Port Site Infiltration Research Articles

Erector Spinae Plane Block in Laparoscopic Cholecystectomy, Is There a Difference? A Randomized Controlled Trial.

Background:The ultrasound (US)-guided erector spinae plane (ESP) block and oblique subcostal transversus abdominis plane (OSTAP) block are used to decrease postoperative pain and subsequently opioids consumption.Aim:The aim was to test the hypothesis that US-guided ESP blocks can produce more reduction in opioid usage during the first 24 h after laparoscopic cholecystectomy when compared to OSTAP block.Settings and Design:Seventy adult patients (20–60 years old) who were planned to undergo elective laparoscopic cholecystectomy were allocated in three groups in randomized controlled trial.Materials and Methods:The three groups received either port site infiltration, US-guided bilateral ESP block (ESP group), or OSTAP (OSTAP group) with bupivacaine hydrochloride 0.25%.Statistical Analysis:Postoperative 24 h Morphine consumption, visual analogue scale (VAS), the intraoperative fentanyl (μg) and equivalent morphine dose in the recovery unit were recorded and analyzed using one-way analysis of variance.Results:The mean 24-h morphine consumption was statistically significant between groups (P < 0.001), but it was insignificant between ESP and OSTAP (P = 0.173). Median (range) and interquartile range of intraoperatively consumed fentanyl showed significance between the three groups (P < 0.001). There was insignificance between ESP block Group II and OSTAP block Group III (P = 0.95) by post hoc analysis. The mean values of VAS at both rest and movement of the control group were significantly higher than the ESP block group at 6 and 12 h postoperative.Conclusion:Bilateral US-guided ESP block was found to be as effective as bilateral US OSTAP block. There was more decrease in intraoperative rescue fentanyl, PACU morphine analgesia, 24-h morphine, and pain assessment score in both groups than the control port-site infiltration group.Clinical trial registration number: NCT03398564.

Ultrasound-guided Anterior Quadratus Lumborum Block for Postoperative Pain after Laparoscopic Pyeloplasty: A Randomized Controlled Trial.

Background:Quadratus lumborum block (QLB) has provided adequate analgesia and lowered postoperative opioid requirement in comparison to controls for some urological surgeries.Aims:The aim of this study was to assess the efficacy of postprocedure ultrasound-guided QLB in comparison to port-site infiltrations with local anesthetics (as control) in lowering postoperative pain after laparoscopic pyeloplasty.Settings and Design:This was a prospective, single-blinded, randomized controlled trial.Materials and Methods:Fifty-three adults undergoing laparoscopic pyeloplasty were randomly allocated to either anterior QLB group (n = 27) or port-site infiltration Group P (n = 26) with 20 mL of 0.5% ropivacaine. The primary outcomes were static and dynamic pain on the Visual Analog Scale (VAS) of 0–100 at the 30th min, 2nd, 6th, 12th, and 24th hour after surgery. The secondary outcomes were number of patients requiring rescue analgesics and having postoperative nausea or vomiting (PONV) in 24 hours after surgery.Statistical Analysis:Intergroup comparison of VAS was done with Student's t-test. Categorical data were analyzed using the Chi-square test.Results:The static VAS scores were found to be significantly lower in QLB group at the 2nd, 6th, and 12th hour, and the dynamic VAS was lower at all time points after the 30th min in the QLB group. The number of patients requiring rescue analgesics were significantly lower in the QLB group (13 as compared to 21 in Group P; P = 0.015). The incidence of PONV was comparable. No other side effects were seen.Conclusion:Ultrasound-guided anterior QLB is more effective in comparison to traditional technique of port-site local anesthetic infiltration for providing analgesia after laparoscopic pyeloplasty.

Comparison of Analgesic Efficacy of US Guided ESP Block With Port Site Infiltration Following Laparoscopic Cholecystectomy

Comparison of Analgesic Efficacy of US Guided ESP Block With Port Site Infiltration Following Laparoscopic Cholecystectomy

Ultrasound-guided subcostal transversus abdominis plane block with liposomal bupivacaine compared to bupivacaine infiltration for patients undergoing robotic-assisted and laparoscopic hysterectomy: a prospective randomized study.

