Clinical implications of the transversus abdominis plane block in adults

Dexmedetomidine vs Dexamethasone as an Adjuvant to Levobupivacaine in Ultrasound-Guided Transversus Abdominis Plane Block for Postoperative Analgesia in Patients Undergoing Total Abdominal Hysterectomies

Background

In the postoperative period, open total abdominal hysterectomy (TAH) surgeries induce considerable pain. Multimodal strategies are being used to alleviate pain.

Objectives

This study aimed to examine the efficacy and safety of dexamethasone and dexmedetomidine as an adjuvant to levobupivacaine in ultrasound-guided transversus abdominis plane (TAP) blocks for postoperative pain in TAH patients.

Methods

A total of 72 patients with ASA grade I and grade II were randomly and equally assigned to two groups. After the completion of surgery with a subarachnoid block (SAB), patients in group 1 received a mixture of 20 mL of 0.25% levobupivacaine and 4 mg of dexamethasone on each side of the TAP block. Patients in group 2 received a mixture of 20 mL of 0.25% levobupivacaine and dexmedetomidine, with a total dose of 1 µg/kg body weight evenly distributed bilaterally in the TAP block. Patients were evaluated for pain using the Visual Analog Scale (VAS), total tramadol consumption as rescue analgesia, time to first rescue analgesia, any adverse effects, and patient satisfaction.

Results

When comparing VAS scores for pain assessment, we observed that the mean VAS score was initially comparable between the two groups for the first hour. However, at 6, 9, and 12 h, VAS scores were significantly lower in group 2. The mean total tramadol consumption was higher in group 1 than in group 2 (213.33 ± 44.08 vs 161.11 ± 37.93 mg, P-value 0.027). The time to the first rescue analgesia after the TAP block in the postoperative period was significantly longer in group 2 (47.5 ± 62.76 vs 77.22 ± 56.14 min, P-value 0.002). No significant side effects were noted, and a greater proportion of patients in group 2 expressed satisfaction with their overall pain treatment.

Conclusions

The addition of dexmedetomidine to levobupivacaine is superior to the addition of dexamethasone, as it prolongs the duration of the block in the dexmedetomidine group. However, the use of dexamethasone as an adjuvant is a good alternative option, particularly due to its lower cost and reduced incidence of adverse effects such as postoperative nausea and vomiting.

Navigating Pain Relief: A Comprehensive Review of Transversus Abdominis Plane Block

This comprehensive review explores the multifaceted role of the transversus abdominis plane (TAP) block in contemporary pain management. Beginning with a definition and historical evolution, the article elucidates the mechanism of action, emphasizing local anesthesia, interference with pain signal transmission, and its impact on visceral and somatic pain. The review systematically investigates the diverse indications for TAP block, ranging from its applications in various surgical procedures to postoperative pain management and chronic pain conditions. Noteworthy abdominal wall block variations, including rectus sheath block and quadratus lumborum block, underscore the adaptability of TAP block in diverse clinical scenarios. The implications for clinical practice highlight its pivotal role in enhancing recovery after surgery, reducing opioid reliance, and providing patient-centered care. Furthermore, the article outlines recommendations for further research, addressing ongoing trials, technological innovations, and potential expansions into non-surgical settings. In conclusion, TAP block emerges as a dynamic and indispensable tool in pain management, potentially redefining paradigms and optimizing patient outcomes across a spectrum of medical contexts.

Identification of interfascial plane using injection pressure monitoring at the needle tip during ultrasound-guided TAP block in cadavers

INTRODUCTION

Consistency in needle tip positioning within interfascial planes while performing infiltrative blocks under ultrasound guidance can be difficult. The exact determination of such planes may beyond the physical limits of common ultrasound machines. Aim of this pilot study was to understand if real-time continuous injection pressure monitoring at the needle tip, combined with ultrasound guidance, can help to immediately and consistently identify an interfascial plane needle tip placement.

METHODS

We performed four ultrasound-guided transversus abdominis plane (TAP) blocks on fresh cadaver using a modified conventional peripheral nerve block needle. The sensing needle contains Fabry-Perot miniaturized pressure sensor floating at the needle tip, connected to a measuring unit via an optical fiber. Injection-pressure measured at the needle tip was continuously recorded, while the needle was advanced toward the target and 0.9% saline was continuously injected via an electronic pump.

RESULTS

A recognizable, recurrent three-peaks injection pressure pattern was identified, while advancing the needle through the abdominal wall, the pressure peaks being identified with the needle to fasciae contact. In four different blocks, a total of 12 peaks and 12 troughs were identified. The mean injection pressure (95% CI) of the peaks varied substantially from the mean injection pressure of the troughs, from 119.55 kPa (95% CI 87.3 to 151 kPa) to 30.99 kPa (95% CI 12.5 to 47.5 kPa), respectively. The peaks (troughs) arose from reproducible pressure curves and were related to the needle tip encountering the muscle fasciae.

CONCLUSION

The identified injection pressure pattern, together with ultrasound image, may help in determine real-time the needle tip position, while performing a TAP block.

Ultrasound-guided transversus abdominis plane block as an effective anesthetic technique for transverse colostomy in a high-risk elderly patient: A case report

Ultrasound-guided transversus abdominis plane (TAP) block is considered to be one of most prevalent and effective adjuvant analgesic methods for various abdominal surgeries. However, whether TAP blocks can be used alone as an effective anesthetic technique in minor abdominal operations has rarely been reported. Here we presented a 66-year-old male who had sustained right somatic dysfunction and mild brain dysfunction caused by cerebral infarctions and poorly treated hypertension. The patient received a confine operation of transverse colostomy to alleviate an intestinal obstruction caused by rectal cancer. A 22G needle was advanced in the plane under ultrasound guidance until it reached the TAP. A total of 10 mL 0.375% ropivacaine with 5 mg dexamethasone and 10 μg dexmedetomidine was injected into the TAP. The operation went stably and smoothly without any complaints. After the operation, the patient returned to the care of the surgical recovery staff with patient-controlled intravenous analgesia (PCIA) containing 0.7 mg/kg oxycodone and 2.5 μg/kg dexmedetomidine. During the perioperative period, the elderly patient did not experience apparent or unbearable pain. All these evidences indicated the ultrasound-guided subcostal and lateral TAP block was a simple and effective procedure for transverse colostomy in a high-risk elderly patient.

Analgesic efficacy of ultrasound-guided transversus abdominis plane block in dogs undergoing ovariectomy

Background

In medicine, the transversus abdominis plane (TAP) block has been shown as an effective method of analgesia in several surgical procedures. In this context, this prospective, randomized, blinded study aimed to evaluate the analgesic efficacy of TAP block, guided by ultrasound in female dogs submitted to ovariectomy.

Methods

Therefore, 32 animals randomly assigned in two groups (n = 16) were used. Groups consisted of TAP block control (TBC) which received water injection (0.2 ml kg⁻¹ point), and TAP block bupivacaine (TBB) which received bupivacaine (0.2 ml kg⁻¹ point at 0.25%); both groups were submitted to four-point approach. Animals were pre-medicated with acepromazine (0.03 mg kg⁻¹) and meperidine (2 mg kg⁻¹) IM, propofol was used as anesthetic induction (3–5 mg kg⁻¹) IV, and isoflurane was used to maintain. To standardize groups, the animals received a continuous infusion of remifentanil (0.2μg kg⁻¹ min) and rocuronium (0.6 mg kg⁻¹) IV in the intraoperative period. Variables measured were the heart and respiratory rates, blood pressure, temperature, peripheral oxyhemoglobin saturation, exhaled carbon dioxide concentration, exhaled isoflurane concentration, serum cortisol, analgesia, and sedation. Before the pre-anesthetic medication (Baseline) and 1, 2, 4, 6, and 8 h after extubation, pain and sedation were assessed using a numeric rating scale (NRS), Glasgow composite measure pain scale (GCMPS-SF), and sedation scale. Moreover, serum cortisol was measured at different moments.

