Laparoscopic versus ultrasound-guided visualization of transversus abdominis plane blocks

The Efficacy of Transversus Abdominis Plane (TAP) Blocks When Completed by Anesthesiologists Versus by Surgeons: A Systematic Review and Meta-Analysis

Background/Objectives: Current literature has demonstrated the benefits of transversus abdominis plane (TAP) blocks for reducing postoperative pain and opioid consumption for an array of surgical procedures. Some randomized controlled trials and retrospective studies have compared ultrasound guidance TAP blocks completed by anesthesiologists (US-TAP) to laparoscopic guidance TAP blocks completed by surgeons (LAP-TAP). However, the findings of these studies have not been consolidated to improve recommendations and patient outcomes. Our objective is to consolidate and summarize current literature regarding the efficacy of TAP blocks for postoperative pain control and opioid consumption when performed with ultrasound guidance (US-TAP, compared to laparoscopic guidance (LAP-TAP). Methods: We performed a systematic review and meta-analysis of RCTs and retrospective studies to evaluate US-TAP versus LAP-TAP blocks for postoperative pain control and opioid consumption. We searched PubMed/MEDLINE, CINAHL, Cochrane, and Web of Science databases for all articles meeting the search criteria until the time of article extraction in February 2024. The primary outcome variables were postoperative pain scores and opioid consumption. The secondary outcome variables were complications, time taken to perform the block, length of stay (LOS) in the hospital, and cost of performing the block. Results: Of the 1673 articles initially identified, 18 studies met the inclusion criteria for evaluation. Of the included studies, 88.9% and 77.8% found no significant difference in postoperative pain scores or opioid consumption, respectively, between US-TAP and LAP-TAP groups. Six studies (33.3%) found that LAP-TAP was faster to perform than US-TAP. Meta-analysis demonstrated no statistically significant differences in postoperative pain scores or opioid consumption between groups but showed that block times were significantly longer in the US-TAP group. Conclusions: US-TAP and LAP-TAP blocks may be equivocal in terms of reducing postoperative pain and opioid consumption. LAP-TAPs may be less time-consuming and more cost-effective and viable alternatives to US-TAP blocks in the perioperative setting.

Laparoscopic guided liposomal bupivacaine injection compared to transversus abdominus plane block for postoperative pain after robotic gynecologic oncology surgery

OBJECTIVE

The purpose of this study was to determine if laparoscopically guided transversus abdominis plane block (Lap-Tap) with liposomal bupivacaine provides superior postoperative pain control when compared to ultrasound-guided block (US-Tap) with liposomal bupivacaine at the time of robotic surgery for gynecology oncology patients.

METHODS

This was a prospective randomized controlled trial assigning patients to one of two cohorts: Cohort 1 consisted of US-Tap administered before the procedure using liposomal bupivacaine, Cohort 2 consisted of Lap-Tap administration with laparoscopic visualization using the medication above. Primary outcomes were pain scores and total opioid use in Oral Morphine Equivalents (OME) during the first 72 h after surgery. Secondary outcomes were postoperative pain satisfaction and oral narcotic requirements.

RESULTS

There was a significant increase in oral narcotic use in the first 24 h in the US-Tap cohort compared to the Lap-Tap cohort: Lap-Tap mean = 6.73 ± 8.22 OME versus US-Tap mean = 12.69 ± 12.94 p = 0.018 OME. The increase was equivalent to one additional Hydrocodone-Acetaminophen 7.5 mg/325 mg in the first 24 h after surgery. However, total oral narcotic use over the first 72 h was not significantly different between the two cohorts: Lap-Tap mean = 21.73 ± 19.83 OME, US-Tap mean = 32.50 ± 29.47, p = 0.062 OME. In addition, there was no significant difference in satisfaction or pain scores between the US-Tap and Lap-Tap groups at 24, 48, or 72-hours.

CONCLUSIONS

Lap-Taps are comparable to US-Tap for postoperative analgesia during the first 72-h after surgery when performing robotic-assisted gynecologic oncology surgery.

Ultrasound Verification of Laparoscopic-Assisted Transversus Abdominis Plane Blocks in Children Undergoing Laparoscopic Procedures

Purpose: Ultrasound-guided transversus abdominis plane (TAP) blocks have been demonstrated to decrease postoperative pain; however, laparoscopic-assisted TAP (L-TAP) blocks have not been well studied in children. Our study utilized intraoperative ultrasound to verify whether surgeon-administered blocks using only laparoscopic visualization were reliably delivered into the correct plane. Materials and Methods: Patients undergoing laparoscopic procedures were enrolled to receive L-TAP blocks. Preblock and postblock ultrasounds were performed to document the plane of local anesthetic delivery. Ultrasound images were reviewed by two blinded anesthesiologists to determine whether the L-TAP block was administered into the desired plane. Results: Fifty-one patients were enrolled. The average age was 5.9 years (range: 2 days to 17 years) and the mean weight was 25.4 kg (range: 2.64-118.8 kg). The most common procedures were inguinal hernia repair (n = 19), appendectomy (n = 10), and gastrostomy-tube placements (n = 13). Nine surgeons performed 93 L-TAP blocks (average: 10.3 blocks/surgeon). Ultrasound confirmed distribution in the correct plane in 53.5/93 blocks (57.5%; 58.0% for attending surgeons), with 77.4% concurrence between the anesthesiologist reviewers. Conclusion: L-TAP achieves delivery of local anesthetic into the correct tissue plane in over half the cases with minimal training. Further studies are needed to examine the effect of L-TAP blocks on reducing postoperative pain in pediatric patients.