|Year : 2016 | Volume
| Issue : 3 | Page : 358-365
Comparative study evaluating the efficacy of ultrasound-guided transversus abdominis plain block versus intraperitoneal injection of local anesthetics in pain control following laparoscopic colectomy
Aktham A Shoukry MD , Waleed H Nofal, Sanaa M Elfawal
Department of Anaesthesia, ICU and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||05-Aug-2015|
|Date of Acceptance||19-Feb-2016|
|Date of Web Publication||31-Aug-2016|
Aktham A Shoukry
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, 11566 Cairo
Source of Support: None, Conflict of Interest: None
Laparoscopic surgeries are being widely conducted nowadays for its well-known advantages such as less postoperative pain, shorter length of hospital stay, decreased morbidity and mortality, and reduced healthcare costs. Many analgesic modalities have been applied for this type of surgery, of which we have chosen the intraperitoneal injection (IP) of local anesthetics and the transversus abdominis plane (TAP) block. We studied the effect of both techniques on postoperative pain scores and their effect on abdominal and shoulder pain after laparoscopic colectomy.
Patients and methods
Fifty patients were enrolled in the study. All of them were of American Society of Anesthesiology (ASA) physical status I or II and scheduled for elective laparoscopic colectomy surgery. Patients were randomly allocated into one of two groups (25 patients each): the TAP block group (TAP group) and the IP of local anesthetics group (IP group). Pain score using the numerical rating scale (NRS), hemodynamic parameters, amount of consumption of rescue analgesia, shoulder pain, and adverse reactions were recorded.
The main outcome variable was the pain score in the immediate postoperative period and the next 3 h; the mean NRS scores were lower in the TAP group than in the IP group in the previously mentioned time periods, with a highly significant difference. Also, there was a significant difference in the NRS score at the fourth hour postoperatively; however, the subsequent NRS scores at the different time intervals showed no significant difference until the end of the 24th hour postoperatively. In the TAP group, 20 patients (80%) complained of abdominal pain at least once in the first 24 h after surgery, whereas all the patients in the IP group experienced abdominal pain, with a significant difference between the two groups. The overall analgesic consumption in milligrams and the total number of analgesic doses were found to be less in the TAP group, with a highly significant difference.
The results of this study demonstrated that the TAP block is a more effective analgesic modality for abdominal pain than the IP local anesthetic during the early postoperative period after laparoscopic colectomy but IP is more effective in relieving postoperative shoulder pain.
Keywords: intraperitoneal injection of local anesthetics, laparoscopic colectomy, transversus abdominis plane block
|How to cite this article:|
Shoukry AA, Nofal WH, Elfawal SM. Comparative study evaluating the efficacy of ultrasound-guided transversus abdominis plain block versus intraperitoneal injection of local anesthetics in pain control following laparoscopic colectomy. Ain-Shams J Anaesthesiol 2016;9:358-65
|How to cite this URL:|
Shoukry AA, Nofal WH, Elfawal SM. Comparative study evaluating the efficacy of ultrasound-guided transversus abdominis plain block versus intraperitoneal injection of local anesthetics in pain control following laparoscopic colectomy. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 Apr 14];9:358-65. Available from: http://www.asja.eg.net/text.asp?2016/9/3/358/189096
| Introduction|| |
Laparoscopic surgeries are being widely conducted nowadays for its well-known advantages such as less postoperative pain, shorter length of hospital stay, decreased morbidity and mortality, and reduced healthcare costs. The advances in techniques and equipment have allowed more complicated laparoscopic surgeries, such as laparoscopic colectomy, to be performed safely. Compared with open colectomy, laparoscopic colectomy has been shown to be associated with faster return of bowel function, earlier resumption of oral intake, shorter hospital stay, and decreased postoperative analgesia requirement ,,. However, despite the decreased demand for analgesics, those patients still experience pain in the form of upper and lower abdominal and shoulder pain. Many analgesic modalities have been applied for these types of surgeries, of which we have chosen the intraperitoneal injection (IP) of local anesthetics and the transversus abdominis plane (TAP) block . We studied the effect of both techniques on postoperative pain scores and their effect on the abdominal and shoulder pain associated with laparoscopic surgery.
| Patients and methods|| |
The study was approved by the ‘research and ethics committee’ of the Anesthesia and Intensive Care Department, Ain Shams University, and all patients gave their written, valid, and informed consent for being a part of the study. Fifty consecutive patients undergoing laparoscopic left or sigmoid colectomy were included in the study. The study was conducted at Ain Shams University Hospitals during the period from October 2013 to April 2015. They were allocated equally to the TAP group or the IP group.