Results

The results show that in the intraoperative period, there was no significant difference between groups. After surgery, in TBC, 13 out of 16 animals required analgesic rescue, whereas, in TBB, this occurred only in one animal. Regarding the measurement of serum cortisol, the TBC group showed a significant difference when compared to the baseline time in the traction of the first ovary (p < 0.0001), 2 h (p = 0.0441), and 8 h (p = 0.0384) after extubation. In TBB, cortisol showed a significant increase only in the traction of the first ovary and 2 h after extubation (p < 0.0001).

Conclusion

The technique using ultrasound-guided TAP block in two points approach by hemiabdomen with 0.2 ml kg⁻¹ bupivacaine 0.25% was effective in providing post-operative analgesia in dogs undergoing ovariectomy.

Transversus Abdominis Plane Block Reduces Intraoperative Opioid Consumption in Patients Undergoing Periacetabular Osteotomy

Background: Administering intraoperative analgesia in patients undergoing periacetabular osteotomy (PAO) is challenging due to both the relevant surgical approach and osteotomies, which are associated with pain. The aim of this study was to assess the effect of the transversus abdominis plane block (TAPb) on intraoperative opioid consumption and circulation parameters in PAO patients. Patients and Methods: We conducted a two-group randomized-controlled trial involving 42 consecutive patients undergoing PAO for symptomatic developmental dysplasia of the hip (DDH) in our department. Patients assigned to the study group received an ultrasound-guided TAPb with 0.75% ropivacaine before the beginning of the surgery and after general anesthesia induction. Patients assigned to the control group did not receive a TAPb. General anesthesia was conducted according to a defined study protocol. The primary endpoint of the study was the intraoperative opioid consumption, measured in morphine equivalent dose (MED). Secondary endpoints were the assessment of intraoperative heart rate, mean arterial pressure (MAP), need for hypotension treatment, and length of hospital stay (LOHS). A total of 41 patients (n = 21 TAPb group, n = 20 control group) completed the study; of these, 33 were women (88.5%) and 8 were men (19.5%). The mean age at the time of surgery was 28 years (18–43, SD ± 7.4). All operations were performed by a single high-volume surgeon and all TAPb procedures were performed by a single experienced senior anesthesiologist. Results: We observed a significantly lower intraoperative opioid consumption in the TAPb group compared to the control group (930 vs. 1186 MED per kg bodyweight; p = 0.016). No significant differences were observed in the secondary outcome parameters. We observed no perioperative complications. Conclusion: Ultrasound-guided TAPb significantly reduces intraoperative opioid consumption in patients undergoing PAO.

Laparoscopic-guided distal loco-regional anesthetic infiltration technique in TAPP inguinal hernia repair: a double-blind randomized clinical trial

BACKGROUND

Ultrasound-guided transversus abdominis plane block (US-TAP) is an important component of multimodal analgesia in laparoscopic inguinal hernia repair, although it has certain limitations. To overcome them, surgeons have developed several techniques to perform local anesthetic infiltration under laparoscopic guidance, but no trials evaluating these in transabdominal preperitoneal (TAPP) hernia repair were conducted till the date. The aim of this study was to compare the efficacy of a novel laparoscopic-guided local anesthetic infiltration technique (LDAI) with US-TAP in postoperative pain control and analgesic consumption for patients undergoing elective TAPP hernia repair.

METHODS

This was a double-blind randomized controlled trial conducted at a single tertiary academic center between 2019 and 2020 on adult patients undergoing elective laparoscopic TAPP inguinal hernia repair. Postoperative pain and analgesic consumption were compared for LDAI vs. US-TAP up to 30 postoperative days.

RESULTS

62 patients were included (31 LDAI, 31 US-TAP). Female gender was significantly higher in the LDAI group (8, 25.81%; US-TAP 0; p = 0.005). Mean anesthetic time (US-TAP group: 142.2 min, SD = 17.7; LDAI group: 127.1 min, SD = 15.5; p < 0.001) and mean operative time (US-TAP group: 117.2 min, SD = 15.9; LDAI group: 103.8 min, SD = 15.2; p < 0.001) were significantly shorter in the LDAI group. Pain scores assessed at the first-hour postoperative, at the moment of discharge, and at 8, 24, and 48 postoperative hours showed no significant differences between both groups. No significant difference was found regarding postoperative analgesic rescue administration in the recovery room and analgesic consumption after discharge between groups.

CONCLUSION

LDAI is a safe and effective local anesthetic technique in elective TAPP hernia repair. Pain control is similar to US-TAP block, with shorter anesthesthetic and surgical time and better health resources allocation.

Randomized Comparative Study Between Bilateral Erector Spinae Plane Block and Transversus Abdominis Plane Block Under Ultrasound Guidance for Postoperative Analgesia After Total Abdominal Hysterectomy

Introduction: Ultrasound-guided erector spinae plane (ESP) block has emerged as an effective and safe analgesic regional technique and it also provides visceral pain relief. Our aim was to compare the analgesic efficacy of ESP block over transversus abdominis plane (TAP) block under ultrasound guidance following a total abdominal hysterectomy.

Methods: This was a prospective, randomized, comparative study. Thirty females posted for elective open total abdominal hysterectomy under general anesthesia were randomly allocated into two groups. Ultrasound-guided ESP block was applied in group E at the T-9 level bilaterally. The study solution was prepared by mixing 20 ml of 0.5% bupivacaine plus 10 ml of 2% lignocaine and 1 ml (50mcg) of fentanyl and 9 ml of normal saline forming total 40 ml of which 20 ml was injected on each side. Group T received ultrasound-guided TAP block with 20 ml of study solution bilaterally. The study solution was prepared similarly by mixing 20 ml of 0.5% bupivacaine plus 10 ml of 2% lignocaine and 1 ml (50mcg) of fentanyl and 9 ml of normal saline (total 40 ml) of which 20 ml was injected into each side. Tramadol 100mg iv was given as rescue analgesia whenever NRS ≥ 4 or on-demand in the postoperative period. The primary outcome was changes in a numerical rating scale (NRS) pain score postoperatively between two groups in 24 h, duration of analgesia and total rescue analgesic required during 24 h. The secondary outcome was patient satisfaction level and side effects if any.

Results: Demographic data were comparable in both groups. The NRS pain score was significantly lower ​​​​in group E than in group T at second, third, fourth, fifth (p < 0.001) and at sixth hour (p < 0.05) postoperatively. The mean duration of analgesia was significantly more in Group E (4.73±0.7 h) compared to group T (2.60±0.51 h) (p < 0.001). The tramadol consumption was seen significantly more in 24 h in group T (233.33±25.82 mg) than in group E (193.33±17.59 mg). Patient satisfaction score was significantly higher at 12 h with mean value of 6.07±0.26 in group E compared to 3.40±0.91 in group T.

Conclusion: We conclude that ultrasound-guided ESP block provide better postoperative pain control and prolonged duration of analgesia with less tramadol consumption compared to ultrasound-guided TAP block in patients after total abdominal hysterectomy.

Postoperative analgesic effectiveness of quadratus lumborum block: systematic review and meta-analysis for adult patients undergoing hip surgery

BACKGROUND

Quadratus lumborum block is a truncal block with several technique variations. It has been reported as providing effective analgesia for postoperative pain. The aim of this study is to determine the efficacy of the QL block in providing postoperative analgesia for hip surgery when compared with placebo or no block or other analgesic techniques.

METHODS

Randomized trials evaluating quadratus lumborum block benefits in elective hip surgery were sought. The primary outcome was the 24 h opioid requirement after surgery. Two independent reviewers selected the studies and extracted the data.

