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Asian J Endosc Surg ISSN 1758-5902
O R I G I N A L A RT I C L E
Ultrasound-guided rectus sheath block for single-incision laparoscopic cholecystectomy Hideki Kamei,1 Nobuya Ishibashi,1 Gouichi Nakayama,1 Nobuya Hamada,2 Yutaka Ogata1 & Yoshito Akagi3 1 Department of Surgery, Kurume University Medical Center, Kurume, Japan 2 Department of Anesthesiology, Kurume University School of Medicine, Kurume, Japan 3 Department of Surgery, Kurume University School of Medicine, Kurume, Japan
Keywords Postoperative pain; rectus sheath block; single-incision laparoscopic cholecystectomy Correspondence Hideki Kamei, Department of Surgery, Kurume University Medical Center, 155-1 Kokubu-machi, Kurume, Fukuoka 839-0863, Japan. Tel: +81 942 22 6111 Fax: +81 942 22 6657 Email: [email protected] Presented at the 21st International Congress of the European Association for Endoscopic Surgery, Vienna, Austria, 19–22 June 2013 Received 17 August 2014; revised 14 September 2014; accepted 24 September 2014 DOI:10.1111/ases.12178
Abstract Introduction: Single-incision laparoscopic cholecystectomy (SILC) is increasingly applied for cholecystectomy and has been reported as safe and feasible, with short-term operative outcomes equivalent to four-port cholecystectomy. Although many investigators in randomized studies have noted the cosmetic advantages of SILC, the benefit of decreased pain in SILC remains controversial. Therefore, this study aimed to assess the efficacy of the rectus sheath block in SILC with respect to subjective pain. Methods: From April 2010 to March 2012, 75 patients with symptomatic gallstone or gallbladder polyps were assigned to one of three groups: (i) four-port laparoscopic cholecystectomy (n = 29); (ii) SILC (n = 15); and (iii) rectus sheath block in SILC (n = 30). We evaluated the operative details, length of hospital stay, and the need and usage of analgesia. Postoperative pain was recorded at 2, 6, 12, and 24 h after surgery based on a visual analog scale. Results: There was no difference with regard to age, ASA score, BMI, duration of operation, or length of hospital stay among the three groups. A significantly lower pain score was observed in the rectus sheath block in SILC group than in the SILC group at 2 and 6 h after operation. The pain score and need for analgesia were similar between the SILC group and the four-port cholecystectomy group. Conclusion: SILC using an ultrasound-guided rectus sheath block significantly reduces postoperative pain.
Introduction In recent years, increasing attention has been given to the benefits of SILS compared to standard multiport laparoscopic cholecystectomy. A systematic review and metaanalysis have described its safety and feasibility for the treatment of uncomplicated benign gallbladder disease (1,2). Nevertheless, no consensus has been reached on postoperative pain following single-incision laparoscopic cholecystectomy (SILC) compared with conventional laparoscopic cholecystectomy (3–7). Pain after laparoscopic cholecystectomy may be due to the several factors related to abdominal trauma, abdominal distension by insufflated gas, and/or residual carbon dioxide (8,9). In addition, we have previously shown that
148
messenger RNA levels of tumor necrosis factor-α in mouse brain were increased following laparotomy by long incision compared with a short incision (10). Moreover, Persec et al. reported that α2 adrenergic agonist acted centrally before the pain stimulus set in, resulting in effective reduction of postoperative pain and inflammatory responses (11). Therefore, both the severity of trauma caused by wound length and pain could be important factors for the systemic inflammatory response after surgery. Many single-port devices such as the SILSTM Port (Covidien, Norwalk, USA) have been employed in singleincision procedures, usually through a 15–20-mm skin incision at the single-access point, typically the umbilicus. As a result, the umbilical wound for SILC requires a
Asian J Endosc Surg 8 (2015) 148–152 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Rectus sheath block
H Kamei et al.
larger incision than that for conventional laparoscopic cholecystectomy. The scale of postoperative pain in laparoscopic surgery has been found to be related to the length of the umbilical incision and seems not to be influenced by the other smaller incisions. Accordingly, we decided to assess the management of postoperative pain due to the umbilical wound in SILC. The aim of this study was therefore to investigate the efficiency of using a rectus sheath block to reduce postoperative pain in SILC.
