腹腔镜辅助腹横肌平面阻滞与 切口局麻对腹腔镜阑尾切除术后镇痛效果的比较

Postoperative analgesic effect of laparoscopic-assisted transversus abdominis plane block versus wound infiltration in laparoscopic appendectomy

摘要

目的: 比较腹腔镜辅助腹横肌平面（Lap-Tap）阻滞与手术切口局部麻醉（WI）在腹腔镜阑尾切除术（LA）术后镇痛方面的有效性与安全性。方法 选择2021年8月至2025年5月行 LA 的 74 例急性阑尾炎患者,采用随机数字表法分为 Lap-Tap 组（n=38）与 WI 组（n=36）。Lap-Tap 组采用罗哌卡因完成 Lap-Tap 操作,腹部切口注射生理盐水;WI 组采用罗哌卡因切口注射,注射生理盐水完成Lap-Tap 操作。记录术后2h、6h、12h、24h、48h疼痛评分及补救性镇痛、首次下床活动时间、首次排气时间、相关并发症等。结果 两组术后2h、6h、12h、24h、48h疼痛评分及术后 48 h 内氟比洛芬酯用量、使用阿片类药物镇痛例数差异无统计学意义。两组均无操作相关并发症发生。结论 LA 术中采用 Lap-Tap 阻滞与 WI 在术后 48 h 内疼痛评分无明显差异。由于 WI 操作技术难度较低,可能更加适于 LA 术后局部镇痛。

Abstract

Objective: To compare the efficacy and safety of laparoscopic-assisted transversus abdominis plane（Lap-Tap） block versus wound infiltration（WI）for postoperative analgesia in laparoscopic appendectomy（LA）. Methods: A total of 74 patients with acute appendicitis who underwent LA from Aug. 2021 to May 2025 were enrolled and randomly divided into the Lap-Tap group （n=38）and the WI group（n=36）by means of the random number table method.Patients in the Lap-Tap group received Lap-Tap block with ropivacaine and saline injection at abdominal incisions, while those in the WI group received ropivacaine infiltration at surgi- cal incisions and saline injection for Lap-Tap block.Pain scores at 2h、6h、12h、24h、48h and 48 h after operation, as well as rescue analge- sia, time to first ambulation, time to first flatus, and related complications were recorded. Results: There were no statistically significant differences in pain scores at 2h、6h、12h、24h、48h and 48 h after operation, the dosage of flurbiprofen axetil within 48 h postoperatively, and the number of patients receiving opioid analgesia between the two groups.No procedure-related complications occurred in either group. Conclusions: No significant difference is found in pain scores within 48 h after operation between Lap-Tap block and WI during LA.WI may be more suitable for local postoperative analgesia in LA due to its lower technical difficulty.

关键词

麻醉 / 阑尾切除术 / 腹腔镜检查 / 腹横肌平面阻滞 / 镇痛

Key words

Anesthesia / Appendectomy / Laparoscopy / Transversus abdominis plane block / Analgesia

