Modified Thoracoabdominal Nerves Block Through Perichondrial Approach: a New Strategy With a Wide Range of Utilization in Laparoscopic Gynecological Surgeries.
Condition: Analgesic Efficacy of M-TAPA Block Accomplished Prior to Surgery in Patients Undergoing Laparoscopic Gynecological Surgeries
Study type: Interventional
Phase: Phase 2

Summary: 
      The current study was to assess the analgesic effects of the modified thoracoabdominal nerves
      block through perichondrial approach (M-TAPA) block in patients undergoing gynecological
      laparoscopic surgeries.The primary goal was to evaluate the analgesic efficacy of M-TAPA
      block accomplished prior to surgery in patients undergoing Laparoscopic gynecological
      surgeries
    

Detailed description: 
      All patients were thoroughly assessed preoperatively by history evaluation as regards current
      medical condition and drug therapy, careful clinical examination and laboratory evaluations
      (complete blood picture, liver function and renal function tests). Explanation of the
      anaesthesia method was done to all patients and they were instructed wisely on how to utilize
      the 10 cm linear visual Analogue scale (VAS), with (0) denoting pain free state, whereas (10)
      stands for the worst intractable pain [9]. Fifteen minutes before induction, all patients
      were premedicated with i.v. midazolam 0.03 mg kg-1 In the operating room, an i.v. cannula was
      placed and secured, then standard monitoring including (pulse oximetry, ECG, non- invasive
      blood pressure and end tidal carbon dioxide) were applied to each patient using multichannel
      (Datex ohmeda S/5, Germany) monitor. Anaesthesia was induced with lidocaine (1mg/kg) followed
      by (1.5 - 2 mg/kg) propofol -till cessation of verbal contact- and (1-1.5 μg/kg) fentanyl.
      Endotracheal intubation was accomplished with rocuronium (1mg/kg) and a suitable sized tube.
      Anaesthesia was maintained with sevoflurane (1-2 %) with (50 %) oxygen in air. Controlled
      mechanical ventilation was provided to maintain ETCO2 between (33-35 mmHg) and an oxygen
      saturation of 98 %.

      Patients will be randomly assigned- using closed envelope technique- into 2 groups (30
      patient) each:

      Group (M): The M-TAPA block will be combined with general anaesthesia. Group (C): (control
      group) conventional general anaesthesia receiving multimodal analgesia.

      In group (M), after the induction of anaesthesia and with the patient in the supine position,
      the block was performed before starting of the surgical procedure as described by Tulgar et
      al. [8]. After surgical skin disinfection with 10 % povidone-iodine, it was covered with
      sterile surgical fenestrated drapes. A high frequency (6-12 MHz) US linear probe (Fujifilm
      Sonosite, Tokyo, Japan) covered with a sterile cover was placed in the sagittal plane on the
      10 th costal margin in the midline. The probe was then angulated deeply to visualize the
      lower surface of the costal cartilage. Via in plane technique, a 21 gauge Tuohy needle
      (Stimuplex B-Braun Medical, Melsungen, Germany) was inserted cranially between the lower
      fascia of the costal cartilage and upper fascia of the transversus abdominis muscle by moving
      the needle tip towards the posterior aspect of the 10 th costal cartilage with caution not to
      cross the cranial edge of the 10th costal cartilage and 20 mL of bupivacaine (0.25 %) was
      injected bilaterally, in the midclavicular line.

      In group (C), ketorolac 0.75 mg/kg and paracetamol 10 mg/kg were administered intravenously
      before surgical stimulus.

      Inadequate analgesia expressed in the form of elevated blood pressure or accelerated heart
      rate 20 % above baseline value was managed by administration of 0.5 (μg/kg) fentanyl bolus as
      a rescue analgesia. Perioperative hypothermia was managed by warming of i.v fluids and forced
      air warming to exposed areas. Precise fluid replacement was provided to all subjects
      according to the standard guidelines applied during anaesthesia.

      At the end of surgery, sevoflurane vaporizer was shut off followed by administration of 100 %
      oxygen. Muscle relaxant was reversed with neostigmine 0.04 mg/kg and atropine 0.02 mg/kg
      slowly i.v, after oropharyngeal secretions were suctioned. The tube was removed after
      ensuring that the patients regained consciousness, breathed spontaneously and respond to
      verbal command. IV ondansetron (8) mg was given to all patients to guard against
      postoperative nausea and vomiting.

      Patients were transferred to the PACU, where monitoring of heart rate, arterial blood
      pressure, respiration, and temperature were done by recovery nurses unaware to the study
      design to avoid bias. Postoperative analgesia was administrated with paracetamol i.v. 1 gm/8
      hr throughout the first 24 hours postoperatively and standardized intravenous
      patient-controlled analgesia (IV-PCA) with morphine (0.5 mg/mL, 2-mg bolus, lock-out period
      10 mins, and 4 hrs limit of 20 mg) based on reaching the score of ≥ (4) VAS.
    

Intervention name(s): The M-TAPA block; Ketorolac
Intervention type(s): Procedure; Drug
Intervention description(s): A high frequency (6-12 MHz) US linear probe was placed in the sagittal plane on the 10 th costal margin in the midline. The probe was then angulated deeply to visualize the lower surface of the costal cartilage. Via in plane technique, a 21 gauge Tuohy needle was inserted cranially between the lower fascia of the costal cartilage and upper fascia of the transversus abdominis muscle by moving the needle tip towards the posterior aspect of the 10 th costal cartilage and 20 mL bupivacaine (0.25 %) was injected.; conventional general anaesthesia receiving multimodal analgesia
Intervention MeSH terms: Ketorolac
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Prevention