Patients and Methods From April 2010 to March 2012, 75 patients (37 women and 38 men) were assigned to one of three groups: (i) the four-port cholecystectomy (4PLC) group (n = 29); (ii) the SILC group (n = 15); and (iii) the rectus sheath block in SILC (RSB-SILC) group (n = 30). All patients were informed about the intervention technique and provided written informed consent. No factor that could affect surgical difficulty, such as BMI, ASA classification, disease, or grade of inflammation, was considered in the choice of procedure. The 74 patients included in this study were selected from among 75 consecutive patients with symptomatic gallstone or gallbladder polyps. One patient was excluded from this study because of hemorrhagic risk factor. All operations were performed by a surgeon qualified under the Endoscopic Surgical Skill Qualification System in Japan. The rectus sheath block was administered by a single anesthesiologist experienced in this technique. Perioperative conditions were similar in all patients. During a preoperative visit, patients were adequately instructed on the concept of the visual analog scale, which ranged from 0 (no pain) to 10 (worst pain). A visual analog scale score was provided by each patient at 2, 6, 12, and 24 h after the operation. Pain was deduced from the consumption of pain-relieving medications. Patients received pain medications only on demand, and these were administered in incremental strength, beginning with peripheral analgesics. The experimental design was approved by the Research and Ethics Committee at our hospital. Surgical techniques
(5 mm), and right subcostal anterior axillary line (5 mm). Cholecystectomy was then carried out according to the critical exposure technique. SILC A 2.5-cm incision was made in the umbilicus in the SILC procedure. We used EZ AccessTM (Hakko Medical, Nagano, Japan) as the special single-port device. After umbilical access was obtained, a 5-mm flexible scope (Olympus, Tokyo, Japan) and two instruments were introduced. The gallbladder was lifted with a Mini Loop Retractor II (Covidien) in the right subcostal midclavicular line. Cholecystectomy was performed as in a conventional cholecystectomy. Rectus sheath block procedure An ultrasound-guided rectus sheath block was applied before any skin incision was made. A transducer was placed immediately lateral to the umbilicus in the transverse position. The needle was inserted in a medial-tolateral orientation through the subcutaneous tissue to pierce the anterior rectus sheath. The needle was further advanced through the body of the muscle until the tip was positioned between the posterior aspect of the rectus abdominis muscle and the rectus sheath. After negative aspiration, 1–2-mL local anesthetic was injected to verify and confirm the needle tip location. When injection of the local anesthetic appeared to be intramuscular, the needle was advanced 1–2 mm, and its position was re-checked by injection. This was repeated until the needle position was correctly achieved. A successful block was recorded if the plane between the rectus muscle and posterior rectus sheath was seen to expand with local anesthetic under ultrasound vision (Figure 1). In this study, 10-mL local anesthetic (0.375% ropivacaine) per side was adequate for effective analgesia. Statistical analysis All data were expressed as means ± SD. Statistical analysis was performed by ANOVA, Fisher’s protected least significant difference test, χ2 test, and Kruskal–Wallis test with JMP® 10 (SAS Institute Inc., Cary, USA). Differences between the means were considered to be significant at P < 0.05.
Conventional laparoscopic cholecystectomy Conventional laparoscopic cholecystectomy required the introduction of a 10-mm flexible scope through a 1.2-cm incision in the umbilicus. Three additional incisions were made, and ports were placed in the subxiphoid epigastric region (12 mm), right subcostal midclavicular line
Results Patient characteristics are summarized in Table 1. There was no significant difference in age, sex, BMI, ASA score, and postoperative pathological diagnosis among the
Asian J Endosc Surg 8 (2015) 148–152 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
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Figure 1 Transabdominal ultrasound images (a) before and (b) after rectus sheath block.
