Pain following laparoscopic procedures can be at par with or even worse than that of an open surgery, requiring a proactive pain management to be offered at the earliest. A single medication is rarely effective for treating such pain of multi-factorial origin following a laparoscopic surgery.1Management of postoperative pain may involve oral or intravenous non-steroidal anti inflammatory agents (NSAIDs), opiates, epidural analgesia, and various peripheral nerve blocks (PNBs).There are various drawbacks to using intravenous or oral analgesics. Acetaminophen in lower doses (<2 g/day) is not an effective analgesic for moderate to severe pain, and high doses can cause acute liver failure. In a similar vein, gastrointestinal harm can result from taking higher doses of NSAIDs for moderate to severe pain.2 Systemic or neuraxial opioids are the mainstay for treating postoperative pain, as they are effective against both somatic and visceral components of pain. However, they also bring upon a plethora of undesirable side effects like nausea, vomiting, constipation, sedation and respiratory depression. Currently, multimodal analgesic technique involving abdominal nerve block along with intravenous analgesics is becoming popular for such patients.3,4 Local analgesics, for example, ropivacaine, bupivacaine, etc., are commonly used for nerve block and intra-peritoneal application. Ropivacaine is a long-acting amino amide local anesthetic drug with duration of drug action of two to eight hours; it has been shown to effectively reduce pain without clinical toxicity. Ropivacaine acts preferentially on pain and sensory nerves rather than motor nerve block in comparison to bupivacaine, and hence, is suitable for immediate pain control after lower abdominal surgeries. Also, there is a significantly lower risk of systemic as well as cardiac toxicity with ropivacaine because of its higher clearance rate.5,6 Literature has demonstrated better efficacy of ropivacaine administered through ultrasound guided- transversus abdominis plane (USG-guided TAP) block, in terms of lower pain scores on visual analogue scale (VAS) in the immediate post-operative period, when compared against other drugs, including opioid as well as non-opioids (e.g., bupivacaine, i.v. morphine and regular diclofenac/ acetaminophen), among patients undergoing varied laparoscopic surgeries.7,8 A limitation to use of local anaesthetic in peripheral nerve block (PNBs) for providing postoperative analgesia is that the analgesic effect lasts only a few hours, after which a moderate to severe pain may be perceived, resulting in the need for an alternative analgesic regimen. Various adjuvants that are frequently added to local anesthetics to prolong analgesia following single-injection peripheral nerve blocks but often with limited success and unproven safety.9,10 However, studies involvingperineural buprenorphine, dexamethasone and dexmedetomidine have most consistently demonstrated prolongation of PNB.10 Glucocorticoids exert their anti-inflammatory, analgesic, immunosuppressive, and antiemetic effects by inhibition of phospholipase A2 and by glucocorticoid-receptor activation.11Perineural dexamethasone, as an adjuvant to peripheral nerve block, has been associated with faster onset of analgesia, longer duration of analgesia, decreased postoperative pain intensity, and decreased postoperative analgesic requirements compared against local anaesthetic alone.12,13 Dexmedetomidine is a lipophilic a2 -methylol derivative, and a highly selective adrenergic receptor agonist with an a2: a1-adrenoreceptor affinity ratio of 1620:1, seven times greater than that of clonidine.13Like other a2 agonists, has characteristics including sedation, analgesia, anti-anxiety, and inhibition of sympathetic activity, mild respiratory inhibition, and stable hemodynamics but can lead to adverse reactions, such as bradycardia, hypotension, and excessive sedation. As an adjunct