Transversus Abdominis Plane Block for Laparoscopic Hysterectomy Pain: A Meta-Analysis

Transversus abdominis plane (TAP) blocks for prevention of postoperative pain in women undergoing laparoscopic and robotic gynaecological surgery

RATIONALE

Pain control following laparoscopic gynaecologic surgery is key to successful recovery. The efficacy of the transversus abdominis plane (TAP) block compared to no block or a local anaesthetic injection has not been well established in this population.

OBJECTIVES

To evaluate the benefits and harms of single-shot transversus abdominis plane blocks for the prevention of postoperative pain in women undergoing laparoscopic and robotic gynaecological surgery compared to no block, sham block, or injection of local anaesthetic.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two trials registers, and handsearched abstracts to 6 December 2024.

ELIGIBILITY CRITERIA

We included prospective randomised controlled trials (RCTs) of adult women undergoing minimally invasive gynaecologic surgery that compared single-shot TAP block to no block, sham block, or injection of local anaesthetic. We excluded studies that were non-randomised or of non-gynaecologic surgery.

OUTCOMES

Critical and important outcomes: participant-reported pain intensity 24 hours following surgery (combined, at rest, and with movement), adverse events (serious adverse events, nausea and vomiting, postoperative sedation), opioid consumption 24 and 48 hours after surgery. Other outcomes: pain intensity 2, 6, 12, and 48 hours after surgery, opioid consumption intraoperatively, time from surgery to first participant requirement for postoperative opioid, time from surgery until discharge.

RISK OF BIAS

We assessed the risk of bias with RoB 1.

SYNTHESIS METHODS

We conducted meta-analyses using random-effects models. We calculated mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes. We reported serious adverse events as described by the study authors. We summarised the certainty of evidence using GRADE methods.

INCLUDED STUDIES

We included 21 RCTs with a total of 1645 participants. Studies were conducted in 10 countries, and published between 2011 and 2023. Six studies compared TAP block to no block, eight compared TAP block to an injection of local anaesthetic, and seven studies compared TAP block to sham block. Studies reported pain outcomes in various ways, so we made assumptions to allow us to combine data.

SYNTHESIS OF RESULTS

1. TAP block compared to no block TAP blocks may result in little or no difference in pain 24 hours after surgery for women undergoing laparoscopic or robotic gynaecologic procedures (MD -4.66, 95% confidence interval (CI) -11.06 to 1.74; 4 RCTs, 242 women; I2 = 88%; very low-certainty evidence). TAP blocks may result in little or no difference in pain at rest (MD -0.16, 95% CI -1.60 to 1.28; 2 RCTs, 146 women; I2 = 0%, low-certainty evidence), or pain with movement (MD -1.59, 95% CI -4.44 to 1.25; 2 RCTs, 146 women; I2 = 0%, low-certainty evidence) 24 hours after surgery. Two studies reported serious adverse events. None reported an event related to the TAP block (out of 50 women). TAP blocks may result in little or no difference in postoperative nausea and vomiting (RR 0.60, 95% CI 0.24 to 1.54; 2 RCTs, 111 women; I2 = 0%, low-certainty evidence). TAP blocks may have little or no effect on 0- to 24-hour postoperative morphine consumption (MD 3.08, 95% CI -3.71 to 9.88; 3 RCTs, 140 women; I2 = 70%; very low-certainty evidence). None of the studies reported 48-hour morphine consumption. 2. TAP block compared to local anaesthetic Women who received TAP blocks may experience a small reduction in 24-hour postoperative pain compared to local anaesthetic (MD -11.58, 95% CI -20.52 to -2.64; 6 RCTs, 393 women; I2 = 89%; low-certainty evidence). None of the studies reported pain at rest or with movement. Four studies reported serious adverse events. None reported an event related to the TAP block (out of 168 women). TAP block may result in little or no difference in postoperative nausea and vomiting compared to local anaesthetic (RR 0.63, 95% CI 0.34 to 1.15; 1 RCT, 62 women; low-certainty evidence). There may be little or no difference in opioid consumption 0 to 24 hours after surgery for women who received a TAP block compared to local anaesthetic (MD -8.21, 95% CI -19.69 to 3.27; 2 RCTs, 177 women; I2 = 81%; very low-certainty evidence). TAP block compared to local anaesthetic may result in little or no difference in opioid consumption 0 to 48 hours after surgery (MD -15.80, 95% CI -32.11 to 0.51; 1 RCT, 40 women; low-certainty evidence). 3. TAP block compared to sham block TAP block probably results in a small decrease in 24-hour postoperative pain compared to sham block (MD -14.26, 95% CI -27.03 to -1.48; 4 RCTs, 371 women; I2 = 98%; moderate-certainty evidence). None of the studies reported pain at rest. TAP block probably results in a small reduction in pain with movement 24 hours following surgery (MD -3.60, 95% CI -6.72 to -0.48; 1 RCT, 60 women; moderate-certainty evidence). Six studies reported serious adverse events. None reported an event related to the TAP block (out of 307 women). There may be little or no difference in postoperative nausea and vomiting between TAP and sham blocks (RR 0.68, 95% CI 0.45 to 1.03; 3 RCTs, 244 women; I2 = 0; low-certainty evidence). There may be little or no difference in 24-hour postoperative morphine consumption between TAP and sham blocks (MD -13.08, 95% CI -30.78 to 4.63; 5 RCTs, 310 women; I2 = 99%; low-certainty evidence). None of the studies reported 48-hour postoperative opioid consumption.