Table 1 Comparison of patient characteristics and pathological data
Age (years) Sex, women (%) BMI ASA classification (I/II/III) (n) Pathologic diagnosis (n) Adenomyomatosis or polyps Acute or chronic cholecystitis Mild Moderate Superimposed
4PLC (n = 29)
SILC (n = 15)
RSB-SILC (n = 30)
P-value
65.1 ± 12.8 37.9 22.1 ± 5.2 23/6/0
56.8 ± 18.8 60.0 22.5 ± 3.2 11/4/0
57.9 ± 12.8 53.3 23.1 ± 3.3 15/14/1
0.06 0.3† 0.66 0.14†
7
2
3
14 5 3
11 2 0
15 10 2
0.3†
There were no significant differences in patients’ characteristics and pathological data. †χ2 test was employed for comparison of sex, ASA classification, and severity of cholecystitis. The other data were analyzed using ANOVA and then Fisher’s protected least significant difference test. Data are expressed as mean ± SD. 4PLC, four-port cholecystectomy; RSB-SILC, rectus sheath block in single-incision laparoscopic cholecystectomy; SILC, single-incision laparoscopic cholecystectomy.
Table 2 Comparison of postoperative outcomes
Duration of operation (min) Bleeding amount (mL) Surgical-site infections (SSI) (n) Superficial SSI Organ or space SSI Length of stay (days) Frequency of analgesic request (n)
4PLC (n = 29)
SILC (n = 15)
RSB-SILC (n = 30)
P-value
106.6 ± 62.8 9.67 ± 22.1
91.8 ± 39.6 7.53 ± 14.4
96.2 ± 34.5 10.63 ± 22.0
0.85 0.60
1 0 6.96 ± 3.96 2.24 ± 1.78
1 0 5.53 ± 1.84 3.13 ± 2.29
1 1 5.50 ± 2.20 1.60 ± 1.63
0.77† 0.25 0.055
Postoperative outcomes were not significantly different in each group. †χ2 test was employed for comparison of surgical-site infections. The other data were analyzed using ANOVA and then Fisher’s protected least significant difference test. Data are expressed as mean ± SD. 4PLC, four-port cholecystectomy; RSB-SILC, rectus sheath block in single-incision laparoscopic cholecystectomy; SILC, single-incision laparoscopic cholecystectomy.
three groups. There were no differences among the three groups with regard to operation times and blood loss. Postoperative complications were also similar (Table 2). Although there were no significant differences in the number of requests for analgesia between the RSB-SILC group and the other groups, they were lower in the RSB-SILC group than in the other groups (Table 2).
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Postoperative pain was measured with the visual analog scale at 2, 6, 12, and 24 h postoperatively. The pain score was markedly decreased in the RSB-SILC group than the other groups at 2 h after operation (RSBSILC: 1.73 ± 1.11, P = 0.001 vs SILC group and P = 0.003 vs 4PLC group) (Table 3). Similarly, the pain score at 6 h postoperatively was significantly lower in the RSB-SILC
Asian J Endosc Surg 8 (2015) 148–152 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
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H Kamei et al.
Table 3 Visual analog scale scores at several time points Time point
4PLC (n = 29)
SILC (n = 15)
RSB-SILC (n = 30)
P-value
At 2 h At 6 h At 12 h At 24 h
2.79 ± 1.23* 2.37 ± 1.20 2.06 ± 0.92 1.93 ± 1.19
3.20 ± 1.14* 2.73 ± 0.88** 2.13 ± 0.83 1.86 ± 1.06
1.73 ± 1.11 1.73 ± 1.14 1.90 ± 1.15 1.70 ± 1.02
P < 0.01 P < 0.05 0.643 0.764
*P < 0.01 compared to RSB-SILC group, **P < 0.05 compared to RSB-SILC group. Visual analog scale scores at each point were compared between groups by ANOVA and post-hoc testing. Data are expressed as mean ± SD. 4PLC, four-port cholecystectomy; RSB-SILC, rectus sheath block in singleincision laparoscopic cholecystectomy; SILC, single-incision laparoscopic cholecystectomy.
group than in the SILC group (RSB-SILC: 1.73 ± 1.14, P = 0.002 vs SILC group) (Table 3). However, no difference in pain score was noted at 12 and 24 h among the three groups (Table 3). Pain score did not differ between the SILC and the 4PLC groups postoperatively at any time points (Table 3).
