|Year : 2016 | Volume
| Issue : 4 | Page : 558-562
Ultrasound-guided transversus abdominis plane block for control of postoperative pain after laparoscopy-assisted robotic abdominal cancer surgery
Essam Mahran, Mohamed E Hassan
Department of Anesthesia ICU and Pain Management, National Cancer Institute, Cairo University, Cairo, Egypt
|Date of Submission||25-Oct-2016|
|Date of Acceptance||17-May-2016|
|Date of Web Publication||12-Jan-2017|
78th Elmanial Street, Cairo, 35855
Source of Support: None, Conflict of Interest: None
Background and objective
Transversus abdominis plane (TAP) block is a recently developed method for analgesia that is now widely used in a variety of abdominal surgeries. Robotic laparoscopy is being increasingly adopted for surgical resection of abdominal cancers. We studied the efficacy and safety of TAP block to control pain after robot-assisted laparoscopic abdominal cancer surgery.
Totally, 30 patients scheduled for robot-assisted laparoscopic abdominal cancer surgery (hysterectomy, colorectal cancer resection, or cystectomy) received general anesthesia. Before extubation the patients were randomized into two equal groups: group T, in which TAP block was performed by means of an ultrasound-guided subcostal approach, and group C (control group), in which no TAP block was performed or other regional anesthesia was induced. We measured visual analog scale (VAS) both at rest and during episodes of coughing at 1, 2, 6, 12, and 24 h postoperatively. We measured total 24 h morphine consumption, in addition to complications and postoperative nausea and vomiting.
VAS both at rest and during coughing was lower in the T group at all time intervals until 12 h (P<0.001). At 24 h there was no significant difference in VAS but there was marked difference in the total morphine consumption between the T group (26.0±1.8) and the C group (64.3±4.3). Except for two cases of postoperative nausea and vomiting in each group there were no complications detected.
Ultrasound-guided TAP block by subcostal approach is an effective and safe method for providing analgesia that markedly reduces morphine consumption after robot-assisted laparoscopic abdominal cancer surgery
Keywords: abdominal cancer surgeries, laparoscopic robotic surgery, subcostal approach, transversus abdominis plane block, ultrasound guided
|How to cite this article:|
Mahran E, Hassan ME. Ultrasound-guided transversus abdominis plane block for control of postoperative pain after laparoscopy-assisted robotic abdominal cancer surgery. Ain-Shams J Anaesthesiol 2016;9:558-62
|How to cite this URL:|
Mahran E, Hassan ME. Ultrasound-guided transversus abdominis plane block for control of postoperative pain after laparoscopy-assisted robotic abdominal cancer surgery. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2017 Sep 23];9:558-62. Available from: http://www.asja.eg.net/text.asp?2016/9/4/558/198254
| Introduction|| |
Tansversus abdominis plane (TAP) block is a recently developed method for providing analgesia in abdominal surgeries and was first described in 2001 . Hebbard et al  was the first to demonstrate ultrasound (US) guidance for TAP block. US-guided TAP block has the advantages of precise needle location and diffusion of local anesthetic over the conventional blind technique, which also carries a higher risk of injury to abdominal organs . The TAP block enables pain control by blocking sensory nerves through injection of local anesthetics into the neurofascial plane in the abdominal muscle . The approaches to perform TAP block include subcostal, through the midaxillary line, and blind through the Petit triangle. Milan et al.  and Bhatia et al.  have proven that the subcostal approach gives more spread of local anesthetic and a wider range of nerve involvement over other approaches for TAP block. Laparoscopy-assisted robotic surgeries are being increasingly adopted for surgical resection of many abdominal cancers including colorectal surgeries, cystectomy, and hysterectomy with advantages of higher accuracy and fewer surgical complications ,. The efficacy of TAP block was studied after abdominal surgery and cesarean section ,. Others studied its efficacy after laparoscopic cholecystectomy , but data on its efficacy after robotic laparoscopic cancer surgeries are still insufficient. We conducted this randomized study to evaluate the safety and efficacy of TAP block to control pain and reduce morphine consumption after laparoscopic robotic cancer surgery.