to general anesthesia, dexmedetomidine has been shown to reduce requirements for inhaled anesthetic vapors and opioids; as a neuraxial adjunct, it has been shown to increase the duration of sensory and motor blockade.14, 15Peripheral action is the widely accepted mechanism by which dexmedetomidine enhances the blocking effect as an adjuvant.16However, studies involving human subjects have shown dexmedetomidine to have modest efficacy as an adjuvant to nerve blocks. The addition of dexmedetomidine 100 mcg to 40 mL of levobupivacaine 0.5% during axillary brachial plexus block was found to significantly prolong the mean ± S.D. time to the first request for a supplemental analgesic, from 887 ± 261 minutes to 1009 ± 164 minutes.17 Similar results were obtained with the addition of dexmedetomidine 1 μg/kg to 10 mL of ropivacaine hydrochloride 0.5% for posterior tibial nerve blocks; the mean sensory block duration increased significantly, from 16.2 hours with ropivacaine alone to 21.5 hours in subjects also receiving dexmedetomidine.18 Rafiin (2001) adopted the transversus abdominal plane (TAP) block as a landmark-guided approach to achieve field block around triangle of Petit (ToP), employed to provide analgesicsupport at the anterior as well as lateral abdominal wall. This involves facial plane between the internal oblique and transversusabdominis muscles, which is filled with a local anaesthetic solution under ultrasound guidance.19 The American Society of Regional Anaesthesia (ASRA) has noted that TAP block is a useful alternative for lower abdomen gynecological procedures due to its simple procedural design, greater degree of analgesia (T6-L1), longer duration, and higher quality of analgesia.20,21 However, some studies did not reveal any additional postop pain control after TAP block with ropivacaine alone, and hence, the results cannot be said to have been consistent.22,23Adjuvants that are frequently added to local anesthetics, but often with limited success and unproven safety.11Out of these adjuvants, most commonly used ones are the α2 agonist drugs and dexamethasone, owing to their analgesic potential and safety profile.24 Singla et al (2021)25 conducted a randomized controlled trial upon 100 patients, to assess the efficacy of addition of dexmedetomidine or dexamethasone to ropivacaine in ultrasound guided TAP block for post-operative analgesia in caesarean section. It was found that the time to initial self-reporting of post-operative pain as well as the time to first rescue analgesic were significantly longer in group B than group A. Furthermore, the VAS score at the time of initial self-reporting of pain was also found to be significantly lower among group B patients. Thakur et al (2019)26 evaluated the role of dexmedetomidine and dexamethasone as adjuncts to bupivacaine in USG- guided TAP block among 120 patients of caesarean section. Patients were divided into B, BDM and BDX groups randomly, to either receive VAS score was found to be significantly higher in group B, slightly lower in group BDX, followed by being lowest in group BDM. Duration of analgesia was significantly prolonged in group dexmedetomidine in comparison to bupivacaine and dexamethasone groups. Overall rescue analgesic demands were also found to be lower in group BDM in comparison to group B and BDX. Sedation score and patient’s satisfaction score was higher in group BDM as compared to group B and BDX. Although both dexamethasone and dexmedetomidine are accepted agents, the current standard of practice is giving dexamethasone with 0.2% ropivacaine in USG- guided TAP block. Based on conclusion of the abovementioned studies, and the paucity in literature with respect to use of these two adjuvants of ropivacaine, present study was planned to compare the post-operative analgesic efficacy of dexmedetomidine and dexamethasone as adjuvant to ropivacaine in USG guided TAP block among total laparoscopic hysterectomy patients.