Discussion In the development of laparoscopic techniques, reducing surgical trauma is considered to be a leading factor. Certainly, the first transvaginal NOTES was reported as noteworthy (12), but pure NOTES has yet to be established in routine clinical practice. As such, surgeons have recently shown an increased interest in SILS. Most studies on SILC have suggested that there are no differences in feasibility, safety, and outcome compared with the standard techniques. Whereas studies have shown that SILC offers better cosmesis, several randomized studies have failed to demonstrate a significant clinical advantage with respect to postoperative pain. Reliable evidence has yet to be reported demonstrating that SILC is less invasive than the conventional approach (13,14). Based on our initial experiences with SILC, postoperative pain appears to be an important clinical issue. The management of postoperative pain after laparoscopic surgery includes not only epidural anesthesia but also other analgesic techniques. Recently, peripheral nerve blocks have been used in the management of postoperative pain after laparoscopic surgery (15). Peripheral nerve blocks have a favorable side-effect profile compared to both opioid-based and epidural-based regimens in terms of improved analgesia with reduced risk of postoperative nausea and vomiting, minimal bladder interference, and a shorter hospital stay (16). Indeed, Conaghan et al. described the transversus abdominis plane block in laparoscopic colorectal surgery as effective in reducing postoperative pain compared with the use of a patient-controlled analgesia pump (17). However, no
previous study has investigated the correlation between use of a peripheral nerve block and SILC. We focused on the rectus sheath block as the peripheral nerve block to reduce postoperative pain in SILC because this procedure requires only a single incision into the umbilicus between the T7 and T11 intercostal nerves (16). Our data found that a rectus sheath block reduced pain scores at 2 and 6 h after SILC, indicating that a depression of neural stimuli from the umbilical site caused a decrease in the responsiveness of the central nervous system. There was no significant difference at 12 and 24 h among the three groups. This is probably because ropivacaine wears off within 10 h. In addition, there were no significant differences in frequency of analgesic request between the SILC group and the other groups. A likely possibility is that these blocks only provide analgesia to the abdominal wall and not the abdominal organs. It is noted that there was no difference in pain score or in requirement for analgesia between the SILC and 4PLC groups. According to Philipp et al. (18), pain scores and wound complication rates were higher for SILC than for 4PLC because of the longer incision or because of local ischemia induced by the placement of a single larger port. In conclusion, postoperative pain after SILC was improved by our using an ultrasound-guided rectus sheath block, which may contribute to less adverse biological response. The rectus sheath block may provide excellent postoperative analgesia and decreased need for analgesia; it also may facilitate earlier mobilization and discharge. Although we have found clinical benefits from using RSB-SILC, further larger randomized trials are needed to confirm these results.
Acknowledgment The authors have no conflicts of interest or financial ties to disclose.
References 1. Markar SR, Karthikesalingam A, Thrumurthy S et al. Singleincision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: Systematic review and metaanalysis. Surg Endosc 2012; 26: 1205–1213. 2. Pisanu A, Reccia I, Porceddu G et al. Meta-analysis of prospective randomized studies comparing single-incision laparoscopic cholecystectomy (SILC) and conventional multiport laparoscopic cholecystectomy (CMLC). J Gastrointest Surg 2012; 16: 1790–1801. 3. Asakuma M, Hayashi M, Komeda K et al. Impact of singleport cholecystectomy on postoperative pain. Br J Surg 2011; 98: 991–995.
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4. Leung D, Yetasook AK, Carbray J et al. Single-incision surgery has higher cost with equivalent pain and qualityof-life scores compared with multiple-incision laparoscopic cholecystectomy: A prospective randomized blinded comparison. J Am Coll Surg 2012; 215: 702–708. 5. Luna RA, Nogueira DB, Varela PS et al. A prospective, randomized comparison of pain, inflammatory response, and short-term outcomes between single port and laparoscopic cholecystectomy. Surg Endosc 2013; 27: 1254–1259. 6. Marks JM, Phillips MS, Tacchino R et al. Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: 1-year results of a prospective randomized, multicenter, single-blinded trial of traditional multiport laparoscopic cholecystectomy vs single-incision laparoscopic cholecystectomy. J Am Coll Surg 2013; 216: 1037– 1047. 7. Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G et al. Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: A randomized controlled trial. Surg Endosc 2010; 24: 1842–1828. 8. Wills VL & Hunt DR. Pain after laparoscopic cholecystectomy. Br J Surg 2000; 7: 273–284. 9. Jackson SA, Laurence AS, Hill JC. Does post-laparoscopy pain relate to residual carbon dioxide? Anaesthesia 1996; 5: 485–487. 10. Kamei H, Yoshida S, Yamasaki K et al. Severity of trauma changes expression of TNF-α mRNA in the brain of mice. J Surg Res 2000; 89: 20–25.
