Laparoskopische Eingriffe + Regionalanästhesie:

Sinn oder Unsinn?

J. Blasl

November 2015

AIC 12.-14.11. 2015 Wien „Von der Instabilität zur Stabilität“

Conflict of interest in relation to the above mentioned topic:

x I have NO conflict of interest O I have conflicts of interest (please specify): � received travel grants, speaking fees, writing fees and other honoraria……………………… ……………………………………………………………................................................. � received fees for consulting…………………………………………………………………………………………… � received research funding……………………………………………………………………………………………… � employed by a related company……………………………………………………………………………………. � holding stocks or shares in a company which might be affected by mine publications ……………………………………………………………………………………………………………………...... � others………….........…………………………………………………………………………………………………

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Laparoskopische Eingriffe + Regionalanästhesie: Sinn oder Unsinn?

J. Blasl

Laparoskopische Eingriffe + Regionalanästhesie: Sinn oder Unsinn?

- Laparoskopiearten - Proceduren spez. Schmerz - Verfahrensempfehlungen - Fast Track - Nur RA ? - EK – Golden Standard - TAP

- Literatur - Technik - Alltag

- Conclusio

Laparoskopische Eingriffe + Regionalanästhesie:

Herbst 2015: SILS-Wedgeresektion Magen, LAGB, Gastric Banding, Sleeve-Gastrektomie, Pouch-Neuanlage, SILS- Fundoplicatio, Hiatusplastic, Hemihepatektomie, Pankreaslinksresektion, SILS-Milzexstirpation Leberteilresektion, SILS-CHE, SILS –TVR, SILS-Rectopexie, SILS-Ileocoecalresektion ,Hemicolektomie, AE, Sigmares.,TAMIS, SILS-IPOM, SILS-TAPP, Retroperit. Adrenalektomie, Bridenileus – diagnost. Lap, Adhäsiolyse,, Narbenhernie-IPOM, Re.Lap bei Peritonitis, SILS-TEP - H.Ing, BPV mit sublay mesh,

Single incision laparoscopic surgery animation. Madhoun N et al . Colorectal surgery Oct 2015

LOS more than 1d shorter for SILS , lower blood loss , decreased blood transfusion requirement ,shorter time to flatus ,shorter hospital stay, smaller incision

Surgical Procedure-specific Pain

Anesthesiology 2013 BJA 1997

Surgical Procedure-specific Pain Intensity

¾high pain intensities were often ignored or not taken seriously, so that analgesic administration was delayed and/or insufficient. ¾In laparoscopic surgeries with high postoperative pain scores, comparably low opioid doses were used. ¾the administration of analgesics should be adjusted according to the individual patient’s reported pain scores and desire for additional medication.

Epidural analgesia for laparoscopic …… might not be necessary in the context of fast-track program Abdominal Wall Block ?

Laparoscopic colonic resection

Operative techniques: Laparoscopic colonic resection is recommended over open colon surgery for reducing postoperative pain, if the conditions outlined above allow (Grade A) Epidural analgesia: recommended in high-risk pulmonary patients (Grade D) Wound infiltration/infusion: Pre-closure wound infiltration with LA (Grade B)

…. with Morphine-mixed hyperbaric Bupivacaine is adequate and safe for elective LC in otherwise healthy patients and minimises postoperative pain and opioid use. Success and safety of this technique, however, necessitates knowledgeable patient, gentle surgical procedure, and co-operation among patient and members of the perioperative care team. Spinal anaesthesia for laparoscopic cholecystectomy: a feasibility and safety study. Gautam B 2009 Kathmandu 12

performed safely under epidural anaesthesia …. severe COPD. 1998 Aug Laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory disease. Pursnani KG et al Lancashire GB 6

…. with proper selection of patients and limiting IAP to 10-12 mmHg, … can be safely performed with spinal anaesthesia with some supplementation Regional anaesthetic technique for laparoscopic appendcectomy 2014 Sep Ibadan Nigeria 8

….the sole anaesthesia technique is feasible, safe and cost effective for elective CHE Laparoscopic Cholecystectomy Under Spinal Anaesthesia vs. General Anaesthesia: A Prospective Randomised Study. 2014 Aug Bangalore, India 25/25

.. routine anaesthesia of choice is feasible and safe. … can be recommended to be the anaesthesia technique of choice for conducting laparoscopic cholecystectomy in hospital setups in developing countries where cost factor is a major factor. Laparoscopic cholecystectomy under spinal anaesthesia: A prospective, randomised study.Tiwari S et lal. J Minim Access Surg. 2013 Apr. Uttar Pradesh India 224

Laparoskopische Eingriffe – NUR Regionalanästhesie ?

Bauchspiegelung ohne Vollnarkose hat enorme Vorteile für Patienten

gaslose Lift-Laparoskopie Spinale/EK

Bewusstes „Teilhaben“ im Operationssaal Während OP kommunizieren Operateur und Anästhesist mit Patientin http://www.laparoskopie-ohne-vollnarkose.de/

Laparoskopische Eingriffe – NUR Regionalanästhesie ?

