Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block After Laparoscopic Bariatric Surgery: a Double Blind, Randomized, Controlled Study

Background

The efficacy of ultrasound-guided transversus abdominis plane (USG-TAP) block as a part of multimodal analgesia was evaluated in morbidly obese patients undergoing laparoscopic bariatric surgery.

Methods

We studied 100 patients with body mass index >35 kg/m². They were randomly allocated to study (USG-TAP) and control groups. Pain scores at rest and on movement at various time points up to 24 postoperative hours were compared. Other parameters evaluated were patients requiring Tramazac hydrochloride (TMZ) as rescue analgesic, sedation score, time to ambulate, any adverse events, and patient satisfaction.

Results

The median visual analogue scale pain score of the study (USG-TAP) group was consistently lower at 1, 3, 6, 12, and 24 h at rest and on movement, in the postoperative period. Number of patients requiring TMZ required in the first, third, and sixth hour was significantly lower in the USG-TAP group. The prolonged sedative effect of the TMZ affected the time to ambulate. Patients in the control group remained more sedated. Four patients in the control group required BIPAP support postoperatively; no adverse event was observed. Time to ambulate was 6.3?±?1.8 h in USG-TAP and 8?±?1.8 h in control groups; P?<?0.001. Patient satisfaction scores were significantly higher in the USG-TAP group; P?<?0.001.

Conclusions

Our study demonstrates that the USG-TAP as part of multimodal analgesic technique in morbidly obese patients undergoing laparoscopic gastric bypass reduces opioid requirement, improves pain score, decreases sedation, promotes early ambulation, and has greater patient satisfaction.     

Anterior Rectus Sheath in Inguinal Hernia Repair: Preliminary Study

Inguinal hernia repair using the anterior rectus sheath flap represents a tension-free repair with potential advantages (no foreign material or tension on the suture line). The aim of this research was to evaluate the method of inguinal hernia repair using the anterior rectus sheath and to compare it with tension-free mesh repair (modified Lichtenstein repair). In total, 62 patients were evaluated. Each patient's age, gender, type of hernia, total operating-room time, the length of postoperative hospital stay, and the recurrence-free period were recorded, as well as the total number of postoperatively administered doses of analgesics, and analyzed using the Mann–Whitney test. No difference in age (p =. 08), postoperative hospital stay (p = 0.810), or postoperative use of analgesics (p =. 116) was observed between two groups. Total operating-room time was significantly longer in patients undergoing mesh repair (median 80 min, range 45–150) compared to anterior rectus sheath repair (median 65 min, range 45–125) (p =. 049). No complications or recurrences were noted in either group. Thus, this study showed good results using the anterior rectus sheath repair for primary, uncomplicated inguinal hernias, comparable to mesh repair.     

Ultrasound-Guided Transversus Abdominis Plane (TAP) Block for Laparoscopic Gastric-Bypass Surgery:a Prospective Randomized Controlled Double-Blinded Trial

Background

Despite the laparoscopic approach, patients can suffer moderate to severe pain following bariatric surgery. This randomized controlled double-blinded trial investigated the analgesic efficacy of ultrasound-guided transversus abdominis plane (TAP) blocks for laparoscopic gastric-bypass surgery.

Methods

Seventy patients undergoing laparoscopic gastric-bypass surgery were randomized to receive either bilateral ultrasound-guided subcostal TAP block injections after induction of general anesthesia or none. All patients received trocar insertion site local anesthetic infiltration and systemic analgesia. The primary outcome was cumulative opioid consumption (IV morphine equivalent) during the first 24 h postoperatively. Interval opioid consumption, pain severity scores, rates of nausea or vomiting, and rates of pruritus were measured during phase I recovery, and at 24 and 48 h postoperatively.

Results

There was no difference in cumulative opioid consumption during the first 24 h postoperatively between the TAP (32.2 mg [95% CI, 27.6–36.7]) and control (35.6 mg [95% CI, 28.6–42.5]; P?=?0.41) groups. Postoperative opioid consumptions during phase I recovery and the 24–48-h interval were similar between groups, as were pain scores at rest and with movement during all measured intervals. The rates of nausea or vomiting and pruritus were equivalent.

