Ultrasound-guided rectus sheath block for single-incision laparoscopic cholecystectomy

Regional anaesthesia for postoperative pain management following laparoscopic, visceral, non-oncological surgery a systematic review and meta-analysis

BACKGROUND

Postoperative pain management following laparoscopic, non-oncological visceral surgery in adults is challenging. Regional anaesthesia could be a promising component in multimodal pain management.

METHODS

We performed a systematic review and meta-analysis with GRADE assessment. Primary outcomes were postoperative acute pain intensity at rest/during movement after 24 h, the number of patients with block-related adverse events and the number of patients with postoperative paralytic ileus.

RESULTS

82 trials were included. Peripheral regional anaesthesia combined with general anaesthesia versus general anaesthesia may result in a slight reduction of pain intensity at rest at 24 h (mean difference (MD) - 0.72 points; 95% confidence interval (CI) - 0.91 to - 0.54; I2 = 97%; low-certainty evidence), which was not clinically relevant. The evidence is very uncertain regarding the effect on pain intensity during activity at 24 h (MD -0.8 points; 95%CI - 1.17 to - 0.42; I2 = 99%; very low-certainty evidence) and on the incidence of block-related adverse events. In contrast, neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) may reduce postoperative pain intensity at rest in a clinical relevant matter (MD - 1.19 points; 95%CI - 1.99 to - 0.39; I2 = 97%; low-certainty evidence), but the effect is uncertain during activity (MD - 1.13 points; 95%CI - 2.31 to 0.06; I2 = 95%; very low-certainty evidence). There is uncertain evidence, that neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) increases the risk for block-related adverse events (relative risk (RR) 5.11; 95%CI 1.13 to 23.03; I2 = 0%; very low-certainty evidence).

CONCLUSION

This meta-analysis confirms that regional anaesthesia might be an important part of multimodal postoperative analgesia in laparoscopic visceral surgery, e.g. in patients at risk for severe postoperative pain, and with large differences between surgical procedures and settings. Further research is required to evaluate the use of adjuvants and the additional benefit of regional anaesthesia in ERAS programmes.

PROTOCOL REGISTRATION

PROSPERO CRD42021258281.

Effect of a Local Anesthetic Injection Kit on Pain Relief and Postoperative Recovery After Transumbilical Single-Incision Laparoscopic Cholecystectomy

Purpose

This study was conducted to explore whether incisional infiltration using a local anesthetic injection kit could better relieve postoperative pain and enhance the quality of recovery compared with ultrasound-guided rectus sheath block (RSB) or conventional local anesthetic infiltration in patients undergoing transumbilical single-incision laparoscopic cholecystectomy (SILC).

Patients and Methods

A total of 60 patients undergoing SILC with American Society of Anesthesiology functional status scores of I-II were randomized into the rectus sheath block group (RSB group), conventional local wound infiltration group (LAI-I group) and incisional infiltration using a local anesthetic injection kit group (LAI-II group). The primary outcomes were the patient-controlled intravenous analgesia (PCIA) demand frequency within 48 hours after the operation and postoperative pain measured by a visual analog scale (VAS) at 2 h, 4 h, 8 h, 24 h, and 48 h after surgery. Secondary outcomes were the total procedure times, cumulative consumption of anesthetic drugs, duration of surgery, duration and awaking time of anesthesia, early recovery indicator and side effects.

Results

The PCIA demand frequency in LAI-II group was significantly lower compared with patients in the RSB and LAI-I group (both P < 0.001). Moreover, the total procedure times in LAI-I and LAI-II group was significantly shorter than that in the RSB group (P < 0.001, respectively), but it was comparable between LAI-I and LAI-II group (P = 0.471). Though lower at 2h and 4h postoperative in LAI-II group, pain scores at each time point had no statistical differences among three groups. There were no significant differences among three groups for other outcomes as well.

Conclusion

The effect of ultrasound-guided RSB and conventional local anesthetic infiltration in SILC patients were found to be similar in terms of relieving postoperative pain and promoting recovery. Incisional infiltration using a local anesthetic injection kit can significantly reduce the demand frequency of PCIA, which serves as a rescue analgesic.