AUTHORS' CONCLUSIONS

Amongst women undergoing minimally invasive gynaecologic surgery, we did not find a clinically meaningful effect of TAP block on postoperative pain or opioid consumption. However, there may be a small reduction of pain using TAP blocks compared to local anaesthetic or sham blocks. The TAP block is probably safe, since no adverse events were noted amongst the 525 women who received a block, and for whom safety data were available. The evidence is limited by heterogeneity in the results, risk of bias in the studies, and assumptions made for synthesis when combining data.

FUNDING

The review had no dedicated funding.

REGISTRATION

Protocol (2022): DOI: 10.1002/14651858.CD015145.

Use of quadratus lumborum block in gynecologic procedures

OBJECTIVE

Adequately managing post-operative pain is essential for improving patient outcomes and reducing post-operative complications. The quadratus lumborum (QL) block is a truncal nerve block technique that was recently developed to provide analgesia during abdominal and hip surgical procedures. While many studies have shown the outstanding analgesic effect of QL blocks, this technique is not well-known or commonly used in gynecologic procedures.

FINDINGS

This narrative review describes evidence in current literature on the safety and effectiveness of QL blocks when used for gynecologic procedures. The studies show that including QL blocks as part of the approach to managing post-operative pain in gynecologic patients can reduce post-operative pain, reduce analgesic consumption, and lengthen time to first analgesic. They also suggest that QL blocks are more effective at managing post-operative pain and have a lower risk for systemic toxicity compared with transversus abdominis plane blocks.

SUMMARY

According to current randomized controlled trials, QL blocks have been shown to be effective in managing post-operative pain after gynecologic surgical procedures. Further studies on effectiveness in different procedures, adjuvants, and optimum dosing of local anesthetic are needed to determine the best application of QL blocks in gynecologic procedures.

Spinal Anesthesia Prior to Laparoscopic Hysterectomy Resulted in Decreased Postoperative Pain and Opioid Use

Study Objective

To determine if a pre-operative morphine/bupivacaine spinal injection prior to laparoscopic hysterectomy reduced postoperative pain and resulted in less opioid consumption during the hospital stay.

Methods

A retrospective cohort study (Canadian Task Force Classification II-2) was conducted at a single institution regional referral center (community hospital) in North Carolina. Three hundred nineteen patients met criteria for inclusion: 192 received spinal anesthesia and 127 did not. Baseline demographics were similar between the two groups. Median pain scores were significantly lower in the treatment than the control group on day of surgery (DOS) (2 vs. 6; P < 0.001) and postoperative day 1 (POD1) (2 vs. 4; P < 0.001).

Results

Primary outcomes were pain scores on DOS and POD1 and inpatient opioid use. Pain scores were obtained using the 0 to 10 Numerical Rating Scale. Opioids were converted to oral morphine milliequivalents (OME). Median opioid use was also significantly lower in the treatment than the control group on DOS (0 vs. 15.00 OME; P < 0.001) and POD1 (0 vs. 7.5 OME; P < 0.001). Median length of stay between the groups was not significantly different.