The present study was a comparative, double- blindprospective study, conducted upon 100 patients undergoing elective total laparoscopic hysterectomy at SantokbaDurlabhji Memorial Hospital cum Medical Research Institute, Jaipur, Rajasthan. Aim of the study was to compare post-operative analgesic efficacy and duration of analgesia between dexamethasone and dexmedetomidine as adjuvant of 0.2% ropivacaine in USG-guided transversusabdominis plane block in total laparoscopic hysterectomy. Primary objectives of the study were, firstly, to compare efficacy of post-operative analgesia between dexamethasone and dexmedetomidine as adjuvant of 0.2% ropivacaine in USG-guided transversusabdominis plane block in total laparoscopic hysterectomy using VAS score, and secondly, to compare the duration of post-operative analgesia by dexamethasone and dexmedetomidine as adjuvant of 0.2% ropivacaine in USG-guided transversusabdominis plane block in total laparoscopic hysterectomy. Secondary objectives of the study were to compare the total amount of diclofenac consumption in the initial 24 hours post-operative period between the two groups, to study the side effect caused if any, across both groups, and to compare patient satisfaction across both groups. The sample size was calculated at 80% study power and α- error of 0.05. Assuming Standard Deviation (σ) of 202.31 minutes for time to first analgesic consumption in Ropivacaine group as found in the study by Singlaet al⁹, for minimum detectable mean difference of 120 minutes (M1- M2) in time to first analgesic consumption, 45 patients in each group were required as sample size. This was further enhanced and rounded off to 50 patients in each group in final sample size for present study, anticipating 10% attrition. Patients within the age group of 18- 65 years, body weight equal to or above 50 kg, posted for elective total laparoscopic hysterectomy surgery, with ASA grade I and II, not known to be allergic to local anaesthetic drugs, were included in the study after obtaining informed consent. Patients who were obese (BMI >30kg/m²), suffering from coagulopathy or were under anticoagulant medications within the last one week before surgery, were known to be allergic to local anaesthetic drugs as well as the patients who had conversion of laparoscopic to open surgery, were excluded from the study. Patients were allocated randomly into two groups: Group A: n=50; 0.2% Ropivacaine + 0.1mg/ kg Dexamethasone, and Group B: n=50; 0.2% Ropivacaine + 0.5 mcg/kg Dexmedetomidine. After the approval from the scientific research committee and institutional ethics committee, the process of sample collection was started by June 2023 and the sample was achieved in November 2023. There was no financial burden on the patient and there was no cost difference between dexamethasone and dexmedetomidine. A standard patient information sheet and consent form used in the institute for medical research involving human subjects was utilized for the purpose of this study. To record the socio-demographic data and various variables included in the study a specifically created proforma was utilized. Patients were counseled about the intensity of pain normally associated with the surgery and pain relief that could be achieved with the technique employed. Patients were trained to assess pain using Visual Analogue Scale (VAS) during preoperative evaluation. Once the surgery was over and TAP block administered, patients were reversed using Inj. Neostigmine 0.05 mg/ kg and Inj. Glycopyrrolate 0.01 mg/ kg and were subsequently extubated. Patients were observed in the PACU by a blinded investigator for various study parameters at five different times, i.e., at: T0 (on arrival to the PACU), T1 (2 hours post arrival in to PACU), T2 (6 hours post arrival in to PACU), T3 (12 hours post arrival in to PACU) and T4 (24 hours post arrival in to PACU) postoperatively. Duration of analgesia (VAS score ≥3) and supplemental rescue analgesic requirements with respect to 0 hours was recorded over 24 hoursby the blinded investigator. Postoperative pain assessment was done in all patients using Visual Analogue Scale (VAS) score at T0-4. Rescue analgesia in the form of i.v. injection diclofenac 75mg was administered to the patients. Side effects, if occurred were also noted and managed accordingly. Thereafter, patients were asked to rate their satisfaction with pain management on a 5- point Likert scale. The data was entered and analyzed using standard statistical software. Frequency distribution and cross tabulation was performed to prepare the tables. PRISM software was used to prepare the graphs. Descriptive analyses were performed to obtain the baseline characteristic of the study population of both the groups. Quantitative data was expressed as mean and standard deviation whereas categorical data was expressed as number and percentages. Kolmogorov-Smirnov test was used to check the normality of the data. Statistical analysis was done by using chi square for the categorical data & independent- t test for comparing the means. Conclusions was obtained by calculating & comparing P value with level of significance 0.05 i.e., 5%.Outcome measure for drug efficacy was the VAS- score. Continuous monitoring was done aimed at maintaining VAS- score <3. Secondary outcome measure was rescue analgesia requirement.

