Sohini Majumdar^1*, Sona Dave²

¹Senior Resident, ²Professor, Department of Anaesthesiology, Topiwala National Medical College And B.Y.L Nair Ch. Hospital, Mumbai, INDIA.

Email: dr.sohini1992@gmail.com

RESULTS

Among patients undergoing laparoscopic cholecystectomy. 120 patients were randomly divided into following two groups: Group 1 (Oblique subcostal TAP block) and Group 2 (Port site infiltration). The mean age of the patients among Group 1 was 41.05 ± 11.08 years and Group 2 was 42.65 ± 9.35 years.

There was no statistically significant difference between the groups for mean age, gender, BMI and ASA grade as per Student t-test (p>0.05).

Table 1: General characteristics

The mean duration of surgery was comparable in Group and Group B (41.08 ± 9.07 mins vs. 42.62 ± 9.22 mins). The mean duration of analgesia was comparable between the groups and statistically not significant as per Student t-test (54.35 ± 9.39 minutes vs. 56.25 ± 7.67 minutes; p>0.05). Intraoperatively throughout the study, heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), SpO2 levels were comparable between the groups as per Student t-test (p>0.05). There was no significant difference in the baseline Peak Expiratory Flow Rate (PEFR) between two groups (372.35±55.83 l/min vs. 373.25±56.49 l/min; p>0.05) but there was significant decrease in PEFR in Group 2 than Group 1 at postoperatively 24 hours as per Student t-test (329.83±17.36 l/min vs. 266.83±39.08 l/min; p<0.05). There was no significant difference in the baseline partial pressure of carbon dioxide (PaCO2) between two groups (40.37±6.78 mmHg vs. 41.72±5.94 mmHg; p>0.05) and PaCO2 at postoperatively 24 hours (44.88±9.82 mmHg vs. 47.07±9.13 mmHg; p>0.05).

Table 2: Operative parameters

The VAS score on shift was comparable between both the groups but the VAS score at post-operative time intervals (2 hours, 4 hours, 8 hours, 12 hours and 24 hours) was significantly lower in Group 1 compared to Group 2 as per Student t-test (p<0.05).

Table 3: Comparison of VAS score at various postoperative time intervals

2 (3.3%) and 11 (18.3%) patients in Group 1 and Group 2 respectively required rescue analgesic. It was observed that significantly lower number of patients in Group 1 required rescue analgesic compared to Group 2 as per Chi-Square test (p<0.05).

Table 4: Distribution of Rescue Analgesic

2 (5%) and 5 (8.3%) patients in Group 1 and Group 2 respectively had nausea and vomiting. The incidence of nausea and vomiting was less in Group 1 compared to Group 2 however this difference was statistically not significant as per Chi Square test (p>0.05).

