The role of transversus abdominis plane blocks in women undergoing total laparoscopic hysterectomy: A retrospective review

The Role of TAP/RS Block in Minor Gynecologic Laparoscopic Surgery: A Randomized Clinical Trial

OBJECTIVES

The aim of the study was to compare, in patients undergoing minor gynecological laparoscopic procedures, the effects of ultrasound (US)-guided transversus abdominis plane (TAP) + rectus sheath (RS) block versus no TAP/RS block in terms of post-surgical pain control using the numeric pain rating scale (NRS) and the degree of patient satisfaction, according to the main goals of Early Recovery After Surgery (ERAS) programs. The primary outcome is to value the postoperative abdominal pain using NRS in both groups. Secondary outcomes are to evaluate blood values, presence of postoperative nausea and vomiting (PONV), postoperative ileus, level of patient expected satisfaction, time of discharge, length of stay (LOS), and the amounts of additional analgesics required.

DESIGN

In this prospective randomized controlled trial, patients were randomly assigned to loco-regional anesthesia (LRA) group, who received TAP and RS block under US guidance, or no loco-regional anesthesia (N-LRA) group. Enrolled patients were randomized 1:1 to either receive bilateral TAP/RS block with ropivacaine or sham treatment (patches were applied on the abdominal wall of the patients under general anesthesia).

PARTICIPANTS

All patients aged between 18 and 75 years, with ASA (American Society of Anesthesiologists) physical status 1-2, undergoing laparoscopic minor gynecological surgery, were enrolled.

SETTING

The study was conducted to the University of Campus Bio-Medico Hospital of Rome.

METHODS

Half an hour before surgery, all patients received gabapentin 300 mg per os. Once the patient underwent general anesthesia, US-guided bilateral TAP/RS block was performed by the anesthesiology team, while the uterine manipulator was positioned by a gynecology resident (not involved in the study). In the operative room, all patients received the same standardized anesthetic regimen. Postoperative abdominal pain was assessed at rest, after palpation, during movement, and after a cough by evaluating the patient at 6, 12, 18, 24, 36, 48, and 72 h after surgery, using the NRS from 0 to 10 in both groups. The amount of drug used for analgesia in the first 48 h after surgery was recorded. Moreover, hemoglobin, white blood cells, and c-reactive protein levels were recorded at 24, 48, and 72 h. The presence of PONV and the postoperative ileus was recorded throughout convalescence. The expected level of patient satisfaction at discharge and finally the LOS were assessed.

LIMITATIONS

The major weakness of this study is that 60 mL of 0.5% ropivacaine was administered to each patient, without considering weight differences, yet contemporary literature rarely suggests volume/dose titration in fascial blocks.

RESULTS

A total of 104 women, undergoing gynecological minor laparoscopic surgery, were enrolled and assigned to LRA group (53 pts) and N-LRA group (51 pts). Postoperative pain was significantly reduced in patients who received TAP/RS block. A reduction in the intake of non-steroidal anti-inflammatory drugs after surgery was registered in LRA group (p < 0.01). Moreover, a significant reduction of LOS (45.97 ± 9.87 vs. 65.08 ± 17.32 h; p < 0.01) and PONV was observed in the LRA group, as well as a better level of patient satisfaction at discharge (9.43 ± 0.94 vs. 8.26 ± 1.19; p < 0.01), compared to the N-LRA group.

CONCLUSIONS

US-guided TAP and RS block significantly reduces postoperative pain after minor gynecologic laparoscopic surgery and improves patients' post-operative recovery.

Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update

BACKGROUND

Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges.

METHODS

Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly.

CONCLUSIONS

The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.

Interventional Pain Management in the Treatment of Chronic Pelvic Pain

PURPOSE OF REVIEW

Chronic pelvic pain syndrome (CPPS) is a common yet complex disease in the field of urology, gynecology, and pain management. This review article summarizes the anatomy and physiology of CPP with an in-depth discussion of established and emerging interventional treatment options.

RECENT FINDINGS

Though psychosocial variables play a significant role in the development and propagation of CPPS, interventional treatment strategies are available to ameliorate symptoms. Sympathetic and peripheral nerve blocks along with chemical and radiofrequency denervation are conventional, evidence-based treatments. Recent advances in spinal cord stimulation and dorsal root ganglion stimulation offer novel and effective therapeutic options to treat CPPS. A biopsychosocial model should be employed for effective management of CPPS with advances in neuromodulation offering newfound hope in alleviating symptoms and restoring function.

