TY - JOUR
AU - Aminian, A
AB - Abstract Background Although patient-controlled analgesia for pain management after abdominal surgery is common, efforts to find alternative effective methods to control postoperative pain are continuing. The aim of this study was to compare postoperative pain levels following intermittent regional administration of bupivacaine via a catheter placed in the rectus sheath or subcutaneously at abdominal surgery through midline incisions. Methods Consecutive patients undergoing elective midline laparotomy were assigned randomly to a group with two catheters placed over the fascia (suprafascial group) before surgical wound closure or to a group with catheters placed between the two sheaths of each rectus muscle (interfascial group). Pain levels were determined every 12 h, both at rest and with movement, by means of a standard visual analogue scale (VAS) for 72 h after surgery. The amounts of administered opioid were recorded. Results Sixty patients were enrolled in the study (30 patients in each group). The median VAS score 36 h after surgery, both at rest and with movement, was significantly lower in the interfascial group than in the suprafascial group (P < 0·050). Repeated-measures ANOVA also showed a significant difference in the postoperative VAS scores (P < 0·007). The amount of self-administered morphine was significantly lower in the interfascial group, overall (P = 0·001) as well as on postoperative day 1 (P = 0·001) and day 2 (P = 0·016). Bowel sounds returned more quickly in the interfascial group (P = 0·040). Conclusion Locoregional catheter administration of bupivacaine following midline laparotomy is more effective when the catheter is placed in the rectus sheath compared with suprafascial delivery. Registration number: IRCT138810142982N1 (http://www.irct.ir). Introduction Patient-controlled analgesia (PCA) is being used increasingly for postoperative pain management. Although this is an effective method of pain control, efforts are continuing to find alternative effective methods to relieve pain after abdominal surgery1–8. Some studies have already suggested that infusion of local anaesthetics at the wound site can decrease postoperative pain levels1–4. Other studies have shown similar opiate analgesic requirements (administered on patient demand) with placebo and local anaesthetic administration in abdominal incisions5,6. The wide variety of anaesthetic administration techniques used in different studies may explain why controversy exists in the literature8–18. In addition to advances in PCA devices and newer methods of anaesthesia, rectus sheath blockade has been proposed as a means of relieving pain after midline abdominal surgery1,4,7,9,14,18. Despite many efforts to assess the effect of locally administered anaesthetic agents2,3,5,6,8,12,13, the ideal location for perfusion remains unclear. Several studies have examined different sites in the abdomen for perfusion with anaesthetics1,4,6,7,9,12,14,18, but it is still not clear which catheter location is most effective. The objective of the present study was to examine early surgical outcomes and postoperative pain after midline laparotomy, comparing intermittent postoperative local administration of bupivacaine via a catheter between the rectus sheath layers with administration via a catheter in the subcutaneous space. Methods In this randomized clinical trial, consecutive patients undergoing intra-abdominal surgery at Shariati Hospital, Tehran, Iran, an affiliate of Tehran University of Medical Sciences (TUMS), were enrolled between June 2011 and February 2012. The study protocol was approved by the research ethics committee of TUMS, and written informed consent was obtained from all patients. Patients aged 18 years or more, undergoing elective abdominal surgery using midline laparotomy, through an incision of 15–25 cm in length, and who had an American Society of Anesthesiologists (ASA) physical status of grade I or II were included. Exclusion criteria were: simultaneous incision larger than 1 cm (for example colostomy), major gastrointestinal abdominal surgery lasting for more than 2 h (such as total gastrectomy, total colectomy or pancreaticoduodenectomy), history of hypersensitivity or adverse reaction to the medications being examined (bupivacaine, morphine), chronic liver or renal