PurposeTo determine if a transversus abdominis plane (TAP) block with liposomal bupivacaine reduces total postoperative opioid use in the first 72 hrs following laparoscopic or robotic hysterectomy compared to port-site infiltration with 0.25% bupivacaine.MethodsPatients received either a true TAP block procedure with 266 mg liposomal bupivacaine and 50 mg of 0.25% bupivacaine and sham port infiltration or sham TAP block procedure with true port-site infiltration with 100–125 mg of 0.25% bupivacaine. All patients had a standardized, scheduled, non-opioid pain management plan. The primary outcome was total IV morphine equivalents used in the first 72 hrs following surgery. Secondary outcomes included assessment of postoperative pain over the study period and quality of recovery measures.ResultsPatients undergoing TAP blockade required fewer total opioid equivalents during the observation period than patients allocated to infiltration (median 21 versus 25 mg IV Morphine equivalents, P=0.03). Opioid use was highest in the first 24 hrs after surgery, with less difference between the groups during days 2 and 3 postoperatively. There were 5 in the TAP group and 0 in the infiltration group were opioid free at 72 hrs. Those in the TAP group had improved quality of recovery (QoR15) with no change in overall benefit of analgesia score.ConclusionTAP blockade reduced the requirement for opioid pain medication in the first 72 hrs after surgery, had more patients opioid free at 72 hrs, and improved patients’ quality of their recovery.

Comparison of intraincisional vs intraperitoneal bupivacaine for the control of postoperative pain after laparoscopic cholecystectomy

Background: The aim of this study was to compare the efficacy of infiltration of local anaesthetic bupivacaine at incision site (port site) and intraperitoneally on postoper­ative pain in patients undergoing laparoscopic cholecystectomy.Methods: This was a randomized controlled study carried out on patients undergoing laparoscopic cholecystectomy. The patients were divided into three groups of 60 patients each. Group 1 was the control group which did not receive either intraincisional or intraperitoneal bupivacaine. Group 2 received intraincisional bupivacaine 0.25% 20 ml, while group 3 received 20 ml solution of bupivacaine 0.25% 20 ml intraperitoneally. Postoperative pain was recorded for 24 hours post-operatively.Results: The incidence of abdominal pain was significantly lower in the group which received intraincisional bupivacaine upto 12 hours postoperatively. Right shoulder pain was low in group receiving intraperitoneal bupivacaine as compared to group 2, but it was not statistically significant.Conclusions: Intraincisional (port site) infiltration of bupivacaine is more effective than intraperitoneal infiltration for postoperative pain relief after laparoscopic cholecystectomy. It is easier to apply and there is less requirement of postoperative analgesics.

Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations

Background and objectivesLaparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review...

Feasibility study for a randomized clinical trial of bupivacaine, lidocaine with adrenaline, or placebo wound infiltration to reduce postoperative pain after laparoscopic cholecystectomy.

BackgroundShort‐term pain relief can be achieved by local anaesthetic infiltration of port sites at the end of laparoscopic surgery. This study aimed to assess feasibility of performing an RCT to evaluate short‐term postoperative analgesia after laparoscopic surgery in Nigeria using two local anaesthetics for port‐site infiltration versus saline placebo.MethodsThis was a placebo‐controlled, patient‐ and outcome assessor‐blinded, external feasibility RCT. Patients undergoing elective laparoscopic cholecystectomy for symptomatic ultrasound‐proven gallstones were randomized into three groups: lidocaine with adrenaline (epinephrine), bupivacaine or saline control. The feasibility of recruitment, compliance with randomized treatment allocation, and completion of pain and nausea outcome measures were evaluated. Pain was assessed at 2, 6, 12 and 24 h after surgery using a 0–10‐point numerical rating scale (NRS) and a four‐point verbal rating scale. Nausea was assessed using NRS at the same time points. Clinical outcomes were assessed only in patients who received the correct randomized treatment allocation.ResultsOf 79 patients screened for eligibility, 69 were consented and randomized (23 per group). Overall, compliance with randomized treatment allocation was achieved in 64 patients (93 per cent). All pain and nausea assessments were completed in these 64 patients. On the NRS, most patients had moderate to severe pain at 2 h (39 of 64, 61 per cent), which gradually reduced. Only six patients (9 per cent) had moderate to severe pain at 24 h.ConclusionRecruitment, compliance with the randomized allocation, and completion of pain outcome measures were satisfactory. This study demonstrates the feasibility of conducting a surgical RCT in a resource‐limited setting. Registration number: ISRCTN 17667918 (https://www.isrctn.com).