The Efficacy of Transverse Abdominis Plane Block for Postoperative Analgesia in Laparoscopic Hysterectomy: A Randomized Prospective Study

BACKGROUND AND AIM

Postoperative pain is an inevitable acute pain for which a multimodal analgesic approach is required. The aim of this study was to quantify and compare the efficacy of transverse abdominis plane (TAP) block as a postoperative analgesic for patients undergoing laparoscopic hysterectomies versus intravenous opioid analgesics.

METHOD

Sixty female patients were enrolled and randomized into two groups following a computer-generated sequence of numbers. In group T (n=30) patients received an ultrasound-guided bilateral TAP block with 20 of 0.375% levobupivacaine on each side immediately after surgery. Patients in group O (opioid group, n = 30) received intravenous (i.v.) tramadol (100mg) immediately after surgery. Rescue analgesic (inj. tramadol 50mg) i.v. bolus given in both groups if visual analog scale (VAS) >4. In the postanesthesia care unit (PACU), the vital signs, episodes of nausea, vomiting, and VAS score of each patient were recorded every two hours for the first 24 hours.

RESULT

Total consumption of rescue analgesic (inj. tramadol 50 mg i.v.) during the first 24 hours was significantly higher in group O (186.47+37.48mg) than in group T (107.28+26.34mg). No significant difference was observed in intraoperative vital parameters (HR, NIBP, SPO₂). The VAS scores were significantly low in group T. Incidence of postoperative nausea and vomiting (PONV) was significantly higher in group O (13 out of 28 patients) than in group T (five out of 28 patients) with P value =0.043.

CONCLUSION

Our study indicated bilateral ultrasound-guided TAP block is a good alternative to opioids for postoperative analgesia.

Efficacy and Safety of a Surgeon-Performed Laparoscopic-Guided, 4-point Transversus Abdominis Plane Block: A retrospective review

We performed a retrospective chart review from October 2017 to March 2019 to demonstrate the safety and efficacy of a surgeon-performed, laparoscopically guided, transversus abdominis plane (TAP) blocks for robot-assisted gynecologic procedures. A total of 116 patients who underwent robot-assisted gynecologic surgery, at 1 academic hospital, with administration of a 4-point TAP block were included. A 4-point TAP block was performed under laparoscopic visualization, by the same surgeon, after induction of anesthesia and immediately after placement of the laparoscope. Liposomal bupivacaine (20 mL) and 0.5% bupivacaine (20 mL) mixed with saline were used as the injectant. All information from the surgical admission and the postoperative follow-up were reviewed. Data were presented in our descriptive study. A total of 116 patients were included with a mean age of 40.6 years (19-80 years) and a mean body mass index of 30.6 kg/m² (17.2-53.3 kg/m²). Of the patients, 70.7% were discharged to home on the day of surgery. Of the 29.3% of patients who were admitted, 20.6% were admitted because of pain control. Those who were admitted for pain control comprised 6.0% of the total of all study participants. There were no adverse events in our cohort and no readmissions because of pain control. A surgeon-performed TAP block, under laparoscopic visualization, is a safe and efficacious intervention to reduce postoperative pain and may add to a multimodal approach for enhanced recovery protocols.

Ultrasound and Plastic Surgery: Clinical Applications of the Newest Technology

BACKGROUND

Color Doppler ultrasound (CDUS) has not been routinely used in plastic and reconstructive surgery. Barriers to use have included large, cumbersome equipment, low-definition images, cost, and availability. In addition, programs in plastic surgery have not included training with ultrasound (US); thus, many current-day practitioners are unfamiliar with and reluctant to use this technology. Nevertheless, recent studies have demonstrated the utility of US in surgical planning. With the miniaturization, clearer imaging, and decreased costs of the latest US technology, previous barriers to use have largely been eliminated.

METHODS

Fifty-six patients scheduled for either reconstructive or aesthetic surgery were evaluated preoperatively and/or intraoperatively by a single surgeon with the linear 12-4 probe of a Philips Lumify CDUS device (Philips, Reedsville, Penn). For patients undergoing flap reconstruction, potential donor sites were imaged in order to locate the largest perforator. For patients undergoing abdominal procedures, intraoperative visualization of the abdominal muscular layers was used for the delivery of anesthesia during transversus abdominis plane block. Lastly, the superficial fascial system (SFS) was subjectively evaluated in all preoperative patients.