| Methods|| |
After obtaining approval from the local institute’s ethics committee and written informed consent from each patient, we studied 30 patients who had undergone laparoscopy-assisted robotic cancer surgeries at our institute (National Cancer Institute, Cairo) from 1 January 2015 to 1 October 2015. Inclusion criteria were being of American Society of Anesthesiologists grade I or II and age 30–70 years. The surgeries included were laparoscopic robotic colorectal surgery, hysterectomy, and cystectomy. We excluded patients with a history of local anesthetic or morphine allergy or opioid addiction, patients with coagulopathy, and those with systemic or local infection at the needle insertion site. All patients received balanced general anesthesia [midazolam (0.05 mg/kg), propofol (2 mg/kg), and cisatracurium (0.15 mg/kg)]. Analgesia was given using only short-acting drugs [fentanyl (2 μg/kg) at induction, followed by remifentanyl infusion (0.05–0.2 μg/kg/min guided by blood pressure)]. Anesthesia was maintained with sevoflurane in oxygen/air mixture and cisatracurium topup doses guided by bispectral index and a nerve stimulator. At the end of the surgery, the patients were randomly divided (by means of computer-generated random number assignment) into two equal groups: group T (TAP), in which a TAP block (bupivacaine 0.25%, 20 ml on each side) was performed before extubation, and group C (control), in which no TAP block was performed or other regional analgesia was provided. The TAP block was performed adopting the US-guided subcostal approach using an US machine (LOGIQ 500 pro series; GE Ultraschall, Solingen, Germany) ([Figure 1]). The scanning probe was a linear multifrequency 13–16 MHz transducer.
The needle used was a 150 mm, 22 G echoplex block needle, Vygon. We followed the subcostal approach as it gives more spread of the local anesthetic and a wider range of nerve involvement . The patient lies in the supine position with the US probe placed parallel to the subcostal margin near the xiphoid process. The transverse abdominal muscle is identified as the more hypoechoic muscle layer just beneath the rectus abdominis near the xiphoid ([Figure 2]). The needle is advanced by the in-plane technique, passing just below the rectus to the transverse abdomen. The local anesthetic is deposited with intermittent aspiration every 5 ml and visualized as a hypoechoic layer transecting the TAP. Visualization of the hypoechoic spread, with the fascial layer above and the muscle layer below, ensures proper deposition.
|Figure 2: Ultrasound anatomy during subcostal approach for TAP block. L/M, lateral and medial; RA, rectus abdominis; SC, subcutaneous tissue; TA, transversus abdominis; TAP, transversus abdominis plane.|
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Patients of both groups were observed in the postanesthesia care unit for 1 h (during which patient-controlled analgesia was initiated) and then shifted to the high-dependency unit for the remaining 23 h and then to the ward. During this 24 h period, the patients received intravenous morphine through patient-controlled analgesia (background morphine infusion of 1 mg/h, bolus dose of 0.25 mg, lockout interval of 10 min). We measured total morphine consumption in the first 24 h in patients of both groups. Pain severity was assessed using the visual analog scale (VAS) both at rest and during cough. We also measured the incidence of complications such as injury to abdominal organs, drug allergy, inadvertent local anesthetic spread, and postoperative nausea and vomiting (PONV).
Sample size estimation
The sample size was calculated considering that a mean difference of 28 mg in morphine consumption between the test and control groups would be clinically relevant. At a power of 90%, a level of significance of 5%, and a SD of 20 mg as reported by Carney et al. , the minimum number of patients was calculated as 12 per group. To compensate for possible dropouts and to increase the power of the test (analysis of variance), we included 15 patients in each group.
Data management and statistical analysis were performed using the statistical package for social sciences, version 21 (SPSS Inc., Chicago, Illinois, USA).
Numerical data were summarized using mean and SD. Categorical data were summarized as percentages. The Kolmogorov–Smirnov test of normality was performed to assess the normality of continuous variables before starting the analysis. Comparisons between the two groups with respect to normally distributed numeric variables were made using the t-test. Non-normally distributed numeric variables were compared by means of the Mann–Whitney test. For categorical variables, differences were analyzed with the χ2-test and Fisher’s exact test when appropriate. All P values are two-sided. P values less than 0.05 were considered significant.
| Results|| |
[Table 1] shows that the two groups were comparable regarding type of surgery and surgical duration with no statistically significant differences.