RESULTS

Thirteen randomized-controlled trials were included in this study. The included studies had significant heterogeneity regarding comparator groups; therefore, a limited quantitative analysis was undertaken for the comparison of QL block versus no block or placebo only. QL block reduced the opioid use by 15.78 (95% CI, 2.31 to 29.26) mg IME in the first postoperative 24 h compared with no block or placebo with no difference in static pain scores, pain grade was reduced by 2.95 (95% CI, 2.40 to 3.60) in the QL block group compared with placebo or no block in the first postoperative 24 h during movement.

CONCLUSIONS

Our meta-analysis indicates that QL block may be effective for analgesia in patients after hip surgery compared with placebo or no block. There is currently limited evidence comparing QL block with other analgesic techniques for hip surgery.

Regional abdominal wall nerve block versus epidural anesthesia after hepatectomy: analysis of the ACS NSQIP database

BACKGROUND

The aim of this study is to determine whether regional abdominal wall nerve block is a superior to epidural anesthesia (EA) after hepatectomy.

METHODS

Patients undergoing open hepatectomy in the NSQIP targeted file (2014-2016) were identified. Those with INR > 1.5, Platelets < 100, bleeding disorders, undergoing liver ablation without resection, and spinal anesthesia were excluded. Patients with regional abdominal wall nerve block (RAB), mostly transversus abdominis plane (TAP) block, were matched (1:1) to those undergoing EA using propensity scores to adjust for baseline differences.

RESULTS

Out of 1727 patients who met our inclusion criteria, 361 (21%) had RAB. Of whom 345 were matched (1:1) to those who underwent EA. The matched cohort was well-balanced regarding preoperative characteristics, extent of hepatectomy, concurrent ablations as well as biliary reconstruction. RAB was associated with shorter hospital stay (median: 6 days vs. 5 days, p = 0.007). Overall morbidity (44.1% vs. 39.4%, p = 0.217), serious morbidity (27% vs. 25.2%, p = 0.603), and mortality (2.6% vs. 2.3%, p = 0.806) were not different between the two groups. Individual complications, readmission rate, and blood transfusion were not different between the two groups.

CONCLUSION

Regional abdominal nerve block is associated with shorter hospital stay than epidural anesthesia without an increase in overall postoperative morbidity or mortality. RAB is a viable alternative anesthesia adjunct to EA in patients undergoing hepatectomy. However, given the retrospective nature of this study further studies comparing the modalities should be considered to definitively define the utility of RAB.

The evaluation of the efficacy of 0.25% Bupivacaine and 0.5% Ropivacaine in ultrasound guided bilateral transversus abdominis plane block for post operative analgesia in lower abdominal surgeries

The increasing use of nerve blocks for post operative analgesia has led to the development of several newer interfascial injection techniques for analgesia of the chest and abdominal wall. The unique feature of ultrasound guided truncal blocks is that in all of these techniques, in contrast to peripheral nerve blocks, no nerve or plexus needs to be identified. Local anaesthesia is injected in a particular muscle plane, in which the injectate spreads and reaches the intended nerves. Transversus abdominis plane (TAP) block has become a common analgesic method after surgery involving the abdominal wall. Aim: 1. To assess the efficacy of 0.25% Bupivacaine and 0.5% Ropivacaine in pain relief after lower abdominal surgeries using ultrasound guided transversus abdominis plane block (TAP). 2. Requirement of first rescue dose. 3.To assess complications related to the technique and drug related adverse effects. Methods: A comparative, randomised, double blinded study was carried out on 60 ASA physical status grade I and II patients of either sex between 18-40 years of age, scheduled for elective lower abdominal surgeries. 60 patients were divided equally by using computer generated random numbers into two groups. Group B received 15 ml of 0.25% Bupivacaine. Group R received 15 ml of 0.5% Ropivacaine. The TAP block was performed at the end of the surgery using the ultrasound. Results: Mean duration of analgesia was 373.75 minutes with SD of 66.1512 in Bupivacaine group and 687 minutes with SD of 119.433 in Ropivacaine group. The difference was highly significant in Group R compared to Group B (p < 0.0001). Conclusion: Thus, we conclude that 0.5% Ropivacaine provided longer duration of analgesia than 0.25% Bupivacaine when used in TAP block for providing post operative analgesia after lower abdominal surgeries.

Improving Pain Management After Cesarean Birth Using Transversus Abdominis Plane Block With Liposomal Bupivacaine as Part of a Multimodal Regimen

As educators, advocates, and champions for women's health, nurses play pivotal roles throughout a woman's pregnancy and childbirth journey. Most women experience postsurgical pain after cesarean birth and are prescribed opioids. Caution around opioid use warrants opioid-reducing strategies, particularly because exposure to opioids exacerbates risk for developing persistent postsurgical opioid use. Multimodal approaches can help address this concern. Regional anesthesia using transversus abdominis plane blocks with aqueous formulations of local anesthetics can reduce opioid consumption and pain but has a short duration of action. Liposomal formulation of bupivacaine prolongs its release, overcoming this obstacle. Transversus abdominis plane blocks with liposomal bupivacaine can reduce opioid use and pain after cesarean birth, improving recovery. These findings represent numerous implications for nursing practice to improve postcesarean pain management.

Comparison of Three Different Doses of Dexmedetomidine Added to Bupivacaine in Ultrasound-Guided Transversus Abdominis Plane Block; A Randomized Clinical Trial

Background

Adding dexmedetomidine to bupivacaine has been shown to prolong the analgesic effects of the transversus abdominis plane (TAP) block. However, the optimal dose of this adjuvant drug is unclear.

Objectives

Identifying optimal doses of dexmedetomidine added to bupivacaine in the TAP block.

Methods

In this randomized controlled trial, 86 patients candidate for elective open inguinal herniorrhaphy under spinal anesthesia were divided randomly into three groups; low (L), medium (M), and high (H) dose of dexmedetomidine, that finally 80 cases ended the study and were analyzed. At the end of the surgery, the patients underwent ultrasound-guided TAP block. In all patients of the three groups, the analgesic base of the block was 20 mL bupivacaine 0.125% that was supplemented with 0.5, 1, or 1.5 µ/kg of dexmedetomidine in groups L, M, and H, respectively.

Results

The maximum duration of the block was 4 hours in group L and 8 hours in groups M and H. None of the patients needed to receive analgesic at 0, 2, and 24 hours after the block. The dose of analgesic required in the first 8 hours of the block in groups M and H was less than in group L (P < 0.02). Patients in groups H and M were more satisfied with the block (P < 0.01) and experienced less pain compared with group L (P < 0.01). Drowsiness and sedation were observed in patients up to 4 hours after the TAP block, which was dependent on the dexmedetomidine dose (P < 0.01).

Conclusions

Based on our results, the optimal dose of supplemental dexmedetomidine could be 1 µ/kg in the TAP block.

A randomised comparative study of transversus abdominis plane block with or without intravenous diclofenac sodium as a component of multimodal regimen for post-operative analgesia following caesarean section

Aims

Post-operative analgesia is a major component of perioperative care. An ideal method of pain relief after caesarean section should be cost-effective and safe for mother and baby. This study aims to evaluate the analgesic efficacy of transversus abdominis plane (TAP) block combined with intraoperative diclofenac aqueous for post-operative analgesia in caesarean section.

Methods

A prospective randomised double-blind study was conducted on 60 patients over a period of six months. Patients were enrolled in two groups (n = 30). Group A and Group B both received bilateral landmark based TAP block using ropivacaine 0.75% (1.5 mg/kg), 20 ml at end of surgery. Group B received diclofenac sodium aqueous 75 mg intravenous intraoperatively.