Single-shot regional anesthesia for laparoscopic cholecystectomies: a systematic review and network meta-analysis

BACKGROUND

Different regional anesthesia (RA) techniques have been used for laparoscopic cholecystectomy (LC), but there is no consensus on their comparative effectiveness. Our objective was to evaluate the effect of RA techniques on patients undergoing LC using a network meta-analysis approach.

METHODS

We conducted a systematic review and network meta-analysis. We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Science and Social Science Citation Index) using the following PICOS criteria: (P) adult patients undergoing LC; (I) any RA single-shot technique with injection of local anesthetics; (C) placebo or no intervention; (O) postoperative opioid consumption expressed as morphine milligram equivalents (MME), rest pain at 12 h and 24 h post-operation, postoperative nausea and vomiting (PONV), length of stay; and (S) randomized controlled trials.

RESULTS

A total of 84 studies were included. With the exception of the rectus sheath block (P = 0.301), the RA techniques were superior to placebo at reducing opioid consumption. Regarding postoperative pain, the transversus abdominis plane (TAP) block (-1.80 on an 11-point pain scale) and erector spinae plane (ESP) block (-1.33 on an 11-point pain scale) were the most effective at 12 and 24 h. The TAP block was also associated with the greatest reduction in PONV.

CONCLUSIONS

RA techniques are effective at reducing intraoperative opioid use, postoperative pain, and PONV in patients undergoing LC. Patients benefit the most from the bilateral paravertebral, ESP, quadratus lumborum, and TAP blocks.

Minimal effective dose of ultrasound-guided rectus sheath block to reduce oral analgesic requirement after ambulatory laparoscopic tubal resection: a randomized controlled superiority trial

Background

The effective dose during ultrasound-guided rectus sheath block (URSB) for reducing pain after laparoscopic tubal ligation is reported to be 100 mg of 0.25% bupivacaine. We examined the minimal effective dose of 0.25% bupivacaine for URSB on oral analgesic requirement after ambulatory single-port laparoscopic tubal resection.

Methods

A prospective, randomized controlled, superiority trial was conducted among patients who had been scheduled for ambulatory laparoscopic tubal resection between September 2015 and January 2019 at a tertiary care hospital in southern Thailand. Anesthesia was induced following protocol. The intervention group was allocated to receive a bilateral URSB using 10 ml of 0.25% bupivacaine on either side after intubation (total 50 mg) while the control group did not receive the sham block. Patients and assessors were blinded to the study intervention. All patients received a multimodal analgesia regimen as follows: fentanyl and ketorolac intraoperatively and fentanyl and oral acetaminophen at the post-anesthetic care unit. Postoperative oral analgesic requirement (acetaminophen and/or ibuprofen) at home was the primary outcome. Postoperative time to first analgesic requirement, oral analgesia (acetaminophen/ibuprofen), and pain score at 6 and 24 h were accessed via telephone interviews. Percentage, effect size (ES), and 95% confidence interval (CI) were presented.

Results

A total of 66 out of 79 eligible patients were analyzed (32 intervention, 34 control). Intraoperative fentanyl consumption was significantly lower in the intervention group (ES [95% CI]: 0.58 [0.08, 1.07] mcg, p = 0.022). Time to first oral analgesia in the intervention group was significantly longer than that of the control group (ES [95% CI]: 0.66 [0.14, 1.16] h, p = 0.012). The proportion of oral analgesia requirement at 24 h after surgery in the control group was significantly higher than that in the intervention group (97% vs 75%, p = 0.012). Pain scores at 6 and 24 h were similar in both groups although slightly lower in the intervention group (ES [95% CI]: 0.22 [−0.26, 0.71], p = 0.368 and 0.33 [−0.16, 0.81], p = 0.184, respectively).

Conclusion

A dose of 0.25% bupivacaine 50 mg for URSB reduced the oral analgesic requirement at 24 h and prolonged the time to first analgesic requirement after ambulatory laparoscopic tubal resection.