Patients of either sex aged between 30 and 70 years, of ASA I or ASA II physical status, who weighed -/+20% of their ideal body weight, and were undergoing elective laparoscopic colectomy were selected for the study.
Patient refusal, age less than 30 years or more than 70 years, ASA III or ASA IV physical status, history of coagulation abnormality or bleeding tendency (regional techniques are contraindicated), known allergy to the local anesthetic used, emergency colectomy, complicated or recurrent abdominal surgeries, or conversion to laparotomy were the exclusion criteria. Patients with chronic pain syndrome, where pain evaluation was judged unreliable because of neurological disease or treatment with steroids before surgery, were also excluded.
Preoperatively, all patients were familiarized with the concept of the numerical rating scale (NRS) [Figure 1]. They were asked to verbally rate their level of perceived pain intensity on a numerical scale from 0 to 10, with ‘0’ representing no pain and ‘10’ representing ‘the worst possible pain’ .
In the preinduction room, a 16-G intravenous cannula was inserted under local anesthesia and the patients were premedicated with midazolam 2 mg and ondansetron 4 mg.
Standard intraoperative monitors were applied, in the form of continuous ECG (leads II and V5), pulse oximetry, noninvasive blood pressure monitor, and EtCO2 concentration monitor.
General anesthesia was induced in patients of both groups with propofol at a dose of 2 mg/kg body weight, rocuronium bromide 0.6 mg/kg, and nalbuphine 20 mg.
After tracheal intubation, the minute ventilation was adjusted to maintain end-tidal (EtCO2) concentrations between 30 and 35 mmHg.
General anesthesia was maintained with oxygen (50%) in air and isoflurane (1–1.5% end-tidal concentration). Dose adjustment of isoflurane concentration and intraoperative rescue analgesia (nalbuphine 0.1 mg/kg intravenously) was based on clinical signs and hemodynamic measurements. Signs of inadequate analgesia were defined as increase in heart rate and/or blood pressure by more than 20% from baseline. This was treated with 0.1 mg/kg of nalbuphine intravenously as a top-up dose and by increasing the isoflurane concentration in case of inadequate response to intravenous nalbuphine.
If there was a decrease in blood pressure by more than 20% from baseline, the patient received a 500 ml saline infusion, and if there was no response 5 mg ephedrine was given. If bradycardia occurred atropine 0.01 mg/kg was given intravenously.
The surgical technique was similar for all patients. CO2 insufflation was performed with the patients placed in the supine position. During laparoscopy, intra-abdominal pressure was maintained at 12–14 mmHg. The Trendelenburg position was adjusted at 30° when needed. CO2 was carefully evacuated at the end of surgery by manual compression of the abdomen with open trocars.
The patients were randomly assigned to one of the two groups using computer-generated random numbers.
In the TAP group, after the end of the surgery and before the patient's recovery from general anesthesia, an ultrasound-guided bilateral TAP block was given. After resterilization of the abdominal wall with 10% povidone iodine, an ultrasound machine (Mindray M5; Shinzen Mindray Bio-Medical Electronics Co. Ltd, Shenzhen, China) with a broadband linear array probe (5–10 MHz) was used, with an imaging depth of 4–6 cm. The ultrasound probe was placed transverse to the abdomen (horizontal plane) in the midaxillary line between the costal margin and the iliac crest. After identification of the three muscle layers, using the in-plane technique, a 100-mm short bevel 20-G needle was inserted in a sagittal plane in a medial to lateral orientation approximately 1–2 cm medial to the medial aspect of the ultrasound probe ,.