Results

The difference of visual analogue score (VAS) at movement was significant at 4 and 6 h in Group A versus Group B (3.00 ± 0.64 versus 2.37 ± 0.89, 4.43 ± 0.68 versus 3.53 ± 1.2). At rest, VAS score was lower in Group B than in Group A at all time intervals (P < 0.05). Time to demand of first dose of rescue analgesic was prolonged in Group B (11.5 ± 4.1 h) than in Group A (7.55 ± 1.41 h). Mean dose of analgesic consumption in first 24 h was lesser in Group B (61.67 ± 34.57 mg) than in Group A (98.33 ± 37.68 mg). Patient satisfaction score was higher in Group B (8 ± 1.04) than in Group A (6.23 ± 1.04).

Conclusion

TAP block along with intraoperative diclofenac aqueous as component of multimodal regimen provides superior post-operative analgesia and better patient satisfaction as compared to TAP block alone.

Combined caudal retrocostal and lateral ultrasound-guided approach for transversus abdominis plane injection: A descriptive pilot study in pig cadavers

Transversus abdominis plane (TAP) block is a regional anesthetic technique used to desensitize the abdominal wall in several species. This study aimed to describe the anatomical characteristics of the abdominal wall and to identify a feasible approach for an US-guided TAP injection that would result in adequate staining of the relevant nerves in the abdominal wall in pig cadavers. Fresh cadavers from five Landrace pigs (age, 12 weeks; body weight, 35.5 ± 1.6 kg) were used. One pig (n = 1) was anatomically dissected, and four pigs (n = 4; i.e., 8 hemiabdomens) were used for TAP injections and evaluation of dye spread. The volume of 0.3 mL/kg/injection point of methylene blue was injected bilaterally. In the caudal retrocostal approach, the injection was performed ventral to the most caudal part of the costal arch. In the lateral approach, the injection was performed between the last rib and iliac crest. A needle was inserted in plane for the caudal retrocostal and the lateral approach caudocranially and craniocaudally, respectively. Successful staining was defined as presence of dye on the nerve for a length of >1 cm in its entire circumference. The TAP was found between different muscle layers in the described anatomical regions. In the caudal retrocostal approach the TAP was found between the external abdominal oblique and transversus abdominis muscle bellies. In the lateral approach the TAP was found between the internal abdominal oblique and transversus abdominis muscles. The approach combining lateral and caudal retrocostal injections at the studied volume stained a median of 5 (3–6) target nerves from the fourth-last thoracic nerve to L2 (six nerves). Combined caudal retrocostal and lateral TAP injections of 0.3 mL/kg/injection point, resulted in staining of target nerve branches which supply the periumbilical and caudal abdominal wall in pig cadavers.

Transversus abdominis Plane Block for Improved Early Postoperative Pain Management after Periacetabular Osteotomy: A Randomized Clinical Trial

Background: Patients undergoing periacetabular osteotomy (PAO) may experience significant postoperative pain due to the extensive approach and multiple osteotomies. The aim of this study was to assess the efficacy of the transversus abdominis plane (TAP) block on reducing opioid consumption and improving clinical outcome in PAO patients. Patients and Methods: We conducted a two-group randomized-controlled trial in 42 consecutive patients undergoing a PAO for symptomatic developmental dysplasia of the hip (DDH). The study group received an ultrasound-guided TAP block with 20 mL of 0.75% ropivacaine prior to surgery. The control group did not receive a TAP block. All patients received a multimodal analgesia with nonsteroidal anti-inflammatory drugs (NSAID) (etoricoxib and metamizole) and an intravenous patient-controlled analgesia (PCA) with piritramide (1.5 mg bolus, 10 min lockout-time). The primary endpoint was opioid consumption within 48 h after surgery. Secondary endpoints were pain scores, assessment of postoperative nausea and vomiting (PONV), measurement of the quality of recovery using patient-reported outcome measure and length of hospital stay. Forty-one patients (n = 21 TAP block group, n = 20 control group) completed the study, per protocol. One patient was lost to follow-up. Thirty-three were women (88.5%) and eight men (19.5%). The mean age at the time of surgery was 28 years (18-43, SD ± 7.4). All TAP blocks were performed by an experienced senior anaesthesiologist and all operations were performed by a single, high volume surgeon. Results: The opioid consumption in the TAP block group was significantly lower compared to the control group at 6 (3 mg ± 2.8 vs. 10.8 mg ± 5.6, p < 0.0001), 24 (18.4 ± 16.2 vs. 30.8 ± 16.4, p = 0.01) and 48 h (29.1 mg ± 30.7 vs. 54.7 ± 29.6, p = 0.04) after surgery. Pain scores were significantly reduced in the TAP block group at 24 h after surgery. There were no other differences in secondary outcome parameters. No perioperative complication occurred in either group. Conclusion: Ultrasound-guided TAP block significantly reduces the perioperative opioid consumption in patients undergoing PAO.

Laparoscopic Posterior Versus Lateral Transversus Abdominis Plane Block in Gynecology

Background and Objectives

Transversus abdominis plane (TAP) block is a safe and effective type of regional anesthesia technique used in laparoscopic gynecologic surgery to minimize postoperative pain. Our study aimed to compare the analgesic effects of the posterior versus lateral approaches to laparoscopic-assisted TAP block in minimally invasive gynecologic surgery.

Methods

We performed a randomized controlled trial with 82 patients allocated to either posterior (n = 38) or lateral (n = 44) TAP block groups. Laparoscopic-assisted posterior or lateral TAP block was administered using liposomal bupivacaine mixture. All subjects were asked to fill out a questionnaire, which included postoperative pain scores at 6 h, 12 h, 24 h, 48 h, and 72 h, as well as narcotic utilization postoperatively. Both groups were compared for postoperative pain scores, opioid consumption, perioperative, and demographic characteristics.

Results

A total of 67 patients were analyzed in our study (n = 33 in posterior arm, n = 34 in lateral arm). Demographic characteristics including race, body mass index, comorbidities, American Society of Anesthesiologists classification, pre-operative diagnosis, complication rates, length of stay, and estimated blood loss were comparable between the two groups. The distribution of different operative procedures was similar between the two groups. There was no statistically significant difference in pain scores at 6 h, 12 h, 24 h, 48 h, and 72 h postoperatively between the two groups. However, patients receiving posterior TAP had a significant reduction in narcotic intake (p = 0.0009).

Conclusion

Laparoscopic-assisted TAP block is a safe and effective option for regional analgesia in laparoscopic gynecologic surgery. Posterior TAP block may help to reduce narcotic usage postoperatively.

Randomised, double-blinded, placebo-controlled trial to investigate the role of laparoscopic transversus abdominis plane block in gastric bypass surgery: a study protocol

INTRODUCTION

Evaluating the efficacy of a laparoscopically guided, surgical transversus abdominis plane (TAP) and rectus sheath (RS) block in reducing analgesic consumption while improving functional outcomes in patients undergoing laparoscopic bariatric surgery.

METHODS

150 patients Living with obesity undergoing elective laparoscopic Roux-En-Y gastric bypass for obesity will be recruited to this double-blinded, placebo-controlled randomised controlled trial from a Bariatric Centre of Excellence over a period of 6 months. Patients will be electronically randomised on a 1:1 basis to either an intervention or placebo group. Those on the intervention arm will receive a total of 60 mL 0.25% ropivacaine, divided into four injections: two for TAP and two for RS block under laparoscopic visualisation. The placebo arm will receive normal saline in the same manner. A standardised surgical and anaesthetic protocol will be followed, with care in adherence to the Enhanced Recovery after Bariatric Surgery guidelines.

ANALYSIS

Demographic information and relevant medical history will be collected from the 150 patients enrolled in the study. Our primary efficacy endpoint is cumulative postoperative narcotic use. Secondary outcomes are peak expiratory flow, postoperative pain score and the 6 min walk test. Quality of recovery (QoR) will be assessed using a validated questionnaire (QoR-40). Statistical analysis will be conducted to assess differences within and between the two groups. The repeated measures will be analysed by a mixed modelling approach and results reported through publication.