Conclusions

Bilateral TAP blocks do not provide additional analgesic benefit when added to trocar insertion site local anesthetic infiltration and systemic analgesia for laparoscopic gastric-bypass surgery.     

经腹直肌入路改良Kugel疝修补术治疗腹股沟疝

目的探讨经腹直肌入路改良Kugel疝修补术治疗腹股沟疝的应用价值。方法采用经腹直肌入路改良Kugel疝修补术治疗腹股沟疝18例,其中腹股沟斜疝12例,腹股沟直疝5例,股疝1例。结果全部治愈,手术时间20～60 min,平均40 min;住院时间3～8 d,平均4 d。未见皮下血肿、阴囊积液、异物感等并发症。随防6个月无病例复发。结论经腹直肌入路改良Kugel疝修补术操作简便,安全,效果确切,术后恢复快,副反应少,值得临床偿试。     

单孔腹腔镜治疗小儿腹股沟嵌顿斜疝的探讨

目的：探讨单孔腹腔镜治疗小儿腹股沟嵌顿斜疝的疗效。方法2013年3-9月,单孔腹腔镜治疗小儿腹股沟嵌顿斜疝48例。术前诊断右侧嵌顿疝32例,左侧嵌顿疝16例。经脐切口置入trocar建立气腹,置入Z形腹腔镜,经探查孔置入无损伤钳,探查患侧疝内容物类型、嵌顿程度。腹腔镜下辅以体外手法复位将嵌顿疝复位,观察嵌顿脏器损伤情况。如嵌顿脏器无损伤,行腹腔镜下疝囊高位结扎术。探查对侧如存在隐匿疝则同时处理。结果48例均顺利完成单孔腹腔镜手术。术中探查合并对侧隐匿疝10例。嵌顿疝内容物36例为肠管,8例为卵巢,4例为网膜。手法协助复位均顺利还纳,镜下观察5 min,48例嵌顿脏器均血运良好。单侧疝（38例）手术时间10-18 min,平均15 min;双侧疝（10例）手术时间16-30 min,平均24 min。麻醉清醒后进食,疼痛均能耐受。术后10-15 h（平均12 h）出院。随访3-13个月,无切口感染,无阴囊水肿、血肿等并发症,无复发。结论单孔腹腔镜治疗小儿腹股沟嵌顿斜疝不破坏腹股沟管解剖结构,可高位结扎,直视下探查嵌顿疝内容物损伤情况,探查对侧有无隐匿疝。该技术安全、有效、微创,值得推广。     

A Comparative Study of the Transversus Abdominis Plane (TAP) Block Efficacy on Post-bariatric vs Aesthetic Abdominoplasty with Flank Liposuction

The transversus abdominis plane (TAP) block acts on the nerves localised in the anterior abdominal wall muscles. We evaluated the efficacy on post-bariatric (PB) patients undergoing body-contouring abdominoplasty. We retrospectively evaluated PB patients undergoing abdominoplasty with flank liposuction and compared results to a matched group of TAP aesthetic patients. Outcomes evaluated were the analgesic requirements during the early postoperative days. Fifty-one patients (PB n = 27, aesthetic n = 24) were assessed. No complications were observed. All PB patients required analgesia until the second postoperative day contrarily to most aesthetic ones. Patients with greater flap resected and higher pre-abdominoplasty BMI had greater morphine consumptions. In PB patients, the larger amount of tissues resected corresponded to a greater stimulation of pain fibres that cannot be paralleled by a concomitant increase of the local anesthetic administered. This partially invalidates TAP’s efficacy on PB patients.     

单孔腹腔镜手术治疗小儿腹股沟疝(鞘膜积液)

目的探讨单孔腹腔镜手术(single-incision laparoscopic surgery,SILS)治疗小儿腹股沟疝及鞘膜积液的疗效。方法 2006年6月～2011年4月应用SILS及改制的普通硬膜外穿刺针完成176例小儿腹股沟疝及鞘膜积液手术。取脐部纵切口,直视下置入3 mm或5 mm腹腔镜,用改制的16号硬膜外穿刺针带4号丝线经皮沿内侧腹膜下潜行穿入,依次越过腹壁下动静脉、输精管、髂外血管和精索,越过精索后刺破腹膜进入腹腔,更换有凹槽的穿刺针沿外侧腹膜下穿入,到达结扎线处进入腹腔,将结扎线带出体表,体外收紧结扎,悬吊于腹壁,完成手术。结果 176例SILS手术成功,术中发现对侧隐性疝58例,均同期处理。手术时间7～50 min,平均16 min。所有患儿术后3 d出院。176例随访12个月,1例同侧复发,1例同侧并发直疝(手术证实),55例鞘膜积液无复发。结论 SILS治疗小儿腹股沟疝操作简单,疗效满意。     

