Novel external oblique muscle plane block for blockade of the lateral abdominal wall: a pilot study on volunteers

Comparison of Analgesic Method in Laparoscopic Gastrectomy Using External Oblique Intercostal Block Versus Wound Infiltration: A Randomized Controlled Trial

Background: External oblique intercostal block (EOIB) is effective in relieving pain in the T6 to T10 dermatomes; however, there is limited evidence comparing EOIB with conventional regional anesthesia. In this randomized controlled trial, it was hypothesized that EOIB would provide more effective analgesia than wound infiltration (WI) in laparoscopic gastrectomy. Methods: Thirty-two patients (aged 20-85 years) with American Society of Anesthesiologists Performance Status of 1 to 2, scheduled for laparoscopic gastrectomy, were randomly divided into EOIB and WI groups. Both procedures were performed using 40 mL of 0.25% levobupivacaine. The primary outcome was the numerical rating scale (NRS) score 12 h postoperatively. Secondary outcomes were NRS at 2, 24, and 48 h postoperatively, variation in quality of recovery-15 score on postoperative days 1 and 2 from preoperative baseline, postoperative fentanyl consumption, and variation in World Health Organization Disability Assessment Scale 2.0 scores between baseline and 3 months postoperatively. Plasma concentrations of levobupivacaine and pinprick sensation in the T4-11 dermatomes post-EOIB were evaluated to determine the exploratory endpoints. Results: There were no differences in the NRS scores 12 h postoperatively at rest and during movement between the EOIB and WI groups (mean standard deviation 1.3 [1.1] vs. 1.5 [1.4] and 3.1 [1.6] vs. 3.8 [1.7], respectively). Secondary outcomes did not differ significantly between the groups. The time to peak plasma concentration of levobupivacaine following EOIB was 45 min. Conclusions: No significant differences in NRS scores were observed between the analgesic effects of EOIB and WI at 12 h postoperatively.

The key to success in blocking lateral cutaneous branches with re-modified thoracoabdominal nerves block through perichondrial approach: a newly discovered space between the endothoracic fascia, diaphragm, and costodiaphragmatic recess

PURPOSE

This study aimed to determine whether the administration of a modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) could result in the blockade of the lateral cutaneous branches. This study focused on a newly discovered anatomical space/plane adjacent to the M-TAPA plane, which we termed "space between the endothoracic fascia, diaphragm, and costodiaphragmatic recess: SEDIC."

METHODS

Thirteen sides of nine formalin-embalmed cadavers were macroscopically dissected to investigate the anatomical spaces related to the effects of M-TAPA. Furthermore, ten adult volunteers were administered 20 mL of 0.2% ropivacaine into the abdominal plane (corresponding to the M-TAPA plane) and the SEDIC, and a pinprick test was performed 1 h after the injection.

RESULTS

Cadaver macrodissection revealed the presence of the SEDIC adjacent to the M-TAPA plane. The SEDIC was completely spatially isolated from the M-TAPA plane by the presence of costal cartilage and/or tendinous structures. In the volunteer study, the administration of local anesthetics into the SEDIC effectively blocked the lateral cutaneous branches of T8-T12, in addition to the anterior branches.

CONCLUSION

Our study revealed the presence of the SEDIC adjacent to the M-TAPA plane. Administration of local anesthetics into the SEDIC, named re-modified TAPA, may have the potential to enhance the analgesic effect in the abdominal region.

Comparison of Quality of Recovery between Modified Thoracoabdominal Nerves Block through Perichondrial Approach versus Oblique Subcostal Transversus Abdominis Plane Block in Patients Undergoing Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial

Modified thoracoabdominal nerves block through a perichondrial approach (M-TAPA) provides a wide analgesic range. Herein, we examined the quality of recovery (QoR) of M-TAPA for total laparoscopic hysterectomy (TLH) compared with oblique subcostal transversus abdominis plane block (OSTAPB) and measured plasma levobupivacaine concentrations (PClevo). Forty female patients undergoing TLH were randomized to each group. Nerve blocks were performed bilaterally with 25 mL of 0.25% levobupivacaine administered per side. The primary outcome was changes in QoR-15 scores on postoperative days (POD) 1 and 2 from the preoperative baseline. The main secondary outcomes were PClevo at 15, 30, 45, 60, and 120 min after performing nerve block. Group differences (M-TAPA-OSTAPB) in mean changes from baseline in QoR-15 scores on POD 1 and 2 were -11.3 (95% confidence interval (CI), -24.9 to 2.4, p = 0.104; standard deviation (SD), 22.8) and -7.0 (95% CI, -20.5 to 6.6, p = 0.307; SD, 18.7), respectively. Changes in PClevo were similar in both groups. The post hoc analysis using Bayesian statistics revealed that posterior probabilities of M-TAPA being clinically more effective than OSTAPB were up to 22.4 and 24.4% for POD 1 and 2, respectively. In conclusion, M-TAPA may not be superior to OSTAPB for TLH.

Ultrasound-guided external oblique and rectus abdominis plane "EXORA" block for postoperative pain after laparoscopic cholecystectomy: a propensity-matched study

BACKGROUND

Various types of plane blocks are used for analgesia in the upper abdomen. The purpose of this study was to evaluate the efficacy of the external oblique and rectus abdominis plane (EXORA) block for antero-lateral upper abdominal analgesia.