If transversus abdominis plane blocks are to be used in laparoscopy then the gynaecologist is best placed to administer them.

The role of transabdominal plane (TAP) blocks in laparoscopic surgery is unclear, and their implementation is generally left to the discretion of the anaesthetist. The anaesthetist attempts to interrupt sensory innervation across several dermatomes by instilling local anaesthetic below the fascial plane between the internal oblique and the transverse abdominis muscles. The technique may involve one or two entry points on each side of the abdomen. The ‘blind’ TAP block relies upon orientation using superficial anatomical landmarks and a ‘double pop’ sensation indicating the needle is sited correctly. Inadvertent visceral injuries have been reported as well as suboptimal placement in the majority of patients and so visualisation with ultrasound to guide needle placement has been advocated (McDermott et al. BJA 2012;108:499–502). However, the excellent visualisation of the abdominal cavity provided by laparoscopy has promoted laparoscopically delivered TAP blocks. Randomised controlled trials (RCTs) have evaluated TAP blocks across surgical practice and systematic evidence syntheses have found them to be associated with modest improvements in overall quality of recovery and corresponding reductions in postoperative pain up to 24 hours postsurgery and requirements for analgesia (Brogi et al. Can J Anaesth 2016;63:1184–96). Most data pertaining to the impact of TAP blocks on recovery from laparoscopic surgery have come from trials involving laparoscopic cholecystectomy. Data specific to gynaecological surgery are scarce, although two small RCTs evaluating ultrasound-guided TAP blocks in laparoscopic hysterectomy have been conducted, albeit with conflicting results (Kane et al. Am J Obstet Gynecol 2012;207:419.e1–5; De Oliveira GS Jr et al. Obstet Gynecol 2011;118:1230–7.). The study in BJOG by R Kargar et al. (BJOG 2019;126:647–54) reports an RCT comparing laparoscopic TAP blocks with standard port-site infiltration of local anaesthetic and placebo in women undergoing complex laparoscopic endometriosis surgery. A benefit of laparoscopically deployed TAP and port-site blocks was shown compared with placebo in pain relief up to 12 hours following surgery. However, laparoscopic TAP blocks were no more effective than conventional port-site anaesthesia. The investigators missed an opportunity to evaluate the cumulative effect of combining TAP blocks with local port-site anaesthetic. So where are we now? Well, local port-site anaesthesia should be continued but further work is needed to ascertain who may benefit from TAP blocks whether used as an alternative or in combination with port-site blockade. Confounders, such as the type and duration of laparoscopic surgery, the size of ports, patient characteristics such as obesity, and local anaesthetic regimens need to be accounted for. In addition, the question of how TAP blocks should be delivered and by whom will be of interest; blindly or ultrasound-guided by the anaesthetist or under laparoscopic guidance by the gynaecologist? I suspect most surgeons are aware that the amount of time available on operating lists for actual surgery is diminishing because of prolongation of anaesthetic times and the requirement for WHO safety check lists. Peering through the anaesthetic room the eager, optimally prepared but time-poor surgeon can become deflated observing the anaesthetist manipulating a portable ultrasound machine in order to ‘line up’ the TAP blocks. I believe the opportunity to claw this time-consuming task from our enthusiastic anaesthetic colleagues will be welcomed by most surgeons! Dr Clark reports personal fees from Bayer, personal fees from Smith & Nephew, personal fees from Hologic, outside the submitted work. A completed disclosure of interest form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Evidence-Based Management of Postoperative Pain in Adults Undergoing Laparoscopic Sleeve Gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is a common weight loss operation that is increasingly being managed on an outpatient or overnight stay basis. The aim of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after LSG. A systematic review utilizing preferred reporting items for systematic reviews and meta-analysis with PROcedure SPECific Postoperative Pain ManagemenT methodology was undertaken. Randomized controlled trials (RCTs) published in the English language from inception to September 2018 assessing postoperative pain using analgesic, anesthetic, and surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases. Significant heterogeneity was identified in the 18 RCTs included in this systematic review. Gabapentinoids and transversus abdominis plane blocks reduced LSG postoperative pain. There was limited procedure-specific evidence of analgesic effects for acetaminophen, non-steroidal anti-inflammatory drugs, dexamethasone, magnesium, and tramadol in this setting. Inconsistent evidence was found in the studies investigating alpha-2-agonists. No evidence was found for intraperitoneal local anesthetic administration or single-port laparoscopy. The literature to recommend an optimal analgesic regimen for LSG is limited. The pragmatic view supports acetaminophen and a non-steroidal anti-inflammatory drug, with opioids as rescue analgesics. Gabapentinoids should be used with caution, as they may amplify opioid-induced respiratory depression. Although transversus abdominis plane blocks reduced pain, port-site infiltration may be considered instead, as it is a simple and inexpensive approach that provides adequate somatic blockade. Further RCTs are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.