disease, history of previous midline laparotomy, body mass index greater than 30 kg/m2, chronic preoperative opioid consumption, and inability to use the PCA device. All surgical wounds were clean or clean-contaminated based on the classification of the American College of Surgeons committee for surgical wound infection control19. Eligible patients were assigned randomly to one of two study groups. Both the patient and the physician assessing outcomes were blinded to the study group assignment. An independent statistician used a computer-generated randomization list to assign subjects to groups. The randomization sequence was allocated by a coordinator, who was not involved in the study, at the time of fascial closure. Throughout the study, the list was concealed from investigators. Surgical technique The two study groups were divided according to postoperative catheter position near the midline laparotomy incision. Two multiholed catheters were inserted to infuse bupivacaine. Infant 6-Fr feeding tubes (Well Lead Medical Company, Cixi, China) were used, with 1-mm diameter holes every 1 cm along the incision length. The catheters were placed in two different regions, based on the intraoperative randomization. In the first group (the suprafascial group), two catheters were placed just over the fascia under the subcutaneous tissue, one on the right side and another on the left, after closure of the fascia. In the second group (the interfascial group), a catheter was placed between the rectus muscle sheaths under direct vision. After creating two small openings, one on the right side and one on the left, in the posterior rectus sheath (each 5 cm from the midline and along the length of incision), the catheter was passed between the rectus muscle and the posterior sheath using long forceps, avoiding epigastric vessel injury. The other end of the catheter was exteriorized via the incision site for administration of anaesthetic drugs through antimicrobial filters (Fig. 1). The rectus fascia was then closed using continuous monofilament non-absorbable synthetic sutures. The skin incision was closed using interrupted absorbable sutures for subcutaneous tissue and non-absorbable monofilament sutures for the skin. All catheters were fixed to the skin using non-absorbable monofilament sutures. The catheters remained in place until the last administration of bupivacaine 48 h after surgery. All surgical procedures were performed by the two attending surgeons. Fig. 1 Open in new tabDownload slide Schematic positions of catheters in the two study groups Patients received 1 ml 0·25 per cent bupivacaine per centimetre of incision length through each catheter every 6 h for 48 h. The first administration was performed in the operating theatre at the end of the operation. For pain control during the recovery period, an intravenous bolus of morphine (0·1 mg/kg) was administered immediately after surgery. Narcotic opioid rescue agents were administered through a PCA device (Accumate® 1000; Wooyoung Medical, Jincheon-Gun, South Korea). Patients were taught to use the PCA device and the pain visual analogue scale (VAS) before surgery. The PCA device was set to inject an intravenous bolus of 1 mg morphine no more frequently than every 8 min, on patient demand. No other oral or rectal analgesia was used in the first 3 days after surgery. All patients were mobile by the end of the first postoperative day. Discharge criteria included return of bowel function with no associated nausea or vomiting, tolerance of normal diet, no requirement for parenteral analgesic drugs, no fever and/or leucocytosis, and no other complications. Anaesthetic technique The general anaesthesia protocol was standardized for all patients. Premedication with chlordiazepoxide (5 mg orally) was used in all patients. Upon arrival in the operating room, patients received 0·9 per cent saline solution (5 ml/kg intravenously). Standard monitoring was established and all patients were administered midazolam (0·03 mg/kg) and fentanyl (2·5 µg/kg) 3 min before induction with sodium thiopental (5 mg/kg) and atracurium besylate (0·5 mg/kg). After tracheal intubation, subjects were ventilated mechanically with a mixture of 50 per cent oxygen and 50 per cent nitrous oxide. The ventilation rate was adjusted to maintain an end-tidal partial pressure of carbon dioxide