ETHICS AND DISSEMINATION

Ethics approval was obtained (20170749-01H) through our institutional research ethics board (Ottawa Health Science Network Research Ethics Board) and the study results, regardless of the outcome, will be reported in a manuscript submitted for a medical/surgical journal.

TRIAL REGISTRATION NUMBER

Pre-results NCT03367728.

A Challenging Cesarean Delivery and Perioperative Course in a Former Polysubstance Abuser Without the Use of Traditional Opioids

Substance abuse is a major challenge in the United States. According to the Human Resources and Services Administration, we are in an opioid crisis with over 130 people a day dying from opioid-related drug overdoses. As awareness of this epidemic has grown, there has been an increase in patients coming in for surgery requesting a narcotic-free anesthetic. This presents both a challenge and an opportunity for the anesthesiologist who has a duty to respect the patient’s autonomy while simultaneously achieving the appropriate perioperative outcome. The considerations are especially important in the vulnerable population of pregnant women.

Reducing the pain: A cost-effectiveness analysis of transversus abdominis plane block using liposomal bupivacaine for outpatient laparoscopic ventral hernia repair

Background

Transversus abdominis plane block with liposomal bupivacaine has been studied as an effective method of reducing the need for postoperative opioids and increasing same-day discharge rates. However, less is known about the cost-effectiveness of this strategy relative to opioids alone for hernia repair. We performed an economic evaluation of these strategies using a computer simulation model.

Methods

A decision tree was constructed to determine cost-effectiveness as measured by incremental cost-effectiveness ratios per quality-adjusted life-year. Base-case costs, quality-adjusted life-year values, and probabilities were derived from published studies and Medicare fee schedules. For input parameters for which we could not find values in the published literature, we used expert opinion. A 1-month time horizon was selected to focus on the immediate postoperative period. Finally, we performed 1-way, 2-way, and probabilistic sensitivity analyses.

Results

The liposomal bupivacaine transversus abdominis plane block was a dominant strategy yielding a $456.75 decrease in cost and an 0.1 increase in quality-adjusted life-years relative to opioids alone. In 1-way sensitivity analysis of cost incremental cost-effectiveness ratio, values were most sensitive to variations in the amount saved by same-day discharge and the cost of bupivacaine. In probabilistic sensitivity analyses, transversus abdominis plane strategy was cost-effective at a willingness-to-pay threshold of $50,000/quality-adjusted life-year in 94.5% of iterations and at a willingness-to-pay threshold of $100,000/quality-adjusted life-year in 97.1% of iterations.

Conclusion

The use of liposomal bupivacaine transversus abdominis plane block resulted in cost savings and improved quality-adjusted life-years in base-case analyses and was cost-effective at conventional willingness-to-pay thresholds in the majority of iterations in probabilistic sensitivity analyses.

•

A decision tree was constructed to determine cost-effectiveness as measured by incremental cost-effectiveness ratios (ICER) per quality-adjusted life-year (QALY).

•

The liposomal bupivacaine TAP block was a dominant strategy yielding a $456.75 decrease in cost and an 0.1 increase in QALYs relative to opioids alone.

•

In 1-way sensitivity analysis of cost, ICER values were most sensitive to variations in the amount saved by SDD and the cost of bupivacaine.

•

In probabilistic sensitivity analyses, TAP strategy was cost-effective at a willingness-to-pay threshold of $50,000/QALY in 94.5% of iterations and pay threshold of $100,000/QALY in 97.1% of iterations.

Efficacy of Dexmedetomidine as an Adjuvant to Bupivacaine in Ultrasound-Guided Transverse Abdominis plane Block for Laparoscopic appendicectomy: A Randomised Controlled Study

Objective

Dexmedetomidine is an alpha 2-adrenergic agonist that prolongs analgesia as an adjuvant when added in neuraxial and peripheral nerve blocks. The aim of the present study was to evaluate the efficacy of dexmedetomidine as an adjuvant to bupivacaine in ultrasound (USG)-guided transverse abdominis plane (TAP) block for postoperative analgesia in laparoscopic appendicectomy.

Methods

A total of 60 American Society of Anesthesiologists I and II adult patients aged between 16 and 60 years planned for laparoscopic appendicectomy were randomised into two groups (A and B). Group A patients received 20 mL of 0.125% bupivacaine+1 μg kg⁻¹ dexmedetomidine, whereas group B patients received 20 mL of 0.125% bupivacaine alone on both sides at the time of USG-guided TAP block. Haemodynamic variables, pain scores, sedation scores, time to first dose of rescue analgesic and side effects, if any, were assessed and compared between the groups.

Results

Demographic and operative characteristics were comparable in both groups. The mean duration of analgesia was more in group A (7.33 h) than in group B (4.8 h). The requirement of rescue analgesics was more in group B (80%) than in group A (56.7%). The sedation and pain scores at 2, 4 and 6 h were better in group A than in group B (p<0.05). The heart rate, systolic blood pressure and diastolic blood pressure were lower in group A during the postoperative period than in group B.

Conclusion

The addition of dexmedetomidine as an adjuvant to bupivacaine in TAP block provides prolonged postoperative analgesia and better pain control with reduced need for rescue analgesics than bupivacaine alone in patients undergoing laparoscopic appendicectomy.

Transversus abdominis plane block and intrathecal morphine use in cesarean section: a retrospective review

OBJECTIVES

Cesarean delivery is an extremely common surgical procedure practiced worldwide. It is an open abdominal surgery, and is associated with significant postoperative pain. One modality that helps alleviate this pain is the transversus abdominis plane (TAP) block. This analysis sought to evaluate postoperative pain when this block was used in conjunction with intrathecal morphine.

METHODS

A retrospective review was performed of 142 patients who underwent cesarean section at our institution. Of those, 43 patients had a TAP block performed. The primary outcome for this analysis was the time to first opioid administration following discharge from the operating room. Secondary outcomes included differences in postoperative pain scores, and overall opioid consumption.

RESULTS

The average time to first opioid use postoperatively decreased in the TAP group when compared with the No-TAP group, 23.3 versus 12.1, respectively (difference of 48.2% (95% CI 74.0% to 24.3%); p<0.001) and opioid consumption was significantly decreased within the first 24 hours following surgery from 4.55 intravenous morphine equivalents (IVME) to 2.67 IVME, respectively (difference of 107.1% (95% CI 145.1% to 69.2%); p=0.006). Visual analog pain scores were significantly decreased in the TAP group versus the No-TAP group up to 36 hours postoperatively.

CONCLUSIONS

TAP blocks performed in conjunction with intrathecal morphine may decrease opioid use in the first 24 hours and improve pain scores for at least 36 hours following cesarean section. Because of the favorable safety profile, TAP blocks may contribute meaningfully to multimodal anesthesia for cesarean sections.

The efficacy of transversus abdominis plane block for post-operative analgesia after the cesarean section performed under general anesthesia

OBJECTIVE:

Several methods are used to control the pain after cesarean operations. Recently, the transverse abdominis plane block (TAP) has been proposed to compensate for the problems developed by preexisting methods. In the present study, we compared the analgesic efficacy of the TAP block after caesarean section in a prospective, randomized, double-blinded controlled trial.

METHODS:

In this study, thirty patients undergoing cesarean sections under general anesthesia were divided into two groups. Patients in Group T (n=15) on whom TAP Block with USG guidance was performed using 0.25% bupivacaine totally 60 ml. The patients in Group C were administered (n=15), 0.9% NaCl totally 60 ml (30 ml at each side) with USG guidance. Post-operative demand of meperidine using a patient-controlled analgesia device was recorded.

RESULTS:

First time on the need for analgesia were significantly higher in the control group (Group C). The total dose of meperidine, tenoxicam, paracetamol used for analgesia was significantly higher in the Group C. The outset times of breastfeeding and mobilization did not change between the groups.