Comparison of Analgesic Efficacy of Ultrasound Guided Subcostal Transversus Abdominis Plane Block with Port Site Infiltration Following Laparoscopic Cholecystectomy

Patients have significant pain following laparoscopic cholecystectomy. Several modalities have been used to manage this pain. Subcostal transversus abdominis plane (TAP) block is one of the components of multimodal analgesia and has been described as an effective technique for postoperative pain management. This study compares the impact of subcostal TAP block with port site local infiltration following laparoscopic cholecystectomy for postoperative pain and opioid consumption. This is a prospective, randomized, interventional study. Sixty patients were enrolled and divided into two groups having 30 patients in each group. Group A received bilateral ultrasound guided subcostal TAP block with 10 mL of 0.25% bupivacaine after the completion of surgery. Group B received similar amount of local anesthetic infiltrated over all the laparoscopic port sites. Pain at rest and on movement was assessed using VAS scale in post-operative period at 0 min, 30 min, 2, 4, 6, 12 and 24 hours. Time of first rescue analgesic requirement and total opioid consumption over 24 hours were recorded. Patients receiving Subcostal TAP block had reduced postoperative pain as compared to port site infiltration and statistically significantly in first two hours after surgery. The 24 hours opioids consumption was significantly less (125mg ±25.42 versus 175mg ±25.42, p <0.001) in Subcostal TAP block group. Time for request of first rescue analgesic was prolonged in patients receiving the Subcostal TAP block (3.20±0.84 hours vs 1.70±0.65 hours, p <0.001). Ultrasound guided bilateral Subcostal TAP block provides effective post-operative analgesia and reduces opioid consumption in patients undergoing laparoscopic cholecystectomy.

Efficacy of laparoscopic-guided transversus abdominis plane block for patients undergoing robotic-assisted gynaecologic surgery: A randomised control trial.

Background and Aims:Transverse abdominis plane (TAP) block has been used regularly as part of multimodal analgesia for caesarean sections and other lower abdominal surgeries. Adequate postoperative analgesia provided with regional blocks allows faster postoperative recovery and better patient satisfaction. In our study, we are comparing the analgesic efficacy of laparoscopic-guided TAP block with port infiltration using a local anaesthetic in patients undergoing gynaecologic robotic surgeries.Methods:After obtaining approval from the hospital ethics committee, Central Trial Registry of India (CTRI) clearance and written informed consent from patients, this prospective double-blinded randomised control trial was conducted on patients undergoing robotic-assisted gynaecologic surgery under general anaesthesia. Group B patients received bilateral TAP block under direct laparoscopic vision with 15 ml of 0.1% ropivacaine on each side and Group C patients received routine port site infiltration with 30 ml of 0.1% ropivacaine. Postoperative pain score was measured till 24 hours, need for rescue analgesics, complications associated were noted. Independent two sample 't' test, Mann Whitney u test, Chi-square and Fisher's exact test were used for statistical analysis.Results:Pain score was significantly lower in Group B patients up to 24h (P < 0.001). The use of rescue analgesic was also significantly less in group B compared to Group C (P < 0.001). No adverse events were noted in both groups.Conclusion:Laparoscopic-guided TAP block is effective and superior to port site infiltration in providing postoperative analgesia in patients undergoing robotic-assisted gynaecologic surgery.

Comparison of ultrasound-guided transversus abdominis plane (TAP) block versus local infiltration during paediatric laparoscopic surgeries.

