|Year : 2016 | Volume
| Issue : 1 | Page : 29-34
To evaluate the efficacy of novel approach to transversus abdominis plane block for postoperative analgesia after abdominal surgeries
Avanish Saxena1, Amrita Gupta2, Devpriya Mitra1, Juhi Singhal1, Mayank Agarwal1
1 Department of Surgery, S.N. Medical College, Agra, Uttar Pradesh, India
2 Department of Anaesthesia, S.N. Medical College, Agra, Uttar Pradesh, India
|Date of Web Publication||5-May-2016|
89, Vimal Vatika, Kamla Nagar, Agra, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: The surgical transversus abdominis plane (TAP) block is a novel approach for postoperative analgesia after abdominal surgeries. The block was given intraperitoneally during the intraoperative period. We evaluated its analgesic efficacy in patients during the first 48 h of the postoperative period after abdominal surgery, in a randomized, controlled, double-blind clinical trial. Materials and Methods: Thirty adult patients undergoing surgery requiring midline abdominal incision were randomized and divided into two groups. Group-T received TAP block with 20 ml of 0.5% bupivacaine intraperitoneally, and Group-P received TAP block with normal saline (placebo). Each patient was evaluated by a blinded investigator in the postanesthesia care unit and at 1, 2, 4, 6, 12, 24, 36, and 48 h. Results: Diclofenac consumption was almost reduced by 50% in TAP group in comparison to placebo group (mean diclofenac requirement of the TAP group vs. placebo group was 110 ± 25 mg and 225 ± 28 mg, respectively; P < 0.0001). Mean time to first request of analgesic was significantly prolonged in TAP block (210 min) as compared to placebo (90 min). Postoperative verbal analog scores at rest and at movement were significantly reduced in TAP block group from 4 to 24 h postoperatively as compared to placebo group. All TAP block patients were quite satisfied with the postoperative analgesic regimen. Conclusion: Postoperative analgesic consumption of diclofenac was almost reduced to half in TAP block group as compared to placebo group, and also, time to first request of analgesic was significantly prolonged in TAP block group. The surgical TAP block is a novel approach for providing postoperative analgesia which is easy to perform, safe and has no adverse effects.
Keywords: Abdominal surgeries, intraperitoneal transversus abdominis plane block, transversus abdominis plane block, triangle of Petit
|How to cite this article:|
Saxena A, Gupta A, Mitra D, Singhal J, Agarwal M. To evaluate the efficacy of novel approach to transversus abdominis plane block for postoperative analgesia after abdominal surgeries. Saudi Surg J 2016;4:29-34
|How to cite this URL:|
Saxena A, Gupta A, Mitra D, Singhal J, Agarwal M. To evaluate the efficacy of novel approach to transversus abdominis plane block for postoperative analgesia after abdominal surgeries. Saudi Surg J [serial online] 2016 [cited 2022 Jan 28];4:29-34. Available from: https://www.saudisurgj.org/text.asp?2016/4/1/29/181812
| Introduction|| |
Most of the pain experienced by patients after abdominal surgery is derived from the abdominal wall incision.  There are three layers of abdominal wall, i.e. the external oblique, internal oblique, and transversus abdominis and their associated fascial sheaths.  The muscular wall is innervated by nerve afferents that course through the transversus abdominis neurofascial plane.  Blockade of these nerve afferents via abdominal field blocks is limited, and the degree of block achieved could be unpredictable. 
Rafi demonstrated transversus abdominis plane (TAP) block in 2001 as a new alternative and reliable approach to the blockade of the neural afferents in the anterior abdominal wall.  This block provides analgesia to parietal peritoneum, muscles of anterior abdominal wall, and skin by introducing local anesthetics into the TAP via the triangle of Petit; it is possible to block the sensory nerves of the anterior abdominal wall before they pierce the musculature to innervate the abdomen. 
In this prospective, randomized, double-blinded study, our aim was to evaluate the effectiveness of surgical TAP block given at the end of the surgery in reducing the need of additional analgesic requirement during the first 48 h postoperatively. This technique facilitates early mobilization with less pain scores at rest and movement.
| Materials and Methods|| |
After approval from the institutional committee, informed written consent was taken from the patients. This study was conducted on thirty adult patients with American Society of Anesthesiologists (ASA) Grade I and Grade II, with age group of 20-60 years, scheduled for abdominal surgeries such as open prostatectomy and abdominal hysterectomy.
The patients with drug allergy, morbid obesity, and sepsis and patients with age <18 years were not included in this study.
As a part of routine preoperative preparation, all patients had received metoclopramide 10 mg and ranitidine 50 mg, 30 min before shifting to operation theater. Standard monitoring including electrocardiograph, arterial blood pressure and arterial oxygen saturation, and pulse rate monitoring were attached to the patient. General anesthesia was given using intravenous (IV) propofol 2-2.5 mg/kg and succinylcholine 1 mg/kg. Anesthesia was maintained using oxygen, nitrous oxide, and isoflurane. Neuromuscular blockade was achieved with vecuronium (0.1 mg/kg). Before closure of abdominal wall layers, patients received TAP block. We utilized the unique intraperitoneal approach of TAP block, with 20 ml of 0.5% bupivacaine (Group-T) or 20 ml of 0.5% normal saline (Group-P); a blunt tipped needle was advanced from inside the abdominal wall through parietal peritoneum, then transverse abdominis muscle and into the TAP as indicated by "single pop" sensation [Figure 1]. By providing TAP from inside, there is decrease in risk of inadvertent visceral injury.
|Figure 1: This is regarding the technique of intraperitoneal transversus abdominis plane block|
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The patient was randomly allocated to receive TAP block with 20 ml of 0.5% bupivacaine (Group-T) or 20 ml of 0.5% normal saline (Group-P). The allocation sequence was given using computer-generated random number table. The patient and the investigator performing the block and providing postoperative care were blinded to the group assignment. All patients received 1.5 mg/kg of injection diclofenac and IV ondansetron 0.1 mg/kg 30 min before completion of surgery. After completion of surgery, neuromuscular blockade was reversed with neostigmine and atropine. The patient was extubated and transferred to postanesthesia care unit (PACU) for further monitoring.
