Mustafa BIÇAK, Fikret SALIK, Hakan AKELMA

Laparoskopik Safra Kesesi Ameliyatlarında Transversus Abdominis Plan Bloğu, İntravenöz Non-Steroid Anti İnflamatuar İlaç ve Lokal Anestezik İnfiltrasyonunun Karşılaştırılması

Amaç: Bu çalışmada laparoskopik kolesistektomi yapılan hastalarda usg yardımıyla yapılan bilateral tap blok uygulaması, port giriş yerine lokal anestezik infiltrasyonu ve preemptif deksketoprofen uygulamasının postoperatif etkilerini karşılaştırarak artan laparoskopik cerahi oranları ve bu tür hastaların perioperetif ağrı yönetimi konusunda literatüre katkı sağlamayı amaçladık.Materyal ve Metod: Çalışmamız 08.01.2019 tarihli 228 sayılı Gazi Yaşargil Eğitim ve Araştırma Hastanesi yerel etik kurulu onayı alındıktan sonra randomize prospektif olarak planlandı. Hastalara ağrının değerlendirilmesinde kullanılan Vizüel Analog Skala (VAS) ve Sayısal Ağrı Skalası (NRS) ile ağrı şiddeti belirlendi. Çalışmaya dâhil edilen hastalar rastgele 3 gruba ayrıldı. Tüm hastalara genel anestezi uygulandı. Grup 1’deki hastalara cerrahi inzisyondan 30dk önce preemptif olarak 50 mg deksketoprofen yapıldı. Grup 2’ deki hastalara cerrahi insizyon öncesi belirlenen laparoskopik port giriş yerlerine lokal anestezik uygulandı ve ek analjezik yapılmadı. Grup 3 deki hastalara bilateral subkostal transversus abdominis plan bloğu (TAP) uygulandı. Anestezinin idamesinde ortalama arteryel basınçta bazal değerine göre %20 artış görülen hastalara 1 mcg/kg iv fentanyl uygulandı ve kayıt edildi.Bulgular: Çalışmaya 94 hasta alındı. 2 hasta morbit obezite (BMI>35) ve 2 hasta koagülopati nedeniyle çalışma dışı bırakıldı. 90 hasta 3 gruba ayrılıp analiz edildi. Postoperatif aneljezi süresi Grup 1‘de 15,83±10,94 saat, Grup 2‘de 14,95±10,39 saat, Grup 3‘te 23,21±4,29 saat olarak tespit edildi. Gruplar arası fark istatistiksel olarak anlamlı bulundu. Ek aneljezik ihtiyacı olan hasta sayısı Grup 1‘de %36,9(n=11), Grup 2’de %46,9(n=14), Grup 3’te %3(n:1) tespit edildi. Gruplar arası fark istatistiksel olarak anlamlı fark bulundu. Postoperatif ilk 24 saatlik dönemde hasta başına ortalama tramadol tüketim miktarları karşılaştırıldığında Grup 1‘de 55±90.11mg, Grup 2‘de 92,5±145,5mg, Grup 3‘te 13,33±73,0 mg bulundu. Gruplar arası fark istatistiksel olarak anlamlı bulundu. Postoperatif ilk 24 saat VAS skorları incelendiğinde 30.dk, 1., 2., 4., 8. ve 16. saatlerde Grup 3’de istatistiksel olarak daha düşük bulundu. 12. ve 24. saatlerde ise tüm gruplarda benzer sonuçlar tespit edildi. Sonuç: Sonuç olarak bu çalışmada elde ettiğimiz veriler laparoskopik kolesistektomi ameliyatlarında postoperatif ağrı yönetiminde usg eşliğinde bilateral tap blok uygulamasının başarılı bir yöntem olduğu yönündedir.

Anahtar Kelimeler:

Laparoskopik kolesistektomi, Bilateral TAP blok

Comparison of Transversus Abdominis Plane Block, Intravenous Non-Steroid Anti-Inflammatory Drug and Local Anesthetics Infiltration in Laparoscopic Gall Bladder Surgery

Background: In this study, we aimed to contribute to the literature on increasing laparoscopic surgery rates and perioperative pain management of such patients by comparing bilateral tap block application performed with the help of usg in patients undergoing laparoscopic cholecystectomy, local anesthetic infiltration instead of port entry, and postoperative effects of preemptive dexketoprofen application.Materials and Methods: Our study was planned prospectively, after the approval of the local ethics committee of Gazi Yaşargil Training and Research Hospital, numbered 228, dated 08.01.2019. Pain severity was determined with the Visual Analogue Scale (VAS) and Numerik Pain Scale(NRS) used to evaluate the pain. The patients included in the study were randomly divided into 3 groups. General anesthesia was applied to all patients. Patients in Group1 received 50 mg dexketoprofen as a preemptive 30 minutes before surgical insertion. Local anesthetics were applied to the laparoscopic port entry sites determined before the surgical incision in Group2 patients and no additional analgesics were performed. Bilateral subcostal transversus abdominis plan block (TAP) was applied to the patients in Group3. Patients with a 20% increase in the mean arterial pressure in the maintenance of anesthesia compared to the baseline value were administered 1 mcg/kg iv fentanyl and recorded.Results: 94 patients were included in the study. 2 patients were excluded from the study due to morbid obesity (BMI>35) and 2 patients due to coagulopathy. 90 patients were divided into 3 groups and analyzed. Postoperative analgesia duration was 15.83±10.94 hours in Group1, 14.95±10.39 hours in Group2, 23.21±4.29 hours in Group3. The difference between the groups was found statistically significant. The number of patients with additional analgesic needs was 36.9%(n=11) Group 1, 46.9%(n=14) Group 2, and 3%(n=1) in Group3. The difference between the groups was found statistically significant. When the average amount of tramadol consumption per patient was compared in the first 24 hours postoperatively, it was found 55±90.11mg in Group1 92.5±145.5mg in Group2 13.33±73.0 mg in Group3. The difference between the groups was found statistically significant. When VAS scores were examined in the first 24 hours postoperatively, it was found statistically lower in Group3 at 30 min, 1,2,4,8 and 16 hours. Similar results were detected in all groups at 12 and 24 hours. Conclusions: As a result, the data we obtained in this study is that bilateral tap block application is a successful method in postoperative pain management in laparoscopic cholecystectomy surgeries.

Keywords:

Bilateral TAP block, Laparoscopic cholecystectomy,

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