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11. Persec J, Persec Z, Husedzinovic I. Postoperative pain and systemic inflammatory stress response after preoperative analgesia with clonidine or levobupivacaine: A randomized controlled trial. Wien Klin Wochenschr 2009; 121: 558–563. 12. Marescaux J, Dallemagne B, Perretta S et al. Surgery without scars: A report of transluminal cholecystectomy in a human being. Arch Surg 2007; 142: 823–826. 13. McGregor CG, Sodergren MH, Aslanyan A et al. Evaluating systemic stress response in single port vs. multi-port laparoscopic cholecystectomy. J Gastrointest Surg 2011; 15: 614– 622. 14. Tsimogiannis KE, Tellis CC, Tselepis AD et al. α-Defensins and hsCRP levels in inflammatory response of standard and laparoendoscopic single-site cholecystectomy. Surg Endosc 2012; 26: 627–631. 15. De Oliveira GS Jr, Castro-Alves LJ, Nader A et al. Transversus abdominis plane block to ameliorate postoperative pain outcomes after laparoscopic surgery: A metaanalysis of randomized controlled trials. Anesth Analg 2014; 118: 454–463. 16. Abrahams MS, Horn JL, Noles LM et al. Evidence-based medicine: Ultrasound guidance for truncal blocks. Reg Anesth Pain Med 2010; 35: S36–S42. 17. Conaghan P, Maxwell-Armstrong C, Bedforth N et al. Efficacy of transversus abdominis plane blocks in laparoscopic colorectal resections. Surg Endosc 2010; 24: 2480–2484. 18. Philipp SR, Miedema BW, Thaler K. Single-incision laparoscopic cholecystectomy using conventional instruments: Early experience in comparison with the gold standard. J Am Coll Surg 2009; 209: 632–637.
Asian J Endosc Surg 8 (2015) 148–152 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Asian J Endosc Surg ISSN 1758-5902
O R I G I N A L A RT I C L E
Ultrasound-guided rectus sheath block for single-incision laparoscopic cholecystectomy Hideki Kamei,1 Nobuya Ishibashi,1 Gouichi Nakayama,1 Nobuya Hamada,2 Yutaka Ogata1 & Yoshito Akagi3 1 Department of Surgery, Kurume University Medical Center, Kurume, Japan 2 Department of Anesthesiology, Kurume University School of Medicine, Kurume, Japan 3 Department of Surgery, Kurume University School of Medicine, Kurume, Japan
Keywords Postoperative pain; rectus sheath block; single-incision laparoscopic cholecystectomy Correspondence Hideki Kamei, Department of Surgery, Kurume University Medical Center, 155-1 Kokubu-machi, Kurume, Fukuoka 839-0863, Japan. Tel: +81 942 22 6111 Fax: +81 942 22 6657 Email: [email protected] Presented at the 21st International Congress of the European Association for Endoscopic Surgery, Vienna, Austria, 19–22 June 2013 Received 17 August 2014; revised 14 September 2014; accepted 24 September 2014 DOI:10.1111/ases.12178
Abstract Introduction: Single-incision laparoscopic cholecystectomy (SILC) is increasingly applied for cholecystectomy and has been reported as safe and feasible, with short-term operative outcomes equivalent to four-port cholecystectomy. Although many investigators in randomized studies have noted the cosmetic advantages of SILC, the benefit of decreased pain in SILC remains controversial. Therefore, this study aimed to assess the efficacy of the rectus sheath block in SILC with respect to subjective pain. Methods: From April 2010 to March 2012, 75 patients with symptomatic gallstone or gallbladder polyps were assigned to one of three groups: (i) four-port laparoscopic cholecystectomy (n = 29); (ii) SILC (n = 15); and (iii) rectus sheath block in SILC (n = 30). We evaluated the operative details, length of hospital stay, and the need and usage of analgesia. Postoperative pain was recorded at 2, 6, 12, and 24 h after surgery based on a visual analog scale. Results: There was no difference with regard to age, ASA score, BMI, duration of operation, or length of hospital stay among the three groups. A significantly lower pain score was observed in the rectus sheath block in SILC group than in the SILC group at 2 and 6 h after operation. The pain score and need for analgesia were similar between the SILC group and the four-port cholecystectomy group. Conclusion: SILC using an ultrasound-guided rectus sheath block significantly reduces postoperative pain.