The needle tip was directed into the plane between the internal oblique and the transversus abdominis muscle. After careful aspiration, a small volume of local anesthetic (1 ml) was injected to open the plane between the two muscles, which was followed by injection of the full dose of local anesthetic. If the 1 ml dose appeared to be within the muscles rather than between them, the needle was readjusted until the local anesthetic injectate (appearing as a hypoechoic shadow compared with the muscle layers) was seen on ultrasound to spread out in the plane between the two muscles . A volume of 25 ml of 0.25% levobupivacaine was injected into each side taking into consideration the toxic dose of levobupivacaine. The TAP block was performed by a single anesthesiologist experienced in this type of block.
In the IP group, previously prepared 50 ml of levobupivacaine 0.25% was instilled into the peritoneal cavity by the surgeon through the laparoscopic trocar entry sites at the end of surgery while the instillation port was directed towards the abdominal side of the diaphragm, using a laparoscopic camera.
At the end of surgery, extubation was performed after the patient had regained consciousness and adequate reversal of muscle relaxant was observed. The patients were transferred to the postanesthesia care unit.
In the postanesthesia care unit, an anesthesiologist unaware of the technique performed received the patient and recorded the following: heart rate, systolic and diastolic blood pressure, and SpO2 every 5 min. Pain assessment was carried out using the NRS immediately after surgery when the patient had completely recovered and regained consciousness from general anesthesia (NRS0). Adverse effects such as itching, postoperative nausea, and vomiting were recorded. Nausea was treated with 10 mg metoclopramide intravenously, vomiting was treated with 4 mg ondansetron intravenously, and itching was treated with pheniramine maleate (45.5 mg/2 ml) intravenously.
In the ward, the NRS score was recorded for all patients hourly for the next 6 h, every 2 h for another 6 h, and then every 3 h until the end of the first postoperative day. Rescue analgesia in the form of ketorolac 30 mg intramuscularly was given if the NRS score was 4 or above and the time of administration of the first rescue analgesic was recorded. Shoulder pain was recorded in both patients groups and ketorolac 30 mg intramuscularly was given if shoulder pain existed. The number of patients who complained of shoulder pain and the time interval between the end of surgery and the start of pain were recorded.
The sample size was calculated using PS (version 3.0.43; Department of Biostatistics, Vanderbilt University, Nashville, USA) with the following parameters: power of the study 80%, expected change in median 20%, and a error 0.05, when the postoperative pain score was the primary outcome measure.
Data were analyzed using the Statistical Package for Social Science (SPSS), version 21.0, Illinois, Chicago, USA. Quantitative data were expressed as mean ± SD. Qualitative data were expressed as frequency and percentage. The independent-samples t-test was used to compare between means in the two groups. The χ2 and Fisher's exact tests were used as appropriate to compare proportions between two qualitative parameters. P-values less than 0.05 were considered significant and P-values less than 0.01 were considered highly significant.
| Results|| |
Three patients from the TAP group and two from the IP group were excluded because of conversion to laparotomy and they were replaced to maintain the sample size of 25 patients in each group.
The demographic data were not significantly different between the two groups [Table 1]; no patients were excluded because of prolonged surgical time or Trendelenburg position.
The main outcome variable was the pain score in the immediate postoperative period and for the next 3 h; the mean NRS scores were less in the TAP group than in the IP group in the previously mentioned time intervals with a highly significant difference. Also, there was a significant difference in the NRS score at the fourth hour postoperatively; however, the following NRS scores at the different time intervals showed no significant difference until the end of the 24th hour postoperatively [Table 2].
|Table 2 Statistical analysis of the numerical rating scale at different time intervals in the two groups|
Click here to view
On comparing groups IP and TAP, there was a significant difference in heart rates immediately after surgery and postoperatively up to the third postoperative hour; thereafter, difference in heart rate was statistically nonsignificant until the 24th hour [Figure 2].
In the TAP group, 20 patients (80%) complained of abdominal pain at least once in the first 24 h after surgery, whereas all the patients in the IP group experienced abdominal pain, with a significant difference between the two groups [Table 3].
|Table 3 Number of patients with shoulder pain and those who needed rescue analgesia|
Click here to view
We also calculated the analgesic consumption and the total doses given for managing the postoperative abdominal pain; this was less in the TAP group, with a highly significant difference. In addition, the time for the first dose to be requested was markedly shorter in the IP group with a highly significant difference, as shown in [Table 4].
