Laparoscopic Cholecystectomy Clinical Trial
Official title:
Analgesic Efficacy of Ultrasound-guided Quadratus Lumborum Block Versus Transversus Abdominis Plane Block in Laparoscopic Cholecystectomy
In laparoscopic cholecystectomy, overall pain is a conglomerate of three different and
clinically separate components: incisional pain (somatic pain) due to trocar insertion sites,
visceral pain (deep intra abdominal pain), and shoulder pain due to peritoneal stretching and
diaphragmatic irritation associated with carbon dioxide insufflation. Moreover, it has been
hypothesized that intense acute pain after laparoscopic cholecystectomy may predict
development of chronic pain (e.g., postlaparoscopic cholecystectomy syndrome). Without
effective treatment, this ongoing pain may delay recovery, mandate inpatient admission, and
thereby increase the cost of such care.
Recently, the uses of peripheral axial blocks that deliver local anesthetic into the
transversus abdominis fascial plane have become popular for operations that involve
incision(s) of the abdominal wall. Thus, the Transversus Abdominis plane (TAP) block has been
shown to reduce perioperative opioid use in elective abdominal surgery, including open
appendicectomy, laparotomy, and laparoscopic cholecystectomy. However, the efficacy of the
TAP block is reportedly only reliable in providing analgesia below the umbilicus. The
ultrasound-guided subcostal transversus abdominis (STA) block is a recently described
variation on the TAP block which produces reliable supraumbilical analgesia. Deposition of
local anesthetic in this plane has shown to block dermatomes T6 to T10 with an occasional
spread to T12. This variant will be discussed in our study.
Currently, the Quadratus Lumborum block (QL block) is performed as one of the perioperative
pain management procedures for all generations (pediatrics, pregnant, and adult) undergoing
abdominal surgery. The local anesthetic injected via the approach of the posterior QL block (
QL 2 block ) can more easily extend beyond the TAP to the thoracic paravertebral space or the
thoracolumbar plane, the posterior QL block entails a broader sensory-level analgesic and may
generate analgesia from T7 to L1. Use of posterior QL block in laparoscopic cholecystectomy
has not been investigated before and it is the variant that will be discussed in our study.
The aim of this study is to compare the analgesic efficacy of ultrasound guided posterior
quadratus lumborum block and subcostal transversus abdominis plane block in laparoscopic
cholecystectomy. The primary outcome will be assessment of postoperative opioid analgesic
requirements. The secondary outcomes will include assessing intraoperative analgesic
requirements, stress of trocar insertion and insufflation, postoperative visual analogue
scale (VAS), length of stay at post-anesthesia care unit (PACU), time of first request to
analgesia, incidence of nausea, and vomiting.
The study will hypothesize that quadratus lumborum block will be more superior than or equal
to transversus abdominis block because it could cover all the dermatome segments from
caudally L1 to cranially till T6 segments as the drug is expected to travel from the QL to
the higher paravertebral spaces.
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