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TAP Block in Lap Cholecystectomy

MAterIAls And Methods 38.84 ± 2.67 years. There was no significant difference seen in
This is a comparative study conducted at St Joseph Hospital, the duration of surgery and time taken for return to normal
activity in both the groups. Mean hospital stay was significantly
Ghaziabad from October 2019 to March 2020. All cases of less for group I patients as compared with group II (Table 1).
symptomatic cholelithiasis aged between 18 years and 65 years The mean VAS score of patients in group I at 3, 6, and
and American Society of Anesthesiologists (ASA) class I and II 12 hours was significantly low as compared with group II, and
were included in the study and underwent elective laparoscopic the requirement of rescue analgesia was also significantly less in
cholecystectomy. Patients of ASA class III, IV, and V and patients group I. At 24 and 48 hours, there was no significant difference in
with coagulopathies, liver or renal failure, choledocholithiasis, pain intensity in both the groups (Table 2).
intraoperative drain placement, post-ERCP, surgery duration more
than two hours, previous upper abdominal surgeries, conversion to
open cholecystectomy, and difficult extraction of gallbladder were dIscussIon
excluded from the study. A total of 154 patients participated in the Laparoscopic cholecystectomy is the gold standard procedure
study and were randomized into two groups of 77 patients each for symptomatic cholelithiasis and most commonly performed
1
using a computerized random number table. Informed consent was laparoscopic procedure worldwide. Though the pain,
obtained from the patients. All patients underwent standard four- discomfort, and duration of stay after minimally invasive
port laparoscopic cholecystectomy performed by a single team of procedure are less as compared to open technique, but early
surgeons experienced in laparoscopic surgeries. Pneumoperitoneum postoperative pain after laparoscopic cholecystectomy is still
was maintained at 12 to 14 mmHg. The gallbladder was delivered prevalent and it may increase patient stay and discomfort
through epigastric port in all patients. Group I received TAP block following surgery. 1–3
under laparoscopy guidance in which TAP block using 0.25% There are various factors responsible for the pain after
bupivacaine was instilled using a 23-gauge needle at following laparoscopic cholecystectomy. It may arise from incision site
4 points, bilateral subcostal infiltration between anterior axillary line (somatic pain), from gallbladder bed (visceral pain), or may be due
and midclavicular line (10 mL each), and bilaterally just above the iliac to stretching caused by pneumoperitoneum. 2
crest in midaxillary line (15 mL each). Direct visualization of needle Many studies and researches had been conducted in the
and the bulge with the laparoscope confirmed the proper instillation last 30 years for the pain management after laparoscopic
of drug in the plane containing thin fibers of transversus abdominis cholecystectomy. Various methods like infiltration of local
muscle (Fig. 1). Group II patients received 20 mL 0.25% bupivacaine
divided into 6 mL each for umbilical and epigastric port and 4 mL each
for right midclavicular line and anterior axillary line port, respectively, Table 1: Patients characteristics, other intraoperative and postoperative
and infiltrated in the subcutaneous plane before closure. All patients factors
in both groups received 50 mg tramadol injection in the immediate TAP block Bupivacaine
postoperative period as standard protocol. group (group I) group (group II)
Pain intensity was recorded by the same team using a visual Intraoperative factors n = 77 n = 77 p value
analogue scoring (VAS) system at intervals of 3, 6, 12, 24, and Mean age (years) 39.54 ± 3.23 38.48.2 ± 2.55 0.89 (NS)
48 hours, respectively. Intramuscular diclofenac sodium 75 mg was Sex
used as rescue analgesia for patients with VAS score >5. Male 8 (10.38%) 10 (12.98%) 0.94 (NS)
Data analysis was performed using the Statistical Package for Female 69 (89.62%) 67 (87.02%) 0.85 (NS)
Social Sciences Version 17.0 software (SPSS Inc.; Chicago, IL, USA). Mean duration of 50.45 ± 3.6 52.63 ± 4.5 0.78 (NS)
A p-value <0.05 was considered statistically significant. surgery (minutes)
Mean duration of stay 1.55 ± 0.56 2.2 ± 0.68 0.022(HS)
results in hospital (days) 3.23 ± 1.56 3.55 ± 1.07 0.21(NS)
Return to routine
A total of 154 patients underwent laparoscopic cholecystectomy activities (days)
out of which 136 were females. The average age of patients was TAP, transversus abdominis plane block; NS, nonsignificant; HS, highly
significant

Table 2: Comparative analysis of postoperative pain using VAS (visual
analog scoring) and requirement of rescue analgesia
TAP block Bupivacaine
Time interval (hr) group (group I) group (group II) p value
3 1.38 ± 0.23 3.83 ± 0.76 <0.001(HS)
6 2.12 ± 0.54 3.45 ± 0.30 <0.001 (HS)
12 2.01 ± 0.87 3.67 ± 1.20 <0.001 (HS)
24 2.65 ± 1.53 2.14 ± 1.11 0.65 (NS)
48 1.56 ± 0.56 1.69 ± 0.79 0.89 (NS)
Requirement of
rescue analgesia (n) 12 22 0.012 (HS)
TAP, transversus abdominis plane block; NS, nonsignificant; HS, highly
Fig. 1: Laparoscopic-assisted TAP block significant

88 World Journal of Laparoscopic Surgery, Volume 14 Issue 2 (May–August 2021)