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Laparoscopic appendectomy is the most frequently performed surgery in patients who develop acute appendicitis. This surgical technique is more advantageous than an open appendectomy in terms of fewer complications, less postoperative pain, and a faster return to normal daily activities. Even though the laparoscopic technique is minimally invasive, postoperative pain is inevitable. Furthermore, it may affect the patients' mobility and cause them to stay in the hospital for a more extended period .The study aimed to compare the effectiveness and the safety of ultrasound-guided erector spinae plane block versus ultrasound-guided transversus abdominis plane block (TAP) as postoperative analgesia methods after laparoscopic appendectomy.
Acute appendicitis develops in a progressive and irreversible manner, even if the clinical course of acute appendicitis can be temporarily modified by intentional medications. Reliable and real-time diagnosis of acute appendicitis can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy is considered as the first therapeutic choice for Acute appendicitis .
The reported advantages of laparoscopic appendectomy compared with open appendectomy are less postoperative pain, less wound infection, and better cosmetic results. Even though the laparoscopic technique is minimally invasive, postoperative pain is inevitable. Furthermore, it may affect the patients' mobility and cause them to stay in the hospital for a more extended period .An intraperitoneal injection of local anesthetics is one of the analgesic modalities that are used to control pain in such cases but it is insufficient analgesic in most of patients and has short duration effect .
Recently Ultrasound-guided nerve blocks were effectively used for postoperative analgesia in different types of surgical procedures .Both erector spinae plane block and oblique subcostal transversus abdominis plane block have been used effectively to reduce pain after laparoscopic appendectomy.
In ultrasound-guided Transversus Abdominis Plane (TAP) Block local anesthetic (LA) is deposited in the plane between the transversus abdominis and posterior sheath of the rectus muscle in approximately midway between the iliac crest and costal margin .To anesthetize The terminal branches of the lower six thoracic and first lumbar nerve lie within, providing analgesia of the anterior and lateral abdominal wall .This block has a low risk for serious complications such as bowel or diaphragm perforation and lacerations of the liver. Abdominal wall hematoma, vascular injury, and local anesthetic toxicity are also potential but rare complications . Owing to safety of ultrasound-guided needle placement a 'real-time' visualization through dynamic scanning is used .
The ultrasound-guided Erector Spinae Plane (ESP) block is a paraspinal fascial plane block in which local anesthetic is administered between the erector spinae muscle and the thoracic transverse processes at the levels of the T7-T9 transverse processes, resulting in spread between the T6 and T12 segmental levels, blocking the dorsal and ventral rami of the abdominal spinal nerves.
This blockage of the dorsal and ventral rami of the spinal nerves helps to achieve a multi-dermatomal sensory block of the anterior, posterior, and lateral abdominal walls.
ESP block Complications such as vascular puncture, pleural puncture and pneumothorax are the primary complications .Also local anethetic toxicity, infection at needle insertion site and allergy also can occur .
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Group A (ESP) block group | Active Comparator | the first group (ESP) will be placed in the lateral decubitus position. The ultrasound probe will be placed in longitudinal orientation at the level of the T9spinous process and then moved the probe 3 cm laterally from the midline. The ultrasound landmarks, which included the T9 transverse process and the overlying erector spinae muscle, will be identified. Under complete aseptic conditions, an 80-mm 21-gauge block needle will be inserted in plane at an angle of 30-40° in cranial-to-caudal direction until the tip contacted the T9 transverse process. After hydro-dissection with 3 mL of isotonic saline solution confirmed the correct needle tip position, 20mL of 0.25% bupivacaine will be injected deep to the erector spinae muscle. The same procedure will be repeated with 20mL of 0.25% bupivacaine solution on the contralateral side. |
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| Group B TAP block group | Active Comparator | patients who will receive TAP block. A high-frequency ultrasound probe placed transversely, approximately midway between the iliac crest and costal margin shows the three muscle layers of the abdominal wall. A regional block needle can then be inserted anteriorly and slightly away from the probe and carefully advanced until it reaches the transversus plane. In this 'in-plane' technique. The needle and its tip are visualised throughout the procedure, as it enters the transversus plane after piercing the fascial layer below the internal oblique muscle. The needle will be directed toward the transversus abdominis fascia and injected 20 mL of 0.25% bupivacaine between the rectus abdominis and transversus abdominis muscles. The same procedure will be repeated with 20mL of 0.25% bupivacaine solution on the contralateral side. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| erector spinae plane block (ESP) | Procedure | patients will receive Ultrasound-guided erector spinae plane block (ESP) block for postoperative analgesia of adult patients undergoing laparoscopic appendectomy. |
| Measure | Description | Time Frame |
|---|---|---|
| a numerical rating scale (NRS) | an 11-point scale where 0 indicates no pain and 10 indicates the worst imaginable pain. Patients will chose a whole number to express the degree of their pain both at rest and when moving. | Patients will be asked to record their level of pain at 30 minutes as well as at two, four, six, eight, 12, 18 and 24 hours postoperatively. |
| Measure | Description | Time Frame |
|---|---|---|
| Intraoperative heart rate | Heart rate (HR)in beat per minute will be recorded every 5 min till the end of the surgery. | the duration of surgery |
| Incidence of complications | Including nerve injury, hematoma formation, Local anesthetic toxicity, and intravascular injections; |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Amira Fathy, MD | Ainshams university | Study Director |
| Mohsen Basyoni, MD | Ainshams university | Study Chair |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Ain shams university hospitals | Cairo | Egypt |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 30851501 | Background | Altiparmak B, Korkmaz Toker M, Uysal AI, Kuscu Y, Gumus Demirbilek S. Ultrasound-guided erector spinae plane block versus oblique subcostal transversus abdominis plane block for postoperative analgesia of adult patients undergoing laparoscopic cholecystectomy: Randomized, controlled trial. J Clin Anesth. 2019 Nov;57:31-36. doi: 10.1016/j.jclinane.2019.03.012. Epub 2019 Mar 6. | |
| 19020158 |
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: a double -blinded randomized clinical study.