Introduction In recent years, increasing attention has been given to the benefits of SILS compared to standard multiport laparoscopic cholecystectomy. A systematic review and metaanalysis have described its safety and feasibility for the treatment of uncomplicated benign gallbladder disease (1,2). Nevertheless, no consensus has been reached on postoperative pain following single-incision laparoscopic cholecystectomy (SILC) compared with conventional laparoscopic cholecystectomy (3–7). Pain after laparoscopic cholecystectomy may be due to the several factors related to abdominal trauma, abdominal distension by insufflated gas, and/or residual carbon dioxide (8,9). In addition, we have previously shown that
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messenger RNA levels of tumor necrosis factor-α in mouse brain were increased following laparotomy by long incision compared with a short incision (10). Moreover, Persec et al. reported that α2 adrenergic agonist acted centrally before the pain stimulus set in, resulting in effective reduction of postoperative pain and inflammatory responses (11). Therefore, both the severity of trauma caused by wound length and pain could be important factors for the systemic inflammatory response after surgery. Many single-port devices such as the SILSTM Port (Covidien, Norwalk, USA) have been employed in singleincision procedures, usually through a 15–20-mm skin incision at the single-access point, typically the umbilicus. As a result, the umbilical wound for SILC requires a
Asian J Endosc Surg 8 (2015) 148–152 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Rectus sheath block
H Kamei et al.
larger incision than that for conventional laparoscopic cholecystectomy. The scale of postoperative pain in laparoscopic surgery has been found to be related to the length of the umbilical incision and seems not to be influenced by the other smaller incisions. Accordingly, we decided to assess the management of postoperative pain due to the umbilical wound in SILC. The aim of this study was therefore to investigate the efficiency of using a rectus sheath block to reduce postoperative pain in SILC.
Patients and Methods From April 2010 to March 2012, 75 patients (37 women and 38 men) were assigned to one of three groups: (i) the four-port cholecystectomy (4PLC) group (n = 29); (ii) the SILC group (n = 15); and (iii) the rectus sheath block in SILC (RSB-SILC) group (n = 30). All patients were informed about the intervention technique and provided written informed consent. No factor that could affect surgical difficulty, such as BMI, ASA classification, disease, or grade of inflammation, was considered in the choice of procedure. The 74 patients included in this study were selected from among 75 consecutive patients with symptomatic gallstone or gallbladder polyps. One patient was excluded from this study because of hemorrhagic risk factor. All operations were performed by a surgeon qualified under the Endoscopic Surgical Skill Qualification System in Japan. The rectus sheath block was administered by a single anesthesiologist experienced in this technique. Perioperative conditions were similar in all patients. During a preoperative visit, patients were adequately instructed on the concept of the visual analog scale, which ranged from 0 (no pain) to 10 (worst pain). A visual analog scale score was provided by each patient at 2, 6, 12, and 24 h after the operation. Pain was deduced from the consumption of pain-relieving medications. Patients received pain medications only on demand, and these were administered in incremental strength, beginning with peripheral analgesics. The experimental design was approved by the Research and Ethics Committee at our hospital. Surgical techniques
(5 mm), and right subcostal anterior axillary line (5 mm). Cholecystectomy was then carried out according to the critical exposure technique. SILC A 2.5-cm incision was made in the umbilicus in the SILC procedure. We used EZ AccessTM (Hakko Medical, Nagano, Japan) as the special single-port device. After umbilical access was obtained, a 5-mm flexible scope (Olympus, Tokyo, Japan) and two instruments were introduced. The gallbladder was lifted with a Mini Loop Retractor II (Covidien) in the right subcostal midclavicular line. Cholecystectomy was performed as in a conventional cholecystectomy. Rectus sheath block procedure An ultrasound-guided rectus sheath block was applied before any skin incision was made. A transducer was placed immediately lateral to the umbilicus in the transverse position. The needle was inserted in a medial-tolateral orientation through the subcutaneous tissue to pierce the anterior rectus sheath. The needle was further advanced through the body of the muscle until the tip was positioned between the posterior aspect of the rectus abdominis muscle and the rectus sheath. After negative aspiration, 1–2-mL local anesthetic was injected to verify and confirm the needle tip location. When injection of the local anesthetic appeared to be intramuscular, the needle was advanced 1–2 mm, and its position was re-checked by injection. This was repeated until the needle position was correctly achieved. A successful block was recorded if the plane between the rectus muscle and posterior rectus sheath was seen to expand with local anesthetic under ultrasound vision (Figure 1). In this study, 10-mL local anesthetic (0.375% ropivacaine) per side was adequate for effective analgesia. Statistical analysis All data were expressed as means ± SD. Statistical analysis was performed by ANOVA, Fisher’s protected least significant difference test, χ2 test, and Kruskal–Wallis test with JMP® 10 (SAS Institute Inc., Cary, USA). Differences between the means were considered to be significant at P < 0.05.