A nationwide analysis of the use and outcomes of perioperative epidural analgesia in patients undergoing hepatic and pancreatic surgery. Amini N et al. AmJSurg 2015 Sept

2002 -2012: 3961 (7,4%) The use of EA among minimally invasive procedures increased from 3.8% in 2000 to 9.1% in 2012. EA: reduction specific pulmonary-related complications, sepsis, in-hospital mortality

2002 -2010 : Analgesia superiority over conventional analgesia, did not affect pneumonia, respiratory failure, urinary retention, anastomotic leak, and postoperative ileus. Epidural analgesia 2.14% 4102 (191576 ) longer hospital stay by 0.60 day + higher hospital charges by $3732.71 +higher rate of urinary tract infection, epidural analgesia appears to be safe.

reasons for the decline invasive costly + labour-intensive advances in surgical techniques prophylactic anticoagulant regimens severe neurologic complications evidence of decreased morbidity ? evidence of postop.mortality ?

Transversus abdominis plane block for postoperative analgesia after laparoscopic surgery Int J Clin Exp Med 2014 14

Daryl I. Smith et al . Rochester

significant reduction in analgesic consumption during 24 h; effectively increase incidence of postoperative nausea and vomiting adverse effect needs more clinical trials to confirm due to the small number of participants - significant heterogeneity

TAP

bilateral TAP block with 0.5% bupivacaine reduces pain intensity and fentanyl request and prolongs time to the first analgesic request. Adding sufentanil to the block solution reduced neither pain intensity nor fentanyl further consumption. Efficacy of transverse abdominis plane block in reduction of postoperation pain in laparoscopic cholecystectomy Salimina A et al. 2015 Aug 14. Teheran 18/18/18

good evidence: a reduction in pain scores and analgesic requirement, no significant difference when compared to local anaesthetic infiltration of trocar insertion sites. Does a transversus abdominis plane (TAP) local anaesthetic block improve pain control in patients undergoing laparoscopic cholecystectomy? A best evidence topic. UK 2013 Jun

TAP .. improved immediate short-term opioid use and pain outcomes. Pain improvement was durable throughout the hospital stay. blocks did not translate into less overall narcotic use, shorter length of stay, or lower readmission rates. The effect of transversus abdominis plane blocks on postoperative pain in laparoscopic colorectal surgery a prospective, randomized, double-blind trial. Keller DS et al. Dis Colon Rectum 2014 Nov 41/38 Cleveland, Ohio.

TAP

Compared with local anesthetic infiltration, bilateral TAP blocks decreased the cumulative morphine use at 24 h and 48 h postoperatively Effect of local wound infiltration and transversus abdominis plane block on morphine use after laparoscopic colectomy: a nonrandomized, single-blind prospective study. Park JS et al 2015 May Daegu, Korea.30/29

ultrasound guidance; no difference to analgesic consumption, no difference secondary outcomes of daily VAS, respiratory outcome, time to return of gut function, length of hospital stay, postoperative complications, and patient satisfaction. TAP blockade appears to be a safe intervention but confers no specific advantage following laparoscopic colorectal surgery. Transversus abdominis plane blockade in laparoscopic colorectal surgery a double-blind randomized clinical trial Int J Colorectal Dis. 2015 Sep 74-68

.. combined with paracetamol and Nonsteroidal anti-inflammatory drugs (NSAID) treatment, had no effect on morphine consumption, VAS pain scores, or frequency of nausea and vomiting after robot-assisted laparoscopic hysterectomy compared with paracetamol and NSAID alone. (ropivacaine 0.5%, 20 ml on each side) Transversus abdominis plane TAP block after robot-assisted laparoscopic hysterectomy a randomised clinical trial. Torup H et al. Denmark 2015 Mai 31/30

TAP Ziel : antero-lateral rami of the thoracoabdominal nerves (Th6-Th12).

– lateral classical TAP block (above the iliac crest and below the thoracic cage) (El-Dawlatly et al. and Shibata et al.) bilat. - welltrained approximately 5-6 min

Idea: dermatomes Th6-Th12 antero-medial muscles abdominal wall + underlying parietal peritoneum

- USG oblique subcostal transversus abdominis plane blockade (Hebbard 2010): lower (Th10-Th 12) + upper (Th6-Th9) abdominal wall

Optimum: entire abdominal wall (TH6-L1): classical TAP + intercostal TAP (epigastric area) posterior TAP block benefits : reduced postoperative opioid requirements lower pain scores or a reduction in opioid-related side effects, higher patient satisfaction versus surgical procedures, anaesthetic doses, techniques, and timing (pre- or post-incisional)

Quadratus lumborum (QL) block visualize the thoracolumbar fascia at the lateral edge of the QL distribution area from Th6 to L1 dermatomes

pattern of a shamrock with three leaves

Truncal blocks

2012

2012

entire abdominal wall pain-free all the antero-lateral rami of the thoracoabdominal nerves (Th6-Th12). Intercostal TAP plexus (Th6-Th9) + classical TAP plexus (Th10-Th12)

Wann ist Arbeit sinnvoll?

Which Drug is Better For Post-op Pain Control?

TAP Blokade

Tageschirurgie CHE Chirurgie - Laparatomie

Rectus sheath

The central portion of the anterior abdominal wall is innervated by the ventral branches of the thoracolumbar nerves (Th6-L1) Between the belly of the rectus abdominis muscle and the posterior rectus sheath

12 Monate TAP 453 TAP Kath 59 Rectus sheath 26

Which Drug is Better For Post-op Pain Control?

2011/6 - 161

2012/6 - 132

2013/6 - 118

2014/6 - 49

2015/6 - 67

PACU 50 - 60% Reduction of morphine

Kohärenz von beruflicher Tätigkeit und persönlichen Interessen, Werten, Fähigkeiten

Bedeutsamkeit der Tätigkeit

Wissen um das „Warum“

Einbindung in übergeordneten Zusammenhang

Wann ist Arbeit sinnvoll?