The Efficacy of Thoracoabdominal Nerve Block With Serratus Intercostal Plane and Rectus Sheath Block in Cholecystectomy

Comparison of Postoperative Analgesic Efficacy of Perichondrial Approach Modified Thoracoabdominal Nerve Block and the Combination of Serratus Intercostal Plane and Rectus Sheath Block Via to Patients Who Underwent Cholecystectomy

Cholecystectomy is a widespread surgical procedure performed worldwide for acute cholecystitis. This operation can be performed using open surgery or laparoscopic techniques. Laparoscopic technique is superior to open surgery in terms of less pain at incision sites, shorter hospital stay, improved quality of life, and faster recovery times.However, despite being a minimally invasive surgery, laparoscopic cholecystectomy (LC) can still cause moderate to severe pain. Severe pain can lead to delayed postoperative ambulation, decreased patient satisfaction, the development of chronic pain, and is associated with increased lung and heart complications. Postoperative pain in LC can stem from various causes. To reduce the postoperative pain caused by LC, non-steroidal anti-inflammatory drugs, paracetamol, opioids, local anesthetics, and various regional anesthesia techniques are used.Multimodal analgesia has shown that the use of regional anesthesia and analgesia is crucial in reducing the neuroendocrine stress response in pain and trauma situations. The use of interfascial plane blocks performed under ultrasound guidance in LC surgery, considered easy and safe, has increased in recent years. The thoracoabdominal plane block (TAPA) applied through a perichondrial approach reaches a broader dermatomal area than the transversus abdominis plane (TAP) block and the oblique subcostal transversus abdominis plane (OSTAP) block.Serratus intercostal plane block (SIPB) has been found effective for somatic analgesia in a case series after gastrectomy and cholecystectomy surgeries. Subsequent studies have indicated the effectiveness of SIPB for open upper abdominal surgeries. Rectus sheath block (RSB) is used to provide postoperative analgesia after various surgeries, including laparoscopic and upper abdominal surgeries. Ultrasound-guided RSB in LC has significantly reduced postoperative pain.In this study, similar to the combination of RSB and SIPB was planned to be applied to enhance the effectiveness and quality of analgesia in the mid-abdomen. A group in LC surgery was administered bilateral M-TAPA, while another group received bilateral RSB + right SIPB, aiming to compare the postoperative analgesic effectiveness.

Study Overview

• Status: Completed
• Conditions: Pain Management
• Intervention / Treatment: Procedure: Group M-TAPA; Procedure: Group Serratus Intercostal Plane Block and Rectus Sheath Block

Detailed Description

The gallbladder is a small organ located in the right upper quadrant of the abdomen. Bile, which aids in the digestion of food, is collected in this organ. Gallstones are solid particles that form as a result of changes in the composition and concentration of bile caused by hormones, medications, diet, and weight changes. Sometimes, gallstones that form can block the normal flow of bile by exiting the gallbladder, leading to a condition known as acute cholecystitis when the cystic duct is obstructed by a gallstone. This condition causes distension and inflammation of the gallbladder.

Cholecystectomy is a common surgical procedure performed worldwide for acute cholecystitis. The management of acute cholecystitis is divided into medical and surgical approaches. Medical management includes bed rest, analgesic agents, antibiotic therapy, and intravenous fluid replacement. Surgical management involves a procedure called cholecystectomy, which is the surgical removal of the gallbladder. This operation can be performed using open surgery or laparoscopic techniques. The laparoscopic technique is superior to open surgery in terms of less pain at incision sites, shorter hospital stay, improved quality of life, and faster recovery times. However, laparoscopic cholecystectomy (LC), despite being a minimally invasive surgery, can still cause moderate to severe pain.

Severe pain can lead to delayed postoperative ambulation, decreased patient satisfaction, the development of chronic pain, and is associated with increased lung and heart complications. Postoperative pain in LC can arise from various causes. While a significant portion of postoperative pain in LC is attributed to incision sites (50-70%), it also originates from pneumoperitoneum (20-30%) and cholecystectomy (10-20%). Multimodal analgesia, including non-steroidal anti-inflammatory drugs, paracetamol, opioids, local anesthetics, and various regional anesthesia techniques, should be considered for pain control. Opioids may cause side effects such as postoperative nausea and vomiting (PONV), constipation, and respiratory depression. Neuraxial analgesia is rarely used in LC due to possible complications and technical difficulties.