CONCLUSION:

The USG-TAP block with 0.25% bupivacaine 60 ml (30 ml on each side) significantly reduced post-operative pain in patients undergoing the cesarean section. We think that TAP block is a comfortable and feasible method which reduces post-operative analgesia need and does not lead any serious complications.

Evaluation of Ultrasound-Guided Transversus Abdominis Plane Block for Postoperative Analgesia in Patients Undergoing Intraperitoneal Onlay Mesh Repair

Introduction:

Ventral hernia is a commonly performed surgical procedure in adults. Laparoscopic intraperitoneal onlay mesh repair (IPOM) of ventral hernia is procedure of choice. IPOM of ventral hernia is associated with significant pain. Hence, our aim was to study the efficacy of instilling preemptive local analgesia for reducing postoperative pain in patients undergoing laparoscopic ventral hernia repairs.

Objective:

To study the role of local infiltration of 10 ml of 0.5% ropivacaine in the anterior abdominal wall preoperatively to improve pain scores compared to conventional intravenous systemic analgesia.

Materials and Methods:

The study pool consists of two groups of patients (25 in each group) admitted for laparoscopic uncomplicated ventral hernia repair. Analysis was performed by the SPSS program (Company – International Business Machines Corporation, headquartered at Armonk, New York, USA) for Windows, version 17.0. Normally distributed continuous variables were compared using ANOVA. Categorical variables were analyzed using the Chi-square test.

Results:

Both groups were matching in terms of demographic features. Postoperatively, pain assessment was performed every 30 min for the first 2 h and was followed up for a period of 24 h at intervals (4, 6, 12, and 24 h). Postoperatively, patients were also assessed for time of ambulation, time of return of bowel sounds at 6, 12, and 24 h, and length of hospital stay. Side effects and complication were noted.

Conclusion:

Our study demonstrated that supplementing US-guided transversus abdominis plane (TAP) block to conventional systemic analgesics resulted in decreased VAS scores and decreased requirement of rescue analgesics. The patients ambulated early had earlier appearance of bowel sounds and decreased length of hospital stay. There was also decreased incidence of nausea and vomiting. TAP block for laparoscopic IPOM surgery significantly decreases postoperative pain and opioid requirement in patients.

Addition of dexmedetomidine or fentanyl to ropivacaine for transversus abdominis plane block: evaluation of effect on postoperative pain and quality of recovery in gynecological surgery

Background

Transversus abdominis plane (TAP) block is reportedly a preferable technique for reducing postoperative pain in abdominal surgeries. The aim of this study was to compare the analgesic efficacy and recovery quality after gynecological surgery by adding dexmedetomidine or fentanyl into an ultrasound-guided TAP block.

Methods

We randomly assigned 100 elective gynecological patients into four groups (TAP, TAP-DEX, TAP-FEN, and control, n=25 in each). TAP blocks were performed postoperatively. The control group received patient-controlled intravenous analgesia (PCIA), the TAP group received TAP blocks with 0.375% ropivacaine, the TAP-DEX group received 0.375% ropivacaine with dexmedetomidine 1 µg/kg, and the TAP-FEN group received 0.375% ropivacaine with fentanyl 1 µg/kg. The primary outcomes were the first request time for PCIA bolus and quality of postoperative recovery assessed using the QoR-40 questionnaire 2 days after surgery. The secondary outcomes were the visual analog scale (VAS) scores at rest across the different time intervals, the total number of PCIA boluses required in 24 and 48 hours postoperatively, and associated complications.

Results

The first request time for PCIA was significantly longer in the TAP-DEX than in the TAP, TAP-FEN, and control groups (9.86±0.77, 7.86±0.56, 8.79±0.55, and 1.56±0.65 hours, respectively; P<0.01). The QoR-40 scores were highest in the TAP-DEX group (P<0.05). The mean PCIA bolus consumption in the first 24–48 hours was lowest in TAP-DEX group. VAS showed significant differences between TAP-DEX and TAP-FEN groups only at 6 hours (P<0.01).

Conclusion

The use of dexmedetomidine as an adjuvant to TAP blocks could facilitate postoperative analgesia and improve the quality of recovery without increasing related complications.

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.

Clinical analgesic efficacy of dexamethasone as a local anesthetic adjuvant for transversus abdominis plane (TAP) block: A meta-analysis

BACKGROUND

Perineural dexamethasone has been shown to prolong the duration of local anesthetic (LA) effect in regional anesthesia; however, the use of perineural dexamethasone as an adjuvant to to the transversus abdominis plane (TAP) block remains controversial. This meta-analysis sought to assess the efficacy of dexamethasone in prolonging the TAP block and enhancing recovery after abdominal surgery.

METHODS

We identified and analyzed 9 RCTs published on or before September 30, 2017, regardless of the original language, after searching the following 6 bibliographic databases: PubMed, EMBASE, Medline, Springer, Ovid, and the Cochrane Library. databases. These studies compared the effects of perineural dexamethasone mixed with local anesthetic versus local anesthetic alone in the TAP block. The Cochrane Collaboration's Risk of Bias Tool was used to evaluate the methodological quality of each RCT. The primary outcomes were the time until the first request for postoperative analgesics and the analog pain scores at 2, 6, 12, and 24 h after surgery. The secondary outcomes were the analgesic consumption and the incidence of nausea and vomiting on the first day after surgery. We used Trial Sequential Analysis (TSA) to control for random errors.

RESULTS

Perineural dexamethasone prolonged the duration of LA effect in the TAP block [mean difference (MD): 2.98 h; 95% confidence interval (CI): 2.19 to 3.78] and reduced analog pain scores at 2 h [MD: -1.15; 95% CI: -2.14 to -0.16], 6 h [MD: -0.97; 95% CI: -1.51 to -0.44], and 12 h [MD: -0.93; 95% CI: -1.14 to -0.72] postoperatively. Furthermore, the use of perineural dexamethasone was associated with less analgesic consumption [standard mean difference: -1.29; 95% CI: -1.88 to -0.70] and a lower incidence of nausea and vomiting [odds ratio: 0.28; 95% CI: 0.16 to 0.49] on the first day after surgery.

CONCLUSION

Dexamethasone prolongs the LA effect when used as an adjuvant in the TAP block and improves the analgesic effects of the block.

Efficacy of Pectoral Nerve Block Type II for Breast-Conserving Surgery and Sentinel Lymph Node Biopsy: A Prospective Randomized Controlled Study

Objectives

The pectoral nerve block type II (PECS II block) is widely used for postoperative analgesia after breast surgery. This study evaluated the analgesic efficacy of PECS II block in patients undergoing breast-conserving surgery (BCS) and sentinel lymph node biopsy (SNB).

Methods

Patients were randomized to the control group (n=40) and the PECS II group (n=40). An ultrasound-guided PECS II block was performed after induction of anesthesia. The primary outcome measure was opioid consumption, and the secondary outcome was pain at the breast and axillary measured using the Numerical Rating Scale (NRS) 24 hours after surgery. Opioid requirement was assessed according to tumor location.

Results

Opioid requirement was lower in the PECS II than in the control group (43.8 ± 28.5 µg versus 77.0 ± 41.9 µg, p < 0.001). However, the frequency of rescue analgesics did not differ between these groups. Opioid consumption in the PECS II group was significantly lower in patients with tumors in the outer area than that in patients with tumors in the inner area (32.5 ± 23.0 µg versus 58.0 ± 29.3 µg, p=0.007). The axillary NRS was consistently lower through 24 hr in the PECS II group.

Conclusion

Although the PECS II block seemed to reduce pain intensity and opioid requirements for 24 h after BCS and SNB, these reductions may not be clinically significant. This trial is registered with Clinical Research Information Service KCT0002509.

