Pain related to robotic cholecystectomy with lower abdominal ports: effect of the bilateral ultrasound-guided split injection technique of rectus sheath block in female patients: A prospective randomised trial

Abstract

Background: Robotic cholecystectomy (RC) using port sites in the lower abdominal area (T12-L1) rather than the upper abdomen has recently been introduced as an alternative procedure for laparoscopic cholecystectomy. Therefore, we investigated the time course of different components of pain and the analgesic effect of the bilateral ultrasound-guided split injection technique for rectus sheath block (sRSB) after RC in female patients.

Methods: We randomly assigned 40 patients to undergo ultrasound-guided sRSB (RSB group, n = 20) or to not undergo any block (control group, n = 20). Pain was subdivided into 3 components: superficial wound pain, deep abdominal pain, and referred shoulder pain, which were evaluated with a numeric rating scale (from 0 to 10) at baseline (time of awakening) and at 1, 6, 9, and 24 hours postoperatively. Consumption of fentanyl and general satisfaction were also evaluated 1 hour (before discharge from the postanesthesia care unit) and 24 hours postoperatively (end of study).

Results: Superficial wound pain was predominant only at awakening, and after postoperative 1 hour in the control group. Bilateral ultrasound-guided sRSB significantly decreased superficial pain after RC (P < 0.01) and resulted in a better satisfaction score (P < 0.05) 1 hour after RC in the RSB group compared with the control group. The cumulative postoperative consumption of fentanyl at 6, 9, and 24 hours was not significantly different between groups.

Conclusions: After RC with lower abdominal ports, superficial wound pain predominates over deep intra-abdominal pain and shoulder pain only at the time of awakening. Afterwards, superficial and deep pain decreased to insignificant levels in 6 hours. Bilateral ultrasound-guided sRSB was effective only during the first hour. This limited benefit should be balanced against the time and risks entailed in performing RSB.

Figure 1

Ultrasound images of the rectus sheath block. A, The needle was inserted into the space between the medial side of the IEVs and the TF. B, The needle was repositioned into the space between the lateral side of the IEVs and the TF. Arrow heads represent needle. IEVs = inferior epigastric vessels, TF = transversalis fascia.

Figure 2

Consolidated standards of reporting trials study flow diagram.

Figure 3

The characteristics of postoperative pain. Superficial incisional pain was significantly more severe than deep pain immediately after the operation. Superficial incisional and deep pains were both significantly greater than shoulder pain during the first 1 hour postoperatively. (∗) P < 0.05 compared with deep pain; (†, ‡) P < 0.05 compared with shoulder pain.

Figure 4

A box plot of pain scores in the 2 groups. The middle line in each box represents the median value and the outer margins of the box represent the interquartile range. A, Superficial incisional pain; B, deep pain; C, referred shoulder pain. (∗) P < 0.05, Wilcoxon rank-sum test. RSB = rectus sheath block.