of 30–35 mmHg. Anaesthesia was maintained with 1 minimum alveolar concentration isoflurane, inspired at a fresh gas flow rate of 4 l/min. In addition, boluses of fentanyl (1 µg/kg) and atracurium besylate (0·2 mg/kg) were given every 30 min. The bispectral index of patients (algorithmic analysis of electroencephalogram during general anaesthesia measuring the depth of the patient's consciousness to avoid intraoperative awareness) was maintained between 45 and 55. Some 30 min before awakening, 0·1 mg/kg morphine sulphate was administered. At the end of the procedure, halogenated agents were switched off and 100 per cent oxygen was given at a fresh gas flow rate of 8 l/min, and neuromuscular blockade was reversed with 2·5 mg neostigmine and 1·25 mg atropine. Following tracheal extubation, patients were transferred to the postanaesthesia care unit and discharged to the ward when the Aldrete score (a scoring system used to determine when the patient is sufficiently recovered to be transferred to the ambulatory surgical ward) was 9 or above. Outcome assessment Pain was measured using a 0–10 VAS (0, no pain; 10, most severe pain) every 12 h until 72 h after surgery. A blinded physician instructed patients to rate their pain both at rest and with cough. The VAS for cough at 12 h after surgery was not done to avoid the most painful intervention of the study. The total amount of self-administered opioid was recorded using a PCA device. Common postoperative symptoms were assessed daily, including nausea and/or vomiting, recovery of bowel sounds, time to first bowel movement (time to first passage of flatus), cardiopulmonary complications, wound complications (such as infection, haematoma), catheter failure, systemic toxicity from regional anaesthetics and length of hospital stay. Late wound complications, including incisional hernia, were assessed 3 months after the operation. Statistical analysis Calculation of the sample size was performed with total postoperative morphine dose as the primary outcome20. In a previous pilot study by the authors of similar patients, the mean(s.d.) total dose of administered morphine after midline laparotomy was found to be 87(29) mg. A reduction of 20 per cent in total dose of administered morphine was considered clinically relevant. It was calculated that a total of 60 patients (30 patients per group) would be needed to find such a difference, assuming α = 0·05 and β = 0·20 (a power of 80 per cent). Demographic data and primary clinical characteristics were compared between the groups. Total postoperative morphine dose was determined as the primary endpoint, and VAS scores at rest and coughing, and postoperative complications as secondary outcomes. The Kolmogorov–Smirnov test was used to assess the normality of distribution for continuous variables. Differences between continuous variables were determined with Student's t test, if normally distributed, or with the Mann–Whitney U test, if not normally distributed. Dichotomous variables were compared using the χ2 test. Repeated-measures ANOVA was used to compare the discrete VAS score between the two study groups. The level of significance for all tests was set at P < 0·050 and variances were not assumed to be equal. SPSS® version 17·0 (IBM, Armonk, New York, USA) was used to perform statistical analyses. Results A total of 60 consecutive patients were enrolled in the study and randomized to the suprafascial or interfascial group (30 patients in each group) (Fig. 2). There were no statistically significant differences between the two groups with respect to patient demographics, surgery type, incision length, duration of operation, ASA grade or drain placement (Table 1). Fig. 2 Open in new tabDownload slide CONSORT diagram for the trial Table 1 Demographic data   . Suprafascial group (n = 30) . Interfascial group (n = 30) . P† . Age (years)* 43(17) 41(15) 0·613‡ Sex ratio (F : M) 16 : 14 17 : 13 0·795 ASA grade 0·781  I 21 20  II 9 10 Type of surgery  Subtotal gastrectomy 7 5 0·871  Hemicolectomy 8 9  Hepatobiliary surgery 9 7  Open splenectomy 4 6  Small intestinal surgery 2 3 Incision length (cm)* 22(4) 21(5) 0·871‡ Drain placement 14 12 0·602 Duration of surgery (min)* 116(45) 124(53) 0·514‡ Total dose of bupivacaine (mg)* 427(74) 424(83) 0·871‡   . Suprafascial group (n = 30) . Interfascial group (n = 30) . P† . Age (years)* 43(17) 41(15) 0·613‡ Sex ratio (F : M) 16 : 14 17 : 13 0·795 ASA grade 0·781  I 21 20  II 9 10 Type of surgery  Subtotal gastrectomy 7 5 0·871  Hemicolectomy 8 9  Hepatobiliary surgery 9 7  Open splenectomy 4 6  Small intestinal surgery 2 3 Incision length (cm)* 22(4) 21(5) 0·871‡ Drain placement 14 12 0·602 Duration of surgery (min)* 116(45) 124(53) 0·514‡ Total dose of bupivacaine (mg)* 427(74) 424(83) 0·871‡ * Values are mean(s.d.). ASA, American Society of Anesthesiologists. † χ2 test, except ‡ Student's t test. Open in new tab Table 1 Demographic data   . Suprafascial group (n = 30) . Interfascial group (n = 30) . P† . Age (years)* 43(17) 41(15) 0·613‡ Sex ratio (F : M) 16 : 14 17 : 13 0·795 ASA grade 0·781  I 21 20  II 9 10 Type of surgery  Subtotal gastrectomy 7 5 0·871  Hemicolectomy 8 9  Hepatobiliary surgery 9 7  Open splenectomy 4 6  Small intestinal surgery 2 3 Incision length (cm)* 22(4) 21(5) 0·871‡ Drain placement 14 12 0·602 Duration of surgery (min)* 116(45) 124(53) 0·514‡ Total dose of bupivacaine (mg)* 427(74) 424(83) 0·871‡   . Suprafascial group (n = 30) . Interfascial group (n = 30) . P† . Age (years)* 43(17) 41(15) 0·613‡ Sex ratio (F : M) 16 : 14 17 : 13 0·795 ASA grade 0·781  I 21 20  II 9 10 Type of surgery  Subtotal gastrectomy 7 5 0·871  Hemicolectomy 8 9  Hepatobiliary surgery 9 7  Open splenectomy 4 6  Small intestinal surgery 2 3 Incision length (cm)* 22(4) 21(5) 0·871‡ Drain placement 14 12 0·602 Duration of surgery (min)* 116(45) 124(53) 0·514‡ Total dose of bupivacaine (mg)* 427(74) 424(83) 0·871‡ * Values are mean(s.d.). ASA, American Society of Anesthesiologists. † χ2 test, except ‡ Student's t test. Open in new tab The mean pain VAS score was significantly lower, both at rest and with movement, in the interfascial group within the first 36 h of surgery (Table 2). The mean VAS score in the interfascial group tended to be lower on later postoperative days, but the difference was not statistically significant. Repeated-measures ANOVA also showed a significant difference in postoperative VAS scores between the two groups (P < 0·010). Table 2 Comparison of postoperative outcomes   . Suprafascial group (n = 30) . Interfascial group (n = 30) . P‡ . VAS score at rest*  12 h 4 (4–5) 3 (2–4) 0·013  24 h 4 (3–4) 3 (2–4) 0·045  36 h 3 (3–3) 2 (2–3) 0·004  48 h 2 (2–3) 2 (1–2) 0·080  60 h 2 (1–2) 2 (1–3) 0·850  72 h 1 (1–2) 1 (0–2) 0·178 VAS score on cough*  24 h 5 (4–5) 4 (4–5) 0·031  36 h 5 (4–5) 4 (3–4) < 0·001  48 h 4 (3–5) 3 (3–4) 0·132  60 h 3 (3–4) 3 (2–4) 0·552  72 h 3 (2–3) 3 (2–3) 0·074 Dose of morphine delivered (mg)†  Day 1 38(8) 30(9) 0·001§  Day 2 26(7) 22(6) 0·016§  Day 3 12(5) 10(4) 0·077§  Total 76(16) 62(16) 0·001§ Postop. nausea and vomiting 5 3 0·706¶ Return of bowel sounds (h)† 47(18) 37(14) 0·040§ Return of gas passage (h)† 68(19) 58(23) 0·068§ Wound infection 1 0 0·500¶ Cardiopulmonary complications 1 2 0·100¶ Postop. hospital stay (days)† 4·7(1·4) 5·4(1·5) 0·064§   . Suprafascial group (n = 30) . Interfascial group (n = 30) . P‡ . VAS score at rest*  12 h 4 (4–5) 3 (2–4) 0·013  24 h 4 (3–4) 3 (2–4) 0·045  36 h 3 (3–3) 2 (2–3) 0·004  48 h 2 (2–3) 2 (1–2) 0·080  60 h 2 (1–2) 2 (1–3) 0·850  72 h 1 (1–2) 1 (0–2) 0·178 VAS score on cough*  24 h 5 (4–5) 4 (4–5) 0·031  36 h 5 (4–5) 4 (3–4) < 0·001  48 h 4 (3–5) 3 (3–4) 0·132  60 h 3 (3–4) 3 (2–4) 0·552  72 h 3 (2–3) 3 (2–3) 0·074 Dose of morphine delivered (mg)†  Day 1 38(8) 30(9) 0·001§  Day 2 26(7) 22(6) 0·016§  Day 3 12(5) 10(4) 0·077§  Total 76(16) 62(16) 0·001§ Postop. nausea and vomiting 5 3 0·706¶ Return of bowel sounds (h)† 47(18) 37(14) 0·040§ Return of gas passage (h)† 68(19) 58(23) 0·068§ Wound infection 1 0 0·500¶ Cardiopulmonary complications 1 2 0·100¶ Postop. hospital stay (days)† 4·7(1·4) 5·4(1·5) 0·064§ Values are * median (interquartile range) and † mean(s.d.). VAS, visual analogue scale. ‡ Mann–Whitney U test, except § Student's t test and ¶ χ2 test. Open in new tab Table 2 Comparison of postoperative outcomes   . Suprafascial group (n = 30) . Interfascial group (n = 30) . P‡ . VAS score at rest*  12 h 4 (4–5) 3 (2–4) 0·013  24 h 4 (3–4) 3 (2–4) 0·045  36 h 3 (3–3) 2 (2–3) 0·004  48 h 2 (2–3) 2 (1–2) 0·080  60 h 2 (1–2) 2 (1–3) 0·850  72 h 1 (1–2) 1 (0–2) 0·178 VAS score on cough*  24 h 5 (4–5) 4 (4–5) 0·031  36 h 5 (4–5) 4 (3–4) < 0·001  48 h 4 (3–5) 3 (3–4) 0·132  