Trial registration

Thaiclinicaltrials.orgTCTR20150921002. Registered on 18 September 2015

Laparoscopic surgery and robotic surgery for single-incision cholecystectomy: an updated systematic review

The role of single-incision laparoscopic cholecystectomy (SILC) and single-incision robotic cholecystectomy (SIRC) is still unclear. We update the summarization of the feasibility and safety of SILC and SIRC. A comprehensive search of SILC and SIRC of English literature published on PubMed database between January 2015 and November 2020 was performed. A total of 70 articles were included: 41 covering SILC alone, 21 showing SIRC alone, 7 reporting both, and 1 study not specified. In total, 7828 cases were recorded (SILC/SIRC/not specified, 6234/1544/50); and the gender of 7423 cases was definitively reported: the female rate was 64.0% (SILC/SIRC/not specified, 62.1%/71.5%/74.0%). The weighted mean for body mass index (BMI), operative time, blood loss and post-operative hospital stay was 25.5 kg/m² (SILC/SIRC, 25.0/27.0 kg/m²), 73.8 min (SILC/SIRC, 68.2/88.8 min), 12.6 mL (SILC/SIRC, 12.1/14.8 mL) and 2.5 days (SILC/SIRC, 2.8/1.9 days), respectively. The pooled prevalence of an additional port, conversion to open surgery, post-operative complications, intraoperative biliary injury, and incisional hernia was 4.1% (SILC/SIRC, 4.7%/1.9%), 0.9% (SILC/SIRC, 0.7%/1.5%), 5.9% (SILC/SIRC, 6.2%/4.1%), 0.1% (SILC/SIRC, 0.2%/0.09%), and 2.1% (SILC/SIRC, 1.4%/4.8%), respectively. Compared with conventional laparoscopic cholecystectomy, SIRC has experienced more postoperative incisional hernias (risk difference = 0.05, 95% confidence interval 0.02-0.07; P < 0.0001). By far, SILC and SIRC have not been considered a standard procedure. With the innovation of medical devices and gradual accumulation of surgical experience, feasibility and safety of performing SILC and SIRC will improve.

Ultrasound-Guided Rectus Sheath Block Combined with Butorphanol for Single-Incision Laparoscopic Cholecystectomy: What is the Optimal Dose of Ropivacaine?

Purpose

In recent years, ultrasound-guided rectus sheath block (RSB) has been widely used in postoperative analgesia of abdominal operation. However, there is no uniform standard for the optimal dose of local anesthetics (LA) under ultrasound-guided rectus sheath block. This study aimed to determine the dose of ropivacaine combined with butorphanol that is effective in 50% (ED50) and 95% (ED95) of subjects for successful pain-free ultrasound-guided RSB in single-incision laparoscopic cholecystectomy (SILC).

Patients and Methods

Twenty-four patients scheduled to undergo single-incision laparoscopic cholecystectomy received an ultrasound-guided RSB. The initial dose of ropivacaine injected was 1.7 mg/kg, which was subsequently increased or decreased by 0.2 mg/kg, depending on whether the previous patient was free from pain (numeric rating scale (NRS) score of incisional pain at rest within 12 h after operation ≤ 3). All patients were treated with butorphanol 0.02 mg/kg as preemptive analgesia. The ED50 and ED95 were calculated using a probit regression model.

Results

The ED50 and ED95 of ropivacaine combined with butorphanol in ultrasound-guided rectus sheath block for analgesia in SILC, which were calculated by the probit regression model, were 0.719 mg/kg (95% confidence interval (CI), 0.553 mg/kg−0.873 mg/kg) and 0.967 mg/kg (95% CI, 0.835 mg/kg−1.91 mg/kg), respectively.

Conclusion

As part of a multimodal analgesia strategy, a dose of 0.719 mg/kg ropivacaine provided successful RSB under ultrasound guidance in 50% of the patients who underwent SILC. A dose of 0.967 mg/kg would be successful in 95% of patients.

