Research and Opinion in Anesthesia & Intensive Care

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 7  |  Issue : 2  |  Page : 230--234

Transversus abdominis plane block versus simple instillation of local anesthetics in the peritoneal cavity for postoperative analgesia in laparoscopic prostatectomy


Tarek I Ismail 
 Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Helwan University, Helwan, Egypt

Correspondence Address:
MD Tarek I Ismail
52 TIBA Street, Sporting, Alexandria 21617
Egypt

Abstract

Background Laparoscopic radical prostatectomy is minimally invasive technique used to treat cancer prostate. Controlling post-operative pain is one of the main concerns for better post-operative recovery. This study compared the efficacy of ultrasound guided transversus abdominis plane (TAP) block with intraperitoneal instillation of local anesthetics for reduction of postoperative pain after laparoscopic radical prostatectomy. Methods Forty adult patients scheduled for laparoscopic radical prostatectomy were randomized to receive TAP block (group I) or simple instillation of local anesthetics in the peritoneal cavity (group II). The primary outcome was assessing Visual Analogue scale (VAS) during rest and during mobilization. Secondary outcome was measuring total amounts of supplementary morphine consumption. Results There were significant lower pain scores in group II when compared to group I at rest and on movement till the end of the first 24 hours post-operatively. patients undergoing peritoneal block had reduced total amount of 24 h morphine consumption (8±1.9) in comparison to TAB block group (5.8±1). Conclusion Peritoneal block with local anesthetics provides better post-operative analgesia and reduced morphine consumption up to 24 hours after laparoscopic surgery when compared to TAP block.



How to cite this article:
Ismail TI. Transversus abdominis plane block versus simple instillation of local anesthetics in the peritoneal cavity for postoperative analgesia in laparoscopic prostatectomy.Res Opin Anesth Intensive Care 2020;7:230-234


How to cite this URL:
Ismail TI. Transversus abdominis plane block versus simple instillation of local anesthetics in the peritoneal cavity for postoperative analgesia in laparoscopic prostatectomy. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 Aug 11 ];7:230-234
Available from: http://www.roaic.eg.net/text.asp?2020/7/2/230/287986


Full Text

Prostate cancer is one of the most common cancers among men [1]. Radical prostatectomy remains one of the key techniques to treat prostate cancer [2]. Postoperative pain control is an important aspect of postoperative recovery. Laparoscopic surgeries are widely performed procedures that achieve superior outcomes in recovery time, postoperative pain, cosmetic issues, and morbidity [3]. In robotic surgery, the causes of postoperative pain are multiple, among which are; pain at the site of incision, pain owing to stimulation of nerves and release of inflammatory mediators as a result of rapid insufflation of carbon dioxide in the peritoneal cavity [4], shoulder tip pain owing to remaining amount of gas after the procedure, back pain, and upper abdominal pain by diaphragmatic stretching and phrenic nerve irritation [5],[6]. Regional anesthetic techniques such as ultrasound-guided transversus abdominis plane (TAP) block have become increasingly popular for achieving analgesia in laparoscopic abdominal surgery with small incisions. In TAP block, a local anesthetic agent is injected into the plane between the internal oblique and transversus abdominis muscles, making it a novel regional anesthetic technique [7],[8].

The safety and effectiveness of TAP block has been proven in different types of surgeries, especially in lower abdominal surgeries, as it has been associated with faster recovery [9]. Local anesthetics have been administered into the peritoneal cavity during minimally invasive procedures, such as laparoscopic cholecystectomy and gynecological, laparoscopy for sterilization and diagnosis, in addition to open abdominal procedures, such as total abdominal hysterectomy. Blocking of peritoneal visceral nociceptive conduction is the main mechanism of postoperative analgesia following laparoscopic procedures. Absorption of local anesthetics from the large peritoneal surface also occurs, adding more postoperative analgesia [10]. Each technique was evaluated in different surgical procedures in several studies; however, evaluation of both techniques in laparoscopic radical prostatectomy is not extensively studied.

The aim of the study was to compare the efficacy of ultrasound-guided TAP block with intraperitoneal instillation of local anesthetics for reduction of postoperative pain after laparoscopic prostatectomy.

 Patients and methods



The prospective randomized controlled study was implemented after taking approval of Faculty of Medicine, Helwan University Research Ethics Committee. The study included 40 patients. Eligible patients were American Society of Anesthesiologists physical status grades I–III, able to understand and communicate with the anesthetists, and aged between 40 and 80 years. A written consent was obtained from all patients before participation in the study during preoperative evaluation period at the anesthesia clinic.

This study was conducted at Andalusia Al Shallalat Hospital, Alexandria, during November 2018 to May 2019. This hospital is one of the largest medical institutions that provide adequate facilities for this type of operations.