As shown in table 1,a comparison of mean age, height, weight and BMI between the study groups denoted that the two study groups were comparable in terms of age and the difference was not statistically significant (p>0.05). Table 1: Comparison of demographic profile among study groups Group A Group B p-value Mean ± SD Mean ± SD Age group (years) 53.36 ± 6.54 52.62 ± 6.66 0.974 Height (cm) 159.56 ± 4.18 159.04 ± 5.44 0.5934 Weight (kg) 63.72 ± 4.47 63.52 ± 6.25 0.8231 BMI (kg/m2) 25.0 ± 1.37 25.16 ± 2.01 0.510 Table 2 shows comparison of duration of analgesia (in minutes) among study groups, which was 583.44 ± 30.91 min in Group A and 691.64 ± 35.66 min in Group B. Comparison ofdata between groups, shows a p value of <0.0001, denoting statistically significant difference (p<0.05) in the duration of analgesia, with Group B having prolonged duration of analgesia. Furthermore, thecomparison of rescue analgesia doseshows a mean rescue analgesia doseof145.50 ± 17.99 mg in Group A and 87 ± 27.77 mg in Group B. The difference was statistically significant difference (p<0.05), with Group A requiring higher rescue analgesia dose. Similarly, mean patient’s satisfaction score was 2.92 ± 0.52 in Group A and 3.18 ± 0.69in Group B, with a p value of 0.0359, denoting statistically significant difference (p<0.05) in the patient’s satisfaction score, with Group B having higher patient’s satisfaction score in Group B. Table 2: Comparison of various study parameters among study groups. Group A Group B Difference in mean (95% CI) t-test(df) p-value Duration of analgesia(min) 583.44 ± 30.91 691.64 ± 35.66 108.20 (94.95, 121.44) 16.212 (98) <0.0001 Rescue analgesia dose (mg) 145.50 ± 17.99 87 ± 27.77 58.50 (67.78, 49.21) 12.50 (98) <0.0001 Patient’s satisfaction score 2.92 ± 0.52 3.18 ± 0.69 0.26 (0.017,0.502) 2.128 (98) 0.0359 Table 3: Comparison of various study parameters among study groups. Time Group A Group B p-value Mean ± SD Mean ± SD VAS Score 0 hours 0.52 ± 0.50 0.56 ± 0.50 0.6897 2 hours 1.32 ± 0.47 1.34 ± 0.48 0.8324 6 hours 1.74 ± 0.44 1.42 ± 0.50 0.0013 12 hours 1.88 ± 0.33 1.96 ± 0.88 0.7231 24 hours 1.60 ± 0.49 1.34 ± 0.52 0.0077 Heart Rate (/min) 0 hours 81.80 ± 3.88 81.84 ± 3.93 0.9593 2 hours 86.48 ± 4.25 85.72 ± 3.98 0.3582 6 hours 89.80 ± 3.69 87.04 ± 3.96 0.0005 12 hours 91.16 ± 4.18 90.36 ± 5.43 0.4112 24 hours 91.60 ± 4.35 86.76 ± 4.12 <0.0001 Systolic Blood Pressure (mmHg) 0 hours 105.20 ± 7.01 105.76 ± 6.88 0.6876 2 hours 110.52 ± 6.88 110.32 ± 6.82 0.8843 6 hours 115.60 ± 6.17 111.60 ± 7.14 0.0034 12 hours 115.88 ± 7.54 114.40 ± 7.86 0.3389 24 hours 118.12 ± 6.33 111.96 ± 6.80 <0.0001 Diastolic Blood Pressure (mmHg) 0 hours 71.32 ± 5.23 71.12 ± 5.44 0.8517 2 hours 75.28 ± 5.07 74.80 ± 5.28 0.6442 6 hours 79.24 ± 4.98 76.00 ± 5.39 0.0024 12 hours 79.84 ± 5.65 78.28 ± 6.03 0.1853 24 hours 81.36 ± 5.13 77.08 ± 5.19 0.0001 Mean Arterial Pressure (mmHg) 0 hours 82.61 ± 5.50 82.67 ± 5.44 0.9613 2 hours 87.02 ± 5.37 86.63 ± 5.27 0.7172 6 hours 91.35 ± 5.04 87.87 ± 5.50 0.0014 12 hours 91.89 ± 6.00 90.31 ± 6.20 0.2007 24 hours 93.57 ± 5.28 88.70 ± 5.24 <0.0001 Table 3 shows comparison of VAS score, heart rate, systolic and diastolic blood pressure, as well as the mean arterial pressure among study groups at the baseline (0 hours), 2 hours, 6 hours, 12 hours and 24 hours. Comparison of these parameters between two groups was found to be statistically significant at 6 hours and 24 hours. Table 4: Comparison of frequency of adverse effects among study groups. Adverse effects Group A Group B p-value N % N % Nausea 6 12 6 12 0.9999 Vomiting 2 4 2 4 0.9999 Over-sedation 1 2 2 4 0.5577 Table 4 depictscomparison of adverse effects among study groups. Nausea was the most common adverse effect encountered in either group, followed by vomiting and over-sedation. No other side- effects were recorded among the patients in either group. Comparison of data between groups, shows that there is no statistically significant difference (p>0.05) in the side-effect profile of two study groups.

