Quadratus Lumborum Block vs Transversus Abdominis Plane Block for Post-cholecystectomy Analgesia
Condition: Laparoscopic Cholecystectomy
Study type: Interventional

Summary: 
      In laparoscopic cholecystectomy, overall pain is a conglomerate of three different and
      clinically separate components: incisional pain (somatic pain) due to trocar insertion sites,
      visceral pain (deep intra abdominal pain), and shoulder pain due to peritoneal stretching and
      diaphragmatic irritation associated with carbon dioxide insufflation. Moreover, it has been
      hypothesized that intense acute pain after laparoscopic cholecystectomy may predict
      development of chronic pain (e.g., postlaparoscopic cholecystectomy syndrome). Without
      effective treatment, this ongoing pain may delay recovery, mandate inpatient admission, and
      thereby increase the cost of such care.

      Recently, the uses of peripheral axial blocks that deliver local anesthetic into the
      transversus abdominis fascial plane have become popular for operations that involve
      incision(s) of the abdominal wall. Thus, the Transversus Abdominis plane (TAP) block has been
      shown to reduce perioperative opioid use in elective abdominal surgery, including open
      appendicectomy, laparotomy, and laparoscopic cholecystectomy. However, the efficacy of the
      TAP block is reportedly only reliable in providing analgesia below the umbilicus. The
      ultrasound-guided subcostal transversus abdominis (STA) block is a recently described
      variation on the TAP block which produces reliable supraumbilical analgesia. Deposition of
      local anesthetic in this plane has shown to block dermatomes T6 to T10 with an occasional
      spread to T12. This variant will be discussed in our study.

      Currently, the Quadratus Lumborum block (QL block) is performed as one of the perioperative
      pain management procedures for all generations (pediatrics, pregnant, and adult) undergoing
      abdominal surgery. The local anesthetic injected via the approach of the posterior QL block (
      QL 2 block ) can more easily extend beyond the TAP to the thoracic paravertebral space or the
      thoracolumbar plane, the posterior QL block entails a broader sensory-level analgesic and may
      generate analgesia from T7 to L1. Use of posterior QL block in laparoscopic cholecystectomy
      has not been investigated before and it is the variant that will be discussed in our study.
    

Detailed description: 
      The aim of this study is to compare the analgesic efficacy of ultrasound guided posterior
      quadratus lumborum block and subcostal transversus abdominis plane block in laparoscopic
      cholecystectomy. The primary outcome will be assessment of postoperative opioid analgesic
      requirements. The secondary outcomes will include assessing intraoperative analgesic
      requirements, stress of trocar insertion and insufflation, postoperative visual analogue
      scale (VAS), length of stay at post-anesthesia care unit (PACU), time of first request to
      analgesia, incidence of nausea, and vomiting.

      The study will hypothesize that quadratus lumborum block will be more superior than or equal
      to transversus abdominis block because it could cover all the dermatome segments from
      caudally L1 to cranially till T6 segments as the drug is expected to travel from the QL to
      the higher paravertebral spaces.
    

Intervention name(s): Quadratus lumborum block Group (QL); Transversus abdominis plane Group (TAP); Control group (C); Paracetamol infusion; Ketorolac analgesia; fentanyl
Intervention type(s): Other; Other; Other; Drug; Drug; Drug
Intervention description(s): 20 mL of 0.375% isobaric bupivacaine for each side deposited at the posterior aspect of the quadratus lumborum muscle (QLB type 2) using ultrasound after induction of general anesthesia and 15 minutes before start of surgery; 20 mL of 0.375% isobaric bupivacaine for each side using ultrasound after induction of general anesthesia and 15 minutes before start of surgery; No intervention will be done; Paracetamol infusion (15 mg.kg) will be given by intravenous infusion after induction of general anesthesia.; In PACU Ketorolac 30 mg ampoule will be given by intravenous infusion to all cases and then every 8 hours.; With induction of general anaesthesia, fentanyl (1 microgram.kg) will be given. Intraoperatively, Fentanyl boluses (0.5 microgram.kg) will be given in case of increase in intraoperative mean arterial blood pressure or heart rate of more than 20% of baseline for longer than 5 minutes. Postoperatively, Fentanyl boluses (20 micrograms) will be given if VAS is more than 3 and it might be repeated after 30 minutes until VAS is ≤ 3.
Intervention MeSH terms: Acetaminophen; Ketorolac; Fentanyl
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Basic Science