Effect of ultrasound-guided transversus abdominis plane block with rectus sheath block on patients undergoing laparoscopyassisted radical resection of rectal cancer: A randomized, double-blind, placebocontrolled trial

- Effect of ultrasound-guided transversus abdominis plane block with rectus sheath block on patients undergoing laparoscopy- assisted radical resection of rectal cancer: a randomized, double-blind, placebo-.
- Clinicians have used ultrasound- guided posterior transversus abdominis plane block (TAPB) and rectus sheath block (RSB) for multimodal analgesia after surgery.
- We investigated the analgesic effects of US-guided posterior TAPB with RSB on postoperative pain following laparoscopy-assisted radical resection of early-stage rectal cancer..
- Patients were randomized into 3 groups: the TR Group underwent US- guided bilateral posterior TAPB (40 mL 0.33% ropivacaine) with RSB (20 mL 0.33% ropivacaine).
- the T Group underwent US-guided bilateral posterior TAPB alone.
- and the Control Group received saline alone.
- Results: The three groups had no significant differences in baseline demographic and perioperative data, use of intraoperative medications, recovery parameters, and adverse effects.
- postoperative use of PCIA and rescue analgesic than in the other two groups ( P <.
- Conclusions: Postoperative US-guided posterior TAPB with RSB reduced postoperative opioid use in patients following laparoscopy-assisted radical resection of rectal cancer..
- Keywords: Ultrasound, Transversus abdominis plane, Rectus sheath, Sufentanil, Rectal cancer.
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- Colorectal cancer is one of the most common tumors and is a leading cause of cancer-related deaths world- wide [1].
- Because of the increasing incidence of rectal cancer and the improved rates of recovery after surgery, laparoscopy-assisted radical resection of early-stage rec- tal cancer has become more common [2].
- Although laparoscopy reduces the size of the operative incision, many patients complain of postoperative pain.
- may increase the duration of the hospital stay and reduce patient satisfaction [4]..
- There has been an increasing use of ultrasound (US) technologies, and US-guided peripheral nerve block has become a fundamental part of postoperative multimodal analgesia.
- US-guided posterior transversus abdominis plane block (TAPB) and US-guided rectus sheath block (RSB) have been used during abdominal surgeries, and previous studies indicated that they provide potent anal- gesic effects [5–7].
- Currently, there is limited evidence in the literature to support the use of US-guided poster- ior TAPB combined with RSB..
- The aim of this study is to evaluate the efficacy of US- guided posterior TAPB with or without RSB in postopera- tive pain management for patients following laparoscopy- assisted radical resection of rectal cancer..
- This randomized, double-blinded, placebo-controlled trial was performed following approval of the ethics committee of the Liaocheng People’s Hospital.
- The trial was registered with chictr.org before enrollment of the first participant (Trial registration: ChiCTR, ChiCTR2000029326..
- Two days before surgery, random numbers that were generated by SPSS were used to assign equal numbers of eligible participants to one of the three groups.
- The TR Group received US-guided bilateral posterior TAPB with 40 mL of 0.33% ropivacaine and RSB with 20 mL of 0.33% ropivacaine.
- the T Group received US-guided bi- lateral posterior TAPB with 40 mL of 0.33% ropivacaine and RSB with 20 mL of 0.9% normal saline.
- the Control Group received US-guided bilateral posterior TAPB with 40 mL of 0.9% normal saline and RSB with 20 mL of 0.9% normal saline.
- Randomized results were kept in a sealed envelope and relayed to an independent nurse anesthetist who prepared the drug or placebo on the morning of the operation.
- The remainder of the clinicians, the main anesthesiologist, and the anesthesiologist who administered the TAPB were all blinded to the group allocations..
- of the baseline value, sevoflurane and remifentanil were continuously adjusted.
- IV cisatracurium (0.03 mg/kg) was added hourly until the end of the operation..
- (iii) 3 to 4 cm above the cross point of the right clavicular midline and the umbilicus intersection.
- point of the line between the left anterior superior iliac spine and umbilicus.
- US-guided TAPB and RSB.
- After removal of the tracheal tube, TAPB was performed immediately by a qualified anesthesiologist using US guidance (SonoSite S-Nerve Ultrasound System) and a broadband (4 to 13 MHz) linear array ultrasound probe..
