Laparoscopic Guided Regional Analgesia (Lagra) Reduces Post-Operative Pain After Laparoscopic Cholecystectomy

D. Joyce, R. Craig, S. Mansoor, S. Toomey

Department of General and Colorectal Surgery, Regional Hospital Mullingar, County Westmeath, Ireland

Dear Editor,

The transversus abdominal plane (TAP) block has been successfully employed in abdominal surgery to inhibit somatic pain sensation as part of a multi-modal analgesic regimen1,2. To date one group have investigated the analgesic effect of a laparoscopic assisted TAP block in laparoscopic cholecystectomy (LC) by comparing 4 quadrant regional TAP block against periportal local anaesthesia3. The authors showed a reduction in numerical pain scores in the TAP block group3. The necessity of blockading all 4 quadrants in a single quadrant operation and the exclusion of periportal infiltration in the TAP group is questionable. Our study investigated the analgesic efficacy and perioperative benefits of laparoscopic guided regional anaesthesia (LaGRA) in patients undergoing LC.

This prospective, double-blinded, randomised controlled trial was conducted at the Regional Hospital Mullingar. Eligible patients were randomised using random sequence allocation within sealed envelopes. All participants underwent LC with a 12mm umbilical port site and 3x5mm subcostal ports. LaGRA was administered following the removal of the gallbladder by injecting at 2 points, the first just medial to the lateral 5mm port targetting the TAP plane, and the second lateral to the medial 5mm port targetting the rectus sheath. Correct placement of the needle was confirmed laparoscopically through the visualisation of tenting in the peritoneum when the needle reached the pre-peritoneal space. At this point the needle was withdrawn 1 layer and the block was injected. Correct placement of the needle tip was determined by injection against resistance as the plane opened up and lack of any bulging of the preperitoneal space. Patients in the LaGRA group received 20ml of Chirocaine®2.5mg/ml, whereas those in the control group were administered 20ml 0.9% Normal Saline in unlabeled syringes.

The primary outcome was pain measured at 1, 2 and 6  hours post-operatively on a numeric scale from 1 to 10. Secondary outcomes measures were post-operative analgesia and anti-emetic consumption, and discharge and re-admission rates

Seventy six patients were enrolled in this trial. Thirty four (45%) were randomized to placebo and the remainder (n=42, 55%) underwent LaGRA. There was no difference in the characteristics of patients in either arm of the stuedy. Mean pain scores, for LaGRA and placebo at 1, 2 and 6 hours respectively, were 1.8 versus 2.8, 1.1 versus 2.3, and 1.0 versus 2.3. This difference approached statistical significance at 1 hour (p=0.09) and was statistically significant at 2 and 6 hours (P<0.05) (unpaired t-test, Figure 1). Post operative opiate and anti-emetic use and discharge and readmission rates were similar.

This study illustrates that LaGRA is beneficial for patients undergoing LC. This safe and effective technique has a short learning curve and results in significantly less post-operative pain. It is now a standard component of our daycase LC pathway.

Sources of Funding
None to declare

Conflicts of Interest Statement
None to declare

Corresponding Author
Doireann Joyce,
Midland Regional Hospital Mullingar,
Co. Westmeath,
Phone: 044 934 0221
Fax: +353 (0)44 9340221

1. Johns N, O’Neill S, Ventham NT, Barron F, Brady RR, Daniel T. Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a systematic review and meta-analysis. Colorectal Dis. 2012 Oct;14(10):e635-42.
2. Kim AJ, Yong RJ, Urman RD. The Role of Transversus Abdominis Plane Blocks in Enhanced Recovery After Surgery Pathways for Open and Laparoscopic Colorectal Surgery. J Laparoendosc Adv Surg Tech A. 2017 Sep;27(9):909-914.
3. Elamin G, Waters PS, Hamid H, O’Keeffe HM, Waldron RM, Duggan M, et al. Efficacy of a Laparoscopically Delivered Transversus Abdominis Plane Block Technique during Elective Laparoscopic Cholecystectomy: A Prospective, Double-Blind Randomized Trial. J Am Coll Surg. 2015;221(2):335-44.