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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 (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.
Many methods have been used for postoperative pain management, with several advantages and disadvantages for each. Opioids has been used extensively for postoperative pain management, however it is associated with potentially serious respiratory depression, which should be considered when anesthetizing elderly patients(1).. Non steroidal anti-inflammatory drugs have its opioids sparing effect but it is associated with potentially serious side effect such as gastrointestinal bleeding and renal impairment especially in the elderly (2). Regional or local anesthesia can avoid such side effect 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 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.
Fifty patients of ASAl-III, undergoing laparoscopic cholecystectomy were included in the study .
The exclusion criteria were:
Patient refusal or hypersensitivity to bupivacaine or morphine.
20G canula was placed in the dorsal vein of each hand, 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 plan.
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
Fifty patients were included in this study, 25 in the TAP group(t) and 25 in the control group(m). uguyfPatient's data, are similar for 2 groups as shown in Table 1. Distribution of types of video-assisted thoracoscopic surgery for both groups is similar and shown in table 2. pain scores during the first 4 hours postoperatively are shown in table 3, they are significantly less in group p than group m over the 4 hours p<0.05. The average quantity of morphine administrated per patient in 4h 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 characteristic, in both groups
Data are mean (range), mean (SD)
ASA class (I/II/III)
Table 3: Mean (SD) pain scores for 2 groups
There are many benefits of good postoperative analgesia such as decrease stress response(6), decrease postoperative morbidity especially in elderly patients in witch there is increased incidence of cardiopulmonary co morbidity (7). Other known advantages of effective regional analgesic techniques include reduced pain intensity, decrease 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 thevertebral 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 in deposited by this block in the transversus abdominis plane
provide sensory and muscle blockade. The lumbar triangle of Petit can be identfified easily in all patints by palating 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 workers have proved the beneficial effect of TAP block in decreasing the pain following laparoscopic cholecystectomy or other procedures like caesarian section , hysterectomy, appendectomy (11,12) . We found the effect of this block on pain extended to 24 hrs postoperatively the pharmacological effect of bupivacaine cannot be expected to cover this time finding 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 have been described after laparoscopic cholecystectomy with the goals of providing optimal pain control and avoiding complications
has the important a after laparoscopic cholecystectomy. 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 we could use this facilities as soon as the equipment and experience is available in the future.(13)
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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