经脐单切口腹腔镜下儿童腹股沟疝高位结扎术

目的探讨经脐单切口腹腔镜手术治疗儿童腹股沟疝的应用价值。方法 2010年3月～2011年12月,对腹股沟斜疝439例,其中术前诊断为双侧斜疝94例,术前诊断为单侧斜疝而术中探查为双侧斜疝104例,术中发现单侧直疝2例,传统手术后复发疝16例。在脐上缘做10 mm弧形切口,切口内偏右侧穿入5 mm trocar,偏左侧穿入3 mm trocar,用改良套管钩针行内环口环形荷包缝扎术。结果 241例单侧腹股沟斜疝手术时间（10.1±5.0）min,198例双侧手术时间（15.2±2.5）min。总住院时间1～3 d,平均2 d。所有患儿术后随访6～12个月。1例复发。无阴囊积液、血肿、感染等并发症发生。结论经脐单切口腹腔镜手术治疗儿童腹股沟疝疗效肯定,伤口小,安全快速,操作简便。     

Laparoscopic-Guided Transversus Abdominis Plane (TAP) Block as Part of Multimodal Analgesia in Laparoscopic Roux-en-Y Gastric Bypass Within an Enhanced Recovery After Surgery (ERAS) Program: a Prospective Randomized Clinical Trial

Background

Despite the ultrasound guidance of transversus abdominis plane (TAP) blocks has allowed greater precision of needle placement in the desired tissue plane, visualization of the abdominal wall muscles can be hindered by morbid obesity and could lead to failed regional anesthesia. The aim of this study was to assess the feasibility and effect of laparoscopic-guided TAP block in patients undergoing Roux-en-Y gastric bypass and to compare it with port-site infiltration.

Patients and Methods

A prospective randomized clinical trial was performed. Patients were randomized into two groups: patients undergoing laparoscopic-guided TAP (TAP-lap) and patients undergoing port-site infiltration (PSI). Pain quantification as measured by visual analogic scale (VAS) and morphine needs during the first 24 h were evaluated.

Results

One hundred and forty patients were included, 70 in each group. The mean operation time was 83.3?+?15.6 min in TAP-lap and 80.5?+?14.4 min in PSI (NS). The mean postoperative pain, as measured by VAS, 24 h after surgery was 16.8 +?11.2 mm in PSI and 10?+?8.1 mm in TAP-lap (p?=?0.001). Morphine rescues were necessary in 13.2% in PSI and 2.9% in TAP-lap (p?=?0.026). The mean hospital stay was 2.1?+?1.2 days in TAP-lap and 2.9?+?1.3 days in PSI (p?=?0.019). Hospital discharge during the first 48 h after surgery was possible in 52.9% of the patients in PSI and 71% in TAP-lap (OR 4.75; 95% CI 2.1–10.8; p?=?0.029).

Conclusion

Laparoscopic-guided TAP block can reduce postoperative pain, opioid needs, and hospital stay, when compared with port-site infiltration with the same anesthetic drug, without increasing operation time.

Trial Registration

ClinicalTrials.gov Identifier: NCT03203070

     

腹腔镜TAPP技术在治疗腹股沟复发疝中的应用

目的探讨腹腔镜经腹腹膜前（TAPP）疝修补术治疗腹股沟复发疝的手术技巧及临床效果。方法回顾性分析2009年3月至2012年12月期间首都医科大学附属北京朝阳医院行腹腔镜TAPP疝修补术治疗的130例腹股沟复发疝患者的临床资料。结果129例患者的腹腔镜TAPP疝修补术顺利完成,1例中转开放手术。手术时间为（54．5±16．1）min（30～100min）,住院时间为（4．5±2．1）d（2～11d）。术后疼痛发生率为3．8％（5／130）,阴囊肿胀积液发生率为11．5％（15／130）,排尿困难发生率为1．5％（2／130）,无体内异物感、切口感染、肠梗阻等其他并发症发生。术后130例患者均获访,随访时间为7～50个月、（24．3±11．3）个月,无复发。结论对于腹股沟复发疝的治疗,腹腔镜TAPP疝修补术具有创伤小、并发症少等优势,且其手术安全性高,效果切实可靠。     