Laparoscopic-guided versus transincisional rectus sheath block for pediatric single-incision laparoscopic cholecystectomy: A randomized controlled trial

PURPOSE

The purpose of our study was to compare the effectiveness of transincisional (TI) versus laparoscopic-guided (LG) rectus sheath block (RSB) for pain control following pediatric single-incision laparoscopic cholecystectomy (SILC).

METHODS

Forty-eight patients 10-21 years old presenting to a single institution for SILC from 2015 to 2018 were randomized to TI or LG RSB. Apart from RSB technique, perioperative care protocols were identical between groups. Pain scores were assessed with validated measures upon arrival in the postanesthesia care unit (PACU) and at regular intervals until discharge. The patients and those assessing them were blinded to RSB technique. The primary outcome was pain score 60 min after PACU arrival. Secondary outcomes included pain scores throughout the PACU stay, opioids (reported as morphine milligram equivalents (MME) per kg bodyweight) administered in PACU, length of stay, outpatient pain scores and opioid use, and adverse events. Groups were compared on outcomes using t test and generalized estimating equations for continuous variables and Fisher's exact test for categorical variables with significance at α = 0.05.

RESULTS

Mean age of the 48 subjects was 15 years (range = 11-20). The majority (79%) were female. Indications for surgery included symptomatic cholelithiasis (n = 41), acute cholecystitis (n = 4), gallstone pancreatitis (n = 2) and choledocholithiasis (n = 1). Mean (standard deviation) operative time was 61 (±23) min overall. No statistically significant differences in demographics, indication, operative time, or intraoperative analgesia were observed between TI (n = 24) and LG (n = 24) groups. The mean 60-min pain score was 3.4 (±2.6) in the LG group versus 3.8 (±2.1) in the TI group (p = 0.573). No significant differences were detected between groups in overall PACU or outpatient pain scores, PACU or outpatient opioid use, length of stay, or incidence of complications. Overall, mean opioid use was 0.1 MME/kg in the PACU and 0.5 MME/kg in the outpatient setting. Mean postoperative length of stay was 0.2 day. There were no major complications.

CONCLUSION

Laparoscopic-guided rectus sheath block is not superior to transincisional rectus sheath block for pain control following pediatric single-incision laparoscopic cholecystectomy. The single-incision laparoscopic approach combined with rectus sheath block resulted in effective pain control, low opioid use, and expedited length of stay with no major complications.

LEVEL OF EVIDENCE

Level I, treatment study, randomized controlled trial.

Perioperative Analgesic Effects of Preemptive Ultrasound-Guided Rectus Sheath Block Combined with Butorphanol or Sufentanil for Single-Incision Laparoscopic Cholecystectomy: A Prospective, Randomized, Clinical Trial

Purpose

Pain after single-incision laparoscopic cholecystectomy (SILC), especially visceral pain, often troubles patients and doctors. Whether preemptive butorphanol can relieve visceral pain in patients undergoing SILC remains unknown. The goal of this study was to assess the efficacy of ultrasound-guided bilateral rectus sheath block (RSB) and butorphanol for perioperative analgesia in patients undergoing SILC.

Patients and Methods

Fifty-eight patients who met the criteria were randomly divided into two groups, both of which were given preemptive RSB. Patients were given either butorphanol 0.02mg/kg (group B, n=29) or sufentanil 0.1 µg/kg (group S, n=29) as preemptive analgesia. The primary outcome was the cumulative frequency of rescue analgesic request within 24 hours after operation. Secondary outcomes were numeric rating scale (NRS) scores (from 0 to 10) of incisional pain and visceral pain, the length of hospital stay and the incidence of postoperative adverse events.

Results

The frequency of postoperative rescue analgesic request of group S was significantly higher than that of group B (P=0.021). The NRS scores for visceral pain were lower in group B at 2, 6 and 12 hours after surgery than in group S (both P<0.001). The occurrence of postoperative nausea and vomiting (PONV) was significantly higher in group S. There were no significant differences between two groups for other outcomes.