Conclusion

Pre-operative morphine spinal injection for laparoscopic hysterectomy led to significantly lower pain scores and inpatient opioid consumption. Pre-operative spinal anesthesia for benign laparoscopic hysterectomy appears helpful for enhancing the postoperative experience.

Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update

BACKGROUND

Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges.

METHODS

Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly.

CONCLUSIONS

The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.

Use of Transversus Abdominis Plane Block in Hysterectomy: A Systematic Review

PURPOSE

To examine the effectiveness of transversus abdominis plane (TAP) block in hysterectomy.

DESIGN

Systematic review METHODS: This review followed the guidelines of the PRISMA statement. PubMed, CINAHL, the Cochrane Collaboration, Google Scholar, and other gray literature databases were searched for eligible studies. The evidence level and quality ratings were assessed using the guidelines proposed by the Johns Hopkins Nursing Evidence-Based Practice Model.

FINDINGS

Six randomized controlled trials and three systematic reviews with meta-analysis consisting of 2,164 patients were analyzed. The use of TAP block reduced the pain scores in the early part of the postoperative period with diminishing effect late in the postoperative phase. In addition, TAP block lowered the overall opioid consumption, reduced the incidence of PONV, and prolonged the time for rescue medication. All studies included in the review were categorized as Level I and rated Grade A implying strong confidence in the true effects of TAP block in all outcome measures in the review.

CONCLUSIONS

The addition of TAP block for pain control in hysterectomy patients can improve postoperative pain management. This review found that TAP block has opioid-sparing effects and is safe and effective in reducing pain scores postoperatively in hysterectomy patients.

Addition of Transversus Abdominis Plane Block to Conventional Pain Regimens in Robotic Sacrocolpopexy Procedures-A Pilot Randomized Controlled Trial (SACROTAP)

IMPORTANCE

There have been no randomized trials assessing the benefits of integration of transversus abdominis plane (TAP) blocks in sacrocolpopexy procedure postoperative pain management.

OBJECTIVE

The aim of this study was to assess the variation in pain perception upon adding TAP blocks to conventional oral pain medications in patients undergoing sacrocolpopexy. The primary outcome was the reduction in pain reported using the numeric rating scale (NRS) among patient groups. The secondary outcome was the change in narcotic analgesic use postoperatively.

STUDY DESIGN

This was a prospective double-blind, pilot randomized controlled trial of women undergoing robotic sacrocolpopexy, with and without supracervical hysterectomy, with 20 patients enrolled in each arm. Randomization included receiving a TAP block in addition to the conventional analgesic regimen.

RESULTS

A total of 48 women were approached to participate in the study; 40 women provided consent (20 per study arm) and completed the 7-day follow-up. Patients receiving a TAP block had lower NRS pain scores at 4 hours postoperatively (4.95 ± 0.76 vs 5.50 ± 0.61, P = 0.02), 7 days postoperatively (2.20 ± 1.11 vs 3.15 ± 1.04, P = 0.008), and lower cumulative NRS pain scores at 48 hours postoperatively (14.90 ± 2.2 vs 16.60 ± 2.04, P = 0.02) and 7 days postoperatively (17.10 ± 2.63 vs 19.75 ± 2.65, P = 0.003) than patients not receiving a block. Patients in the intervention group also had lower cumulative morphine milliequivalents at 7 days postoperatively (17.25 ± 10.7 vs 29.25 ± 14.53, P = 0.005).

CONCLUSION

Use of TAP blocks in robotic sacrocolpopexy cases, with or without concurrent hysterectomy, may reduce postoperative pain and narcotic medication needs.

Analgesia for Gynecologic Oncologic Surgeries: A Narrative Review

PURPOSE OF REVIEW

Gynecologic oncologic malignancies are amongst the most common cancers affecting women across the world. This narrative review focuses on the current state of evidence around optimal perioperative pain management of patients undergoing surgeries for gynecologic malignancies with a specific focus on cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

RECENT FINDINGS

Recent improvements in postoperative pain management following all types of gynecologic procedures, including minimally invasive, open-abdominal, or CRS + HIPEC, have been implemented through enhanced recovery after surgery (ERAS) protocols. These protocols encompass the use of preemptive analgesia, neuraxial and regional techniques, local anesthetic infiltration, and multimodal analgesia. The severity of postoperative pain varies for minimally invasive cancer surgery to open debulking procedures. Therefore, an individualized perioperative analgesic plan is critical depending on the surgical approach. For CRS + HIPEC, neuraxial techniques such as thoracic epidurals and opioid sparing multimodal analgesics have shown efficacy in the perioperative period. However, future research is needed as many of these patients develop chronic pain with very limited research done in this realm.