60 h 3 (3–4) 3 (2–4) 0·552  72 h 3 (2–3) 3 (2–3) 0·074 Dose of morphine delivered (mg)†  Day 1 38(8) 30(9) 0·001§  Day 2 26(7) 22(6) 0·016§  Day 3 12(5) 10(4) 0·077§  Total 76(16) 62(16) 0·001§ Postop. nausea and vomiting 5 3 0·706¶ Return of bowel sounds (h)† 47(18) 37(14) 0·040§ Return of gas passage (h)† 68(19) 58(23) 0·068§ Wound infection 1 0 0·500¶ Cardiopulmonary complications 1 2 0·100¶ Postop. hospital stay (days)† 4·7(1·4) 5·4(1·5) 0·064§   . Suprafascial group (n = 30) . Interfascial group (n = 30) . P‡ . VAS score at rest*  12 h 4 (4–5) 3 (2–4) 0·013  24 h 4 (3–4) 3 (2–4) 0·045  36 h 3 (3–3) 2 (2–3) 0·004  48 h 2 (2–3) 2 (1–2) 0·080  60 h 2 (1–2) 2 (1–3) 0·850  72 h 1 (1–2) 1 (0–2) 0·178 VAS score on cough*  24 h 5 (4–5) 4 (4–5) 0·031  36 h 5 (4–5) 4 (3–4) < 0·001  48 h 4 (3–5) 3 (3–4) 0·132  60 h 3 (3–4) 3 (2–4) 0·552  72 h 3 (2–3) 3 (2–3) 0·074 Dose of morphine delivered (mg)†  Day 1 38(8) 30(9) 0·001§  Day 2 26(7) 22(6) 0·016§  Day 3 12(5) 10(4) 0·077§  Total 76(16) 62(16) 0·001§ Postop. nausea and vomiting 5 3 0·706¶ Return of bowel sounds (h)† 47(18) 37(14) 0·040§ Return of gas passage (h)† 68(19) 58(23) 0·068§ Wound infection 1 0 0·500¶ Cardiopulmonary complications 1 2 0·100¶ Postop. hospital stay (days)† 4·7(1·4) 5·4(1·5) 0·064§ Values are * median (interquartile range) and † mean(s.d.). VAS, visual analogue scale. ‡ Mann–Whitney U test, except § Student's t test and ¶ χ2 test. Open in new tab The total amount of morphine delivered was significantly lower in the interfascial group on postoperative day 1 (P = 0·001) and day 2 (P = 0·016). The demand for analgesia, administered via the PCA device, did not significantly differ between the two groups on postoperative day 3 (P = 0·077). Postoperative nausea and/or vomiting occurred in five patients in the interfascial group and three patients in the suprafascial group, a difference that was not statistically significant. Bowel sounds returned significantly faster in the interfascial than in the suprafascial group (mean(s.d.) 37(14) versus 47(18) h respectively; P = 0·040), whereas the difference in gas passage was not significantly different (58(23) versus 68(19) h respectively; P = 0·068) (Table 2). In the suprafascial group, one wound infection was noted on postoperative day 5; this healed uneventfully after wound drainage and sterile normal saline wash. There was no systemic toxicity, anaesthetic or analgesic dosing error, or sedative overdose in either group. With regard to postoperative complications, atelectasis of the lower lobe of the left lung occurred in one patient in the suprafascial group, which resolved with conservative therapy. In the interfascial group, there was one non-massive pulmonary embolism, which resolved with conservative/supportive treatment, and one case of atrial fibrillation, treated successfully with medication. Mean(s.d.) postoperative hospital stay was similar in the two groups: 4·7(1·4) days in the suprafascial group versus 5·4(1·5) days in the interfascial group (P = 0·064). Discussion Schleich15 first introduced rectus sheath blockade in 1899 to relax the abdominal wall during surgery. More recent applications of this technique have shifted to postoperative analgesia/anaesthesia1,7,9,18. To date, many studies have shown great benefits for this technique with minimal additional risks, but the position of the perfusion catheter in these studies has varied widely from the peritoneum to the subcutaneous space1,3,7–10,12,17,18. Therefore, there is no consensus about which medication delivery site provides optimal efficacy of anaesthetic agents. This study compared two sites for administration of boluses of bupivacaine, a long-lasting local anaesthetic, for postoperative pain control. In addition to its anaesthetic properties, bupivacaine has antimicrobial and antifungal activity21, and is superior to lidocaine in this respect21. This may be an added benefit of administration of local anaesthetics. Many studies have discussed the benefits of direct wound perfusion with bupivacaine1–10,12,13,17,18. The success of rectus sheath blockade in postoperative pain management after major gynaecological surgery has been shown4. However, other studies showed no decrease in postoperative demand for analgesics5. Although the study procedures in the latter investigation5 were similar to those in the present