Surgeon-delivered laparoscopic transversus abdominis plane blocks are non-inferior to anesthesia-delivered ultrasound-guided transversus abdominis plane blocks: a blinded, randomized non-inferiority trial
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The transversus abdominis plane (TAP) block is an important non-narcotic adjunct for post-operative pain control in abdominal surgery. Surgeons can use laparoscopic guidance for TAP block placement (LTAP), however, direct comparisons to conventional ultrasound-guided TAP (UTAPs) have been lacking. The aim of this study is to determine if surgeon placed LTAPs were non-inferior to anesthesia placed UTAPs for post-operative pain control in laparoscopic colorectal surgery.
This was a prospective, randomized, patient and observer blinded parallel-arm non-inferiority trial conducted at a single tertiary academic center between 2016 and 2018 on adult patients undergoing laparoscopic colorectal surgery. Narcotic consumption and pain scores were compared for LTAP vs. UTAP for 48 h post-operatively.
60 patients completed the trial (31 UTAP, 29 LTAP) of which 25 patients were female (15 UTAP, 10 LTAP) and the mean ages (SD) were 60.0 (13.6) and 61.5 (14.3) in the UTAP and LTAP groups, respectively. There was no significant difference in post-operative narcotic consumption between UTAP and LTAP at the time of PACU discharge (median [IQR] milligrams of morphine, 1.8 [0–4.5] UTAP vs. 0 [0–8.7] LTAP P = .32), 6 h post-operatively (5.4 [1.8–17.1] UTAP vs. 3.6 [0–12.6] LTAP P = .28), at 12 h post-operatively (9.0 [3.6–29.4] UTAP vs. 7.2 [0.9–22.5] LTAP P = .51), at 24 h post-operatively (9.0 [3.6–29.4] UTAP vs. 7.2 [0.9–22.5] LTAP P = .63), and 48 h post-operatively (39.9 [7.5–70.2] UTAP vs. 22.2 [7.5–63.8] LTAP P = .41). Patient-reported pain scores as well as pre-, intra-, and post-operative course were similar between groups. Non-inferiority criteria were met at all post-op time points up to and including 24 h but not at 48 h.
Surgeon-delivered LTAPs are safe, effective, and non-inferior to anesthesia-administered UTAPs in the immediate post-operative period.
The trial was registered at clinicaltrials.gov Identifier NCT03577912.
KeywordsTransversus abdominis plane (TAP) block Laparoscopy Post-operative pain control Enhanced recovery after surgery
The authors thank Shaelah Huntington and Dr. Marc Shnider for their contributions. This work was conducted with support from Harvard Catalyst|The Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health Award UL1 TR001102) and financial contributions from Harvard University and its affiliated academic healthcare centers. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health.
Compliance with ethical standards
Dr. Curran reports personal fees from KCI Inc, outside the scope of the submitted work. Dr. Wong, Dr. Poylin, and Dr. Cataldo have no conflicts of interest or financial ties to disclose.
- 4.Carmichael JC, Keller DS, Baldini G et al (2017) Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 60:761–784. https://doi.org/10.1097/DCR.0000000000000883 CrossRefGoogle Scholar
- 10.Elkassabany N, Ahmed M, Malkowicz SB et al (2013) Comparison between the analgesic efficacy of transversus abdominis plane (TAP) block and placebo in open retropubic radical prostatectomy: a prospective, randomized, double-blinded study. J Clin Anesth 25:459–465. https://doi.org/10.1016/j.jclinane.2013.04.009 CrossRefPubMedGoogle Scholar
- 11.Jadon A, Jain P, Chakraborty S et al (2018) Role of ultrasound guided transversus abdominis plane block as a component of multimodal analgesic regimen for lower segment caesarean section: a randomized double blind clinical study. BMC Anesthesiol 18:1–7. https://doi.org/10.1186/s12871-018-0512-x CrossRefGoogle Scholar
- 15.Park SY, Park JS, Choi GS et al (2017) Comparison of analgesic efficacy of laparoscope-assisted and ultrasound-guided transversus abdominis plane block after laparoscopic colorectal operation: a randomized, single-blind, non-inferiority trial. J Am Coll Surg 225:403–410. https://doi.org/10.1016/j.jamcollsurg.2017.05.017 CrossRefPubMedGoogle Scholar
- 16.Fields AC, Gonzalez DO, Chin EH et al (2015) Laparoscopic-assisted transversus abdominis plane block for postoperative pain control in laparoscopic ventral hernia repair: a randomized controlled trial. J Am Coll Surg 221:462–469. https://doi.org/10.1016/j.jamcollsurg.2015.04.007 CrossRefPubMedGoogle Scholar
- 17.Elamin G, Waters PS, Hamid H et al (2015) Efficacy of a laparoscopically delivered transversus abdominis plane block technique during elective laparoscopic cholecystectomy: a prospective, double-blind randomized trial. J Am Coll Surg 221:335–344. https://doi.org/10.1016/j.jamcollsurg.2015.03.030 CrossRefPubMedGoogle Scholar
- 19.Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae CrossRefPubMedPubMedCentralGoogle Scholar
- 21.McDonnell JG, O’Donnell B, Curley G et al (2007) The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesth Analg 104:193–197. https://doi.org/10.1213/01.ane.0000250223.49963.0f CrossRefPubMedGoogle Scholar
- 24.Keller DS, Ermlich BO, Delaney CP (2014) Demonstrating the benefits of transversus abdominis plane blocks on patient outcomes in laparoscopic colorectal surgery: review of 200 consecutive cases. J Am Coll Surg 219:1143–1148. https://doi.org/10.1016/j.jamcollsurg.2014.08.011 CrossRefPubMedGoogle Scholar
- 25.Stokes AL, Adhikary SD, Quintili A et al (2017) Liposomal bupivacaine use in transversus abdominis plane blocks reduces pain and postoperative intravenous opioid requirement after colorectal surgery. Dis Colon Rectum 60:170–177. https://doi.org/10.1097/DCR.0000000000000747 CrossRefPubMedGoogle Scholar