the oblique subcostal TAP block, the operation table will be slightly turned left laterally for better visualization of the blocking area. The same high-frequency linear ultrasound (Esaote MyLab5) probe will be placed over the postero-lateral abdominal wall, posterior of the mid-axillary line between the costal margin and iliac crest. After the identification of the internal abdominis, transversus abdominis, and quadratus lumborum muscles, the needle will be advanced into the transversus abdominis plane between the internal abdominis and transversus abdominis muscles, at the aponeurosis of quadratus lumborum and these muscles. The local anesthetic solution (%0.5 Bupivacaine 10ml + %1 Prilocaine 10ml + %0.9 NaCl 10ml) will be injected after negative aspiration.; After the oblique subcostal TAP block, the operation table will be slightly turned left laterally for better visualization of the blocking area. The same high-frequency linear ultrasound probe will be placed over the postero-lateral abdominal wall, posterior of the mid-axillary line between the costal margin and iliac crest. After the identification of the internal abdominis, transversus abdominis, and quadratus lumborum muscles, the needle will be advanced into the transversus abdominis plane between the internal abdominis and transversus abdominis muscles, at the aponeurosis of quadratus lumborum and these muscles. %0.9 NaCl 30ml will be injected after negative aspiration.
Intervention MeSH terms: Bupivacaine; Prilocaine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Transversus Abdominis Plane Block