Direct visualization transversus abdominis plane blocks offer superior pain control compared to ultrasound guided blocks following open posterior component separation hernia repairs

PURPOSE

Transversus abdominis plane (TAP) blockade with long-acting anesthetic can be used during open ventral hernia repair (VHR) with posterior component separation (PCS). TAP block can be performed under ultrasound guidance (US-TAP) or under direct visualization (DV-TAP). We hypothesized that US-TAP and DV-TAP provide equivalent postoperative analgesia following open VHR.

METHODS

A retrospective review of patients undergoing open VHR with PCS who received TAP blocks with 266 mg of liposomal bupivacaine was performed. Data included demographics, comorbidities, length of stay (LOS), average postoperative day (POD) pain scores, and narcotic requirements (normalized to mg oral morphine). Statistical analysis utilized Student's t test and Fisher's exact test.

RESULTS

Thirty-nine patients were identified (22 DV-TAP). There were no differences between the groups with respect to demographics, comorbidities, pre-operative pain medication usage (narcotic and non-narcotic) or herniorrhaphy-related data. The average POD0 pain score was lower for the DV-TAP group (2.35 vs 4.18; p = 0.019). Narcotic requirements on POD0 (48.0 vs 103.76 mg; p = 0.02), POD1 (128.45 vs 273.82 mg; p = 0.03), POD4 (54.29 vs 160.75 mg; p = 0.042), and during the complete hospitalization (408.52 vs 860.92 mg; p = 0.013) were lower in the DV-TAP group. There were no differences between initiation of diet or LOS. During the study, no changes were made to the VHR enhanced recovery pathway.

CONCLUSIONS

DV-TAP blocks appear to provide superior analgesia in the immediate postoperative period. To achieve similar post-operative pain scores, patients in the US-TAP group required significantly more narcotic administration during their hospitalization. The study highlights DV-TAP as a valuable addition to VHR recovery pathways.

Advances in regional anaesthesia: A review of current practice, newer techniques and outcomes

Advances in ultrasound guided regional anaesthesia and introduction of newer long acting local anaesthetics have given clinicians an opportunity to apply novel approaches to block peripheral nerves with ease. Consequently, improvements in outcomes such as quality of analgesia, early rehabilitation and patient satisfaction have been observed. In this article we will review some of the newer regional anaesthetic techniques, long acting local anaesthetics and adjuvants, and discuss evidence for key outcomes such as cancer recurrence and safety with ultrasound guidance.

Ultrasound-guided subcostal-posterior transversus abdominis plane block for pain control following laparoscopic sleeve gastrectomy

OBJECTIVES

To investigate the analgesic effect of a subcostal-posterior transversus abdominis plane (TAP) block combination following laparoscopic sleeve gastrectomy. Methods: This study was conducted at Fatih Sultan Mehmet Educational and Research Hospital, Istanbul, Turkey, between March 2014 and June 2015. A total of 40 patients with a body mass index of 40-60 kg/m2 scheduled for laparoscopic sleeve gastrectomy were randomly allocated into 2 groups. Patients in Group I (n=20) received a bilateral subcostal TAP block, and patients in Group II (n=20) received a bilateral subcostal and posterior TAP block. Pain intensity was assessed at rest and during coughing using the visual analog scale (VAS) prior to and at various time points after TAP block (0 min, 30 min, 2 hours, 4 hours, 6 hours, 12 hours, and 24 hours). Morphine consumption over 24 hours and time to first morphine requirement were recorded.  Results: There was no difference in VAS scores between groups. Morphine consumption was 6.78±5.95 mg in Group I, and 7.28±5.95 mg in Group II (p=0.795). Time to first morphine requirement was 267.22±303.84 min for Group I, and 207.80±209.81 min for Group II (p=0.154).  Conclusions: Subcostal-posterior TAP block provided equivalent analgesia to subcostal TAP block alone following laparoscopic sleeve gastrectomy.

A Randomized Controlled Trial of Comparing Ultrasound-Guided Transversus Abdominis Plane Block with Local Anesthetic Infiltration in Peritoneal Dialysis Catheter Implantation

BACKGROUND

The ultrasound-guided transversus abdominis plane (TAP) block has been demonstrated as a useful analgesia technique in lower-abdomen surgeries. We hypothesized that it could be the principal anesthesia technique for end-stage renal disease (ESRD) patients undergoing peritoneal dialysis (PD) catheter (PDC) implantation using the open dissection method.

METHODS

This was a single-center, prospective, randomized, and double-blinded study. All eligible patients were randomized into 2 groups: the TAP block group (n = 20) and the local anesthetic infiltration (LAI) group (n = 20).

RESULTS

Compared with the LAI group, the TAP block group revealed a remarkably lower visual analogue score, lower switching rate into general anesthesia, higher satisfaction rate, and less rescuing analgesic consumption during operation (p < 0.05). Both PD- and anesthesia-related complications were rare in the 4-week follow-up.

CONCLUSIONS

The ultrasound-guided TAP block had better analgesic effect than LAI and can be used as a principal anesthesia technique for PDC implantation in ESRD patients without previous abdominal surgery.

Postoperative analgesic efficiency of transversus abdominis plane block after ventral hernia repair: a prospective, randomized, controlled clinical trial

BACKGROUND AND AIMS

Effective postoperative analgesia is a key element in reducing postoperative morbidity, accelerating recovery and avoiding chronic postoperative pain. The aim of this study was to evaluate the effectiveness of ultrasound-guided Transversus Abdominis Plane (TAP) block, performed before surgical incision, in providing postoperative analgesia for patients undergoing open ventral hernia repair under general anaesthesia.

METHODS

Seventy elective patients scheduled for open ventral hernia repair surgery under general anaesthesia were divided randomly into two equal groups: Group I received bilateral TAP block performed before surgical incision (n = 35); Group II received systemic postoperative analgesia with parenteral opioid (morphine) alone (n = 35). Postoperatively pain scores at rest and with movement, total morphine consumption and opioid related side effects were recorded.

RESULTS

Postoperative pain scores at rest and mobilization/cough were significantly higher in patients without TAP block (p < 0.05). Mean intraoperative fentanyl consumption was comparable between the two groups: 0.75 ± 0.31 mg in group I (TAP) and 0.86 ± 0.29 mg in group II (MO), p = 0.1299. Patients undergoing preincisional TAP block had reduced morphine requirements during the first 24 hours after surgery, compared to patients from group II, without TAP block (p = 0.0001). There was no difference in the incidence of opioid related side effects (nausea, vomiting) in the both groups during the first 24 postoperative hours.

CONCLUSION

The use of preincisional ultrasound guided TAP block reduced the pain scores at rest and with movement/cough, opioid consumption and opioid-related side effects after ventral hernia repair when compared with opioid-only analgesia.

A Rare Complication of a TAP Block Performed after Caesarean Delivery

The transversus abdominis plane block is a regional anesthesia technique that has become popular. Being a relatively simple procedure, the TAP block has an excellent safety profile and major complications are rare. We present a case of transient femoral nerve palsy occurring after a TAP block with involvement of the sacral plexus for a patient who had undergone a caesarean section.

Subcostal Transverse Abdominis Plane Block for Acute Pain Management: A Review

The subcostal transverse abdominis plane (SCTAP) block is the deposition of local anesthetic in the transverse abdominis plane inferior and parallel to the costal margin. There is a growing consensus that the SCTAP block provides better analgesia for upper abdominal incisions than the traditional transverse abdominis plane block. In addition, when used as part of a four-quadrant transverse abdominis plane block, the SCTAP block may provide adequate analgesia for major abdominal surgery. The purpose of this review is to discuss the SCTAP block, including its indications, technique, local anesthetic solutions, and outcomes.

Transversus abdominis plane block with liposomal bupivacaine compared to oral opioids alone for acute postoperative pain after laparoscopic hysterectomy for early endometrial cancer: a cost-effectiveness analysis

Background

To determine the cost-effectiveness of transversus abdominis plane block with liposomal bupivacaine (TAP) compared to oral opioids alone for acute postoperative pain after laparoscopic hysterectomy for early endometrial cancer.