study (midline catheter placement, perfusion catheter placement above the fascia along the wound length), different results were found. In the present study, two locations for catheter placement were examined: between the abdominal fascia layers and over the rectus muscle fascia. The results showed that bupivacaine administration between two layers of the rectus sheath was more beneficial early in the postoperative period when the pain was particularly severe. Furthermore, the opioid requirement, as measured by patient demand for morphine, was lower in the interfascial than in the suprafascial group. To achieve a successful regional nerve block, anaesthetic agents should be applied as close as possible to nerve endings14. The present study specifically aimed to achieve this. The regional innervation of the rectus abdominis (branches of T6–T11) enters through the posterior aspect of the rectus abdominis muscle and then ramifies to the anterior surface and overlying skin. Hence, the insertion of catheters adjacent to the targeted nerve endings and the administration of sufficient volumes of analgesics are necessary to achieve a good compartment block using rectus sheath blockade7. Interestingly, the greater efficacy of the anaesthetic perfusion between rectus sheath layers was found only in the early postoperative period. This may be explained by the fact that patients usually have more severe pain in the first days after surgery. This pain is more often relieved by analgesic use, which generally declines with time after surgery. Additionally, local perfusion could wash out or dilute levels of inflammatory agents at the surgical wound. This has already been suggested as a mechanism for the efficacy of saline perfusion near the rectus sheath innervation6,17. A Cochrane review regarding the efficacy of transversus abdominis plane (TAP) blockade for pain after abdominal surgery22 found that TAP blockade resulted in significantly reduced postoperative analgesic requirements. In addition, compared with rectus sheath, TAP blockade had more impact on decreasing nausea, vomiting and sedation scores. Considering the anatomy of the abdominal wall, effective nerve blocking in selected adjacent areas may have to be adapted according to the anticipated site of incision. The technique examined in this study, although seemingly effective, has restrictions. Extreme caution is needed when entering the rectus sheath for perfusion catheter insertion to prevent injury to the epigastric vessels. Another potential complication can be local anaesthetic toxicity. In this study, each bolus dose and the total daily dose of bupivacaine were less than the maximum recommended dose. Although there may be a possibility of toxicity owing to the absorption of bupivacaine into the circulation, no studies have reported this complication. The other limitation could be the time needed for catheter insertion. However, as this catheter is used in major abdominal open surgery, the increase in surgical time compared with total operating time would not be noteworthy. The present technique may be an alternative to epidural anaesthesia. With this technique, there is no need for intraoperative patient repositioning or for an additional procedure in critical zones such as the epidural region. Interfascial administration of bupivacaine for rectus sheath blockade may reduce opiate requirements in patients undergoing midline abdominal surgery and hence prevent ileus. Future studies should focus on comparing this technique with epidural anaesthesia or TAP blockade. Disclosure The authors declare no conflict of interest. References 1 Azemati S , Khosravi MB. 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Google Scholar Crossref Search ADS PubMed WorldCat 22 Charlton S , Cyna AM, Middleton P, Griffiths JD. Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery . Cochrane Database Syst Rev 2010 ; (12)CD007705. © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd
TI - Randomized clinical trial of subcutaneous versus interfascial bupivacaine for pain control after midline laparotomy
JF - British Journal of Surgery
DO - 10.1002/bjs.9090
DA - 2013-04-02
UR - https://www.deepdyve.com/lp/oxford-university-press/randomized-clinical-trial-of-subcutaneous-versus-interfascial-VuSXbprwmh
SP - 743
EP - 748
VL - 100
IS - 6
DP - DeepDyve
ER -