We also assessed the effect of the two techniques on the incidence, onset time of shoulder pain, and analgesic consumption. The only significant difference between the two groups was in the number of patients who complained of shoulder pain, being 15 patients (60%) in the TAP group compared with only six patients (24%) in the IP group [Table 3]. However, no significant difference was found between the two groups as regards the onset of shoulder pain or the amount of analgesics consumed for treating this pain, as shown in [Table 5].
The overall analgesic consumption in milligrams and the total number of analgesic doses were compared between the two groups and were found to be less in the TAP group with a highly significant difference, as shown in [Table 6] ([Figure 3] and [Figure 4]).
| Discussion|| |
In general, laparoscopic surgeries are characterized by significantly less postoperative pain as compared with the same surgery if performed through laparotomy ,. However, patients still feel pain after laparoscopic surgery ,; which may be an upper or lower abdominal pain or pain in the shoulder or scapula. This pain may be attributed to the distension of the peritoneum, irritation of the phrenic nerve, or the presence of gas bubbles in the abdomen. It may persist for a few hours or for up to 3 days . Laparoscopic colectomy is increasingly becoming a frequently performed elective surgery for different colonic tumors. It is a lengthy operation with prolonged abdominal insufflation and Trendelenburg times, which contribute to marked visceral and shoulder pain postoperatively. Further, after resection, laparotomy is performed through a small transverse skin incision to remove the resected colon and perform the anastomosis, which also leads to a postoperative parietal pain. Provision of adequate postoperative pain relief is considerably important. Pain intensity usually peaks during the first postoperative hours and is maximum in the first 12–24 h and declines over the next 2–3 days. Postoperative pain is unpredictable, which explains the need for systematic prevention of pain before the patient wakes up from anesthesia .
Laparoscopic colectomy results in less postoperative pain and/or reduced analgesic consumption when compared with open colectomy. However, pain after laparoscopy may be moderate or even severe for some patients and may require opioid treatment. Interestingly, the type of pain after laparoscopy differs considerably from that seen after laparotomy. Indeed, whereas laparotomy results mainly in parietal pain (abdominal wall), patients complain more of visceral pain after operative laparoscopy . Visceral pain peaks during the first hour and is exacerbated by coughing, respiratory movements, and mobilization. It requires opioid administration when the patient is recovering from anesthesia. Scapular pain, especially when an exaggerated Trendelenburg position is used, tends to appear during the night after surgery and hinders sleep ,.
Instillation of an intraperitoneal local anesthetic to reduce postoperative pain has been studied through randomized trials for more than 10 years. The proposed mechanism of action is that the nociceptive receptors in the peritoneum are blocked by the local anesthetic but also systemic absorption may occur through the large peritoneal surface, adding a greater analgesic effect ,.
In a systemic review it has been shown that intraperitoneal infiltration of local anesthetics has been effective in some laparoscopic procedures such as gynecological surgeries but not so in others such as laparoscopic cholecystectomy. This may be due to more tissue dissection in the latter . The failure of IP local anesthetics to produce a sufficient analgesic effect may be due to rapid dilution in the peritoneal cavity; however, we are mindful of the toxic dose of the local anesthetic used, which we cannot exceed .
In our study, we compared the postoperative analgesic effect of levobupivacaine when used as an IP and that of TAP block. We found significant differences between the NRS scores of the TAP group and the IP group immediately postoperatively and for the following 4 h postoperatively. The difference in NRS scores was nonsignificant in the subsequent measurements in the first 24 h when the pain was, in general, mild in intensity in both groups. At the third hour postoperatively there was a significant difference between the NRS scores of the TAP group and the IP group, being lower in the TAP group than in the IP group, which indicates that the bupivacaine effect was faster in the TAP group.
On comparing groups IP and TAP we found that there was a significant difference in heart rates immediately after surgery and postoperatively up to the third postoperative hour; thereafter, the difference in heart rate was statistically nonsignificant until the 24th hour, showing better analgesia in the TAP group in the first 3 h, which led to lower heart rates as compared with the IP group.
