Comparison of analgesic efficacy of four‐quadrant transversus abdominis plane (TAP) block and continuous posterior TAP analgesia with epidural analgesia in patients undergoing laparoscopic colorectal surgery: an open‐label, randomised, non‐inferiority trial

Abstract

SummaryPosterior transversus abdominis plane blocks have been reported to be an effective method of providing analgesia after lower abdominal surgery. We compared the efficacy of a novel technique of providing continuous transversus abdominis plane analgesia with epidural analgesia in patients on an enhanced recovery programme following laparoscopic colorectal surgery. A non-inferiority comparison was used. Adult patients undergoing elective laparoscopic colorectal surgery were randomly assigned to receive continuous transversus abdominis plane analgesia (n = 35) vs epidural analgesia (n = 35), in addition to a postoperative analgesic regimen comprising regular paracetamol, regular diclofenac and tramadol as required. Sixty-one patients completed the study. The transversus group received fourquadrant transversus abdominis plane blocks and bilateral posterior transversus abdominis plane catheters that were infused with levobupivacaine 0.25% for 48 h. The epidural group received an infusion of bupivacaine and fentanyl. The primary outcome measure was visual analogue scale pain score on coughing at 24 h after surgery. We found no significant difference in median (IQR [range]) visual analogue scores during coughing at 24 h between the transversus group 2.5 (1.0-3.0 [0-5.5]) and the epidural group 2.5 (1. 0-5.0 [0-6.0]). The one-sided 97.5% CI was a 0.0 (∞-1.0) difference in means, establishing non-inferiority. There were no significant differences between the groups for tramadol consumption. Success rate was 28/30 (93%) in the transversus group vs 27/31 (87%) in the epidural group. Continuous transversus abdominis plane infusion was non-inferior to epidural infusion in providing analgesia after laparoscopic colorectal surgery.

A randomised controlled trial investigating the analgesic efficacy of transversus abdominis plane block for adult laparoscopic appendicectomy

“…Future studies investigating postoperative analgesia following laparoscopic appendicectomy should focus on TAP techniques that provide a greater area of abdominal wall analgesia (30,31) or on analgesic therapies targeted toward the visceral pain component. The benefits of TAP block for laparoscopic abdominal procedures appear to be less that of the corresponding open surgical procedures, (21,24,(32)(33)(34) and presently, the role of this regional anaesthetic procedure for lower abdominal laparoscopic surgery requires further evaluation with larger clinical trials, both to determine the most effective TAP technique and to investigate more precisely its benefits in terms of surgical recovery.…”

Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways

“…One study found that, after laparoscopic colorectal surgery, a four-quadrant TAP block with continuous infusion via bilateral posterior TAP catheters (0.365% levobupivacaine 2.5 mgÁkg postoperatively). 35 In contrast, a systematic review and meta-analysis on Cesarean delivery found that TAP block alone was less effective than intrathecal morphine in managing pain at 24 hr (mean difference [MD] 0.98; 95% CI 0.06 to 1.91) and resulted in greater 24-hr morphine consumption (MD 8.42 mg; 95% CI 1.74 to 15.10), while the former was associated with an increased incidence of side effects such as sedation and PONV. 36 There are generally few risks associated with TAP block, including intraperitoneal injection of local anesthetic (\ 2%) as well as a few case reports of transient femoral nerve palsy and bowel hematoma.…”

The Use of NSAIDs in the Postoperative Period: Advantage and Disadvantages

“…Morphine delays the recovery of bowel function and slows the functional recovery. Epidural analgesia has no long recommended in laparoscopic surgery therefore in order to reduce postoperative morphine consumption the use of NSAIDs has been advocated as part of multimodal analgesia [87,88]. However, some concerns are raised because some experimental studies have stressed the risk of a higher incidence of anastomotic leakages especially ileum dehiscence, with the use of NSAIDs in postoperative period [89].…”