Conventional laparoscopic cholecystectomy Conventional laparoscopic cholecystectomy required the introduction of a 10-mm flexible scope through a 1.2-cm incision in the umbilicus. Three additional incisions were made, and ports were placed in the subxiphoid epigastric region (12 mm), right subcostal midclavicular line
Results Patient characteristics are summarized in Table 1. There was no significant difference in age, sex, BMI, ASA score, and postoperative pathological diagnosis among the
Asian J Endosc Surg 8 (2015) 148–152 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
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Figure 1 Transabdominal ultrasound images (a) before and (b) after rectus sheath block.
Table 1 Comparison of patient characteristics and pathological data
Age (years) Sex, women (%) BMI ASA classification (I/II/III) (n) Pathologic diagnosis (n) Adenomyomatosis or polyps Acute or chronic cholecystitis Mild Moderate Superimposed
4PLC (n = 29)
SILC (n = 15)
RSB-SILC (n = 30)
P-value
65.1 ± 12.8 37.9 22.1 ± 5.2 23/6/0
56.8 ± 18.8 60.0 22.5 ± 3.2 11/4/0
57.9 ± 12.8 53.3 23.1 ± 3.3 15/14/1
0.06 0.3† 0.66 0.14†
7
2
3
14 5 3
11 2 0
15 10 2
0.3†
There were no significant differences in patients’ characteristics and pathological data. †χ2 test was employed for comparison of sex, ASA classification, and severity of cholecystitis. The other data were analyzed using ANOVA and then Fisher’s protected least significant difference test. Data are expressed as mean ± SD. 4PLC, four-port cholecystectomy; RSB-SILC, rectus sheath block in single-incision laparoscopic cholecystectomy; SILC, single-incision laparoscopic cholecystectomy.
Table 2 Comparison of postoperative outcomes
Duration of operation (min) Bleeding amount (mL) Surgical-site infections (SSI) (n) Superficial SSI Organ or space SSI Length of stay (days) Frequency of analgesic request (n)
4PLC (n = 29)
SILC (n = 15)
RSB-SILC (n = 30)
P-value
106.6 ± 62.8 9.67 ± 22.1
91.8 ± 39.6 7.53 ± 14.4
96.2 ± 34.5 10.63 ± 22.0
0.85 0.60
1 0 6.96 ± 3.96 2.24 ± 1.78
1 0 5.53 ± 1.84 3.13 ± 2.29
1 1 5.50 ± 2.20 1.60 ± 1.63
0.77† 0.25 0.055
Postoperative outcomes were not significantly different in each group. †χ2 test was employed for comparison of surgical-site infections. The other data were analyzed using ANOVA and then Fisher’s protected least significant difference test. Data are expressed as mean ± SD. 4PLC, four-port cholecystectomy; RSB-SILC, rectus sheath block in single-incision laparoscopic cholecystectomy; SILC, single-incision laparoscopic cholecystectomy.
three groups. There were no differences among the three groups with regard to operation times and blood loss. Postoperative complications were also similar (Table 2). Although there were no significant differences in the number of requests for analgesia between the RSB-SILC group and the other groups, they were lower in the RSB-SILC group than in the other groups (Table 2).