RESULTS

For flap reconstruction, 11 patients were preoperatively examined with CDUS in order to locate the largest perforators prior to perforator flap reconstruction. Flaps studied included the deep inferior epigastric perforator, anterolateral thigh, tensor fascia lata, thoracodorsal artery perforator, superior gluteal artery perforator, and the gracilis musculocutaneous. Color Doppler ultrasound findings were confirmed intraoperatively for all cases (100%). In 2 (18.2%) of 11 cases, CDUS identified perforators not detected by computed tomography angiography. Twenty-five patients undergoing either abdominoplasty or deep inferior epigastric perforator flap reconstruction had successful intraoperative visualization of the abdominal wall muscular layers, thus allowing administration of transversus abdominis plane blocks by the operating surgeon. Twenty patients undergoing body contouring surgery had preoperative visualization of the SFS. The SFS was found to be varied not only among different patients but also within individual patients.

CONCLUSIONS

The newest, miniaturized CDUS technology has a variety of applications that may improve patient outcomes and experience in plastic surgery. Our observations require further investigation to quantify the perceived benefits of this new technology.

Effect of posterior quadratus lumborum blockade on the quality of recovery after major gynaecological laparoscopic surgery: A randomized controlled trial

Bilateral quadratus lumborum blockade (QLB) using ultrasound guidance has been introduced as an abdominal truncal block to improve postoperative analgesia and quality of recovery (QoR) after abdominal surgery, but efficacy remains controversial. The primary aim of this study was to evaluate the efficacy of posterior QLB on the postoperative QoR, and secondarily to evaluate postoperative pain after gynaecological laparoscopic surgery (LS). This study was a single-centre randomized controlled trial. QLB group patients underwent bilateral posterior quadratus lumborum injections with 25–30 mL of 0.25% levobupivacaine after induction of general anaesthesia; the control group underwent no block. Both groups were administered fentanyl-based intravenous patient-controlled analgesia postoperatively. The postoperative QoR was measured using the Quality of Recovery 40 (QoR-40) questionnaire score; postoperative pain was evaluated using the visual analogue scale (VAS) and the cumulative postoperative fentanyl dose. Thirty-one and 29 patients were randomised to the QLB and control groups, respectively. The intraoperative remifentanil dosage was significantly less in the QLB group. The median (interquartile range) for the QoR-40 score was not different between the groups: 154 (133–168) in the QLB group and 158 (144–172) in the control group. There were no statistically significant differences in secondary outcome variables. Single-shot QLB did not improve the QoR or postoperative pain in patients managed by multimodal analgesia after gynaecological LS.

The analgesic efficacy of oblique subcostal transversus abdominis plane block after laparoscopic hysterectomy: A randomized, controlled, observer-blinded study

BACKGROUND

We aimed to assess whether an ultrasound (US)-guided oblique subcostal transversus abdominis plane (OSTAP) block would improve the postoperative pain scores and decrease the tramadol consumption after a laparoscopic hysterectomy.

METHODS

Sixty-six female patients with American Society of Anesthesiologists I, II, or III, aged 18 to 65 years who were scheduled for laparoscopic hysterectomy for benign gynecologic pathologies were recruited in this randomized, controlled, observer-blinded trial. Sixty patients completed the study. Patients were randomized into 2 groups. In the OSTAP group, the patients received a bilateral OSTAP block with 40 mL of 0.375% bupivacaine and in the Sham group received an US-guided bilateral OSTAP with 40 mL of 0.9% saline. All patients received tramadol patient-controlled analgesia for the first 24th hour. Patients in the Sham group received an US-guided bilateral OSTAP with 40 mL of 0.9% saline. The primary outcome was the 24th hour tramadol consumption. The secondary outcomes included visual analog scale (VAS) scores during movement, the tramadol consumption at the 1st, 4th, and 12th postoperative hours, and nausea scores at the 24th hour postoperatively.

RESULTS

At all time points, tramadol consumption of the OSTAP group remained significantly lower when compared with Sham group. The OSTAP group showed a statistically significant reduction at the postoperative 24th hour tramadol consumption (mean difference 22 mg, 95% confidence interval -38.4 to -5.6 mL; P = .009). Compared with the Sham group, OSTAP block reduced the VAS scores at all time points during movement. Nausea scores at the 24th postoperative hour were significantly lower in the OSTAP group compared with the Sham group CONCLUSION:: We concluded that bilateral US-guided OSTAP blocks reduced 24th hour tramadol requirements and VAS scores after laparoscopic hysterectomy. The OSTAP block is a promising technique for producing effective and prolonged postoperative analgesia in patients undergoing laparoscopic hysterectomy surgeries.