The use of interfascial plane blocks under ultrasound guidance, considered easy and safe, has increased in LC surgery. The thoracoabdominal plane block (TAPA) applied through a perichondrial approach, showing that it spreads to a broader dermatomal area than the transversus abdominis plane (TAP) block and the oblique subcostal transversus abdominis plane (OSTAP) block. The rectus sheath block (RSB) is used to provide postoperative analgesia after various surgeries, including laparoscopic and upper abdominal surgeries. Ultrasound-guided RSB in LC has significantly reduced postoperative pain.

In this study, the combination of RSB and SIPB was planned to be applied to enhance the effectiveness and quality of analgesia in the mid-abdomen. Patients will be asked to fill out the Quality of Recovery-15 (QoR-15) scale, a self-report questionnaire used to assess the quality of postoperative recovery, in the preoperative waiting area on the morning of the surgery and 24 hours after the surgery. The QoR-15 scale measures recovery quality in five areas: physical comfort, pain, physical independence, psychological support, and emotional state, providing a one-dimensional measurement of recovery quality with scores ranging from 0 to 150. A higher score indicates better recovery quality.

In this study, in laparoscopic cholecystectomy, one group will receive bilateral M-TAPA, and another group will receive bilateral RSB + right SIPB to investigate their superiority in terms of postoperative NRS (Numeric Rating Scale) score, opioid consumption, dermatomal spread, PONV score, and complications, aiming to determine which is more effective.

• Study Type: Interventional
• Enrollment (Actual): 72
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey
  • Center
    • Corum, Center, Turkey, 19040
      • Hitit University Erol Olcok Training and Research Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• American Society of Anesthesiologists (ASA) classification with physical status 1-2
• Between the ages of 18 and 65
• Body Mass Index (BMI) <35
• Has read and accepted the informed consent form voluntarily

Exclusion Criteria:

• The patient's unwillingness to participate in the study
• Patients with a body mass index (BMI) >35
• ASA 3-5 classification
• unable to use the NRS pain scoring system
• allergies to the used local anesthetic and specified analgesic drugs
• individuals declaring pregnancy or breastfeeding
• patients under 18 or over 65 years of age
• those with uncontrolled anxiety
• alcohol and drug addiction
• neuromuscular and peripheral nerve diseases
• using high-dose opioid drugs three days before surgery
• hepatic and renal insufficiency, coagulation disorders
• diabetes mellitus
• patients using anticoagulant drugs
• infections at the site of peripheral block needle entry
• those undergoing a second procedure along with laparoscopic cholecystectomy
• individuals with a history of abdominal surgery or trauma
• conversion of laparoscopic surgery to open surgery
• inability to communicate in Turkish
• NRS score above 7 for consecutive 4 hours despite the planned multimodal analgesia regimen