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Postoperative pain was measured with the visual analog scale at 2, 6, 12, and 24 h postoperatively. The pain score was markedly decreased in the RSB-SILC group than the other groups at 2 h after operation (RSBSILC: 1.73 ± 1.11, P = 0.001 vs SILC group and P = 0.003 vs 4PLC group) (Table 3). Similarly, the pain score at 6 h postoperatively was significantly lower in the RSB-SILC
Asian J Endosc Surg 8 (2015) 148–152 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
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Table 3 Visual analog scale scores at several time points Time point
4PLC (n = 29)
SILC (n = 15)
RSB-SILC (n = 30)
P-value
At 2 h At 6 h At 12 h At 24 h
2.79 ± 1.23* 2.37 ± 1.20 2.06 ± 0.92 1.93 ± 1.19
3.20 ± 1.14* 2.73 ± 0.88** 2.13 ± 0.83 1.86 ± 1.06
1.73 ± 1.11 1.73 ± 1.14 1.90 ± 1.15 1.70 ± 1.02
P < 0.01 P < 0.05 0.643 0.764
*P < 0.01 compared to RSB-SILC group, **P < 0.05 compared to RSB-SILC group. Visual analog scale scores at each point were compared between groups by ANOVA and post-hoc testing. Data are expressed as mean ± SD. 4PLC, four-port cholecystectomy; RSB-SILC, rectus sheath block in singleincision laparoscopic cholecystectomy; SILC, single-incision laparoscopic cholecystectomy.
group than in the SILC group (RSB-SILC: 1.73 ± 1.14, P = 0.002 vs SILC group) (Table 3). However, no difference in pain score was noted at 12 and 24 h among the three groups (Table 3). Pain score did not differ between the SILC and the 4PLC groups postoperatively at any time points (Table 3).
Discussion In the development of laparoscopic techniques, reducing surgical trauma is considered to be a leading factor. Certainly, the first transvaginal NOTES was reported as noteworthy (12), but pure NOTES has yet to be established in routine clinical practice. As such, surgeons have recently shown an increased interest in SILS. Most studies on SILC have suggested that there are no differences in feasibility, safety, and outcome compared with the standard techniques. Whereas studies have shown that SILC offers better cosmesis, several randomized studies have failed to demonstrate a significant clinical advantage with respect to postoperative pain. Reliable evidence has yet to be reported demonstrating that SILC is less invasive than the conventional approach (13,14). Based on our initial experiences with SILC, postoperative pain appears to be an important clinical issue. The management of postoperative pain after laparoscopic surgery includes not only epidural anesthesia but also other analgesic techniques. Recently, peripheral nerve blocks have been used in the management of postoperative pain after laparoscopic surgery (15). Peripheral nerve blocks have a favorable side-effect profile compared to both opioid-based and epidural-based regimens in terms of improved analgesia with reduced risk of postoperative nausea and vomiting, minimal bladder interference, and a shorter hospital stay (16). Indeed, Conaghan et al. described the transversus abdominis plane block in laparoscopic colorectal surgery as effective in reducing postoperative pain compared with the use of a patient-controlled analgesia pump (17). However, no
previous study has investigated the correlation between use of a peripheral nerve block and SILC. We focused on the rectus sheath block as the peripheral nerve block to reduce postoperative pain in SILC because this procedure requires only a single incision into the umbilicus between the T7 and T11 intercostal nerves (16). Our data found that a rectus sheath block reduced pain scores at 2 and 6 h after SILC, indicating that a depression of neural stimuli from the umbilical site caused a decrease in the responsiveness of the central nervous system. There was no significant difference at 12 and 24 h among the three groups. This is probably because ropivacaine wears off within 10 h. In addition, there were no significant differences in frequency of analgesic request between the SILC group and the other groups. A likely possibility is that these blocks only provide analgesia to the abdominal wall and not the abdominal organs. It is noted that there was no difference in pain score or in requirement for analgesia between the SILC and 4PLC groups. According to Philipp et al. (18), pain scores and wound complication rates were higher for SILC than for 4PLC because of the longer incision or because of local ischemia induced by the placement of a single larger port. In conclusion, postoperative pain after SILC was improved by our using an ultrasound-guided rectus sheath block, which may contribute to less adverse biological response. The rectus sheath block may provide excellent postoperative analgesia and decreased need for analgesia; it also may facilitate earlier mobilization and discharge. Although we have found clinical benefits from using RSB-SILC, further larger randomized trials are needed to confirm these results.
Acknowledgment The authors have no conflicts of interest or financial ties to disclose.
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