Laparoscopic-guided transversus abdominis plane block versus trocar site local anesthetic infiltration in gynecologic laparoscopy

Background

Relieving postoperative pain and prompt resumption of physical activity are of the utmost importance for the patients and surgeons. Infiltration of local anesthetic is frequently used methods of pain control postoperatively. Laparoscopically delivered transversus abdominis plane block is a new modification of ultrasound-guided transversus abdominis plane block.

This study was conducted to compare the efficacy of laparoscopic-guided transversus abdominis plane block with trocar site local anesthetic infiltration for pain control after gynecologic laparoscopy.

Results

No statistically significant difference between the two groups in mean visual analogue scale at 1, 18, and 24 h (P = 0.34, P = 0.41, and P = 0.61, respectively), while the mean visual analogue scale was significantly lower in the laparoscopic-guided transversus abdominis plane block group than in the trocar site local anesthetic infiltration group at 3, 6, and 12 h (P = 0.049, P = 0.011, and P = 0.042, respectively). No statistically significant difference was observed in the cumulative narcotics consumed at 3 h (P = 0.52); however, women with transversus abdominis plane block have consumed significantly less amount of narcotics than women with trocar site infiltration at 6, 12, and 24 h (P = 0.04, P = 0.038, and P = 0.031 respectively). Patient satisfaction was significantly higher in the laparoscopic-guided transversus abdominis plane block group (P = 0.035).

Conclusion

Laparoscopic-guided transversus abdominis plane block is more effective in reduction of both pain scores in the early postoperative period and the cumulative narcotics consumption than trocar site local anesthetic infiltration in gynecologic laparoscopy.

Trial registration

Clinical Trials.gov NCT02973451

An Evaluation of the Adding Magnesium Sulfate to Ropivacaine on Ultrasound-Guided Transverse Abdominis Plane Block After Abdominal Hysterectomy

Background

Post-hysterectomy pain is extremely annoying and using transverse abdominis plane (TAP) block can be a useful method to manage postoperative pain, but its duration of effect is challenging. Magnesium sulfate increases, in some cases, the effects of local anesthetics on the peripheral nerve blocks.

Objectives

The current study aimed at investigating the effects of adding magnesium sulfate to ropivacaine in the transverse abdominis plane block after hysterectomy.

Methods

The current randomized, double blind, clinical trial, to manage postoperative pain, was conducted on a total of 60 patients, 30 - 60 years old, ASA (American Society of Anesthesiologists) class I-II undergone elective abdominal hysterectomy candidates to receive ultrasound-guided bilateral transverse abdominis abdominis plane (TAP) blocks. Patients with coagulation disorders, infection, history of any addiction, sensitivity to the local anesthetics and magnesium sulfate were excluded. The subjects were equally allocated into two groups, the control group, ropivacaine plus normal saline (R), and the study group, ropivacaine plus magnesium sulfate (RM). The injection contained 19 mL ropivacaine 0.2% plus 1 mL normal saline in the group R, and 19 mL ropivacaine 0.2% plus 1 mL magnesium sulfate 50% in the RM group on each side. As well as the patients' characteristics, the level of pain score (visual analogue scale = VAS), rescue analgesic demand (diclofenac suppository), and possible adverse effects were evaluated at 1, 2, 6, 12, and 24 hours after the operation in the two groups.

Results

The mean pain scores of the patients at the first hour after surgery were 5.7 ± 0.9 and 5.9 ± 1.1 in R and RM groups, respectively. The scores reached 2.9 ± 0.5 and 2.7 ± 0.4 at the second hour after surgery (the first post-block measurement) and 3.1 ± 0.7 and 2.8 ± 0.7 within the next 24 hours, respectively. Although the pain scores were generally lower at all hours in the RM group, none was statistically significant. The rescue analgesic consumption gradually increased in the two groups, and it was less in the study group than in the control group in the first hours after the block (second hour after surgery); however, it was not statistically significant. No adverse effects were observed in the two groups.

Conclusions

Results of the current study suggested that the addition of magnesium sulfate to ropivacaine in TAP block does not affect the post-hysterectomy pain.