- For the posterior approach, the probe was placed trans- versely in the midaxillary line between the iliac crest and the costal margin [8].
- When the tip of the needle was in the TAP, 2 mL of normal saline was injected to adjust its position..
- Next, RSB was performed on both sides of the linea alba under US-guidance [7].
- For the RSB, the probe was placed transversely on the rectus abdominis and the nee- dle was inserted using US guidance until the tip was in the plane between the rectus abdominis and the poster- ior sheath of the rectus abdominis [9].
- Patients in the TR Group received 20 mL of 0.33% ropivacaine, and pa- tients in the T Group and Control Group received 20 mL of 0.9% normal saline.
- The procedure was divided into 3 or 4 injection sites on the left and right sides of the surgical site to prevent the rectus abdominis tendon from blocking the spread of the drug (Fig.
- Sufentanil was used for PCIA, which was initiated in the post-anesthesia care unit (PACU).
- We therefore ana- lyzed data of the remaining 78 patients.
- In addition, none of the patients required a change of analgesic..
- The Control Group and T Group had no significant differ- ence in use of postoperative sufentanil (P >.
- The three groups had no significant differences in any of the measured recovery parameters (P >.
- 0.05, Table 4) and no differences in the incidences of sufentanil-associated ad- verse effects (P >.
- None of the patients ex- perienced respiratory depression (P >.
- 5 Postoperative sufentanil use in the three groups.
- T Group Table 1 Demographic and perioperative characteristics of the three groups.
- First, pa- tients who received laparoscopy-assisted radical resection of early-stage rectal cancer had significantly reduced use of postoperative PCIA and rescue analgesia when they re- ceived US-guided TAPB with RSB.
- Second, there were no significant differences in the use of postoperative PCIA for groups who received US-guided posterior TAPB with RSB and TAPB alone..
- Multimodal analgesia, including US-guided peripheral nerve block, has proven safety and effectiveness for pain management [17–19].
- For example, a retrospective study of 43 patients undergoing laparoscopic colectomy showed that the combination of US-guided TAP and RSB significantly reduced the use of continuous intravenous fentanyl after surgery [20].
- observed 55 patients with cirrhosis who re- ceived liver surgery and found that repeated US-guided TAPB and RSB (0.2 mL/kg of 0.25% bupivacaine, every 8 h for 48 h) significantly reduced the use of opioids after sur- gery [19].
- observed 40 patients undergoing upper abdominal surgery (hepatectomy or Whipple procedure) and found that US-guided bilateral TAPB and RSB (20 mL of bupivacaine 0.25% for each) sig- nificantly reduced the use of opioids [22].
- Another pro- spective study of 126 patients who received laparoscopic liver resection showed that US-guided bilateral TAP and RSB significantly reduced the patient-reported pain-VAS score, the dosage of ondansetron, and hospital stay [23]..
- found that US-guided TAPB plus RSB pro- longed the analgesia time and reduced postoperative pain in high-risk elderly patients who received emergency ab- dominal surgery [24].
- Table 2 Postoperative functional activity scores in the three groups (n) Variable Group C ( n = 26).
- 6 a Postoperative pain scores at rest in the three groups (NRS = numerical rating scale).
- b Postoperative pain scores with coughing in the three groups.
- Because of improve- ments in US technologies, anesthesiologist now com- monly use US-guided TAPB for perioperative pain management [6, 18].
- First, laparoscopy-assisted radical resection of rectal cancer requires two incisions above the umbilicus, and there may be variations among patients in the pain arising from these incisions.
- There is evidence that the cephalad dermatome levels achieved by posterior TAP is at T 10 , which is more suitable for analgesia of the inci- sion below the umbilicus [8, 31].
- For upper abdominal incisions, US-guided RSB might be a better alternative for injecting local anesthetics into the posterior rectus sheath [32].
- The ventral branch of the T 7 -T 12 intercostal nerve can be blocked, thus anesthetiz- ing the anterior wall of the abdomen from the xiphoid process to the pubic symphysis [33].
- RSB could be performed alongside pos- terior TAPB to block higher dermatomes in the abdom- inal wall, up to T 6 [22].