Blood pressures (systolic, diastolic, and mean) were all comparable in the two study groups. One reason for this is the rescue analgesia given on demand whenever NRS scores reached 4 or more. Hence, the rise in blood pressure due to pain was not prominent in any of the two groups. Studies performed by Gupta et al. , Goldstein et al. , and Kim et al.  also revealed the same findings; moreover, none of the agents used intraperitoneally or in the TAP block was found to cause a rise in blood pressure.
In a double-blind trial of 40 children undergoing emergency open appendectomy, 20 received ultrasound-guided TAP block and 20 constituted the control group. Carney and colleagues reported 50% reduction in postoperative morphine requirement in the TAP group compared with the control group. Jacobs et al.  reported opioid sparing in a group of 10 children undergoing different abdominal procedures. This was also reported in many case reports and series in neonates and young children . Similar results were reported in adults .
Conflicting results to ours have also been reported. Gupta et al.  showed that intraperitoneal instillation of fentanyl (100 μg) along with bupivacaine (0.5% 20 ml) significantly reduces the immediate postoperative pain. It also reduces the intensity of pain even after 24 h. In our study the pain scores were significantly reduced postoperatively in the TAP group than in the IP group until the fourth hour postoperatively, after which the pain scores started to stabilize in the two groups with no significant differences, which indicates that the IP group may have delayed onset of analgesia compared with the TAP block.
We found statistically significantly lower postoperative rescue analgesia doses and total consumption of analgesia in patients under TAP block than in patients in the IP group (P < 0.001), with significantly longer time for the first dose of rescue analgesia required. This is consistent with the results of Fredrickson and Seal  in a prospective audit of the TAP block in eight patients undergoing inguinal hernia repair, and also with the study of Carney et al. .
Interestingly we found that the nature of postoperative pain in these two groups of patients was different, as shoulder pain was separately reported, treated, and followed up. It was revealed that the incidence of postoperative shoulder pain was significantly lower in the IP group than in the TAP group up to the first 24 h postoperatively. Several studies have shown that IP injection of local anesthetics is beneficial in reducing postoperative shoulder pain after laparoscopic surgery, in accordance with the results of Gupta and colleagues ,. However, he conducted his study on patients who had undergone laparascopic cholecystectomy, in whom the visceral pain is expected to be more prominent than parietal pain, in contrast to laparoscopic colectomy in which the reverse is expected because of the abdominal incision.
Collectively, the total amount of analgesics for abdominal and shoulder pain was significantly lower in the TAP group than in the IP group.
In our study, there were no complications during the procedure or after the TAP block especially with the direct visualization of the neurofascial plane and real-time injection of the local anesthetic under ultrasound guidance. Laghari and Harmon  first described the use of ultrasound in TAP block of patients undergoing an appendectomy. Moreover, Fredrickson et al.  and Hebbard et al.  and others  confirmed the value of direct ultrasound imaging with good results in children undergoing inguinal herniorrhaphies.
Limitations of this study include the following: the intensity of pain was described only in terms of integration of dichotomy and not in terms of quality and quantity. As a result, without multifactorial individualized assessment of pain characteristics, visceral and somatic pain was hard to distinguish in the process. The larger doses of rescue analgesia in the IP group compared with the TAP group may explain the fewer number of patients who complained of shoulder pain postoperatively. Moreover, the 24-h duration of observation might have led to overestimation of the rescue analgesic dose with reference to time and underestimation of shoulder pain incidences, since after 24 h pain was found to decrease, requiring fewer analgesic doses. The duration of analgesia provided could have been ascertained more precisely if the study had been conducted for a longer period.
The use of ultrasound for the placement of peripheral nerve blocks has proven efficacious and is beginning to establish a place in clinical practice. The TAP block under ultrasound guidance is easy to perform and provided reliable and effective analgesia in patients undergoing laparoscopic surgery for colectomy. It is hemodynamically safe, with few recorded postoperative complications. Besides, intraperitoneal instillation of bupivacaine reduces the intensity of visceral and shoulder pain postoperatively in laparoscopic surgeries.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]