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Group M-TAPA; M-TAPA: Aseptic conditions are ensured in the area where the block will be performed. Under ultrasound guidance, a linear probe at the sagittal plane and costochondral angle is used to identify the transversus abdominis, internal oblique, and external oblique muscles at the level of the 10th rib. To visualize the lower surface of the rib cartilage in the midline, a sagittal angle is applied with the probe in the direction of the costochondral angle at the edge of the 10th rib. Using a 22-G, 80-100 mm block needle with an in-plane technique, the needle is advanced cranially. The needle tip is directed towards the posterior surface of the 10th rib cartilage, underneath the condyle. Subsequently, 20 ml of 0.25% concentration bupivacaine is injected beneath the condyle. The same procedure will be applied to the opposite side using the same technique.	Procedure: Group M-TAPA; Aseptic conditions are ensured in the area where the block will be performed. Under ultrasound guidance, a linear probe at the sagittal plane and costochondral angle is used to identify the transversus abdominis, internal oblique, and external oblique muscles at the level of the 10th rib. To visualize the lower surface of the rib cartilage in the midline, a sagittal angle is applied with the probe in the direction of the costochondral angle at the edge of the 10th rib. Using a 22-G, 80-100 mm block needle with an in-plane technique, the needle is advanced cranially. The needle tip is directed towards the posterior surface of the 10th rib cartilage, underneath the condyle. Subsequently, 20 ml of 0.25% concentration bupivacaine is injected beneath the condyle. The same procedure will be applied to the opposite side using the same technique.
Active Comparator: Group Serratus Intercostal Plane Block and Rectus Sheath Block; Serratus intercostal plane block:The serratus anterior muscle and intercostal muscles are identified at the level of 8th rib along the right mid-axillary line.Using block needle,20 ml of 0.25% Bupivacaine is injected into the interfascial plane between these muscles.The SIPB will be performed only on right side. Rectus sheath block:a linear probe is placed in a transverse position just above the umbilicus and slightly lateral to the midline.After visualizing the rectus abdominis muscle, posterior rectus sheath,and the hypoechoic space between them,block needle is advanced in-plane along the subcutaneous tissue.The needle is progressed until reaching the space between the epimysium of the muscle and the posterior rectus sheath, passing horizontally through the anterior rectus sheath of the rectus abdominis muscle.10 ml of 0.25% bupivacaine is injected.Adequate spread will lift the epimysium of the rectus abdominis muscle while displacing the posterior fascia and peritoneum downward	Procedure: Group Serratus Intercostal Plane Block and Rectus Sheath Block; Serratus intercostal plane block:The serratus anterior muscle and intercostal muscles are identified at the level of 8th rib along the right mid-axillary line.Using block needle,20 ml of 0.25% Bupivacaine is injected into the interfascial plane between these muscles.The SIPB will be performed only on the right side. Rectus sheath block:a linear probe is placed in a transverse position just above the umbilicus and slightly lateral to the midline.After visualizing the rectus abdominis muscle, posterior rectus sheath,and the hypoechoic space between them,block needle is advanced in-plane along the subcutaneous tissue.The needle is progressed until reaching the space between the epimysium of the muscle and the posterior rectus sheath, passing horizontally through the anterior rectus sheath of the rectus abdominis muscle.10 ml of 0.25% bupivacaine is injected.Adequate spread will lift the epimysium of rectus abdominis muscle while displacing the posterior fascia and peritoneum downward

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Postoperative Pain Examination	Determination of patients' post-operative pain level. The Numeric Rating Scale (NRS), a method that converts the patient's pain perception into a numerical form, will be used to assess postoperative pain. NRS has a numerical scale ranging from 0 to 10. The patient will rate the intensity of pain on a scale from 0, indicating no pain, to 10, representing the worst imaginable pain (NRS 0=no pain, 4=mild to moderate pain, 6-8=severe pain, and >8=intolerable pain). The NRS score will be evaluated both at rest and during active movement situations (such as transitioning from a lying to a sitting position). The Numeric Rating Scale (NRS): (NRS 0=no pain, 4=mild to moderate pain, 6-8=severe pain, and >8=intolerable pain)	24 hour

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Opioid Consumption	Total 24-hour tramadol consumption of patients in mg.	24 hour

Collaborators and Investigators

• Sponsor: Hitit University

Study record dates

Study Major Dates

• Study Start (Actual): February 5, 2024
• Primary Completion (Actual): April 30, 2024
• Study Completion (Actual): August 7, 2024

Study Registration Dates

• First Submitted: January 28, 2024
• First Submitted That Met QC Criteria: January 28, 2024
• First Posted (Actual): February 5, 2024

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: February 25, 2025
• Last Verified: February 1, 2025

More Information

Terms related to this study

• Keywords: Laparoscopic Cholecystectomy; Rectus Sheath Block; Modified Thoracoabdominal Plane Block; Serratus Intercostal Plane Block
• Other Study ID Numbers: 2023-172

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No