4. Discussion
peripheral nerve block, postoperative pain, pain
Post-LC pain is multifactorial, and therefore, multimodal analgesia has been suggested for its treatment. There are several methods for postoperative pain management, including peripheral nerve block techniques, which have received much attention recently due to their positive effect in reducing postoperative pain and good tolerance [There are studies that have demonstrated the efficacy of each of the above blocks in reducing LC postoperative pain scores and lowering the consumption of painkiller. For example, Kadam et al. conducted a study aimed to evaluated postoperative pain and analgesic use during the first day after LC surgery, compared to local anesthetics and the TAP block. There were no significant differences in the postoperative pain scores between the local anesthetic and TAP block groups (In addition, comparative studies which examined the effect of TAP block versus subcostal TAP block have been published. Bhatia et al. conducted a prospective, randomized, double-blind study in which 60 patients who underwent LC received the standard general anesthesia or an ultrasound-guided posterior TAP or a subcostal TAP block. At the initial postoperative measurement times, the subcostal and posterior TAP groups had comparable pain scores. However, 4 hours after the operation, the scores were significantly lower in patients who had received the subcostal TAP block compared to those who were treated with posterior TAP [However, as of yet, there have not been extensive studies of the effect of combined peripheral nerve block techniques in reducing LC postoperative pain scores and the reduction of the consumption of additional analgetic medications. The rationale underlying the combination of the blocks is that administration of both peripheral blocks, each affecting different nerve areas (TAP-T6-L1, subcostal TAP-T7-T12, and rectus sheath-T7-T11), could affect and block the entire area of surgery. Thus, the aim of the current study was to evaluate the postoperative pain control of a combination of TAP + subcostal TAP blocks and subcostal TAP + rectus sheath blocks compared to TAP or subcostal TAP blocks as a standalone treatment. The maximal level of pain upon LC is recorded during the first 24 hours after surgery [Jung et al. examined the effect of the combination of subcostal and lateral TAP blocks on the quality of recovery among 38 patients who underwent LC compared to control patients who underwent a sham block. The primary outcome of the study was the score of the quality of recovery-40 (QoR-40) questionnaire. The combination of the two blocks did not improve the QoR-40 or analgesic consumption during the first 24 hours after the surgery [The lack of difference in the pain level and consequent analgesic consumption between the various block combinations and the standalone blocks might be explained by the fact that the analgesia regimen administered to patients obscured the blocks effect. In addition, the various antinociceptive agents which are included in multimodal general anesthesia affect multiple neurotransmitters and neural relays and thus offset the supposed additive effects of the combined or the standalone blocks [