Table 2 and Table 3 show that the VAS scores both at rest and during coughing were significantly lower in group T than in group C during the first 12 h postoperatively. At 24 h, although there were no significant differences in VAS both at rest and during cough between the two groups, both groups had low VAS with maximal value 3 at rest and 4 during cough.
Regarding the total 24 h morphine consumption we found significant difference in the first 24 h between the two groups as it was markedly lower in the TAP group (26.0±1.8) than in the control group (64.3±4.3), with P value less than 0.001 ([Table 4]).
Except for two cases of postoperative vomiting in each of the two groups no complications were detected, with a percentage of PONV of 13.2% in each group ([Table 5]) and no difference between the two groups.
| Discussion|| |
Here we have studied the analgesic efficacy of US-guided TAP block by injecting bupivacaine 0.25%, 20 ml on each side, after robotic laparoscopic cancer surgery under general anesthesia. We chose a concentration of bupivacaine of 0.25% as it was proven by Ra et al.  to have the same efficacy in TAP block as a concentration of 0.5%. We performed US-guided TAP as the use of US allows direct visualization of the needle tip and proper needle position and avoids unintentional spread of local anesthetic or injury to the liver and intestine . We performed the US-guided TAP block by means of the subcostal approach as it was proven by Milan et al.  and Bhatia et al.  to give a better spread of the local anesthetic compared with posterior US-guided or blind approaches. Group T showed a significantly lower VAS than the control group C as assessed at all time intervals from 1 to 12 h postoperatively. Although at 24 h there was no significant difference between the two groups (both had low VAS values), the total morphine consumption in the first 24 h needed to achieve these low VAS values was markedly lower in group T (26 mg/24 h) than in group C (64.3 mg/24 h), indicating that the TAP block had good analgesic efficacy after robotic laparoscopic cancer surgery for 24 h.
Our results on morphine consumption coincide with the results of Carney et al. , who found that TAP block with ropivacaine reduces postoperative VAS scores and morphine consumption after elective total abdominal hysterectomy. However, they used a different local anesthetic (ropivacaine) and studied only one type of surgery (total abdominal hysterectomy). Melchisedec et al. , found that TAP block reduces the morphine requirement in patients undergoing lower abdominal surgery. These results agree with ours but they studied different surgeries (inguinal hernia repair or appendectomy). Ibrahim and El Shamaa  used the same subcostal approach of TAP block to relieve postoperative pain but they studied a different type of surgery (laparoscopic sleeve gastrectomy). Also McDonnell et al.  have found that TAP block provides effective postoperative analgesia after major abdominal surgery (large bowel resection). Similarly Ra et al.  found that TAP block significantly reduces postoperative pain in patients undergoing laparoscopic cholecystectomy with no difference in efficacy between concentrations 0.25 and 0.5% of levobupivacaine. The analgesic efficacy of TAP block after laparoscopic colorectal surgery was also proven in two recent reports by Walter et al.  and Keller et al. . Our study has the advantage of having investigated TAP block efficacy after three different types of robotic laparoscopic abdominal cancer surgeries (hysterectomy, colorectal surgery, and cystectomy).
However, our results differ from those of Torup et al. , who found no difference between TAP and placebo groups in terms of morphine consumption after robot-assisted laparoscopic hysterectomy. But they used other additional drugs for postoperative analgesia (paracetamol and nonsteroidal anti-inflammatory drugs) along with morphine, which may have affected the results. In addition, they studied only one type of surgery (hysterectomy).
There was no difference in complications and PONV during the 24 h study between the T group and the control group.
With regard to the mechanism of action and exact nerves blocked by TAP block, McDonell et al.  detected that they are from T7 to L1, on the basis of a radioactive examination, whereas Tran et al.  reported that the dye injected into the TAP in cadavers was distributed from T10 to L1. In our study the exact nerves blocked could not be precisely detected under the effect of general anesthesia. Further research in this field may be needed to determine the exact nerves blocked by local anesthetics using TAP block.
We concluded that TAP block by means of an US-guided subcostal approach is a useful method for providing analgesia after robot-assisted laparoscopic abdominal cancer surgeries that can markedly reduce postoperative morphine consumption in the first 24 h without an increase in complications.
We recommend further research to detect the exact sensory nerves blocked by local anesthetics during US-guided TAP block.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]