Laparoscopic Repair of Inguinal Hernia with Biomimetic Matrix

Background and Objectives:

Materials utilized for the repair of hernias fall into 2 broad categories, synthetics and biologics. Each has its merits and drawbacks. The synthetics have a permanent, inherent strength but are associated with some incidence of chronic pain. The biologics rely on variable tissue regeneration to give strength to the repair, limiting their use to specific situations. However, thanks to their transient presence and tissue ingrowth, the biologics do not result in a significant incidence of chronic pain. We studied the use of a biomimetic (REVIVE, Biomerix Corporation, Fremont, CA) in this setting in an attempt to obviate the disadvantages of each material.

Methods:

Fourteen patients underwent laparoscopic repair by totally extraperitoneal and transabdominal preperitoneal techniques of 16 inguinal hernias. Follow-up was as long as 19 mo, and 8 patients were followed for > 12 mo. There were no recurrences and a 5% incidence of functionally insignificant discomfort.

Results:

REVIVE is shown in histology and in vivo to demonstrate regeneration and tissue ingrowth into the polycarbonate/polyuria matrix similar to that in the biologics rather than scarring or encapsulation. There were no recurrences, indicating its strength and resilience as a permanent repair similar to that in the synthetics.

Conclusion:

This is proof of the concept that a biomimetic may bridge the gap between the biologics and synthetics and may be able to be utilized on a regular basis with the benefits of both materials and without their drawbacks.     

One-Trocar Laparoscopic Transperitoneal Closure of Inguinal Hernia in Children

Background  Laparoscopy is an alternative procedure for pediatric inguinal hernia; however, reported techniques necessitate two or three trocars and excellent intra-abdominal skills. This study was designed to describe and evaluate the preliminary result of one-trocar laparoscopic-assisted transperitoneal closure for inguinal hernia in children. Methods  A total of 33 children with inguinal hernia (body weight range, 2270 g to 58 kg) were included in this study from March to November 2007. Under a 5-mm laparoscopic guidance, the hernia defect was enclosed by a nonabsorbable suture, which was introduced into the abdomen by an 18-gauge vascular access on one side of the hernia defect and withdrawn on the opposite side by a homemade hook-pin through a needle puncture wound. Then, extracorporeal knot tying was performed. Results  A total of 52 procedures were performed, and the mean operating time was 46.2 ± 16.2 (range, 18–87) minutes. No cauterization was used during the operations and there was no serious operative morbidity. The mean follow-up period was 7.6 ± 2.5 (range, 4–12) months. No recurrence was observed during this period. Conclusions  This easy technique provides the benefits of laparoscopic herniorrhaphy and combines the advantages derived from the novel use of a hook-pin and vascular access simplicity, low cost, safety, minimized tissue trauma, and improved cosmetics. In addition, only one umbilical trocar wound and another needle puncture point were made. Therefore, this procedure is recommended for pediatric inguinal hernia.     

改良区域阻滞麻醉法在168例腹股沟疝手术中的临床观察

目的分析改良区域阻滞麻醉法在腹股沟疝手术中的临床应用价值。方法对2003年12月至2008年12月期间我院收治的168例腹股沟疝患者应用区域阻滞麻醉,对术中疼痛、肌松程度、手术时间、术后并发症、住院时间和住院费用方面进行临床观察。结果所有患者麻醉效果满意,肌肉松弛,解剖层次清楚,除5例在牵扯精索时有轻微酸痛外,余无任何不适,术后无特殊并发症。平均手术时间40min(包括麻醉),平均住院9d,普通疝修补术平均费用1480元,无张力疝修补术平均费用3265元。结论改良区域阻滞麻醉下行腹股沟疝手术麻醉效果满意、安全性高、简单易行、经济实惠,可作为各种腹股沟疝手术的麻醉方法,更适合在基层医院应用。