Background and Aims:The purpose of this study was to compare the analgesic efficacy of ultrasonography-guided transversus abdominis plane (TAP) blocks with local port site infiltration in children undergoing laparoscopic surgeries.Methods:After ethics committee approval and informed consent, 92 children aged 2–12 years posted for laparoscopic surgeries were randomly divided into Group T and Group L. Port site infiltration was performed in Group L by the surgeon at the time of port placement and end of surgery with 0.4mL/kg of 0.25% bupivacaine. Bilateral TAP block was performed in Group T after induction of anaesthesia, under ultrasonographic guidance with a Logiq E7 GE portable ultrasound unit and a linear 5–10 MHz probe. A 22G hypodermic needle and 0.4 mL/kg of 0.25% bupivacaine were used on each side for the TAP block. The parameters recorded were intraoperative haemodynamics, opioid requirements, postoperative pain scores and the need for rescue analgesia in the first 6 h postoperatively.Results:The median (interquartile range) pain scores were significantly lower in the TAP block group than the local infiltration group at 10 min [2 (0–2.5) vs 2 (3–4); P = 0.011], 30 min [1.5 (0–3) vs 3 (2–5);P < 0.001], 1 h [1.5 (0–2) vs 2 (2–3);P < 0.001] and 2 h [2 (0–2) vs 2 (1.5–2.5); P = 0.010] postoperatively. The need for intraoperative opioids and rescue analgesia was also significantly lower in the TAP block group (P < 0.001).Conclusion:TAP block is superior to local infiltration for intra- and immediate postoperative analgesia in paediatric laparoscopic surgeries.

Efficacy of USG-Guided Bilateral Subcostal Tranversus Abdominis Plane Block and Conventional Port Site Infiltration after Laparoscopic Cholecystectomy: A Prospective Randomised Controlled Study

Efficacy of USG-Guided Bilateral Subcostal Tranversus Abdominis Plane Block and Conventional Port Site Infiltration after Laparoscopic Cholecystectomy: A Prospective Randomised Controlled Study

Transversus abdominis plane block under laparoscopic guide versus port-site local anaesthetic infiltration in laparoscopic excision of endometriosis: a double-blind randomised placebo-controlled trial.

To compare the efficiency of laparoscopically guided transversus abdominis plane block (LTAP) versus port-site local anaesthetic infiltration (LAI) in reducing postoperative pain following laparoscopic excision of endometriosis. A prospective, double-blind randomised controlled trial. A tertiary referral centre for endometriosis and minimally invasive gynaecological surgery. Women undergoing laparoscopic excision of endometriosis from December 2015 through July 2016. Participants were randomised to receive: port-site infiltration with bupivacaine and placebo LTAP (LAI group, n=21); placebo port-site infiltration and LTAP with bupivacaine (LTAP group, n=24); placebo port-site infiltration and placebo LTAP (placebo group, n=25). Post-operative pain at 2-4, 6-8, 10-12 and 24hours, analgesic requirements, TAP block-related complications and opioid-related adverse effects. There were no differences in patient characteristics between the groups. In comparison with placebo, both LTAP and LAI groups had significantly less pain at 2-4, 6-8, and 10-12hours (median 3, 3, 3.5 versus 3, 6, 4 versus 8, 8, 7 for LTAP, LAI, and placebo, respectively, P<0.05). Median differences (and 95% confidence intervals) were as follows; LTAP versus placebo -5 (-6 to -4), -4 (-5 to -3), -3 (-4 to -0.5); LAI versus placebo -4 (-5 to -2), -2 (-3 to -0.5), -1 (-4 to -0.5) at 2-4, 6-8 and 10-12hours, respectively. There were no statistically significant differences between the LTAP and LAI groups. Laparoscopically guided transversus abdominis plane block and LAI both reduce postoperative pain in patients undergoing laparoscopic excision of endometriosis, compared with placebo. We found no differences in effect between LTAP and LAI. TAP block and port-site local infiltration are both effective in reducing postoperative pain in major gynaecological laparoscopic surgery.

A Randomized Controlled Trial Depicting Postoperative Pain Score Following Port-site Infiltration during Laparoscopy

A Randomized Controlled Trial Depicting Postoperative Pain Score Following Port-site Infiltration during Laparoscopy

Laparoscopic-Guided Transversus Abdominis Plane (TAP) Block as Part of Multimodal Analgesia in Laparoscopic Roux-en-Y Gastric Bypass Within an Enhanced Recovery After Surgery (ERAS) Program: a Prospective Randomized Clinical Trial.

