Pre-incision Versus Lapaorscopic-assisted Transversus Abdominis Plane (TAP) and Rectus Sheath Block for Post-Cholecystectomy Pain Management: A Randomized Controlled Trial

INTRODUCTION:

Every year Over 13 million Laparoscopic procedures are performed globally. In the USA, 90% of the cholecystectomies are performed with the laparoscopic technique

• Laparoscopic cholecystectomy is the gold standard in many health centers as it is less invasive compared to open cholecystectomy.
• Good post-operative pain control, not only prevents post-operative complications but is also essential for early ambulation and return to daily routine. It is important to keep side effects minimum besides pain relieve. Therefore pre-emptive wound analgesia has been popularized. Preemptive analgesia(for eg: TAP block) is defined as an anti-nociceptive treatment that is initiated before the surgical procedure in order to reduce the sensitization (occurs because of transmission of pain signals evoked by tissue damage) of the peripheral and central pain pathways. Some analyses have shown no beneficial effect(4) whereas some have failed to reach a final conclusion regarding efficacy of pre-emptive analgesia.
• For post-laparoscopic pain management ,a multimodal approach with non-steroidal anti-inflammatory drugs, opioids and loco-regional techniques have been recommended . The Transversus Abdominis Plane (TAP) block is an analgesia technique that is loco-regional ,consists of infiltrating a local anesthetic solution between the plane of the Transversus abdominis muscle and the internal oblique muscle.
• TAP block has gradually become an alternative postoperative analgesia technology and it was described in 2001 by Rafi. . Several techniques are currently used to deliver TAP blocks, including blinded double pop technique, ultrasound-guided and laparoscopic-assisted approaches. The latter was first described in 2011 by Chetwood et al. while performing laparoscopic nephrectomies . The advantages of this technique include ease of performance, less dependency on specialized skill set or equipment, time efficient, less risk of visceral injury and avoidance of intraperitoneal local anaesthetic infiltration .

RATIONALE: Many studies have demonstrated the therapeutic benefit of laparoscopic-assisted TAP block in initial post-operative pain management in comparision with periportal local anaesthetic infiltration for patients undergoing elective laparoscopic procedures(for eg; for laparoscopic hernia repair). To the best of our knowledge, there is a paucity of data since laparoscopic-assisted TAP block has not been utilized or evaluated prospectively to see if the effectiveness of TAP block varies according to whether it is performed pre-incisional (pre emptive) or intraoperatively under Laparoscopic vision for laparoscopic cholecystectomies. Moreover, the rectus sheath block in conjunction with TAP block has not been evaluated before.

OBJECTIVE :