DISCUSSION Dexamethasone and dexmedetomidine, two accepted adjuvantswith differing mechanism as well as clinical effects, commonly used with ropivacaine in the current practice, were chosen and a comparison of post-operative analgesic efficacy was drawn between the twofor the purpose of the study. In the current study, it can implied from the analysis of the demographic data that there is no significant difference between the two study groups in terms of demographic profile and the two study groups are comparable to each other. A comparison of two groups in the terms of duration of analgesia revealed that the mean duration of analgesiawas 583.44 ± 30.91 min in Group A and 691.64 ± 43.42 min in Group B. The mean duration of analgesia was higher in Group B, and the difference was statistically significant (p-value= <0.0001). The is in line with the findings in the study by Singla et al (2021)25, where the time to initial self reporting of post operative pain (411.35 vs. 338.20 min, P < 0.005) as well as the time to first rescue analgesic (474.30 vs. 407.30 min, P < 0.005) were significantly longer in dexmedetomidine group as compared to dexamethasone group. Similar results were achieved with other peripheral nerve blocks, inter alia, ultrasound-guided supraclavicular brachial plexus (SCBP) block, interscalene brachial plexus block, etc.28,29,30Adinarayanan et al (2019)31in his comparison of dexamethasone and dexmedetomidine with bupivacaine, however, reported significantly extended duration of block with dexamethasone. In terms of Visual Analogue Scale (VAS) score, which was recorded at the baseline (0 hours), 2 hours, 6 hours, 12 hours and 24 hours, and it was found to statistically significant at 6 hours (p- value 0.0013) and 24 hours (p- value 0.0077), with VAS score being higher among patients in Group A at the corresponding points of time. In the study by Singla et al (2021)25, significant difference in VAS score at baseline (0 hours) was reported, with VAS score being lower in dexmedetomidine group, although further assessment of VAS score was not done. The results of the present study were corroborated by Gao et al (2019)8, who reported that VAS score was lower in the ropivacaine with dexmedetomidine group at wake up and at postoperative 2, 4, 12, and 24 hours. Post-operative heart rate was similarly recorded at baseline (0 hours), 2 hours, 6 hours, 12 hours and 24 hours. The mean heart rate was found to be slightly higher in Group B at the baseline (81.84 ± 3.93vs81.80 ± 3.88/ minute) and higher in Group A at 2 hours (86.48 ± 4.25vs85.72 ± 3.98/ minute), 6 hours (89.80 ± 3.69vs87.04 ± 3.96/ minute), 12 hours (91.16 ± 4.18vs90.36 ± 5.43/ minute) and 24 hours (91.60 ± 4.35vs 86.76 ± 4.12/ minute). The comparison was found to be statistically significant at 6 hours (p- value 0.0005), and 24 hours (p- value <0.0001), with heart rate being higher among patients in Group A at the corresponding points of time. Systolic blood pressure as well diastolic blood pressures were also noted at the baseline (0 hours), 2 hours, 6 hours, 12 hours and 24 hours. The mean systolic blood pressure was found to be slightly higher in Group B at the baseline (105.20 ± 7.01vs105.76 ± 6.88 mmHg), comparable between two groups at 2 hours (110.52 ± 6.88vs110.32 ± 6.82 mmHg) and 12 hours (115.88 ± 7.54vs 114.40 ± 7.86 mmHg), while it was higher in Group A at 6 hours (115.60 ± 6.17 vs111.60 ± 7.14 mmHg) and 24 hours (118.12 ± 6.33vs111.96 ± 6.80 mmHg). The comparison was found to be statistically significant at 6 hours (p- value 0.0034) and 24 hours (p- value <0.0001), with systolic blood pressure being higher among patients in Group A at the corresponding points of time. On a similar note, diastolic blood pressure was found to be higher in