Maloney Caroline, Kallis Michelle, El-Shafy Ibrahim Abd, Lipskar Aaron M, Hagen John, Kars Michelle
Department of Surgery, Hofstra Northwell School of Medicine, 300 Community Drive Manhasset, New York 11030.
Department of Surgery, Hofstra Northwell School of Medicine, 300 Community Drive Manhasset, New York 11030; Department of Pediatric Surgery, Northwell Cohen Children's Medical Center, 269-01 76th Ave, New Hyde Park, NY 11040.
J Pediatr Surg. 2018 Mar;53(3):431-436. doi: 10.1016/j.jpedsurg.2017.05.027. Epub 2017 Jun 2.
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.
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.
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).
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.
LEVEL III EVIDENCE.
尽管腹腔镜手术采用微创方法，但仍会引起相当程度的疼痛。区域镇痛技术，如腹直肌鞘阻滞（RSB），在小儿择期脐疝修补术后能改善疼痛管理。这种效果尚未在儿童腹腔镜单切口手术中得到检验。我们旨在比较双侧超声引导下RSB与局部麻醉浸润（LAI）在小儿单切口经脐腹腔镜辅助阑尾切除术（TULA）且同日出院的患者中提供术后疼痛缓解的疗效。
我们回顾性分析了2014年8月至2015年7月在单一机构接受TULA治疗单纯性阑尾炎的275名4至17岁儿童。我们将术前接受双侧RSB的患者（n = 136）与接受LAI的患者（n = 139）进行比较。主要结局是麻醉剂的使用。次要结局包括初始和平均疼痛评分、从麻醉诱导到出院的时间、手术时间、在麻醉后恢复室（PACU）使用镇痛补救剂量的时间以及PACU出院时间。
与接受传统LAI的患者相比，术前接受RSB的患者的总麻醉剂使用量显著减少，吗啡平均用量为0.112mg/kg，而LAI组为0.290mg/kg（p < 0.0001）。接受RSB的患者报告的初始疼痛评分较低（0.38对2.38；p < 0.0001），平均疼痛评分也较低（1.26对1.77；p < 0.015）。与LAI相比，接受RSB的患者使用镇痛补救剂的时间延长（58.93分钟对41.56分钟；p = 0.047）。
对于小儿单纯性阑尾炎的TULA，术前RSB与LAI相比，可减少阿片类药物的消耗并降低疼痛评分。由于增加此操作仅使麻醉时间增加6.67分钟，我们认为它是小儿单切口腹腔镜手术术后疼痛控制的可行选择。
三级证据。