Despite the ultrasound guidance of transversus abdominis plane (TAP) blocks has allowed greater precision of needle placement in the desired tissue plane, visualization of the abdominal wall muscles can be hindered by morbid obesity and could lead to failed regional anesthesia. The aim of this study was to assess the feasibility and effect of laparoscopic-guided TAP block in patients undergoing Roux-en-Y gastric bypass and to compare it with port-site infiltration. A prospective randomized clinical trial was performed. Patients were randomized into two groups: patients undergoing laparoscopic-guided TAP (TAP-lap) and patients undergoing port-site infiltration (PSI). Pain quantification as measured by visual analogic scale (VAS) and morphine needs during the first 24h were evaluated. One hundred and forty patients were included, 70 in each group. The mean operation time was 83.3 + 15.6min in TAP-lap and 80.5 + 14.4min in PSI (NS). The mean postoperative pain, as measured by VAS, 24h after surgery was 16.8+ 11.2mm in PSI and 10 + 8.1mm in TAP-lap (p = 0.001). Morphine rescues were necessary in 13.2% in PSI and 2.9% in TAP-lap (p = 0.026). The mean hospital stay was 2.1 + 1.2days in TAP-lap and 2.9 + 1.3days in PSI (p = 0.019). Hospital discharge during the first 48h after surgery was possible in 52.9% of the patients in PSI and 71% in TAP-lap (OR 4.75; 95% CI 2.1-10.8; p = 0.029). Laparoscopic-guided TAP block can reduce postoperative pain, opioid needs, and hospital stay, when compared with port-site infiltration with the same anesthetic drug, without increasing operation time. ClinicalTrials.gov Identifier: NCT03203070.

Local infiltration versus laparoscopic-guided transverse abdominis plane block in laparoscopic cholecystectomy: double-blinded randomized control trial.

Transverse abdominal plane block (TAP) is a new technique of regional block described to reduce postoperative pain in laparoscopic cholecystectomy (LC). Recent reports describe an easy technique to deliver local anesthetic agent under laparoscopic guidance. This randomized control trial was designed to compare the effectiveness of additional laparoscopic-guided TAP block against the standard full thickness port site infiltration. 45 patients were randomized in to each arm after excluding emergency LC, conversions, ones with coagulopathy, pregnancy and allergy to local anesthetics. All cases were four ports LC. Interventions-Both groups received standard port site infiltration with 3-5ml of 0.25% bupivacaine. The test group received additional laparoscopic-guided TAP block with 20ml of 0.25% bupivacaine subcostally, between the anterior axillary and mid clavicular lines. As outcome measures the pain score, opioid requirement, episodes of nausea and vomiting and time to mobilize was measured at 6 hourly intervals. The two groups were comparable in the age, gender, body mass index, indication for cholecystectomy difficulty index and surgery duration. The pain score at 6h (P = 0.043) and opioid requirement at 6h (P = 0.026) was higher in the TAP group. These were similar in subsequent assessments. Other secondary outcomes were similar in the two groups. Laparoscopic-guided transverses abdominis plane block using plain bupivacaine does not give an additional pain relief or other favorable outcomes. It can worsen the pain scores. Pre registration: The trial was registered in Sri Lanka clinical trial registry-SLCTR/2016/011 ( http://www.slctr.lk/trials/357 ).

Effects of Port Site Bupivacaine Infiltration to Reduce Post Operative Pain in Laparoscopic Cholecystectomy: A Double Blind Randomized Controlled Trial

Background: Laparoscopic cholecystectomy has become the treatment of choice for symptomatic gall stone disease. But post operative pain may prolong hospital stay and increase morbidity. The aim of the study was to find out the effect of port site infiltration of Bupivacaine in reducing post operative pain following routine laparoscopic cholecystectomy. Materials and methods: This is a double blind randomized controlled trial conducted in the Department of Surgery, Chittagong Medical College Hospital, Bangladesh. A total 200 patients underwent routine laparoscopic cholecystectomy were enrolled in the study. All patients are assigned in two groupscontrol group (Infiltration of 20 ml normal saline at port site) and Bupivacaine group (20 ml Bupivacaine at port site). Both groups are followed at 4 hrs, 12 hrs and 24 hrs after operation to assess the intensity of pain by using Visual Analogue Pain Scale (VAS). Time regarding the first analgesic request by the patients, total dose of analgesic, days of return to normal day to day activities and normal works were also recorded. Results: The mean age of control group and Bupivacaine group were 41.64 and 37.54 years respectively. At 4hrs post operative mean pain score were 6.76 and 5.62 respectively (p value 0.015). At 12 hrs mean pain score were 4.4 and 3.88 respectively (p value 0.001). At 24hrs pain score were 2.66 and 2.08 respectively (p value 0.002). Mean time of first analgesic required were 4.8hrs and 7hrs respectively (p value 0.000). Mean duration of hospital stay were 2.26 days and 2.22 days respectively (p value 0.371). Total dose of analgesic required were 12 and 9 between the groups respectively (p value 0.000). Mean time of return to normal day to days activities were 3.98 days and 2.98 days respectively (p value 0.000). Return to normal work after 6.98 days and 6.46 days respectively between the groups (p value 0.008) that is statistically significant. Conclusion : Infiltration of Bupivacaine at port site at post operative period of laparoscopic cholecystectomy patients significantly reduces pain than control group. It helps patients for early mobilization, early return to normal activities and works. Thus it reduces overall cost and morbidity of symptomatic cholelithiasis patients.&#x0D; JCMCTA 2017 ; 28 (2) : 64-68

