Comparison of Three-Quadrant Transversus Abdominis Plane Block and Continuous Epidural Block for Postoperative Analgesia After Transperitoneal Laparoscopic Nephrectomy

Abstract

BackgroundPostoperative pain management is important for the early recovery of the living donor patient. Patient-controlled opioid analgesia, epidural analgesia, or a combination of both is the preferred pain management after abdominal surgery although these approaches have serious side effects. The transversus abdominis plane (TAP) block has been increasingly used for postoperative pain management and the addition of dexamethasone to local anesthetic can prolong the duration of action.ObjectivesThis study evaluated the efficacy of ultrasound-guided three-quadrant TAP block analgesia with the addition of dexamethasone, compared to the continuous epidural analgesia in postoperative cumulative opioid consumption and pain scale in the first 24 hours following transperitoneal laparoscopic living donor nephrectomy.MethodsA prospective randomized control study was conducted on 50 patients with ASA I-II, 18 - 65 years old, BMI 18 - 30, and undergoing transperitoneal laparoscopic donor nephrectomy under general anesthesia. The patients were randomly assigned into either a three-quadrant TAP block group (n = 25) with 20 mL of 0.25% bupivacaine plus dexamethasone 8 mg or a continuous epidural group (n = 25) using 0.125% bupivacaine postoperatively. The morphine consumption and the numerical rating scale (NRS) at rest and movement were evaluated at 2, 6, 12, and 24 hours postoperatively. The postoperative first-time mobilization and duration of urinary catheter usage were recorded.ResultsPatients demographic characteristics were similar in the two groups. During 24 hours after the surgery, cumulative morphine consumption (P = 0.232), the NRS at rest and movement (P > 0.05), and the first-time mobilization (P = 0.075) were not significantly different between the groups, except that the NRS during movement at 12 hours was significantly lower in the TAP block group (P = 0.004). The duration of urinary catheterization was significantly longer as a side effect in the continuous epidural group (P < 0.001).ConclusionsThe three-quadrant TAP block with the addition of dexamethasone showed comparable analgesic effects as the continuous epidural analgesia in cumulative opioid consumption and pain scale in the first 24 hours following transperitoneal laparoscopic donor nephrectomy.

Epidural vs. transversus abdominis plane block for abdominal surgery – a systematic review, meta‐analysis and trial sequential analysis

“…Our first co-primary outcome, the postoperative pain score at rest at 12 h, was reported by 11 trials from 747 patients [14,16,18,19,22,25,26,[28][29][30][31]. It was decreased by a mean difference (95%CI) of 0.69 (0.12-1.27; p = 0.02, I 2 = 94%) with epidural analgesia compared with TAP block (Fig.…”

“…Of the initial 3213 unique article citations identified by the search strategy, 18 randomised controlled trials fulfilled the inclusion criteria [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31]. Details of the screening process are illustrated in Fig.…”

“…1 placed [19,26]. In nine trials, the approach of the TAP block was lateral [15,16,18,19,24,[26][27][28][29], whereas it was subcostal in four trials [21][22][23]30] and combined or either lateral or subcostal in five trials [14,17,20,25,31].…”

“…Transverse abdominis plane block was performed under ultrasound guidance in all of the trials but three, where it was either inserted using the landmark technique 29 or surgically placed 19,26. In nine trials, the approach of the TAP block was lateral 15,16,18,19,24,26,27, whereas it was subcostal in four trials 21,22,23,30 and combined or either lateral or subcostal in five trials 14,17,20,25,31. The TAP block consisted of a single‐shot injection in eight trials 14,15,16,20,23,24,28,29 with the use of a continuous catheter in 10 trials 17,18,19,21,22,25,26,27,30,31.…”

“…or Kandi et al. 14,25,26,28. If the three trials that contributed the most weight to the meta‐analysis of the postoperative pain score at rest at 12 h were excluded 16,19,28, then no difference was found between TAP block and epidural analgesia, with a mean difference (95%CI) of 0.54 (−0.10 to 1.18; p = 0.10, I 2 = 88%).…”