METHODS

This study included 60 patients undergoing laparoscopic cholecystectomy. Patients were divided into control group, intravenous patient-controlled analgesia (IV.PCA) (N.=30) and EXORA group (block with 25 mL 0.25% bupivacaine + IV.PCA [N.=30]). Postoperative pain (at rest) was evaluated at 30 minutes, two, four, six, 12 and 24 hours using Visual Analogue Scale (VAS) scores. Postoperative activity pain at two, four, six, 12 and 24 hours was also assessed using VAS. Secondary outcomes included tramadol use at 12 and 24 hours after surgery, side effect profile, dermatomal spread, and additional analgesic use.

RESULTS

The VAS scores were statistically significantly lower in the EXORA group compared to the other groups (P<0.001). In addition, mean tramadol consumption at 12 and 24 hours was statistically significantly lower in the EXORA group (P<0.001). Sensory block was recorded in the lateral and anterior abdomen at T6 to T11 after EXORA block application.

CONCLUSIONS

The EXORA block used to provide analgesia after laparoscopic cholecystectomy provides analgesia to the upper abdominal wall. Further data may be obtained from cadaveric studies and other studies.

Clinical Experience for Modified Thoracoabdominal Nerve Block Through Perichondrial Approach (M-TAPA) in Five Patients. Dermatomal Evaluation and Application of Different Volumes: A Case Series and Review of Literature

Thoracoabdominal nerves block through perichondrial approach (TAPA) is a novel block and provides abdominal analgesia. TAPA block targets the both anterior and the lateral branches of the thoracoabdominal nerves. Modified-TAPA (M-TAPA) was defined due to the need for blocking certain dermatomes depending on the surgical incision sites. In the literature, the knowledge about the efficiency and dermatomal coverage of M-TAPA is limited. In this case series, we want to report our experiences with this issue.

External oblique muscle plane blocks in combination with modified thoracoabdominal nerves block through perichondrial approach for analgesia in abdominal surgery: A case report

The costal and lateral external oblique muscle plane (EXOP) blocks anesthetize the lateral cutaneous branches, whereas the modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) anesthetizes the anterior branches of the thoracoabdominal nerves. Herein, we report two cases of successful perioperative pain management with the combination of these blocks: case 1 was a 67-year-old man who underwent open cholecystectomy and case 2 was a 38-year-old woman who underwent emergency laparoscopic surgery for strangulation ileus. Both patients were administered the costal and/or lateral EXOP blocks along with bilateral M-TAPA for perioperative analgesia. A pin-prick test performed 1 h after surgery revealed that the cutaneous sensory block covered all areas of the abdominal surgical field. Combined use of these blocks can be a new local analgesic strategy for abdominal surgery.

Analgesic efficacy of modified thoracoabdominal nerves block through the perichondrial approach in laparoscopic cholecystectomy: A retrospective study with propensity analysis

Modified thoracoabdominal nerves block through the perichondral approach (M-TAPA) was recently reported to provide broad analgesia with only a single injection of local anesthetics (LA) on each side. However, the effectiveness of M-TAPA in laparoscopic cholecystectomy (LC) is not often reported. We retrospectively evaluated the analgesic efficacy of M-TAPA in patients who underwent LC and compared it with conventional LA infiltration (LAI) by calculating the propensity score. The primary outcome was the frequency of analgesic use after surgery. Although there was no difference in the frequency of analgesic use within 48 hours (P = .063), there was significantly less analgesic use 24-48 hours after surgery in the TAPA group (P = .02). Intraoperative remifentanil administration also significantly decreased in the TAPA group (P < .001). We found that pre-incisional M-TAPA may have an advantage over LAI with respect to analgesia on postoperative day 1.

Modified thoracoabdominal nerve block through perichondrial approach (M-TAPA) vs local infiltration for pain management after laparoscopic cholecystectomy surgery: a randomized study

PURPOSE

Modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) targets thoracoabdominal nerves. Our primary aim was to compare M-TAPA vs local infiltration on pain management in patients underwent laparoscopic cholecystectomy (LC) surgery.

METHODS

Patients with ASA class I-II patients aged between 18 and 65 years scheduled for elective LC under general anesthesia were enrolled in the study. There were two randomized groups: Group M: M-TAPA group (n = 30) and the local infiltration (LI) group (n = 30). M-TAPA was performed with totally 40 ml 0.25% bupivacaine in the M group. LI was performed in infiltration group. The primary outcome of the study was pain score in the PACU, the secondary outcomes were the patient satisfaction scores, rescue analgesic need, and adverse effects during the 24-h postoperative period.

RESULTS

The static NRS scores were significantly lower in Group M at the postoperative first 4 h (p = 0.001). There was a significant decrease in the dynamic NRS scores in Group M at the postoperative first 16 h (p = 0.001). The incidence of nausea was significantly higher in the LI group (12 vs. 5 patients, p = 0.047). The need for rescue analgesia was significantly lower in Group M (p = 0.009). The patient satisfaction scores were significantly higher in Group M (p = 0.001).

CONCLUSION

M-TAPA provides superior analgesia compared to LI in patients undergoing LC.