Comparison of ultrasound-guided bilateral subcostal transversus abdominis plane block and port-site infiltration with bupivacaine in laparoscopic cholecystectomy.

Background and Aims:Many patients experience moderate-to-severe pain after laparoscopic cholecystectomy. We aimed to compare the efficacy of ultrasound-guided bilateral subcostal transversus abdominis plane (TAP) block with port-site infiltration for post-operative analgesia after laparoscopic cholecystectomy.Methods:Patients undergoing elective laparoscopic cholecystectomy under general anaesthesia were divided into two groups of 40 each to receive ultrasound-guided bilateral subcostal TAP block (T) with 0.25% bupivacaine 20 ml each side or port-site infiltration with 0.5% bupivacaine 5 ml each at 4 ports (I) at the end of the surgery before extubation. All patients received paracetamol 1 g intravenous 8th hourly. Tramadol 1 mg/kg intravenous bolus and diclofenac 1 mg/kg intravenous infusion were used as the first- and second-line rescue analgesics when Numerical Rating Scale (NRS) ≥4, or when the patient complained of pain. NRS at 1, 2, 3, 6, 12 and 24 h after surgery, time to first analgesic request and total dose of analgesics in 24 h were recorded. Chi-square test and independent t-test were used to compare qualitative and quantitative data, respectively.Results:Time to first analgesic (mean±SD) in Group I and Group T was 292.7 ± 67.03 and 510.3 ± 154.55 min and mean tramadol required was141.8 ± 60.01 mg and 48.69 ± 36.14 mg, respectively (P = 0.001 for both). Mean NRS at 2, 3, 6, 12 and 24 h was significantly lower in Group T.Conclusion:Ultrasound-guided bilateral subcostal TAP block provides superior post-operative analgesia after laparoscopic cholecystectomy compared to port-site infiltration.

Ultrasound-guided Combined Fascial Plane Blocks as an Intervention for Pain Management after Laparoscopic Cholecystectomy: A Randomized Control Study.

Background:Pain associated with laparoscopic cholecystectomy is most severe during the first 24 h and the port sites are the most painful. Recent multimodal approaches target incisional pain instead of visceral pain which has led to the emergence of abdominal fascial plane blocks. This study embraces a novel combination of two independently effective fascial plane blocks, namely rectus sheath block and subcostal transversus abdominis plane (TAP) block to alleviate postoperative pain.Study Objective:The aim is to evaluate the effectiveness of the combination of rectus sheath block and subcostal TAP block, to compare its efficacy with that of subcostal TAP block alone and with conventional port site infiltration (PSI) in alleviating postoperative pain in patients undergoing laparoscopic cholecystectomy.Methodology:This prospective, randomized control, pilot study included 61 patients scheduled for elective laparoscopic cholecystectomy and distributed among three groups, namely Group 1: Combined subcostal TAP block with rectus sheath block (n = 20); Group 2: Oblique subcostal TAP block alone (n = 21); and Group 3: PSI group as an active control (n = 20).Results:Combined group had significantly lower pain scores, higher satisfaction scores, and reduced rescue analgesia both in early and late postoperative periods than the conventional PSI group.Conclusion:Ultrasound-guided combined fascial plane blocks is a novel intervention in pain management of patients undergoing laparoscopic cholecystectomy and should become the standard of care.