[1] 张伟耀,周霞.腹腔镜阑尾切除术与开腹阑尾切除术的并发症大样本对比分析[J].中国全科医学,2014,17(3):322-324.
[2] 中华医学会外科分会腹腔镜与内镜外科学组.腹腔镜阑尾切除术常规[J].腹腔镜外科杂志,2006,11(4):359-360.
[3] 邓和军,李庆东,冉崇新,等.腹腔镜阑尾切除术的临床应用价值[J].腹腔镜外科杂志,2004,9(4):241-243.
[4] Waddimba AC,Newman P,Shelley JK,et al.Pain management after laparoscopic appendectomy:Comparative effectiveness of in- novative pre-emptive analgesia using liposomal bupivacaine[J].Am J Surg,2022,223(5):832-838.
[5] 郑宗师,魏波,陈图锋,等.腹腔镜阑尾切除与开腹阑尾切除术的对比研究及 Meta 分析[J/CD].中华普通外科学文献(电子版),2009,3(5):438-442.
[6] 陈心足,宋小海,白丹,等.腹腔镜在急腹症诊疗应用的进展——欧洲内镜外科协会共识解读[J].华西医学,2017,32(12):1835-1840.
[7] Ekstein P,Szold A,Sagie B,et al.Laparoscopic surgery may be associated with severe pain and high analgesia requirements in the immediate postoperative period[J].Ann Surg,2006,243(1):41-46.
[8] Manworren RCB,McElligott CD,Deraska PV,et al.Efficacy of Analgesic Treatments to Manage Children' s Postoperative Pain After Laparoscopic Appendectomy:Retrospective Medical Record Review[J].AORN J,2016,103(3):317.e1-11.
[9] 中国加速康复外科专家组.中国加速康复外科围术期管理专家共识(2016版)[J].中华消化外科杂志,2016,15(6):527-533.
[10] 中华医学会麻醉学分会.成人手术后疼痛处理专家共识[J].临床麻醉学杂志,2017,33(9):911-917.
[11] McDonald V,Wang Y,Patel A,et al.Laparoscopic guided liposomal bupivacaine injection compared to transversus abdominus plane block for postoperative pain after robotic gynecologic oncology surgery[J].Gynecol Oncol,2022,166(3):432-437.
[12] 上海市医学会麻醉科专科分会,上海市医学会普通外科专科分会.普通外科围手术期疼痛管理上海专家共识(2020版)[J].中国实用外科杂志,2021,41(1):31-37.
[13] 秦朝生,柳元铭,刘敬臣.腹横肌平面阻滞的临床应用进展[J].临床麻醉学杂志,2016,32(7):713-716.
[14] Jalil RMA,Yahya N,Sulaiman O,et al.Comparing the effectiveness of ropivacaine 0.5% versus ropivacaine 0.2% for transabdo- minis plane block in providing postoperative analgesia after appendectomy[J].Acta Anaesthesiol Taiwan,2014,52(2):49-53.
[15] Rafi AN.Abdominal field block:a new approach via the lumbar triangle[J].Anaesthesia,2001,56(10):1024-1026.
[16] Hebbard P,Fujiwara Y,Shibata Y,et al.Ultrasound-guided transversus abdominis plane(TAP)block[J].Anaesth Intensive Care,2007,35(4):616-617.
[17] Chetwood A,Agrawal S,Hrouda D,et al.Laparoscopic assisted transversus abdominis plane block:a novel insertion technique during laparoscopic nephrectomy[J].Anaesthesia,2011,66(4):317-318.
[18] Liu YY,Yeh CN,Lee HL,et al.Local anesthesia with ropivacaine for patients undergoing laparoscopic cholecystectomy[J].World J Gastroenterol,2009,15(19):2376-2380.
[19] Dinges HC,Wiesmann T,Otremba B,et al.The analgesic efficacy of liposomal bupivacaine compared with bupivacaine hydrochlo- ride for the prevention of postoperative pain:a systematic review and meta-analysis with trial sequential analysis[J].Reg Anesth Pain Med,2021,46(6):490-498.
[20] Mouton WG,Bessell JR,Otten KT,et al.Pain after laparoscopy[J].Surg Endosc,1999,13(5):445-448.
[21] Molfino S,Botteri E,Baggi P,et al.Pain control in laparoscopic surgery:a case-control study between transversus abdominis plane-block and trocar-site anesthesia[J].Updates Surg,2019,71(4):717-722.
[22] Čustovic S,Pandža H,Delibegovic S.Effect of Local Anesthesia on the Postoperative Pain After Laparoscopic Appendectomy[J]. J Laparoendosc Adv Surg Tech A,2019,29(1):65-71.
[23] Scott NB.Wound infiltration for surgery[J].Anaesthesia,2010,65 Suppl 1:67-75.
[24] Amid PK,Shulman AG,Lichtenstein IL.Local anesthesia for inguinal hernia repair step-by-step procedure[J].Ann Surg,1994, 220（6）:735-737.
[25] Rawal N.Current issues in postoperative pain management[J].Eur J Anaesthesiol,2016,33(3):160-171.
[26] El-Dawlatly AA,Turkistani A,Kettner SC,et al.Ultrasound-guided transversus abdominis plane block:description of a new tech- nique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy[J].Br J Anaesth,2009, 102(6):763-767.