Conclusion

Butorphanol can provide sufficient visceral pain treatment after SILC than the dose of sufentanil in equal analgesic effect.

Effect of ultrasound-guided peripheral nerve blocks of the abdominal wall on pain relief after laparoscopic cholecystectomy

Purpose: The aim of this study was to compare the effect of an ultrasound-guided transversus abdominis plane block (TAPB) and rectus sheath block (RSB) combination, an ultrasound-guided posterior TAP block combined with the local anesthetic infiltration (LAI) and LAI alone on pain relief after laparoscopic cholecystectomy (LC). Patients and methods: One hundred eighty patients who were American Society of Anesthesiologists class Ι or Π were included in this randomized, double-blind, non-inferiority study. All patients underwent three-port LC and were divided into 3 groups. The LAI group had ropivacaine mixed with dexmedetomidine injected around the trocar entrance site preoperatively. The TL group underwent ultrasound-guided posterior TAPB combined with LAI, and the TR group underwent ultrasound-guided TAPB combined with RSB. Postoperative pain was evaluated at the first, 4th, 8th, 24th, and 48th hours. If the visual analogue scale (VAS) score (including incisional pain, visceral pain or shoulder pain) was >3, intravenous dezocine (0.05 mg/kg) was injected slowly. Sleep quality, total consumption of dezocine and time to unassisted walking were recorded. The Global Satisfaction Score (GSS) for analgesia was also assessed within 48 hrs. Results: No difference was found in sleep quality, time to unassisted walking, or requirement for dezocine. We also found no difference in VAS scores at each time point within 48 hrs after LC among the 3 groups, but the GSS for analgesia in the LAI group was significantly increased within 48 hrs compared with the other two groups. Conclusion: Ultrasound-guided peripheral nerve blocks of the abdominal wall can significantly relieve postoperative pain in patients undergoing LC; however, patients receiving LAI expressed more satisfaction than patients in whom other methods were used. LAI is an easy and effective method that can be recommended for routine clinical practice in LC patients who are not converted to an open procedure.

Ultrasound-guided bilateral rectus sheath block vs. conventional local analgesia in single port laparoscopic appendectomy for children with nonperforated appendicitis

INTRODUCTION

Despite its minimally invasive approach, laparoscopic surgery can cause considerable pain. Regional analgesic techniques such as the rectus sheath block (RSB) offer improved pain management following elective umbilical hernia repair in the pediatric population. This effect has not been examined in laparoscopic single-incision surgery in children. We sought to compare the efficacy of bilateral ultrasound-guided RSB versus local anesthetic infiltration (LAI) in providing postoperative pain relief in pediatric single-incision transumbilical laparoscopic assisted appendectomy (TULA) with same-day discharge.

METHODS

We retrospectively reviewed 275 children, ages 4 to 17 years old, who underwent TULA for uncomplicated appendicitis in a single institution from August 2014 to July 2015. We compared those that received preincision bilateral RSB (n=136) with those who received LAI (n=139). The primary outcome was narcotic administration. Secondary outcomes included initial and mean scores, time from anesthesia induction to release, operative time, time to rescue dose of analgesic in the PACU and time to PACU discharge.

RESULTS

Total narcotic administration was significantly reduced in patients that underwent preincision RSB compared to those that received conventional LAI, with a mean of 0.112 mg/kg of morphine versus 0.290 mg/kg morphine (p<0.0001). Patients undergoing RSB reported lower initial (0.38 vs. 2.38; p<0.0001) and mean pain scores (1.26 vs. 1.77; p<0.015). Time to rescue analgesia was prolonged in patients undergoing RSB compared to LAI (58.93min vs. 41.56min; p=0.047).

CONCLUSION

Preincision RSB for TULA in uncomplicated appendicitis in children is associated with decreased opioid consumption and lower pain scores compared with LAI. As the addition of this procedure only added 6.67min to time under anesthesia, we feel that it is a viable option for postoperative pain control in pediatric single-incision laparoscopic surgery.

RETROSPECTIVE COMPARATIVE STUDY

LEVEL III EVIDENCE.