- In the latter approach (which we used), the US probe is placed between the costal margin and the iliac crest at the axillary midline, and then scanned backward until the transverse abdominal muscle moved into the aponeurosis.
- A third possible reason for the contradictory results may be that there is a lack of uniform standards regard- ing the doses of local anesthetics used during US-guided TAPB..
- We found no significant difference in the pain-VAS score or the FAS among the three groups, because all patients used PCIA and rescue analgesics when neces- sary to control the pain-VAS score below 4.
- There was also no significant difference in the measured recovery parameters and sufentanil-associated adverse effects among the three groups, but this may be due to the small sample size..
- First, we did not study the effect of the duration of analgesia provided by the peripheral nerve block.
- Previ- ous studies showed that the analgesia duration from a single-shot TAPB lasts for 24 to 48 h, but it is possible that our use of two nerve blocks and the poor vascularization of the TAP and RS prolonged the dur- ation of analgesia.
- Table 4 Recovery parameters in the three groups.
- Table 3 Use of rescue analgesia in the three groups.
- showed that the blood concentration of ropivacaine did not exceed the toxic threshold of 2.2 μg/mL when 60 mL of ropivacaine 0.375% was used in US-guided TAP [36, 37].
- In conclusion, we found that postoperative US-guided posterior TAPB with RSB significantly reduced postop- erative opioid use by patients following laparoscopy- assisted radical resection of rectal cancer.
- TAPB: Transversus abdominis plane block.
- The raw data of the current study are available from the corresponding author on reasonable request..
- Transversus abdominis plane (TAP) block in laparoscopic colorectal surgery improves postoperative pain management: a meta-analysis.
- Comparison of posterior and subcostal approaches to ultrasound-guided transverse abdominis plane block for postoperative analgesia in laparoscopic cholecystectomy.
- Table 5 Adverse effects in the three groups.
- Effect of local wound infiltration and transversus abdominis plane block on morphine use after laparoscopic colectomy: a nonrandomized, single-blind prospective study.
- Transversus abdominis plane (TAP) block versus thoracic epidural analgesia (TEA) in laparoscopic colon surgery in the ERAS program.
- Patient-controlled analgesia with and without transverse abdominis plane and rectus sheath space block in cirrhotic patients undergoing liver resection.
- Efficacy of Transversus Abdominis and rectus sheath blocks in combination with continuous intravenous fentanyl for postoperative analgesia of laparoscopic colectomy: a retrospective study.
- Transversus abdominis plane block for postoperative pain relief after hand-assisted laparoscopic colon surgery: a randomized, placebo-controlled clinical trial.
- Ultrasound-guided rectus sheath and transversus abdominis plane blocks for perioperative analgesia in upper abdominal surgery: a randomized controlled study.
- The postoperative analgesic effect of ultrasound-guided bilateral Transversus Abdominis plane combined with rectus sheath blocks in laparoscopic hepatectomy: a randomized controlled study.
- Efficacy of US-guided transversus abdominis plane block and rectus sheath block with ropivacaine and dexmedetomidine in elderly high-risk patients.
- A combination of ultrasound-guided rectus sheath and transversus abdominis plane blocks is superior to either block alone for pain control after gynecological transumbilical single incision laparoscopic surgery.
- Effectiveness of ultrasound-guided transversus abdominis plane block and rectus sheath block in pain control and recovery after gynecological transumbilical single-incision laparoscopic surgery.
- Effects of preoperative ultrasound-guided transversus abdominis plane block on pain after laparoscopic surgery for colorectal cancer: a double- blind randomized controlled trial.
- Duration of analgesic effectiveness after the posterior and lateral transversus abdominis plane block techniques for transverse lower abdominal incisions: a meta-analysis..
- Transversus Abdominis plane block in laparoscopic colorectal surgery: a systematic review.
- A randomised controlled trial of the efficacy of.
- ultrasound-guided transversus abdominis plane (TAP) block in laparoscopic colorectal surgery.
- Dermatomal spread following posterior transversus abdominis plane block in pediatric patients: our initial experience.
- Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks.
- Distribution patterns, dermatomal anesthesia, and ropivacaine serum concentrations after bilateral dual transversus abdominis plane block.

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