A standardized postoperative analgesic regimen consisting of regular intramuscular diclofenac 100 mg every 8 hourly was commenced on admission to the PACU in both groups. All patients were asked to give scores for their pain at rest and on movement (knee flexion and extension) using verbal analog score (VAS), by the investigator who was blinded to group allocation. Nausea and vomiting were measured using three-point score (1 - no nausea, 2 - nausea, 3 - vomiting). Rescue antiemetics were given if the patient complained of nausea. The primary outcome measured in our study was total diclofenac consumption in 48 h. Secondary outcomes measured in our study were time to first request of diclofenac, side effects, and patient satisfaction.
Statistical analyses were performed using a standard statistical program (version 2.0: Jandel Corporation San Rafael, CA, USA); all data were recorded and noted on observation charts and were analyzed at the end of the study. Data were expressed as mean along with standard deviation, and normally distributed data were analyzed by one-way analysis of variance. Comparison between two data was made utilizing Student's t-test. A P < 0.05 was considered statistically significant.
| Results|| |
Thirty patients were enrolled in the study. All patients underwent abdominal surgical procedures which require midline abdominal incisions.
The groups were comparable with respect to demographic data, ASA physical status, and type of surgery [Table 1].
Diclofenac consumption was almost reduced by 50% in Group-T as compared to placebo group (total diclofenac requirement in TAP group and placebo group, respectively, was 110 ± 25 mg and 225 ± 28 mg; P < 0.0001). Mean time to first request of analgesic was significantly prolonged in TAP block (210 min) as compared to placebo (90 min). Diclofenac requirement was almost negligible in both the groups during the first 4 h postoperatively as injection diclofenac intramuscularly was given during operative procedure in both the groups. During 4 th -48 th h, diclofenac requirement was decreased in TAP block group as compared to placebo group [Table 2]. Postoperative VAS at rest and at movement was significantly reduced in TAP block group from 4 to 24 h postoperatively as compared to placebo group [Table 3]. Postoperative nausea and vomiting were comparable in both the groups probably due to the effect of IV ondansetron given intraoperatively [Table 4]. Patient satisfaction was calculated using ten-point scale. If the score is > 6, then the patient is extremely satisfied and when score is > 3, the patient is satisfied. Seventy percent of the patients in the TAP block group were satisfied (score > 3) [Table 5].
|Table 2: Interval/total consumption of bupivacaine and requirement of first rescue analgesic |
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| Discussion|| |
Postoperative pain management is one of the most important aspects of patient management.  TAP block is one of the effective components of multimodal postoperative analgesics for various abdominal surgeries. ,,, We studied the novel approach of TAP block. TAP block was given intraperitoneally during surgery which provided effective postoperative analgesia, decreasing total consumption of diclofenac as well as delayed request for supplemental analgesics.
In previous studies, TAP block was given through lumbar triangle of Petit. ,,, The conventional technique of TAP block, through subcutaneous route, resulted in peritoneal puncture and its associated complications, and also, it is difficult to perform in morbidly obese patients. By employing an intraperitoneal approach, asepsis is more easily attained, and block is performed under direct vision, so there is no risk of damage to viscera and blood vessels. 
Our study, like various other studies, ,, showed overall reduction in consumption of postoperative analgesic such as diclofenac in the first 48 h in TAP block groups. There is almost 50% reduction in the requirement of diclofenac postoperatively. Time to first request of analgesic was significantly prolonged in TAP block group (P < 0.0038) as compared to placebo group as other studies. ,,
The reason for prolonged duration of analgesic effect is that TAP is relatively poorly vascularized and drug clearance may be slowed due to which drug remained in plane for longer period.  Furthermore, like many studies, TAP block group also had reduced postoperative VASs at rest and on movement of knee. ,,,, Hence, the patients receiving TAP block were able to ambulate early, had a sound sleep. Hence, 70% of the patients in TAP block group were satisfied with pain relief. Belavy et al. also showed increased patient satisfaction with TAP block. 
Local anesthetic infiltration is commonly used as a traditional method for postoperative analgesia, but TAP block has been found to have better and long lasting effect.  Recently, in children, TAP block has been found to have adequate pain control during the first 48 h postoperatively following surgery.  Some studies have shown that TAP block provides only marginal postoperative analgesia in patients of abdominal laparotomy or laparoscopy and cesarean delivery. 
| Conclusion|| |
Hence, we concluded that intraperitoneal approach to TAP block holds a considerable promise as a part of multimodal analgesic regimen for abdominal surgeries. It significantly resulted in decreased (up to 50%) requirement of diclofenac consumption postoperatively, up to 48 h. The first request of rescue analgesic is also prolonged in patients receiving TAP block. Thus, it is a novel approach which is safe and very easy to perform with no adverse effects till date.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]