Table 5: Post-operative complications

DISCUSSION

Provision of adequate postoperative analgesia reduces the neuro-endocrine stress response, postoperative respiratory complications and the incidence of myocardial ischemia can be minimized. TAP block is a regional anesthetic technique which blocks the abdominal neural afferents by introducing local anesthetic into the neuro-fascial plane between the internal oblique and the transversus abdominis muscle. The ultrasound-guided subcostal transversus abdominis (STA) block is a recently described variation on the TAP block which produces reliable unilateral supraumbilical analgesia.^6,7 In the present study, There was no statistically significant difference between the groups for mean age, gender, BMI and ASA grade as per Student t-test (p>0.05). This is similar to the studies of Abdelmaboud MA⁸ and Bhalekar P et al.⁹ Abdelmaboud MA⁸ study assessing clinical utility of TAP block as analgesia after lower abdominal surgeries in morbidly obese found no statistically significant differences between the study groups with respect to age, sex, BMI, and duration of the surgery. Bhalekar P et al.⁹ assessing whether subcostal TAP block reduces the requirement of rescue analgesics following laparoscopic cholecystectomy found both groups were comparable with respect to mean age, sex distribution, mean weight, ASA physical status, and duration of surgery. There was no significant difference in the baseline Peak Expiratory Flow Rate (PEFR) between two groups (372.35±55.83 l/min vs. 373.25±56.49 l/min; p>0.05) but there was significant decrease in PEFR in Group 2 than Group 1 at postoperatively 24 hours as per Student t-test (329.83±17.36 l/min vs. 266.83±39.08 l/min; p<0.05) which indicates that TAP block provides better pain relief than port site infiltration thus allowing the patient to breathe adequately. This is comparable to the studies of Abdelmaboud MA⁸ and Basaran B et al.¹⁰. Abdelmaboud MA⁸ study observed no significant difference in baseline PEFR between two groups, but there was significant decrease in PEFR in group C (Control group) than group T (TAP group) at 2, 6 h postoperatively. Basaran B et al.¹⁰ in a randomized double-blind study reported OSTAP group had better FVC values at 2 (p=0.029) and 24 h (p=0.019). FEV1 /FVC and PEFR values were similar between groups. In our study, the VAS score on shift was comparable between both the groups but the VAS score at post-operative time intervals (2 hours, 4 hours, 8 hours, 12 hours and 24 hours) was significantly lower in Group 1 compared to Group 2 as per Student t-test (p<0.05). This is consistent with the studies of Abdelmaboud MA⁸, Basaran B et al.¹⁰, Bhalekar P et al.⁹ and Saliminia A et al.¹¹ Bhalekar P et al.⁹ study showed throughout the 24 h after surgery, mean VAS score at rest and on coughing was significantly less in patients of Group B (subcostal TAP group) as compared to Group A (control group). Saliminia A et al.¹¹ study on efficacy of transverse abdominis plane block in reduction of postoperative pain in laparoscopic cholecystectomy reported lower VAS score in the subcostal TAP group than the control group at 1 h (3.44 vs. 5.17), 6 h (3.94 vs. 6.44), 12 h (1.94 vs. 3.39), and 24 h (0.83 vs. 1.44). It was observed in the present study that 2 (3.3%) and 11 (18.3%) patients in Group 1 and Group 2 respectively required rescue analgesic (Inj. Paracetamol, Inj. Tramadol, Inj. Diclofenac). It was observed that significantly lower number of patients in Group 1 required rescue analgesic compared to Group 2 as per Chi-Square test (p<0.05). Similar observations were noted in the studies of Abdelmaboud MA⁸, Erbabacan E et al.,¹² El‑Dawlatly AA et al.¹³, Ra YS et al.,¹⁴, Ghisi D et al.,¹⁵ Chen CK et al.,¹⁶ Bhalekar P et al.,⁹ Carrie C et al.,¹⁷ Sharma P et al.¹⁸ and Basaran B et al.,¹⁰ Bhanulakshmi M et al.¹⁹ study concluded that TAP block can be easily and safely performed and more effective with significant decrease in opioid requirement and pain score. Erbabacan E et al.¹² study comparing TAP block and IV patient-controlled analgesia (PCA) using opioids after lower abdominal surgery observed TAP block was preferable to IV- PCA, as the analgesic effect starts earlier and decreases the systemic effect of the morphine used in PCA. Tolchard S et al.²⁰ study on efficacy of the subcostal TAP block Comparison with conventional port‑site infiltration in laparoscopic cholecystectomy reported that patients in the subcostal TAP group required morphine and tramadol in 1/21 (4.8%) and 6/21 (28.6%) patients, respectively, whereas the control group required morphine and tramadol in 3/22 (13.6%) and 8/22 (36.4%) patients postoperatively which was not statistically significant. It was observed in our study that 3 (5%) and 5 (8.3%) patients in Group 1 and Group 2 respectively had nausea and vomiting. The incidence of nausea and vomiting was less in Group 1 compared to Group 2 however this difference was statistically not significant as per Chi Square test (p>0.05). This finding was consistent with the studies of Abdelmaboud MA⁸ and Basaran B et al.¹⁰ Poorly controlled pain is associated with unwanted postoperative consequences like patient suffering, distress, confusion, respiratory and heart problems, prolonged hospital stays, and expenditures. Good postoperative pain management has been shown to be effective in reducing perioperative morbidity associated with acute coronary events and thrombotic events in high-risk patients.²¹The block of pain impulses by local anesthetic (LA) provides effective pain relief for abdominal surgery, either on its own or as part of a multimodal analgesic regimen. With the development of ultrasound imaging techniques that enable precise target identification.

CONCLUSION

The hospital based randomised, observer blinded, interventional study demonstrated that supplementing a standard multimodal analgesic regimen with a subcostal TAP block vs. port site infiltration provided superior analgesia postoperatively with respect to pain and post-operative respiratory functions measured by PEFR after laparoscopic cholecystectomy and VAS score at post-operative time intervals (2,4,8,12 and 24 hours) was significantly lower in TAP Group compared to port site infiltration Group.

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