Based on initial pilot study, the mean 24-h morphine consumption after laparoscopic prostatectomy using ultrasound-guided TAP block was 8.2 mg with SD 2.57, and using simple instillation of local anesthetics in the peritoneal cavity was 6 mg, with SD 1.15. The minimum required sample size is 14 patients for each group, using alpha error=5% and study power of 80%. The sample was calculated using G. Power statistical software (Version 3.1.9.7). However, the number of patients in each group will be increased to 20 patients.

Patients with overweight (BMI>35), chronic opioid use (>3 months), hepatic or renal failure, allergy to any of the drug used in this study, and history of any psychiatric disease that could affect perception of pain or communication with the medical staff were excluded from the study

Patients were randomly assigned to TAP group, which included patients receiving TAP block for management of postoperative pain, and local instillation (LI) group, which included patients receiving intraperitoneal instillation of local anesthetic agents for relief of pain using a computer-generated table of random numbers. Group allocation was concealed using a sequentially numbered, sealed opaque envelope, which was opened only by the attending anesthesiologist immediately before the procedure.

All patients were subjected to surgery under general anesthesia with endotracheal intubation.

Inside the operating room, intravenous access was obtained, monitor was connected, and baseline noninvasive blood pressure, heart rate, ECG, and pulse oximetry (SpO2) were obtained. The induction of anesthesia was done using intravenous midazolam 0.02 mg/kg, propofol 2 mg/kg, and fentanyl 3 µg/kg. The intubation was done with standard size endotracheal tube (suitable for the patient) after relaxation provided by atracurium besylate 0.5 mg/kg body weight intravenously. Anesthesia was maintained with 50 : 50 oxygen mixed with air, and isoflurane 1–1.5%. Intraoperative monitoring of ECG, heart rate, noninvasive blood pressure, SpO2, capnograph, and nasopharyngeal temperature was continued throughout the operation. At the end of surgery and before awaking the patient from general anesthesia, TAP group (n=20) received bilateral TAP block with 20 ml of 0.25% bupivacaine on each side by Mid-axillary approach under ultrasound guidance with portable ultrasound machine (Mindray, MEC-2000, China) with 5–10 Mhz linear group. With the patient in supine position, under aseptic conditions, the probe was placed transversely between the iliac crest and costal margin. A long peripheral nerve stimulating needle, 22 G, 8 cm, was advanced in-plane.

After visualization of the tip of the needle reaching the plane, careful aspiration was done to exclude vascular puncture, and then a test dose of 2 ml of anesthetic solution was injected to view the hydrodissection, confirming the correct placement. Following this, the total volume of drug was instilled, creating a meniscus between the planes. The LI group (n=20) received 200-mg bupivacaine in 100 ml volume through abdominal port by simple instillation technique, and this was followed by clamping the abdominal drains for nearly 1 h to avoid drainage of the local anesthetics from the abdominal cavity. After awaking from general anesthesia, patients were transferred to the postanesthesia care unit. A standardized postoperative analgesic regimen consisted of regular intravenous acetaminophen 1 g every 6 h and combined with intravenous ketorolac 30 mg at 8 h interval. Visual analog score (VAS) from 1 to 10 was recorded by a blinded investigator at 1, 3, 6, 12, 18, and 24 h during rest and during mobilization (knee flexion). Patients with VAS score more than 4 at any point of time received 0.05 mg/kg intravenous bolus rescue morphine. The nurse also calculated the total amount of the first 24-h morphine consumption. The primary outcome measure in this study was VAS score. Secondary outcome measure was 24-h morphine consumption.

Statistical analyses

Statistical analyses were performed using SPSS (version 21). Demographic data were analyzed using Student t or Fisher’s exact test as appropriate.

The data were tested for normality using the Kolmogorov–Smirnov normality test. Repeated measurements (pain scores) were analyzed by repeated measures analysis of variance where normally distributed, with further paired comparisons at each time interval performed using the t test. For non-normally distributed data, between-group comparisons at each time point were made using Wilcoxon’s ranked sum test. Categorical data were analyzed using the c2 analysis or Fisher’s exact test. Data are presented as mean and SD, and categorical data are presented as raw data and frequencies. The level for all analyses was set as P value of 0.05.

