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Abstract
Objective:
The aim of this study is to describe the novel
transversus abdominis block and to evaluate the
effect of transversus abdominis block versus morphine
on pain after laparoscopic cholecystectomy in
elderly patients.
Methods:
In this randomized double blinded study, 50 patients
were randomly allocated into two groups: Group
t (Transversus abdominal block)(n=25), patients
received transversus abdominus block with bupivacaine
0.25% in addition to an intravenous single-injection
of morphine 5 mg/kg. Group M, the control group,
(n=25), patients received morphine 5mg intravenous
injection. Pain scores were measured postoperatively
using visual analogue scale.
Results:
This
study included 50 patients; 25 in the transversus
abdominis group (t) and 25 in the control group
(m). Pain scores postoperatively were significantly
less in group t than group m. The amount of morphine
consumption postoperatively was significantly
less in transversus abdominis block.
Conclusion:
Preoperative transversus abdominis block combined
improves postoperative pain outcome after laparoscopic
surgeries .
Keywords:
Anesthesia, Postoperative pain, transversus abdominis
block, laparoscopic surgery
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INTRODUCTION
Many methods have been
used for postoperative pain management, with several
advantages and disadvantages for each. Opioids have
been used extensively for postoperative pain management,
however they are associated with potentially serious
respiratory depression, which should be considered when
anesthetizing elderly patients(1). Non steroidal anti-inflammatory
drugs have an opioid sparing effect but are associated
with potentially serious side effects such as gastrointestinal
bleeding and renal impairment, especially in the elderly
(2). Regional or local anesthesia can avoid such side
effects in elderly patients, and laparoscopic cholecystectomy
surgeries are amenable to several forms of regional
anesthesia by which, these techniques include intercostal,
intraperitoneal, epidural and transverses abdominis
plane blocks. (3)
Although laparoscopic surgery is a less invasive procedure
than laparotomy it is still associated with significant
postoperative pain (4) . Single-shot preoperative transverses
abdominis plane block improves postoperative pain treatment
after abdominal surgery in a clinically significant
fashion. (5)
The aim of this study is to evaluate the effect of preoperative
transverses abdominis plane block in decreasing pain
after laparoscopic cholecystectomy in elderly patients.
METHODS
Fifty
patients of ASA l-III, undergoing laparoscopic cholecystectomy
were included in the study.
The exclusion criteria were:
Patient refusal or hypersensitivity to bupivacaine or
morphine.
20G cannula was placed in the dorsal vein of each hand,
and suitable monitoring was applied. Anesthesia was
conducted using Fentanyl 1-2 micg/kg, Propofol1- 2mg\kg
and atracurium 0,5mg\kg. Endotracheal intubation was
performed. After induction of general anesthesia patients
were randomized to receive either TAP block with morphine
(group t n=25) or only morphine (group m n=25). The
TAP block was performed bilaterally before the start
of surgery by the following technique:
The Land mark for this technique is the triangle of
Petit,; for this block it was identified by palpating
the iliac crest inferiorly, latissimus dorsi posteriorly
and the external oblique anteriorly. 22 G 50 mm blunt
end block needle was used to enter this triangle in
a right angle until the first resistance was encountered
which indicated that the needle was entering the fascia
of the external oblique muscle. The needle then advanced
further in the same direction to encounter the second
resistance which indicates the entrance into the transverses
abdominis facial plane.
Then 0.5 ml/kg bupivacaine 0.25% was injected after
aspiration to ensure no blood. All patients in both
groups were given 0.1 mg/kg IV morphine after induction
of anesthesia.
After finishing the procedure, all patients left the
operating room and remained in the recovery room as
long as indicated with usual postoperative care.
Using the visual analogue pain scale (VAS; 0 mm=no pain,
100 mm=worst pain imaginable), patients were asked to
rate their pain every hour after arrival in the recovery
room. VAS was recorded for both groups every hour for
the first 4 hours. Additional Nurse-administered i.v.
boluses of morphine 2 mg were given and recorded if
the patient have more than 30 mm pain score. Total amount
of morphine given was recorded for both groups. All
data were analyzed using student's t-test.
RESULTS
Fifty patients were included in this study, 25 in the
TAP group(t) and 25 in the control group(m). Patient
data, was similar for the 2 groups as shown in Table
1. Pain scores during the first 4 hours postoperatively
are shown in Table 2; they are significantly less in
group p than group m over the 4 hours p<0.05. The
average quantity of morphine administered per patient
in 4hours was 10 mg (range 0-18 mg) in group m and 6
mg (range 0-12 mg) in group p (P<0.05).
Table 1: Patient characteristics, in both groups data
are mean (range), mean (SD)
Table 2: Mean (SD) pain scores for the 2 groups
DISCUSSION
There are many benefits
of good postoperative analgesia, such as decreased stress
response(6), decreased postoperative morbidity especially
in elderly patients in which there is increased incidence
of cardiopulmonary co- morbidity (7). Other known advantages
of effective regional analgesic techniques include reduced
pain intensity, decreased incidence of side effects
from analgesics, and improved patient comfort (8).
The innervations of the skin,
muscles, and parietal peritoneum of the anterior abdominal
is by the lower six thoracic nerves and the first lumbar
nerve (9,10).
The anterior primary rami of these nerves leave their
respective intervertebral foramina and course over the
vertebral transverse process. The anterior primary rami
of these nerves pierce the abdominal wall musculature
course through a neuro-fascial plane between the internal
oblique and transversus abdominis muscle (9,10). So
the local anaesthetic given is deposited by this block
in the transversus abdominis plane and provides sensory
and muscle blockade. The lumbar triangle of Petit can
be identified easily in all patients by palpating the
iliac crest as principal land mark (10).
The results of this study indicate that TAP block decreased
the pain after laparoscopic cholecystectomy during the
first 24 hours.
Other studies have proved the beneficial effect of TAP
block in decreasing the pain following laparoscopic
cholecystectomy or other procedures like caesarian section
, hysterectomy, and appendectomy (11,12). We found the
effect of this block on pain extended to 24 hours postoperatively.
The pharmacological effect of bupivacaine cannot be
expected to cover this time and findings may be explained
by a pre-emptive effect of the block (reducing the nociceptive
input to the central nervous system in the first hour
after surgery may have attenuated central sensitization,
thereby leading to less postoperative pain), but we
think that this is very debatable issue.
A variety of local and regional anesthetic procedures
for pain control after surgery have been described after
laparoscopic cholecystectomy with the goals of providing
optimal pain control and avoiding complications. In
our study we have not reported any clinically significant
complications. Many of the recent studies included the
use of ultrasound-guided sensory block of the anterior
abdominal wall with local anesthesia for postoperative
pain relief. Ultrasound guided techniques are usually
associated with better identification of the anatomical
planes so they are associated with better safety and
accuracy. We hope to use these facilities as soon as
the equipment and experience is available in the future.(13)
CONCLUSION
We conclude that TAP
block given with morphine is an effective way to decrease
pain after laparoscopic cholecystectomy procedures in
comparison to morphine alone.
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