Analgesic Effect of TAP Block After Laparoscopic Cholecystectomy
Analgesic Effect of TAP Block After Laparoscopic Cholecystectomy
TAP block is a locoregional analgesic technique that consists of infiltrating a local
 anesthetic solution between the muscle layers of the abdominal wall. This block produces
 prolonged parietal analgesia.

 The aim of the study is to evaluate whether infiltration of the abdominal wall using TAP
 block reduces postoperative pain and postoperative analgesic consumption, and improves
 patient comfort after laparoscopic cholecystectomy. This effect will be clinically relevant
 only if parietal pain predominates postoperatively.
Between 10 and 20% of the Western population suffer from gallstones. When a surgical
 operation (cholecystectomy) is necessary, the removal of the gallbladder is done by
 laparoscopy in 95% of cases. The risk of having to undergo this operation increases with age
 and on average women are twice as likely as men to have to undergo surgery. In Belgium, only
 4% of these laparoscopic cholecystectomies are performed as one day hospitalization. Although
 this operation is considered a minor surgery, patients sometimes report intense postoperative
 pain that may encourage them to spend a night in the hospital. Better management of
 postoperative pain could increase the number of outpatient procedures. A large individual
 variability in pain intensity is observed after this surgical procedure. Three types of pain
 can be associated with this surgery: parietal pain secondary to the incisions of the wall
 necessary for the introduction of the surgical instruments; deep visceral pain, difficult to
 localize and secondary to surgical trauma in the area of dissection of the gall bladder; and
 scapular pain, a projected pain secondary to the irritation of the diaphragm by
 CO2-pneumoperitoneum. The temporal characteristics and intensity of these three types of pain
 are different. Some report a predominance of parietal pain, while for others visceral pain is
 most intense.

 The Transversus Abdominis Plane (TAP) block is a loco-regional analgesia technique that
 consists of infiltrating a local anesthetic solution between the plane of the transversus
 abdominis muscle and the internal oblicus muscle, laterally at the level of the triangle of
 Petit. The sensory nerves of the abdominal wall pass through this plane. This technique
 produces long-lasting analgesia, between 24-36 hours. Only the nerves responsible for the
 innervation of the abdominal wall are blocked by this infiltration. The metameric extension
 of parietal analgesia varies from one study to another, especially depending on the site of
 infiltration. After posterior TAP block, parietal analgesia concerns the infra-umbilical
 abdominal wall, but can reach in some cases the dermatome T-8. When the surgery involves the
 supra-umbilical abdominal wall, the TAP block is performed at the subcostal level to block
 the nerve branches T-6 to T-10. Infiltration is then performed between the transverse muscle
 and the rectus abdominis at the lateral end of this muscle.

 Several studies have evaluated the efficacy of TAP block for analgesia after laparoscopic
 cholecystectomy. Controversial results have been reported. These controversies can be
 explained in part by the type of TAP block used: lateral versus subcostal approach which
 appears more appropriate for laparoscopic cholecystectomy (supra-umbilical parietal
 incisions). In addition, effective multimodal analgesia, a recommended good medical practice,
 is not always used in these studies. This strategy, by effectively reducing postoperative
 pain, may make the clinical utility of TAP block irrelevant. Finally, in case of predominance
 of parietal pain on visceral pain, the clinical relevance of the TAP block should be
 objectified. In the opposite case (predominance of visceral pain), TAP block would be much
 less effective.

 2.2 Purpose of the study. The purpose of this study is to evaluate the analgesic efficacy of
 TAP subcostal block after laparoscopic cholecystectomy. The effectiveness of the TAP block
 will confirm the importance of the parietal pain component after this type of surgery.
 Decreases in postoperative pain and postoperative opioid consumption, possibly associated
 with a decrease in morphine side effects (nausea, vomiting, sedation, fatigue), may be
 conducive to the development of outpatient laparoscopic cholecystectomy.

 2.3 General description. This randomized double-blind placebo-controlled study will include
 two groups of 20 patients: the TAP block will be performed in a group using a local
 anesthetic solution (levobupivacaine [Chirocaine®] 0.375% Adr 1/200000) in the " treatment "
 group and with saline Adr 1/200000 in the control group.
Inclusion Criteria:

 - all patients aged 18-75 yo scheduled for laparoscopic cholecystectomy

 Exclusion Criteria:

 -  Coagulation disorders

 -  Refusal of participation expressed by the patient

 -  Fibromyalgia

 -  Preoperative morphine treatment

 -  Contraindications to local anesthetics: epilepsy, severe cardiac conduction block (2nd
 and 3rd degree AVB ), allergy

 -  Contraindications to NSAIDs: renal failure, allergy, ischemic heart disease, stroke