Application Of Ultrasound-Guided Modified Thoracoabdominal Nerves Block Through Perichondrial Approach In Laparoscopic Cholecystectomy

Part Ⅰ Efficacy of Modified Thoracoabdominal Nerves Block through Perichondrial Approach in Each Abdominal RegionObjective:To evaluate the effect of ultrasound-guided modified thoracoabdominal nerves block through perichondrial approach(M-TAPA)in each abdominal region and to explore the feasibility of M-TAPA for analgesia after laparoscopic cholecystectomy.Methods:Thirty patients scheduled for laparoscopic cholecystectomy were selected.M-TAPA was performed with 0.25%ropivacaine 30mL on the right side before anesthesia.According to the anatomic landmark lines on abdomen,the right anterior abdominal wall and lateral abdominal wall were divided into 13 regions.After block,10min,20min and 30min were tested by cold temperature method.The positive rate of block more than 50%was defined as effective block in this region and the positive rate of block more than 90%was defined as the best blocking effect region.The onset time of block,the positive rate of block in different regions at different time points and the positive rate of block in different skin segments at 30min were recorded.The complications related to block were recorded.Results:The onset time of M-TAPA was 2.33±0.96min.Effective block area existed at 10min after M-TAPA and the positive rate of regions increased with time.At 30min after M-TAPA,the region in which the positive rate 50-90%were 1,4,9,10 and 13 regions.The region in which the positive rate 90-100%were 2,3,5 and 6 regions.And the positive rate of other regions did not reach 50%.At 30min after M-TAPA,the block range can reach T4 at cranial and L1 at caudal,which is concentrated in T6-T11.No block-related complications occurred in all patients.Conclusion:0.25%ropivacaine 30mL for ultrasound-guided M-TAPA can provide block range which covers the anterior abdominal wall and part of the middle-lower side of lateral abdominal wall on the block side at 30min after block.And it can be used for postoperative analgesia of laparoscopic cholecystectomy and abdominal surgery with incisions in the above range.Part Ⅱ Comparison of the Modified Thoracoabdominal Nerves Block through Perichondrial Approach and Subcostal Transversus Abdominis Plane Block on Postoperative Analgesia in Patients undergoing Laparoscopic CholecystectomyObjective:To compare the effects of ultrasound-guided modified thoracoabdominal nerves block through perichondrial approach(M-TAPA)and subcostal transversus abdominis plane block(TAPB)on postoperative analgesia,early recovery in patients undergoing laparoscopic cholecystectomy.Methods:One hundred and twenty patients scheduled for laparoscopic cholecystectomy were selected.The patients were randomly divided into three groups:M-TAPA combined with general anesthesia group(group M),subcostal TAPB combined with general anesthesia group(group T)and general anesthesia group(group C),40 cases in each group.After induction,patients in group M received bilateral M-TAPA and patients in group T received bilateral subcostal TAPB with 0.25%ropivacaine 30mL on each side of block.Patients in group C received general anesthesia only.All patients used patient-controlled intravenous analgesia(PCIA)after operation.The total dosage of sufentanil in PCIA,the times of pressing PCIA,the time of first pressing PCIA,the cases of rescue analgesia and the score of analgesia satisfaction within 24 hours after operation were recorded.Meanwhile,resting and coughing numerical rating scale(NRS)pain scores were recorded when patients entered the post-anesthesia care unit(PACU)and 2h,4h,8h,12h,24h after operation.The intraoperative dosage of sufentanil and remifentanil in three groups were recorded.And the ultrasound imaging time,puncture time,the block-related complications of the two blocks were recorded.The sleep quality score of the night after operation,the first anal discharge time,the first time out of bed and the adverse reactions within 24 hours after operation were also recorded.Results:Compared with group C,the total dosage of sufentanil in PCIA,the times of pressing PCIA,the cases of rescue analgesia,the consumption of remifentanil in group M and T were less,and the time of first pressing PCIA in group M and T was longer(P<0.05).Compared with group T,the time of first pressing PCIA was longer in group M(P<0.05).The score of analgesia satisfaction in group M was higher than that in group T and C(P<0.05).No difference was found in the dosage of sufentanil during surgery among the three groups(P>0.05).There was no statistical difference in NRS scores at rest and cough among the three groups when they entered the PACU(P>0.05).Compared with group C,group M and group T had lower resting NRS scores at 2h,4h and 8h after operation and also had lower coughing NRS scores at 2h,4h,8h,12h and 24h after operation(P<0.05).Compared with group T,the coughing NRS score at 2h and 4h after surgery in group M was lower(P<0.05).There was no significant difference in ultrasound imaging time and puncture time between group M and group T(P>0.05).No block-related complications occurred in both groups.Compared with group C,sleep quality score of the night after operation in group M and T was higher,the first anal discharge time and the first time out of bed in group M and T were also shorter(P<0.05).And no difference was found in the adverse reactions within 24 hours after surgery among the three groups(P>0.05).Conclusion:Ultrasound-guided M-TAPA can provide satisfactory postoperative analgesia for patients undergoing laparoscopic cholecystectomy,which is a safe and simple nerve block technique,and is helpful to the early recovery of patients.Compared with subcostal TAPB,M-TAPA can reduce the early postoperative pain of patients and increase the satisfaction of patients,which is an alternative optimization method for analgesia after laparoscopic cholecystectomy and is suitable for clinical promotion.