All patients were thoroughly assessed preoperatively by history evaluation as regards
current medical condition and drug therapy, careful clinical examination and laboratory
evaluations (complete blood picture, liver function and renal function tests).
Explanation of the anaesthesia method was done to all patients and they were instructed
wisely on how to utilize the 10 cm linear visual Analogue scale (VAS), with (0) denoting
pain free state, whereas (10) stands for the worst intractable pain [9]. Fifteen minutes
before induction, all patients were premedicated with i.v. midazolam 0.03 mg kg-1 In the
operating room, an i.v. cannula was placed and secured, then standard monitoring
including (pulse oximetry, ECG, non- invasive blood pressure and end tidal carbon
dioxide) were applied to each patient using multichannel (Datex ohmeda S/5, Germany)
monitor. Anaesthesia was induced with lidocaine (1mg/kg) followed by (1.5 - 2 mg/kg)
propofol -till cessation of verbal contact- and (1-1.5 μg/kg) fentanyl. Endotracheal
intubation was accomplished with rocuronium (1mg/kg) and a suitable sized tube.
Anaesthesia was maintained with sevoflurane (1-2 %) with (50 %) oxygen in air. Controlled
mechanical ventilation was provided to maintain ETCO2 between (33-35 mmHg) and an oxygen
saturation of 98 %.

Patients will be randomly assigned- using closed envelope technique- into 2 groups (30
patient) each:

Group (M): The M-TAPA block will be combined with general anaesthesia. Group (C):
(control group) conventional general anaesthesia receiving multimodal analgesia.

In group (M), after the induction of anaesthesia and with the patient in the supine
position, the block was performed before starting of the surgical procedure as described
by Tulgar et al. [8]. After surgical skin disinfection with 10 % povidone-iodine, it was
covered with sterile surgical fenestrated drapes. A high frequency (6-12 MHz) US linear
probe (Fujifilm Sonosite, Tokyo, Japan) covered with a sterile cover was placed in the
sagittal plane on the 10 th costal margin in the midline. The probe was then angulated
deeply to visualize the lower surface of the costal cartilage. Via in plane technique, a
21 gauge Tuohy needle (Stimuplex B-Braun Medical, Melsungen, Germany) was inserted
cranially between the lower fascia of the costal cartilage and upper fascia of the
transversus abdominis muscle by moving the needle tip towards the posterior aspect of the
10 th costal cartilage with caution not to cross the cranial edge of the 10th costal
cartilage and 20 mL of bupivacaine (0.25 %) was injected bilaterally, in the
midclavicular line.

In group (C), ketorolac 0.75 mg/kg and paracetamol 10 mg/kg were administered
intravenously before surgical stimulus.

Inadequate analgesia expressed in the form of elevated blood pressure or accelerated
heart rate 20 % above baseline value was managed by administration of 0.5 (μg/kg)
fentanyl bolus as a rescue analgesia. Perioperative hypothermia was managed by warming of
i.v fluids and forced air warming to exposed areas. Precise fluid replacement was
provided to all subjects according to the standard guidelines applied during anaesthesia.

At the end of surgery, sevoflurane vaporizer was shut off followed by administration of
100 % oxygen. Muscle relaxant was reversed with neostigmine 0.04 mg/kg and atropine 0.02
mg/kg slowly i.v, after oropharyngeal secretions were suctioned. The tube was removed
after ensuring that the patients regained consciousness, breathed spontaneously and
respond to verbal command. IV ondansetron (8) mg was given to all patients to guard
against postoperative nausea and vomiting.

Patients were transferred to the PACU, where monitoring of heart rate, arterial blood
pressure, respiration, and temperature were done by recovery nurses unaware to the study
design to avoid bias. Postoperative analgesia was administrated with paracetamol i.v. 1
gm/8 hr throughout the first 24 hours postoperatively and standardized intravenous
patient-controlled analgesia (IV-PCA) with morphine (0.5 mg/mL, 2-mg bolus, lock-out
period 10 mins, and 4 hrs limit of 20 mg) based on reaching the score of ≥ (4) VAS.