tap block thesis

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• Published: 14 May 2018

Role of ultrasound guided transversus abdominis plane block as a component of multimodal analgesic regimen for lower segment caesarean section: a randomized double blind clinical study

• Ashok Jadon 1 ,
• Priyanka Jain   ORCID: orcid.org/0000-0003-0294-5916 1 ,
• Swastika Chakraborty 1 ,
• Mayur Motaka 1 ,
• Sudhansu Sekhar Parida 1 ,
• Neelam Sinha 1 ,
• Amit Agrawal 1 &
• Asit Kumar Pati 1  

BMC Anesthesiology volume  18 , Article number:  53 ( 2018 ) Cite this article

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While opioids are the mainstay for post-operative analgesia after lower segment caesarean section, they are associated with various untoward effects. Ultrasound guided transversus abdominis plane (TAP) block has been postulated to provide effective analgesia for caesarean section. We evaluated the analgesic efficacy of this block for post caesarean analgesia in a randomised controlled trial.

One hundred thirty-nine mothers undergoing caesarean delivery were randomised to receive TAP block with either 20 ml 0.375% ropivacaine or 20 ml saline after obtaining informed consent. All the subjects received a standard spinal anaesthetic and diclofenac was administered for post-operative pain. Breakthrough pain was treated with tramadol. Post-operatively, all the subjects were assessed at 0, 2, 4, 6, 8, 10, 12, 18 & 24 h. The primary outcome was the time to first analgesic request. The secondary measures of outcome were pain, nausea, sedation, number of doses of tramadol administered and satisfaction with the pain management.

The median (interquartile range) time to first analgesic request was prolonged in the TAP group compared to the control group ( p  < 0.0001); 11 h (8,12) and 4 h (2.5,6) respectively. The median (interquartile range) number of doses of tramadol consumed in the TAP group was 0 (0,1) compared to 2 (1,2) in the control group ( p  < 0.0001). At all points in the study, pain scores both at rest and on movement were lower in the study group ( p  < 0.0001). Maternal satisfaction with pain relief was also higher in the study group ( p 0.0002). One subject in the TAP group had convulsions following injection of local anaesthetic solution. She was managed conservatively with supportive treatment following which she recovered.

TAP block reduces pain, prolongs the duration of analgesia and decreases supplemental opioid consumption when used for multimodal analgesia for pain relief after caesarean section. However, the risk of local anaesthetic systemic toxicity remains unknown with this block. Hence larger safety trials and measures to limit this complication need to be ascertained.

Trial registration

The trial was registered with the Clinical Trial Registry of India ( CTRI/2017/03/008194 ) on 23/03/2017 (trial registered retrospectively).

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Lower segment caesarean section (LSCS) is a major surgical procedure with substantial post-operative pain [ 1 ]. Good control of pain following LSCS is essential to facilitate early mobilisation and to enable adequate care of the new born. Achieving good pain relief is challenging because of the altered physiology and of the possibility of transmission of drugs through breast milk. Although a variety of choices of drugs and routes of administration are available, we are yet to achieve a safe and effective method of pain control after LSCS.

Conventional analgesic regimens use opioids administered through systemic and/or neuraxial routes. Neuraxial methods are effective and safe, but need to be performed by an experienced person and require very close monitoring [ 2 ]. Opioids can also be delivered using intravenous or epidural patient controlled analgesia (PCA). PCA allows patients to have control over their pain management and hence improves their satisfaction with the therapy [ 3 ]. However, unwanted effects like sedation, nausea and vomiting, pruritus and occasionally respiratory depression remain the major drawbacks of opioids [ 4 ]. Secretion into breast milk is the additional concern in this population [ 2 ]. Non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol can only supplement other modes of analgesia and are not sufficient on their own [ 2 ].

Given these issues, peripheral nerve block techniques like transversus abdominis plane (TAP) block were introduced as an effective component of multimodal analgesia after caesarean delivery [ 5 ]. These techniques not only reduced pain quite successfully but also eliminated some of the problems associated with the use of systemic opioids or central neuraxial blocks [ 6 , 7 ]. Ultrasound guided transversus abdominis plane (TAP) block is one such effective method of providing post-operative analgesia for lower abdominal surgeries [ 8 ].

The purpose of this randomised study was to evaluate the efficacy of TAP block for post LSCS pain specifically targeting the Indian population. We assessed the role of this block as a component of a multimodal analgesic regimen that excludes intrathecal morphine.

The trial was approved by the Ethics and Scientific committee of the institution and registered with the Clinical Trial Registry of India (CTRI/2017/03/008194). A total of 139 mothers aged > 18 years with no major systemic disease, who were scheduled for caesarean section under spinal anaesthesia were enrolled into the study after obtaining written informed consent. Exclusion criteria were a history of drug allergy or local anaesthetic toxicity, BMI (body mass index) > 35 kg/m 2 and pregnancy weight < 50 kg (to limit maximum ropivacaine dose to 3 mg/kg), contraindications to regional anaesthesia (bleeding diathesis, infection at the site of block and peripheral neuropathy), severe medical conditions such as severe pre-eclampsia and eclampsia and patients who had intra-operative complications like post-partum haemorrhage.