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- Patients will be allocated in two groups using computer-generated table by a person who has access to the computer-generated table but is not involved in data collection or patient management perioperatively. BLock will be given by Anesthesiologist who is not involved in the study.Data collection will be carried out by a person who is completely blinded to the randomization. The person who analyzed the data statistically will not be involved in randomization or data collection.
| transversus abdominis plane block(TAP) | Procedure | patients will receive Ultrasound-guided transversus abdominis plane block(TAP) Block for postoperative analgesia of adult patients undergoing laparoscopic appendectomy. |
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| the duration of surgery |
| the cumulative consumption of pethidine | At a NRS pain scores of five or above, 50 mg of intravenous pethidine was administered. The total dose of analgesics administered during the first 24 hours will be carefully recorded. | the first 24 postoperatively |
| The duration of time before the first request for rescue analgesia post-surgically. | The maximum allowed dose of pethidine will be set at 5 mg/kg/24 h based on lean body weight. The blocks will be considered as failed blocks if patients require more than two doses of rescue analgesia in the first postoperative hour. | first postoperative hour |
| intraoperative blood pressure monitoring | mean arterial pressure (MAP) in millimeter mercury will be recorded every 5 min till the end of the surgery. | the duration of surgery |
| Background |
| Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Anesth Analg. 2008 Dec;107(6):2056-60. doi: 10.1213/ane.0b013e3181871313. |
| 30621377 | Background | De Cassai A, Bonvicini D, Correale C, Sandei L, Tulgar S, Tonetti T. Erector spinae plane block: a systematic qualitative review. Minerva Anestesiol. 2019 Mar;85(3):308-319. doi: 10.23736/S0375-9393.18.13341-4. Epub 2019 Jan 4. |
| 35860161 | Background | Sertcakacilar G, Yildiz GO. Analgesic efficacy of ultrasound-guided transversus abdominis plane block and lateral approach quadratus lumborum block after laparoscopic appendectomy: A randomized controlled trial. Ann Med Surg (Lond). 2022 Jun 14;79:104002. doi: 10.1016/j.amsu.2022.104002. eCollection 2022 Jul. |
| 29913392 | Background | Tulgar S, Kapakli MS, Senturk O, Selvi O, Serifsoy TE, Ozer Z. Evaluation of ultrasound-guided erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: A prospective, randomized, controlled clinical trial. J Clin Anesth. 2018 Sep;49:101-106. doi: 10.1016/j.jclinane.2018.06.019. Epub 2018 Jun 15. |
| 25580086 | Background | Yu N, Long X, Lujan-Hernandez JR, Succar J, Xin X, Wang X. Transversus abdominis-plane block versus local anesthetic wound infiltration in lower abdominal surgery: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol. 2014 Dec 15;14:121. doi: 10.1186/1471-2253-14-121. eCollection 2014. |
| 42180591 | Derived | Mohamed Soliman EA, Abdelgani Basyoni M, Hafni Soliman AF, Abdelmawla Saleh M, Attia Sami ES. Ultrasound-Guided Erector Spinae Plane Block Versus Transversus Abdominis Plane Block for Postoperative Analgesia in Adult Patients Undergoing Laparoscopic Appendectomy. Anesthesiol Res Pract. 2026 May 22;2026:6654154. doi: 10.1155/anrp/6654154. eCollection 2026. |