Ultrasound-guided Combined Fascial Plane Blocks as an Intervention for Pain Management after Laparoscopic Cholecystectomy: A Randomized Control Study

Background

Pain associated with laparoscopic cholecystectomy is most severe during the first 24 h and the port sites are the most painful. Recent multimodal approaches target incisional pain instead of visceral pain which has led to the emergence of abdominal fascial plane blocks. This study embraces a novel combination of two independently effective fascial plane blocks, namely rectus sheath block and subcostal transversus abdominis plane (TAP) block to alleviate postoperative pain.

Study Objective

The aim is to evaluate the effectiveness of the combination of rectus sheath block and subcostal TAP block, to compare its efficacy with that of subcostal TAP block alone and with conventional port site infiltration (PSI) in alleviating postoperative pain in patients undergoing laparoscopic cholecystectomy.

Methodology

This prospective, randomized control, pilot study included 61 patients scheduled for elective laparoscopic cholecystectomy and distributed among three groups, namely Group 1: Combined subcostal TAP block with rectus sheath block (n = 20); Group 2: Oblique subcostal TAP block alone (n = 21); and Group 3: PSI group as an active control (n = 20).

Results

Combined group had significantly lower pain scores, higher satisfaction scores, and reduced rescue analgesia both in early and late postoperative periods than the conventional PSI group.

Conclusion

Ultrasound-guided combined fascial plane blocks is a novel intervention in pain management of patients undergoing laparoscopic cholecystectomy and should become the standard of care.

The Analgesic Efficiency of Ultrasound-Guided Rectus Sheath Analgesia Compared with Low Thoracic Epidural Analgesia After Elective Abdominal Surgery with a Midline Incision: A Prospective Randomized Controlled Trial

BACKGROUND

Ultrasound-guided rectus sheath blockade has been described to provide analgesia for midline abdominal incisions. We aimed to compare thoracic epidural analgesia (TEA) and rectus sheath analgesia (RSA) with respect to safety and efficacy.

METHODS

Sixty patients who underwent elective laparotomies through a midline incision were assigned randomly to receive either continuous TEA (TEA group, n = 31) or intermittent RSA (RSA group, n = 29). The number of patients who required analgesia, the time to first request analgesia, the interval and the cumulative morphine doses consumption during 72 hours postoperatively, and pain intensity using visual analog score (VAS) at rest and upon coughing were reported in addition to any side effects related to both techniques or administered drugs.

RESULTS

While 17 (54.84 %) patients were in the TEA group, 25 (86.21%) patients in the RSA group required analgesia postoperatively, P = 0.008. Cumulative morphine consumed during the early 72 hours postoperatively median (interquartile range) = 33 mg (27 - 39 mg), 95% confidence interval (28.63 - 37.37 mg) for the TEA group. While in the RSA group, it was 51 mg (45 - 57 mg), 95% CI (47.4 - 54.6 mg), P < 0.001. The time for the first request of morphine was 256.77 ± 73.45 minutes in the TEA group versus 208.82 ± 64.65 min in the RSA group, P = 0.031. VAS at rest and cough were comparable in both groups at all time points of assessment, P > 0.05. The time to the ambulation was significantly shorter in the RSA group (38.47 ± 12.34 hours) as compared to the TEA group (45.89 ± 8.72 hours), P = 0.009. Sedation scores were significantly higher in the RSA group, only at 12 hours and 24 hours postoperatively than in TEA group, with P = 0.041 and 0.013, respectively. The incidence of other morphine-related side effects, time to pass flatus, and patients satisfaction scores were comparable between both groups.

CONCLUSIONS

Continuous TEA had better opioid sparing effects markedly during the early 72 hours postoperatively than that of intermittent RSA with catheters inserted under real-time ultrasound guidance, both had comparable safety perspectives, and RSA had the advantage of early ambulation. RSA could be used as an effective alternative when TEA could not be employed in patients undergoing laparotomies with an extended midline incision, especially after the first postoperative day.

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

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.