Managing Postoperative Pain After Minimally Invasive Gynecologic Surgery in the Era of the Opioid Epidemic

In this review, we examine the evidence behind nonopioid medication alternatives, peripheral nerve blocks, surgical techniques, and postoperative recovery protocols that can help minimize and effectively treat postoperative pain after minimally invasive gynecologic surgery (MIGS). Because of the depth and heterogeneity of the data, a narrative review was performed of reported interventions. A comprehensive review was performed of PubMed, Embase, and the Cochrane Database with a focus on randomized controlled trials. In the absence of literature specific to benign gynecology, similar specialty or procedural data were reviewed. A variety of nonopioid medications, surgical techniques, and postoperative recovery protocols have shown significant improvements in postoperative pain after gynecologic surgery. Nonopioid medication options that are beneficial include acetaminophen, nonsteroidal anti-inflammatories, and antiepileptics. Incision infiltration with local anesthesia also significantly reduces pain. Surgically, minimally invasive approaches, reducing the laparoscopic trocar size to <10 mm, and evacuating the pneumoperitoneum at the end of the case all have significant benefits. Lastly, enhanced recovery pathways show promise in reducing pain after MIGS. By using a multimodal approach, minimally invasive gynecologic surgeons can help to minimize and manage postoperative pain with less reliance on opioid pain medications.

Ultrasound-guided subcostal transversus abdominis plane infiltration with liposomal bupivacaine for patients undergoing robotic-assisted hysterectomy: a retrospective study

OBJECTIVE

We sought to determine the effect of a subcostal transversus abdominis plane (TAP) block with liposomal bupivacaine on postoperative maximal pain score and length of hospital stay among women undergoing robotic-assisted hysterectomy.

METHODS

This was a retrospective study comparing patients before and after consistent implementation of TAP blocks with liposomal bupivacaine during robotic-assisted hysterectomies at a single academic institution. Analysis compared patient demographic and operative characteristics by TAP block use, along with outcomes of interest, including postoperative pain and length of hospital stay.

RESULTS

There was a statistically significant decrease in maximal numerical rating scale pain scores, presence of nausea and vomiting, and length of hospital stay in those who had a TAP block with liposomal bupivacaine compared with those who did not receive a TAP block. These differences remained even after adjustment for potential confounders.

CONCLUSIONS

In this retrospective study, liposomal bupivacaine used in a TAP block was a useful method to provide postoperative pain control in patients undergoing robotic-assisted hysterectomy and was associated with lower postoperative maximal pain scores and length of hospital stay.

A Posterior TAP Block Provides More Effective Analgesia Than a Lateral TAP Block in Patients Undergoing Laparoscopic Gynecologic Surgery: A Retrospective Study

Background. There are a few papers that compared the lateral transversus abdominis plane (TAP) block with the posterior TAP block. Our study aimed to compare retrospectively the quality of analgesia after laparoscopic gynecologic surgery using the lateral TAP block with general anesthesia versus the posterior TAP block with general anesthesia. Method. Sixty-seven adult female patients were included in this retrospective study. Of these patients, thirty-four patients received the lateral TAP block with general anesthesia (lat. TAP group), and the rest of thirty-three patients received the posterior TAP block with general anesthesia (pos. TAP group). Pain scores both at rest and at movement and the use of additional analgesic drugs were recorded in the postoperative care unit within twenty-four hours after the operation. Postoperative complications were noted. Results. Patients who received pos. TAP reported lower visual analog scale (VAS) pain scores in all points, within twenty-four hours after the operation, than patients who received lat. TAP. Moreover, with the use of additional analgesic drugs, the incidence of nausea and vomiting during the first twenty-four hours after surgery was lower in the pos. TAP group than in the lat. TAP group. Conclusion. The posterior TAP block provided more effective analgesia than the lateral TAP block in patients undergoing laparoscopic gynecologic surgery.

Transversus abdominis plane (TAP) block after robot-assisted laparoscopic hysterectomy: a randomised clinical trial

BACKGROUND

Transversus abdominis plane (TAP) block is widely used as a part of pain management after various abdominal surgeries. We evaluated the effect of TAP block as an add-on to the routine analgesic regimen in patients undergoing robot-assisted laparoscopic hysterectomy.

METHODS

In a prospective blinded study, 70 patients scheduled for elective robot-assisted laparoscopic hysterectomy were randomised to receive either TAP block (ropivacaine 0.5%, 20 ml on each side) or sham block (isotonic saline 0.9%, 20 ml on each side). All patients had patient-controlled analgesia (PCA) with morphine on top of paracetamol and ibuprofen or diclofenac. For the first 24 post-operative hours, we monitored PCA morphine consumption and pain scores with visual analogue scale (VAS) at rest and while coughing. Post-operative nausea and number of vomits (PONV) were recorded.