Group A at baseline(71.32 ± 5.23vs71.12 ± 5.44 mmHg), 2 hours(75.28 ± 5.07vs74.80 ± 5.28 mmHg), 6 hours (79.24 ± 4.98vs76.00 ± 5.39 mmHg), 12 hours (79.84 ± 5.65vs78.28 ± 6.03 mmHg) and 24 hours (81.36 ± 5.13vs77.08 ± 5.19 mmHg). The comparison was found to be statistically significant at 6 hours (p- value 0.0024) and 24 hours (p- value 0.0001), with diastolic blood pressure being higher among patients in Group A at the corresponding points of time. A comparison of Mean Arterial Pressure (MAP) was consequently done among study groups at the baseline (0 hours), 2 hours, 6 hours, 12 hours and 24 hours, and was found to be statistically significant at 6 hours (p- value 0.0014) and 24 hours (p- value <0.0001), with Mean Arterial Pressure being higher among patients in Group A. However, Verma and Ranjan (2016)32detected no significant difference between two groups in his study, with mean arterial pressure and mean pulse rate at 10, 15, 30, 45, 60, 90, 120 and 150 minutes being comparable between two study groups. Dose of rescue analgesia required in first 24 hours post-operatively was also noted and compared between two study groups. Mean rescue analgesia dosewas 145.50 ± 17.99 mg in Group A and 87 ± 27.77 mg in Group B. Comparison ofdata between groups, shows a p value of <0.0001, denoting statistically significant difference (p<0.05) in the rescue analgesia dose, with Group A having higher rescue analgesia dose. This was supported by Thakur et al (2019)26, who reported total number of rescue analgesic demands were significantly lower in dexmedetomidine group in comparison to dexamethasone. The results of this study were, however, contradictory to that reported by Adinarayanan et al (2019)31, who found that postoperative pain scores and morphine consumption were comparable between the dexamethasone and dexmedetomidine groups as well as by Sinha et al (2016)7. While comparing the side-effect profile, nausea was the most common adverse effect encountered in either group, followed by vomiting and over-sedation. No other side- effects were recorded among the patients in either group. A comparison ofdata between groups, shows that there is no statistically significant difference (p>0.05) in the side-effect profile of two study groups. This observation was in line with study bySingla et al (2022)25, Thakur et al (2022)26and others28, who did not report any significant difference in side- effect profile of two drugs. Finally, a comparison was drawn between the study groups based upon the patient’s satisfaction score. It was found that the mean patient’s satisfaction score was 2.92 ± 0.52in Group A and 3.18 ± 0.69in Group B, with the difference being statistically significant (p-value= 0.0359) in favour of Group B. This is in line with the findings of Thakur et al (2019)26, who reported higher patient satisfaction score among patients in dexmedetomidine group. Thus, it can be implied that an addition of dexmedetomidine to ropivacaine in TAP block leads to significantly prolonged duration of analgesia, reduced post‑operative pain and haemodynamic fluctuations, along with decrease in the required dose of rescue analgesia and better patient’s satisfaction score in first 24 hours of surgery, as compared with dexamethasone in patients undergoing total laparoscopic hysterectomy.

The present study has some limitations. The follow‑up period for postoperative pain wasshort in this study. A larger sample size would be requiredto assess these end‑points, which was not feasible within thetime frame planned for this study. The results of the study areapplicable to ASA class I and II women in India and henceforth, lack the generalizability. Lastly, the VAS scoreswere measured only at rest, thus this reduces the usefulness ofthe results provided.