[27] Niraj G,Searle A,Mathews M,et al.Analgesic efficacy of ultrasound-guided transversus abdominis plane block in patients under- going open appendicectomy[J].Br J Anaesth,2009,103(4):601-605.
[28] Neethirajan SGR,Kurada S,Parameswari A.Efficacy of Dexmedetomidine as an Adjuvant to Bupivacaine in Ultrasound-Guided Transverse Abdominis plane Block for Laparoscopic appendicectomy:A Randomised Controlled Study[J].Turk J Anaesthesiol Reanim,2020,48(5):364-370.
[29] Cavallaro G,Gazzanelli S,Iossa A,et al.Ultrasound-guided Transversus Abdominis Plane Block is Effective as Laparoscopic Tro- car site infiltration in Postoperative Pain Management in Patients Undergoing Adrenal Surgery[J].Am Surg,2023, 89(11): 4401-4405.
[30] Einarsson JI,Sun J,Orav J,et al.Local analgesia in laparoscopy :a randomized trial[J].Obstet Gynecol,2004,104（6):1335-1339.
[31] Cervini P,Smith LC,Urbach DR.The effect of intraoperative bupivacaine administration on parenteral narcotic use after laparo- scopic appendectomy[J].Surg Endosc,2002,16(11):1579-1582.
[32] Sozbilen M,Yeniay L,Unalp M,et al.Effects of ropivacaine on pain after laparoscopic cholecystectomy :a prospective,randomized study[J].Adv Ther,2007,24（2）:247-257.
[33] Bourget JL,Clark J,Joy N.Comparing preincisional with postincisional bupivacaine infiltration in the management of postopera- tive pain[J].Arch Surg,1997,132(7):766-769.
[34] Arora S,Chhabra A,Subramaniam R,et al.Transversus abdominis plane block for laparoscopic inguinal hernia repair:a rando- mized trial[J].J Clin Anesth,2016,33:357-364.
[35] Zhang J,Liu T,Zhou H,et al.The Safety and Efficacy of Ultrasound-Guided Bilateral Dual Transversus Abdominis Plane(BD- TAP)Block in ERAS Program of Laparoscopic Hepatectomy :A Prospective,Randomized,Controlled,Blinded,Clinical Study[J].Drug Des Devel Ther,2020,14:2889-2898.
[36] Grape S,Kirkham KR,Akiki L,et al.Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy:A systematic review and meta-analysis with trial sequential analysis[J].J Clin Anesth,2021,75:110450.
[37] Tanggaard K,Jensen K,Lenz K,et al.A randomised controlled trial of bilateral dual transversus abdominis plane blockade for laparoscopic appendicectomy[J].Anaesthesia,2015,70（12):1395-1400.
[38] Park JS,Choi GS,Kwak KH,et al.Effect of local wound infiltration and transversus abdominis plane block on morphine use after laparoscopic colectomy:a nonrandomized,single-blind prospective study[J].J Surg Res,2015,195(1):61-66.
[39] Guo Q,Li R,Wang L,et al.Transversus abdominis plane block versus local anaesthetic wound infiltration for postoperative anal- gesia:A systematic review and meta-analysis[J].Int J Clin Exp Med,2015,8(10):17343-17352.
[40] Cai Q,Gao ML,Chen GY,et al.Transversus Abdominis Plane Block versus Wound Infiltration with Conventional Local Anesthe- tics in Adult Patients Underwent Surgery:A Systematic Review and Meta-analysis of Randomized Controlled Trials[J].Biomed Res Int,2020,2020:8914953.
[41] La Regina D,Popeskou SG,Saporito A,et al.Laparoscopic versus ultrasound-guided transversus abdominis plane block in colo- rectal surgery:a non-inferiority,multicentric randomized double-blinded clinical trial[J].Colorectal Dis,2023, 25（9）:1921-1928.
[42] Ravichandran NT,Sistla SC,Kundra P,et al.Laparoscopic-assisted Tranversus Abdominis Plane(TAP)Block Versus Ultra- sonography-guided Transversus Abdominis Plane Block in Postlaparoscopic Cholecystectomy Pain Relief:Randomized Controlled Trial[J].Surg Laparosc Endosc Percutan Tech,2017,27(4):228-232.