RESULTS

Sixty-five patients completed the study, 34 receiving TAP block with ropivacaine and 31 receiving sham block with isotonic saline. We found no differences in median (interquartile range) morphine consumption the first 24 h between the TAP block group [17.5 mg (6.9-36.0 mg)] and the placebo group [17.5 mg (2.9-38.0 mg)] (95% confidence interval 10.0-22.6 mg, P = 0.648). No differences were found for VAS scores between the two groups, calculated as area under the curve/1-24 h, neither at rest (P = 0.112) nor while coughing (P = 0.345), or for PONV between groups.

CONCLUSIONS

In our study, the TAP block 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.

Ultrasound guided subcostal transversus abdominis plane (TAP) infiltration with liposomal bupivacaine for patients undergoing robotic assisted hysterectomy: A prospective randomized controlled study

INTRODUCTION

Optimal pain control after major surgery contributes to a patient's recovery and satisfaction. The use of liposomal bupivacaine in subcostal transversus abdominis plane (TAP) blocks for postoperative pain control after robot assisted abdominal surgery has yet to be studied.

METHODS

We conducted a prospective randomized controlled observer-blinded study comparing bilateral subcostal TAP blocks with bupivacaine to bilateral subcostal TAP blocks with liposomal bupivacaine. These were performed prior to the patient undergoing robot assisted hysterectomy. The patients' pain scores, opioid use, side effects, and satisfaction were followed for 72h after injection.

RESULTS

Total opioid use in the first 72h after injection was significantly decreased in the group that received liposomal bupivacaine compared to bupivacaine. Patients in the liposomal bupivacaine group had significantly lower maximal pain scores at all time periods studied as well as decreased incidence of nausea/vomiting. There was a trend toward decreased length of stay in the liposomal bupivacaine group.

CONCLUSION

Subcostal TAP blocks with liposomal bupivacaine decreased the total opioid requirement for the first 72h after robot assisted hysterectomy when compared to subcostal TAP blocks with bupivacaine.

The analgesic efficacy of ultrasound-guided transversus abdominis plane block with mid-axillary approach after gynecologic laparoscopic surgery: A randomized controlled trial

Background and Aims:

The transversus abdominis plane (TAP) block is widely used in clinical practice as a part of the multimodal analgesic regimen after abdominal surgery. The analgesic efficacy of ultrasound (US)-guided TAP block with the mid-axillary approach was investigated in patients undergoing laparoscopic gynecologic surgery in a randomized controlled clinical trial.

Materials and Methods:

Adult patients (n = 119) undergoing laparoscopic gynecologic surgery were randomized to undergo either TAP block with ropivacaine (Group A, n = 60) or that with saline (Group B, n = 59), in a blinded manner. Following general anesthesia, TAP block was performed bilaterally by infusion of either 20-mL 0.375% ropivacaine/one side in Group A or 20-mL saline/one side in Group B, under US guidance with a mid-axillary approach. Patient-controlled analgesia (PCA) was performed postoperatively with tramadol. The analgesic effect was postoperatively evaluated using a four-grade pain score and the prince Henry pain scale (PHS) at 0, 6, 12, and 24 h. Postoperative tramadol PCA consumption and vomiting/nausea were recorded. Statistical analyses were performed using the Mann-Whitney U-test or Fisher's exact probability test. A P < 0.05 was considered significant.

Results:

There was no statistically significant difference in background characteristics. The dose of remifentanil was significantly higher in Group B (P = 0.01). The pain score (P = 0.02) and PHS (P = 0.01) were significantly lower in Group A at 0 h. Tramadol PCA consumption in the period of 0-6 h (P = 0.01) and postoperative nausea (P = 0.04) were significantly less in Group A.

Conclusion:

Postoperative pain/nausea and PCA consumption were significantly lower in patients with TAP block in the early postoperative stage. TAP block with a mid-axillary approach holds considerable promise as a part of a balanced postoperative analgesic regimen following laparoscopic gynecologic surgery.

Randomized controlled double-blind trial of transversus abdominis plane block versus trocar site infiltration in gynecologic laparoscopy

OBJECTIVE

The objective of the study was to determine whether transversus abdominis plane (TAP) block reduces postoperative pain when compared with trocar site infiltration of bupivacaine in gynecological laparoscopy.