1. Sjövall S, Kokki M, Kokki H. Laparoscopic surgery: a narrative review of pharmacotherapy in pain management. Drugs. 2015 Nov;75(16):1867-89. doi: 10.1007/s40265-015-0482-y. PMID: 26493289. 2. Bansal P, Sood D. Effect of dexmedetomidine as an adjuvant to ropivacaine in ultrasound-guided transversusabdominis plane block for post-operative pain relief in cesarean section. J ObstetAnaesthCrit Care 2018;8:79-82. 3. Tan TT, Teoh WH, Woo DC, Ocampo CE, Shah MK, Sia AT. A randomised trial of the analgesic efficacy of ultrasound-guided transversusabdominis plane block after caesarean delivery under general anesthesia. Eur J Anaesthesiol. 2012;29:88–94. 4. Srivastava U, Verma S, Singh TK, Gupta A, Saxsena A, Jagar KD, Gupta M. Efficacy of trans abdominis plane block for post cesarean delivery analgesia: A double-blind, randomized trial. Saudi journal of anaesthesia. 2015 Jul;9(3):298. 5. Cha SM, Kang H, Baek CW, Jung YH, Koo GH, Kim BG, Choi YS, Cha SJ, Cha YJ. Peritrocal and intraperitoneal ropivacaine for laparoscopic cholecystectomy: a prospective, randomized, double-blind controlled trial. Journal of Surgical Research. 2012 Jun 15;175(2):251-8. 6. Labaille T, Mazoit JX, Paqueron X, Franco D, Benhamou D. The clinical efficacy and pharmacokinetics of intraperitoneal ropivacaine for laparoscopic cholecystectomy. Anesthesia & Analgesia. 2002 Jan 1;94(1):100-5. 7. Sinha S, Palta S, Saroa R, Prasad A. Comparison of ultrasound-guided transversusabdominis plane block with bupivacaine and ropivacaine as adjuncts for postoperative analgesia in laparoscopic cholecystectomies. Indian J Anaesth. 2016 Apr;60(4):264-9. 8. Gao Z, Xiao Y, Wang Q, Li Y. Comparison of dexmedetomidine and dexamethasone as adjuvant for ropivacaine in ultrasound-guided erector spinae plane block for video-assisted thoracoscopic lobectomy surgery: a randomized, double-blind, placebo-controlled trial. Ann Transl Med. 2019;7(22):668. 9. Swain A, Nag DS, Sahu S, Samaddar DP. Adjuvants to local anesthetics: Current understanding and future trends. World journal of clinical cases. 2017 Aug 8;5(8):307-23. 10. Kirksey MA, Haskins SC, Cheng J, et al. Local anesthetic peripheral nerve block adjuvants for prolongation of analgesia: a systematic qualitative review. PLoS One. 2015;10:e0137312. 11. Bailard NS, Ortiz J, Flores RA. Additives to local anesthetics for peripheral nerve blocks: evidence, limitations, and recommendations. Am J Health Syst Pharm. 2014;71:373–85. 12. Tandoc MN, Fan L, Kolesnikov S et al. Adjuvant dexamethasone with bupivacaine prolongs the duration of interscalene block: a prospective randomized trial. J Anesth. 2011; 25:704-9. 13. Movafegh A, Razazian M, Hajimaohamadi F et al. Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade. AnesthAnalg. 2006; 102:263-7. 14. Keniya V, Ladi L, Naphade R. Dexmedetomidine attenuates sympathoadrenal response to tracheal intubation and reduces perioperative anaesthetic requirement. Indian J Anaesth. 2011; 55:352-7. 15. Kanazi GE, Aouad MT, Jabbour-Khoury SI et al. Effect of low-dose dexmedetomidine or clonidine on the characteristics of bupivacaine spinal block. ActaAnaesthesiol Scand. 2006; 50:222-7. 16. Brummett C, Amodeo F, Janda A et al. Perineural dexmedetomidine provides an increased duration of analgesia to a thermal stimulus when compared with a systemic control in a rat sciatic nerve block. RegAnesth Pain Med. 2010;35:427-31. 17. Esmaoglu A, Yegenoglu F, Akin A et al. Dexmedetomidine added to levobupivacaine prolongs axillary brachial plexus block. Anesth Anal. 2010; 111:1548-51. 