THE ROLE OF TAP/RS BLOCK IN MINOR GYNECOLOGIC LAPAROSCOPIC SURGERY: A RANDOMIZED CLINICAL TRIAL.

OBJECTIVES: The aim of the study is to compare, in patients undergoing minor gynecological laparoscopic procedures, the effects of Ultra Sound (US) guided Transversus Abdominis Plane (TAP) + Rectus Sheath (RS) block versus no TAP/RS-block in terms of post-surgical pain control using the Numeric pain Rating Scale (NRS) and the degree of patient satisfaction, according to the main goals of Early Recovery After Surgery (ERAS) programmes. The primary outcome is to value the postoperative abdominal pain using NRS in both groups. Secondary outcomes are to evaluate blood values, presence of postoperative nausea and vomiting (PONV), postoperative ileus, level of patient expected satisfaction, time of discharge, length of stay (LOS) and the amounts of additional analgesics required.

DESIGN: In this prospective randomized controlled trial patients were randomly assigned to Loco Regional Anesthesia (LRA) Group, who received TAP and RS block under US guidance, or No Loco Regional Anesthesia(N-LRA) Group. Enrolled patients were randomized 1:1 to either receive bilateral TAP/RS block with Ropivacaine or sham treatment (patches were applied on the abdominal wall of the patients under general anesthesia).

PARTICIPANTS: All patients aged between 18 and 75 years, with ASA (American Society of Anesthesiologists) physical status 1 to 2, undergoing laparoscopic minor gynecological surgery, were enrolled.

SETTING: The study was conducted to the University of Campus Bio-Medico Hospital of Rome.

METHODS: Half an hour before surgery, all patients received Gabapentin 300 mg per os. Once the patient underwent general anesthesia, US-guided bilateral TAP/RS block was performed by the anesthesiology team, while the uterine manipulator was positioned by a gynecology resident (not involved in the study). In the operative room, all patients received the same standardized anesthetic regimen. Postoperative abdominal pain was assessed at rest, after palpation, during movement and after a cough by evaluating the patient at 6, 12, 18, 24, 36, 48, and 72 hours after surgery, using the NRS from 0 to 10 in both groups. The amount of drug used for analgesia in the first 48 hours after surgery was recorded. Moreover, hemoglobin, white blood cells, and c-reactive protein levels were recordered at 24, 48, and 72 hours. The presence of PONV and the postoperative ileus were recorded throughout convalescence. The expected level of patient satisfaction at discharge and finally the LOS were assessed.

LIMITATIONS: The major weakness of this study is that 60 ml of 0.5% ropivacaine was administered to each patient, without considering weight differences, yet contemporary literature rarely suggests volume/dose titration in fascial blocks.

RESULTS: 104 women, undergoing gynecological minor laparoscopic surgery, were enrolled and assigned to LRA Group (53 pts) and N-LRA Group (51 pts). Postoperative pain was significantly reduced in patients who received TAP/RS block. A reduction in the intake of non-steroidal anti-inflammatory drugs after surgery was registered in LRA Group (p<0.01). Moreover, a significant reduction of LOS (45.97±9.87 vs 65.08±17.32 hours; p<0.01) and PONV was observed in the LRA Group, as well as a better level of patient satisfaction at discharge (9.43±0.94 vs 8.26±1.19; p<0.01), compared to the N-LRA Group.

CONCLUSIONS: US guided TAP and RS block significantly reduces postoperative pain after minor gynecologic laparoscopic surgery and improves patients' post-operative recovery.