STUDY DESIGN

This was a prospective, randomized, double-blinded clinical trial using patients as their own controls. Women undergoing gynecologic laparoscopy using a 4-port symmetrical technique were randomly assigned to right- or left-sided TAP block using 30 mL of 0.25% bupivacaine with epinephrine. Two cohorts of patients were studied. Cohort 1 consisted of anesthesiologist-administered ultrasound-guided TAP block. Cohort 2 consisted of surgeon-administered laparoscopic-guided TAP block. In both cohorts, contralateral port sites were infiltrated with an equal amount of bupivacaine in divided doses. All patients received intraoperative acetaminophen and ketorolac. Postoperative abdominal pain was assessed at 1, 2, 4, 6, 8, 12, 18, 24, and 48 hours on the block and contralateral sides, before and after palpation, using the 10 point visual analog scale. A 2 point difference in the reported pain scores was considered clinically meaningful.

RESULTS

Eighty-eight patients were eligible for statistical analysis: 45 and 43 patients in cohorts 1 and 2, respectively. In both cohorts, most patients reported equal pain on the block side and local side. In cohort 1, there was a statistically significant difference in mean reported pain scores at 2 hours and across time favoring the ultrasound-guided block; however, this did not reach clinical significance. There was no statistically significant difference found at all other time points or when pain scores were objectively assessed after palpation of the incisions. When comparing laparoscopic-guided block with local infiltration, there was no statistically significant difference in reported mean pain scores at all time points or after palpation.

CONCLUSION

As part of this multimodal analgesic regimen, neither block method provided a significant clinical benefit compared with trocar site bupivacaine infiltration.

Multimodal therapy in perioperative analgesia

This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.

The effect of anesthesia choice on post-operative outcomes in women undergoing exploratory laparotomy for a suspected gynecologic malignancy

OBJECTIVE

To determine how anesthesia choice in women undergoing laparotomy for gynecologic malignancy affects pain control and narcotic use.

METHODS

This is a retrospective study of women who underwent laparotomy for suspected gynecologic malignancy from May 2012 to January 2013. Patients were categorized into one of three groups: 1) patient controlled analgesia (PCA); 2) PCA+transversus abdominis plane block (TAP); and 3) patient-controlled epidural analgesia (PCEA). Mean narcotic use and patient reported pain scores were compared.

RESULTS

The analysis includes 112 women (44 PCA, 30 TAP, 38 PCEA). Intraoperative factors were not different between groups with the exception of a significant difference in the rate of intra-operative complications (p=0.020), with lower rates in the PCEA group. The groups differed in intravenous narcotic use in each of the first three postoperative days (day 0: p=0.014; day 1: p<0.0001; day 2: p=0.048), with patients in the TAP group using the least on day 0 and those in the PCEA group using less on postoperative days 1 and 2. In addition, the PCEA group reported lower pain scores on postoperative days 1 and 2 (day 1: p=0.046; day 2: p=0.008).

CONCLUSIONS

The use of patient controlled epidural anesthesia after laparotomy for gynecologic malignancy is associated with decreased IV and PO narcotic use and improved pain control without increasing complications or length of hospital stay. Further investigation with prospective randomized trials is warranted to elucidate the optimal post-operative pain management technique.

Laparoendoscopic single-site isobaric hysterectomy in endometrial cancer

This case highlights the feasibility of laparoendoscopic single-site surgery and isobaric hysterectomy for early clinical stage, low-risk endometrial cancer.

Direct hospital costs of total laparoscopic hysterectomy compared with fast-track open hysterectomy at a tertiary hospital: a retrospective case-controlled study

AIMS

To assess the direct intraoperative and postoperative costs in women undergoing total laparoscopic hysterectomy and fast-track open hysterectomy.

METHODS

A retrospective review of the direct hospital-related costs in a matched cohort of women undergoing total laparoscopic hysterectomy (TLH) and fast-track open hysterectomy (FTOH) at a tertiary hospital. All costs were calculated, including the cost of advanced high-energy laparoscopic devices. The effect of the learning curve on cost in laparoscopic hysterectomy was also assessed, as was the hospital case-weighted cost, which was compared with the actual cost.

RESULTS

Fifty women were included in each arm of the study. TLH had a higher intraoperative cost, but a lower postoperative cost than FTOH (AUD$3877 vs AUD$2776 P < 0.001, AUD$3965 vs AUD$6233 P < 0.001). The total cost of TLH was not different from FTOH (AUD$7842 vs AUD$9009 P = 0.068) and after a learning curve; TLH cost less than FTOH (AUD$6797 vs AUD$8647, P < 0.001). The use of high-energy devices did not impact on the cost benefit of TLH, and hospital case-weight-based funding correlated poorly with actual cost.