18. Rancourt MP, Albert N, Côté M et al. Posterior tibial nerve sensory blockade duration prolonged by adding dexmedetomidine to ropivacaine. AnesthAnalg. 2012;115:958-62. 19. Anaesthesia tutorial of the week [Internet]. World Federation of Societies of Anaesthesiologists; 05 Sept 2011. TransversusAbdominis Plane Block Anaesthesia Tutorial of The Week 239; [cited 2023 Oct 30]. Available from: https://resources.wfsahq.org/atotw/transversus-abdominis-plane-block/ 20. Thakur J, Gupta B, Gupta A, Verma RK, Verma A, Shah P.A prospective randomized study to compare dexmedetomidine and dexamethasone as an adjunct to bupivacaine in transversusabdominis plane block for post-operative analgesia in caesarean delivery.Int J ReprodContraceptObstet Gynecol. 2019;8:4903-8. 21. Sharkey A, Borglum J, Blanco R, McDonnell J. TAP block: Past, present, and future. Am SocRegAnesth Pain Med. 2014;12:15-75. 22. Singh S, Dhir S, Marmai K, Rehou S, Silva M, Bradbury C. Efficacy of ultrasound-guided transversusabdominis plane blocks for post-cesarean delivery analgesia: A double-blind, dose-comparison, placebo-controlled randomized trial Int J ObstetrAnesth. 2013;22:188–93. 23. McKeen DM, George RB, Boyd JC, Allen VM, Pink A. Transversusabdominis plane block does not improve early or late pain outcomes after cesarean delivery: A randomized controlled trial Can J Anaesth. 2014;61:631–40. 24. Singh R, Kumar N, Jain A, Joy S. Addition of clonidine to bupivacaine in transversusabdominis plane block prolongs postoperative analgesia after cesarean section. J AnaesthesiolClinPharmacol. 2016;32(4):501-4. 25. Singla N, Garg K, Jain R, Malhotra A, Singh MR, Grewal A. Analgesic efficacy of dexamethasone versus dexmedetomidine as an adjuvant to ropivacaine in ultrasound-guided transversusabdominis plane block for post-operative pain relief in caesarean section: A prospective randomised controlled study. Indian J Anaesth 2021;65:121-6. 26. Thakur J, Gupta B, Gupta A, Verma RK, Verma A, Shah P. A prospective randomized study to compare dexmedetomidine and dexamethasone as an adjunct to bupivacaine in transversusabdominis plane block for post-operative analgesia in caesarean delivery. Int J ReprodContraceptObstet Gynecol. 2019;8:4903–8. 27. Scott J, Huskisson EC. Graphic representation of pain. Pain. 1976;2:175-84. 28. Mokkarala RR, Badugu JP. Evaluation of dexmedetomidine as adjuvant to 0.5% ropivacaine in comparison to dexamethasone in supraclavicular block. Int J Clin Trials 2022;9(2):89-93. 29. Shekar M, Kanakalakshmi ST, Mathew S, Muhamed S, Duggappa AK, Herekar B. Comparison of ultrasound guided interscalene brachial plexus block using 0.2% ropivacaine with dexmedetomidine and 0.2% ropivacaine with dexamethasone-a prospective observational study. Sri Lankan J Anaesthesiol. 2020 Jun 27;28(2):114-8. 30. Singh N, Gupta S, Kathuria S. Dexmedetomidine vs dexamethasone as an adjuvant to 0.5% ropivacaine in ultrasound-guided supraclavicular brachial plexus block. J AnaesthesiolClinPharmacol. 2020;36(2):238-43. 31. Adinarayanan S, Chandran R, Swaminathan S, Srinivasan G, Bidkar PU. Comparison of dexamethasone and dexmedetomidine as adjuvants to bupivacaine in supraclavicular brachial plexus block: A prospective randomized study. Indian J ClinAnaesth. 2019;6(4):523-7. 32. Verma NK, Ranjan A. A clinical comparison of dexmedetomidine and dexamethasone as adjuvant to ropivacaine in supraclavicular brachial plexus blocks for upper arm surgeries. Int J Adv Res BiolSci 2016; 3: 56-61.