Levobupivacaine versus levobupivacaine plus dexmedetomidine in transversus abdominis plane block in patients undergoing abdominal aortic surgery

Background:

Severe postoperative pain is a major dilemma for patients undergoing abdominal aortic surgery. Transversus abdominis plane (TAP) block has been described a successful pain management technique after major abdominal surgery. Dexmedetomidine was proved to enhance the analgesic action of local anesthetics.

Aim:

This study was aimed to assess the impact of adding dexmedetomidine to levobupivacaine during TAP block in patients undergoing abdominal aortic operations.

Patients and Methods:

We included 114 patients in this prospective trial, and they were enrolled into two groups; the L group received levobupivacaine only, and the LD group received levobupivacaine plus dexmedetomidine. The block was performed before anesthetic induction. Postoperative pain score was our main outcome.

Statistical Analysis:

The collected data were tabulated and analyzed through the SPSS software program IBM's Statistical Package for the Social Sciences (SPSS) statistics for Windows (version 25, 2017) (IBM Corporation, Armonk, NY, USA). The categorical data were expressed as numbers and percentages and then compared using the Chi-square test. The continuous data were expressed as mean and standard deviation if normally distributed, or median and range if abnormally distributed. The former data were compared through the one-way ANOVA, while the latter were compared through the Kruskal–Wallis test. Any P < 0.05 was considered statistically significant.

Results:

Group LD showed significantly earlier sensory blocks compared to the other group. Postoperative pain scores were comparable between the two groups for the initial 4 h following the surgery. Adjuvant dexmedetomidine was associated with better pain scores for the subsequent 12 h compared to Group L. The duration till the first analgesic request showed a significant increase in the LD group (13.3 vs. 11.09 h in Group L). In addition, the same group showed a significant decline in their opioid consumption after the operation (48.95 μg vs. 72.63 μg in the other group). Postoperative nausea and vomiting were significantly increased in Group L.

Conclusion:

Adjuvant dexmedetomidine has a significant beneficial impact on postoperative analgesic profile. Its use as an adjuvant to peripheral and neuraxial nerve blocks should be recommended in pain management practice.

Systematic review and meta-analysis of ropivacaine use in laparoscopic hysterectomy

To assess the efficacy of all forms of ropivacaine administration for the management of pain and opioid use, specifically in patients undergoing laparoscopic hysterectomy. We searched PubMed, Cochrane CENTRAL, Web of Science, and SCOPUS for relevant clinical trials matching our eligibility criteria. Outcomes of interest included: Pain intensity (measured either by visual analog scale score or by numerical rating scale score), QoR-40 score (Overall quality of recovery tool, designed to measure physical comfort, physical independence, pain, emotional status, and need for support), and the need for opioid rescue. We performed the analysis under the fixed-effects model for homogeneous data and random-effects model for heterogeneous data. Most heterogeneous data were solved by the leave-one-out method, in cases where this was not successful, we then proceeded to conduct at least one subgroup meta-analysis in an attempt to solve heterogeneity. We assessed the risk of bias using Cochrane's risk of bias tool. A total of five clinical trials were included. Regarding the pain score, there was no significant difference between either group [standardized mean difference=-0.17, 95% confidence interval (CI): (-0.56, 0.23); p=0.41]. The analysis of the overall RoQ40 scores favored the ropivacaine group over the control group significantly [mean difference (MD)=17.68, 95% CI: (1.48, 33.87); p<0.001]. Regarding the use of opioids, the analysis revealed no significant difference between either group [MD=-2.57, 95% CI: (-6.62, 1.49); p=0.21]. Ropivacaine administration by any method does not seem to be effective in reducing pain or reducing the need for opioid use after laparoscopic hysterectomy procedures; however, the administration did show a significant improvement in the patient's "overall quality of recovery," as measured using the QoR-40 tool.