CONCLUSION

Despite the use of fast-track recovery protocols, the cost of TLH is no different to FTOH and after a learning curve is cheaper than open hysterectomy. Judicious use of advanced energy devices does not impact on the cost, and hospital case-weight-based funding model in our hospital is inaccurate when compared to directly calculated hospital costs.

Fast-track surgery in gynaecology and gynaecologic oncology: a review of a rolling clinical audit

Clinical audit is the process by which clinicians are able to demonstrate to themselves, their patients, hospital administrators, and healthcare financial providers the outcome and safety of their clinical practice. It is a process by which the public can be assured of safety and outcomes. A fast-track surgery program was initiated in January 2008, and this paper represents a rolling clinical audit of the outcomes of that program until the end of June 2012. Three hundred and eighty-nine patients underwent fast track surgical management after having a laparotomy for suspected or confirmed gynaecological cancer. There were no exclusions and the data presented represents the practice and outcomes of all patients referred to a single gynaecological oncologist. The majority of patients were deemed to have complex surgical procedures performed usually through a vertical midline incision. One third of patients had a nonzero performance status, median weight was 68 kilograms, and median BMI was 26.5 with 31% being classified as obese. Median operating time was 2.25 hours, and the median estimated blood loss was 175 mL. Overall the median length of stay (LOS) was 3 days with 95% of patients tolerating early oral feeding. Four percent of patients required readmission, and 0.5% were required to return to the operating room. Whilst the wound infection rate was 2.6%, there were no ureteric, bowel or neurovascular injuries. Overall there were 2 bladder injuries (0.5%), and the incidence of venous thromboembolism was 1%. Subset analysis was also undertaken. Whilst a number of variables were associated with reduced LOS, on multivariate analysis, benign pathology, shorter operating time, and the ability to tolerate early oral feeding were found to be significant. The data and experience presented is the largest and most extensive reported in the literature relating to fast-track surgery in gynaecology and gynaecologic oncology. The public can be reassured of the safety and improved outcomes that can be achieved after the introduction of such a program.

Efficacy of the bilateral ilioinguinal-iliohypogastric block with intrathecal morphine for postoperative cesarean delivery analgesia

The ilioinguinal-iliohypogastric (IIIH) block is frequently used as multimodal analgesia for lower abdominal surgeries. The aim of this study is to compare the efficacy of IIIH block using ultrasound visualization for reducing postoperative pain after caesarean delivery (CD) in patients receiving intrathecal morphine (ITM) under spinal anesthesia. Participants were randomly assigned to 1 of 3 treatment groups for the bilateral IIIH block: Group A = 10 mL of 0.5% bupivacaine, Group B = 10 mL of 0.5% bupivacaine on one side and 10 mL of a normal saline (NSS) placebo block on the opposite side, and Group C = 10 mL of NSS placebo per side. Pain and nausea scores, treatment for pain and nausea, and patient satisfaction were recorded for 48 hours after CD. No differences were noted with respect to pain scores or treatment for pain over the 48 hours. There were no differences to the presence of nausea (P = 0.64), treatment for nausea (P = 0.21), pruritus (P = 0.39), emesis (P = 0.35), or patient satisfaction (P = 0.29). There were no differences in pain and nausea scores over the measured time periods (MANOVA, P > 0.05). In parturients receiving ITM for elective CD, IIIH block offers no additional postoperative benefit for up to 48 hours.

Randomized trial of transversus abdominis plane block at total laparoscopic hysterectomy: effect of regional analgesia on quality of recovery

OBJECTIVE

The objective of the study was to determine whether transversus abdominis plane (TAP) block improves the early postoperative quality of recovery (QoR-40). The secondary objectives measured postoperative pain, length of stay, and narcotic use.

STUDY DESIGN

This was a randomized, single-blinded trial of TAP block versus no block on women undergoing laparoscopic hysterectomy. TAP block patients received 20 mL of 0.5% ropivacaine with epinephrine 1:200,000 placed under ultrasound guidance on each side. The outcomes were measured using validated quality of recovery questionnaires (QoR-40), visual analog scales (VAS) for pain, and documented narcotic use in the electronic medical record.

RESULTS

In 58 women, no differences in demographics were noted between groups. Comparisons of pain and recovery between the 2 groups showed no differences. There was no decrease in narcotic use or length of stay among those who received the TAP block.

CONCLUSIONS

TAP block does not improve postoperative QoR-40 scores or VAS pain scores following laparoscopic hysterectomy, nor does it decrease narcotic pain medication use.