 Results



There was no statistical difference in age of patients, mean BMI, and American Society of Anesthesiologist grades of both groups ([Table 1]).{Table 1}

[Table 2] showed no statistically significant difference between the two groups in VAS score at rest measured at 1 and 3 h. However, in group II, VAS score at rest and measured at 6, 12, 18, and 24 h after surgery showed significant decrease when compared with group I (P<0.05) ([Figure 1]).{Table 2}{Figure 1}

In the same way, in group II, when VAS score at mobilization was measured at 6, 12, 18, and 24 h after surgery, it showed statistically significant decrease when compared with group I (P<0.05) ([Table 3] and [Figure 2]).{Table 3}{Figure 2}

[Table 4] demonstrated that patients undergoing peritoneal block had reduced total amount of 24 h morphine consumption (5.8±1) in comparison with TAB block group (8±1.9); this result was found to be statistically significant (P<0.05).{Table 4}

 Discussion



Cancer prostate is a worldwide problem among men. Laparoscopic radical prostatectomy is minimally invasive technique that is associated with mild to moderate pain [11]. This pain was adequately controlled primarily with NSAIDs and opioids [12]. Opioids, however, may delay recovery and affect the overall outcome owing to opioid undesired adverse effects such as nausea, vomiting, respiratory depression, and delayed return of bowel movement. Thus, other alternatives such as nonopioid analgesics combined with regional techniques should be used and supplemented with opioids only in need [13].

The study evaluated two different analgesic regimens on postoperative pain following laparoscopic radical prostatectomy. TAP block is a promising effective method for postoperative pain control after abdominal surgeries. Successful results with minimal complications were achieved with ultrasound-guided TAP block, making it a safe and effective postoperative analgesic modality in many surgical procedures [14]. Instillation of local anesthetics into the peritoneal cavity is also a successful analgesic modality during some intra-abdominal procedures [15].

For both techniques, the main advantage is that they do not have the adverse effects of opioids, which may delay recovery and cause prolonged stay in the hospital. Pain associated with any laparoscopic procedure is either somatic pain owing to surgical incision (at the port sites), visceral pain secondary to tissue dissection, and shoulder pain secondary to irritation of the diaphragm by the pneumoperitoneum [16]. The influence and intensity of these three types of pain are different. Visceral pain during laparoscopic surgeries is considered the main cause of postoperative pain with minimal influence of the other two types [17]. Efficacy of TAP block is expected when there is predominance of somatic pain over visceral pain as in most open surgical procedures, but when visceral pain is the main cause of pain, as in laparoscopic procedures, TAP block would be less efficient [18].

Intraperitoneal local anesthetics adequately block visceral nociceptive conduction after laparoscopic procedures, but they do not block afferent nociceptive transmission from cutaneous sites [16],[19].

Our primary aim was evaluating postoperative pain during rest and mobilization. VAS scale for pain assessment was used because it was considered as the gold standard for pain assessment [17],[20].

Until 3 h postoperatively, there was no significance difference between the two groups. However, after that, there were significant lower pain scores in group II when compared with group I at rest and on movement till the end of the first 24 h postoperatively.

The efficacy of peritoneal block to provide excellent analgesia was confirmed again through demonstration of 24-h supplementary morphine consumption. The peritoneal block significantly reduced 24-h morphine consumption when compared with TAP group. The superiority of peritoneal block could be explained that open surgical procedures are associated with undesirable pain that arise mainly from the anterior abdominal wall. The sensory supply of anterior abdominal wall is derived from lower six thoracic and first lumbar nerves, which course through the transversus abdominis facial plane, so deposition of local anesthetic solutions in that plane (TAP block) results in sensory block of the anterior abdominal wall mainly [18],[21]. On the contrary, laparoscopic procedures were associated mainly with visceral nociceptive pain with minimal pain from cutaneous sites.

The topical application of local anesthetics to the viscera induces superior analgesic effect by blocking visceral nociception from the peritoneum and the area of surgical tissue excision. Moreover, systemic absorption of local anesthetic through the peritoneal surface may be another reason for nociception attenuation [22]. For most studies, during laparoscopic surgeries, visceral pain is responsible for a large portion of abdominal pain when compared with parietal pain [23]. In the present study, parietal pain was a lesser component of pain; it was induced by trocar incisions, and it was minimal and adequately controlled by the use of NSAID and acetaminophen in each group. As a consequence, pain intensity might be too low to detect a significant analgesic effect of a TAP block [24]. Using both techniques together would lead to better postoperative pain relief with simple analgesics and minimal opioid consumption.

Kahokehr et al. [25] agreed with the results of the current study; they concluded from their meta-analysis that intraperitoneal local anesthetics reduces early postoperative pain and opioid consumption following general laparoscopic surgeries. Similarly, Chin et al. [17] demonstrated in their work that patients complained more of visceral pain than of parietal pain during laparoscopic surgeries, and TAP block did not affect visceral pain transmitted by sympathetic nerves. Kane et al. [26] also described limited overall effect of TAP block on analgesic outcome in laparoscopic surgical procedures. On the contrary, the results of Joris et al. [16] did not match the results of the present study. They showed that intraperitoneal bupivacaine was not effective for treating any type of pain after laparoscopic cholecystectomy.

 Conclusion



Peritoneal block with local anesthetics provides better postoperative analgesia and less opioid requirement up to 24 h after laparoscopic radical prostatectomy when compared with TAP block. Further studies to evaluate the influence of using both techniques together on postoperative pain are recommended.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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