[43] Sharma D,Meena S,Anand G.Randomized single blind trial to compare the short term post-operative outcome and cost analysis of laparoscopic versus ultrasound guided transversus abdominis plane block in patients undergoing bariatric surgery[J].Surg En- dosc,2023,37(9):7136-7143.
[44] Iaquinandi F,Mongelli F,Christoforidis D,et al.Laparoscopic vs.ultrasound-guided transversus abdominis plane(TAP)block in colorectal surgery:a systematic review and meta-analysis of randomized trials[J].Surg Endosc,2024,38(3):1119-1130.
[45] Hamid HK,Emile SH,Saber AA,et al.Laparoscopic-Guided Transversus Abdominis Plane Block for Postoperative Pain Manage- ment in Minimally Invasive Surgery:Systematic Review and Meta-Analysis[J].J Am Coll Surg,2020,231(3):376-386.e15.
[46] Aldalati AY,Hussein AM,Nguyen D,et al.Ultrasound-guided vs.laparoscopic-guided transversus abdominis plane block for postoperative pain following laparoscopic cholecystectomy:a systematic review and meta-analysis[J].Ir J Med Sci,2025, 194(1):323-331.
[47] Taylor JS,Ramamurthi RJ,Austin J,et al.Ultrasound Verification of Laparoscopic-Assisted Transversus Abdominis Plane Blocks in Children Undergoing Laparoscopic Procedures[J].J Laparoendosc Adv Surg Tech A,2022,32(3):325-329.
[48] Ortiz J,Suliburk JW,Wu K,et al.Bilateral transversus abdominis plane block does not decrease postoperative pain after laparo- scopic cholecystectomy when compared with local anesthetic infiltration of trocar insertion sites[J].Reg Anesth Pain Med,2012, 37(2):188-192.
[49] Alttparmak B,Korkmaz Toker M,Uysal AI,et al.Ultrasound-guided erector spinae plane block versus oblique subcostal transver- sus abdominis plane block for postoperative analgesia of adult patients undergoing laparoscopic cholecystectomy:Randomized, controlled trial[J].J Clin Anesth,2019,57:31-36.
[50] Tran DQ,Bravo D,Leurcharusmee P,et al.Transversus Abdominis Plane Block:A Narrative Review[J].Anesthesiology,2019, 131(5):1166-1190.
[51] Carney J,Finnerty O,Rauf J,et al.Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks[J]. Anaesthesia,2011,66(11):1023-1030.
[52] Hamid HKS.How,Why,andWhen to administer transversus abdominis plane block in laparoscopic surgery?[J].Updates Surg, 2021,73(5):2031-2033.
[53] Gitman M,Fettiplace MR,Weinberg GL,et al.Local Anesthetic Systemic Toxicity:A Narrative Literature Review and Clinical Update on Prevention,Diagnosis,and Management[J].Plast Reconstr Surg,2019,144(3):783-795.
[54] Safety Committee of Japanese Society of Anesthesiologists.Practical guide for the management of systemic toxicity caused by local anesthetics[J].J Anesth,2019,33(1):1-8.
[55] Graf BM.The cardiotoxicity of local anesthetics:the place of ropivacaine[J].Curr Top Med Chem,2001,1(3):207-214.
[56] 胡海青,鲍红光,单涛,等.不同浓度罗哌卡因坚脊肌平面阻滞在腹腔镜下胃癌根治术中的应用效果[J].临床麻醉学杂志,2020,36(10):997-1001.
[57] Fusco P,Pascarella G,Stecco C,et al.Factors to consider for fascial plane blocks' success in acute and chronic pain management[J].Minerva Anestesiol,2024,90（1-2):87-97.
[58] Rosenberg PH,Th Veering B,Urmey WF.Maximum recommended doses of local anesthetics :a multifactorial concept[J].Reg Anesth Pain Med,2004,29(6):564-575.
[59] Guerra L,Philip S,Lax EA,et al.Transversus Abdominis Plane Blocks in Laparoscopic Colorectal Surgery:Better Pain Control and Patient Outcomes with Liposomal Bupivacaine than Bupivacaine[J].Am Surg,2019,85(9):1013-1016.
[60] Xu HT,Zimmerman J,Bertoch T,et al.CPL-01,an investigational long-acting ropivacaine,demonstrates safety and efficacy in open inguinal hernia repair[J].Hernia,2024,28(4):1345-1354.