Methods

A cost-effectiveness analysis using a decision tree structure with a 30.5 day time-horizon was used to calculate incremental cost-effectiveness ratio (ICER) values per quality-adjusted life-year (QALY). Base-case costs, probabilities, and QALY values were identified from recently published all-payer national database studies, 2017 Medicare fee-schedules, randomized trials, institutional case series, or assumed, when published values were not available. One-way, two-way and multiple probabilistic sensitivity analyses were performed.

Results

The TAP strategy dominated the oral opioid-only strategy, with decreased costs and increased effectiveness. Specifically, the TAP strategy saved $235.90 under the base-case assumptions. Threshold analyses demonstrated that if the relative same-day discharge probability was ≥ 12% higher in the TAP group, then TAP was cost-saving over oral opioids-alone. Similarly, TAP was cost-saving whenever the costs saved by same-day discharge compared to admission were ≥ $1115.22. Cost-effectiveness of the TAP strategy was highly robust of a variety of sensitivity analyses.

Conclusions

TAP with liposomal bupivacaine was robustly cost-effective at conventional willingness-to-pay thresholds. Further, TAP was cost-saving compared to opioids-only when the same-day discharge rate among TAP users was greater than among opioid-only users.

Electronic supplementary material

The online version of this article (doi:10.1186/s40661-017-0048-7) contains supplementary material, which is available to authorized users.

Feasibility and limits of inguinal hernia repair under local anaesthesia in a limited resource environment: a prospective controlled study

PURPOSE

Local anaesthesia (LA) has proven effective for inguinal hernia repair in developed countries. Hernias in low to middle income countries represent a different issue. The aim of this study was to analyse the feasibility of LA for African hernia repairs in a limited resource environment.

METHODS

Data from patients who underwent herniorrhaphy under LA or spinal anaesthesia (SA) by the 6th and 7th Forward Surgical Team were prospectively collected. All of the patients benefited from a transversus abdominis plane (TAP) block for postoperative analgesia. Primary endpoints concerned the pain response and conversion to general anaesthesia. Secondary endpoints concerned the complication and recurrence rates. Predictors of LA failure were then identified.

RESULTS

In all, 189 inguinal hernias were operated during the study period, and 119 patients fulfilled the inclusion criteria: 57 LA and 62 SA. Forty-eight percent of patients presented with inguinoscrotal hernias. Local anaesthesia led to more pain during surgery and necessitated more administration of analgesics but resulted in fewer micturition difficulties and better postoperative pain control. Conversion rates were not different. Inguinoscrotal hernia and a time interval <50 min between the TAP block and skin incision were predictors of LA failure. Forty-four patients were followed-up at one month. No recurrence was noted.

CONCLUSIONS

Local anaesthesia is a safe alternative to SA. Small or medium hernias can easily be performed under LA in rural centres, but inguinoscrotal hernias required an ultrasound-guided TAP block performed 50 min before surgery to achieve optimal analgesia, and should be managed only in centres equipped with ultrasonography.

Peritoneal Dialysis Catheter Surgery using Transversus Abdominis Plane Block

BACKGROUND

Peritoneal dialysis (PD) catheter surgery can be performed using regional anesthesia. We present our PD catheter placement and extraction experience using ultrasound-guided transversus abdominis plane (TAP) block.

METHODS

In the present study, we analyzed 74 patients from our center with end-stage renal disease (ESRD) who underwent PD catheter placement (60 patients) and removal (14 patients) using a TAP block between June 2011 and December 2015.

RESULTS

The TAP block was successful for 55/60 (91.7%) patients (insertion) and 13/14 (92.9%) patients (extraction). Other patients had pain at the incision site and required general anesthesia. There were no anesthesia-, surgery- or PD catheter-related complications.

CONCLUSION

The TAP block is a safe and effective technique not only for high-risk ESRD patients but for all patients undergoing PD catheter placement or extraction.

A novel transperitoneal abdominal wall nerve block for postoperative pain in laparoscopic colorectal surgery

BACKGROUND

Although the laparoscopic approach reduces pain associated with abdominal surgery, postoperative pain remains a problem. Ultrasound-guided rectus sheath block and transversus abdominis plane block have become increasingly popular means of providing analgesia for laparoscopic surgery.

METHODS

Ninety patients were enrolled in this study. A laparoscopic puncture needle was inserted via the port, and levobupivacaine was injected into the correct plane through the peritoneum. The patients' postoperative pain intensity was assessed using a numeric rating scale. The effects of laparoscopic nerve block versus percutaneous anesthesia were compared.

RESULTS

This novel form of transperitoneal anesthesia did not jeopardize completion of the operative procedures. The percutaneous approach required more time for performance of the procedure than the transperitoneal technique.

CONCLUSION

This new analgesia technique can become an optional postoperative treatment regimen for various laparoscopic abdominal surgeries. What we mainly want to suggest is that the transperitoneal approach has the advantage of a higher completion rate. A percutaneous technique is sometimes difficult with patients who have severe obesity and/or coagulation disorders. Additional studies are required to evaluate its benefits.

Can ultrasound-guided subcostal transverse abdominis plane block be used as sole anesthetic technique?

Subcostal transverse abdominis plane (TAP) block anesthetizes area of the abdomen with cutaneous innervation of T6–T10 dermatomes. These abdominal field blocks become very advantageous when cardiac patient presents for noncardiac surgeries as sole anesthetic or as a part of multimodal anesthesia. A 58-year-male came for open surgical repair of subxiphoid incisional hernia developed post coronary artery bypass grafting (CABG). Echocardiography showed hypokinesia of left ventricle (LV) in the left anterior descending (LAD) artery territory, dilated LV, and ejection fraction of 30%, and coronary angiography after 6 months of CABG showed 70% stenosis of LAD. Surgery was successfully accomplished under ultrasound-guided bilateral subcostal TAP block except for a brief period of pain and discomfort when hernia was being reduced which required narcotic supplementation. The patient remained comfortable throughout the procedure as well as 24 h postoperatively without any analgesic supplementation. Thus, subcostal TAP block can be a safe alternative to neuraxial or general anesthesia for epigastric hernia repair in selected patients.

Open Appendectomy Using Ultrasound Guided Transversus Abdominis Plane Block: A Case Report

Introduction

TAB block has been used as an analgesic adjuvant in many abdominal surgeries with fair reliability, but it has never been used as an anesthetic technique.

Case Presentation

In this case report, a 19- year-old male underwent an open appendectomy using ultrasound-guided TAP block as a single anesthetic technique.

Conclusions

It was concluded that under certain circumstances TAP block can be used as an anesthetic modality

Efficacy of transversus abdominis plane block and rectus sheath block in laparoscopic inguinal hernia surgery

We aimed to assess the efficacy of transversus abdominis plane (TAP) block and rectus sheath (RS) block in patients undergoing laparoscopic inguinal hernia surgery. Few studies have addressed the efficacy and safety associated with TAP block and RS block for laparoscopic surgery. Thirty-two patients underwent laparoscopic inguinal hernia surgery, either with TAP and RS block (Block(+) group, n = 18) or without peripheral nerve block (Block(-) group, n = 14). Preoperatively, TAP and RS block were performed through ultrasound guidance. We evaluated postoperative pain control and patient outcomes. The mean postoperative hospital stays were 1.56 days (Block+ group) and 2.07 days (Block(-) group; range, 1-3 days in both groups; P = 0.0038). A total of 11 patients and 1 patient underwent day surgery in the Block(+) and Block(-) groups, respectively (P = 0.0012). Good postoperative pain control was more commonly observed in the Block(+) group than in the Block(-) group (P = 0.011). TAP and RS block was effective in reducing postoperative pain and was associated with a fast recovery in patients undergoing laparoscopic inguinal hernia surgery.