The subjects were randomly allocated into treatment and control groups using a computer generated sequence of random numbers. The group sequence was concealed in sealed opaque envelopes which were opened only after obtaining informed consent. The injectate syringes containing either 40 ml saline or 40 ml 0.375% ropivacaine were prepared by an anaesthesiologist not involved in the study. The anaesthesiologists, the subjects and the post-operative care providers were blinded to the group assignment.

As per usual hospital practice, pre anaesthetic evaluation was done and metoclopramide (10 mg) and ranitidine (50 mg) were given intravenously as premedications 1 h before surgery. All the study subjects received a standard spinal anaesthetic consisting of 11-12.5 mg of 0.5% hyperbaric bupivacaine. Heart rate, blood pressure & pulse oximetry was monitored in the operating room. All the subjects received 75 mg diclofenac IV before the completion of the surgery.

At the end of the surgery, bilateral US (ultrasound) guided TAP block was performed by one of the investigators using either 20 ml of 0.375% ropivacaine (obtained by mixing 10 ml of 0.75% ropivacaine with 10 ml of normal saline) or 20 ml saline on each side. The procedure was performed using aseptic technique (gown, gloves, facemask and protective sheath for the ultrasound probe). After preparing the skin with antiseptic solution, a linear high frequency ultrasound probe (6-13 MHz, Sonosite M-Turbo©) was placed transversely on the anterolateral abdominal wall between the iliac crest and the costal margin. Under US guidance, the three layers of muscles -external oblique, the internal oblique, and the transversus abdominis were identified. A 21-gauge, 100-mm needle attached with flexible tubing to a syringe filled with saline was used to perform the block. The needle was then introduced through the skin anteriorly in the plane of the ultrasound beam and advanced into the fascial plane between the internal oblique and transversus abdominis muscles with its tip lying in the mid axillary line. To assist with identifying these structures, the probe was moved anteriorly to the rectus sheath and the fascial planes followed laterally. The final position of the probe was to be no further anterior than the anterior axillary line. If satisfactory views were not obtained, the TAP block was not performed. Hydro dissection with saline (2-5 ml) was used to separate the fascial layers. After aspiration to exclude inadvertent vascular puncture, a test dose of 1-2 ml of the drug was injected to confirm needle placement. After a negative test dose, 20 ml of the study solution was injected while closely observing for signs of toxicity (tinnitus, perioral numbness, metallic taste in mouth, slurring of speech and mental status changes). TAP block was performed in a similar fashion on the opposite side.

After completion of the procedure, patients were shifted to the post anaesthesia care unit (PACU) before transferring them to the ward. Both the groups received a standard post-operative analgesic regimen consisting of 75 mg of IV diclofenac every 12 h and 50 mg IV tramadol on demand for breakthrough pain.

All the subjects were assessed at 0, 2, 4, 6, 8, 10, 12, 18 & 24 h after surgery for pain at rest & on movement, nausea and sedation. All the subjects were asked to rate their pain at rest and on movement using a visual analogue scale (VAS) with ‘0’ representing no pain and ‘10’ being the worst imaginable pain. Supplemental analgesia (50 mg tramadol IV) was administered if VAS > 4 on movement or if the mother demanded for it. The time to first analgesic request was noted in all the subjects. If no supplemental analgesia was given within 12 h of surgery, regular dose of diclofenac was administered and the duration of analgesia was considered as 12 h. The severity of nausea was measured according to a 4-point rating score (0- absent, 1- mild, 2- moderate, and 3- severe or vomiting). 4 mg ondansetron IV was offered to subjects who complained of nausea or vomiting. Subjects requiring ≥2 doses were given ondansetron round the clock (4 mg thrice daily). A 4-point scale was used to assess sedation (1- fully awake; 2- somnolent, responds to verbal stimuli; 3- somnolent, responds to tactile stimuli; and 4- somnolent, responds to painful stimuli). Naloxone (1-2mcg/kg) IV was administered if the score ≥ 3. The total number of supplemental doses of tramadol consumed in 24 h was also recorded. At the end of the study, mothers were asked to rate their satisfaction with the pain management on a 3-point scale (1- dissatisfied, 2- satisfied, 3- highly satisfied).

The primary outcome was the time to first analgesic request and the secondary measures of outcome included number of doses of tramadol administered and pain, nausea, sedation & satisfaction scores.

The sample size was calculated based on results obtained from a pilot study conducted at our institute. The sample size was aimed to detect a 25% reduction in the number of doses of tramadol consumed [mean 1.588, standard deviation (SD) 0.795]. Assuming the power of the study at 80% and a clinical significance of 95%, a total of 125 subjects were required to detect this difference. To account for an attrition rate of 10%, we aimed to enrol 138 subjects into the study.

The results were analysed using Medcalc® version 17.9.4. Maternal and intra-operative characteristics were assessed using student’s t -test (two tailed, unequal variances) and chi square test as appropriate. Continuous data were assessed for normality using the Shapiro-Wilk test. Normally distributed data (represented as mean ± SD) were assessed using the student’s t-test (two-tailed, unequal variances) and non-normally distributed data [represented as median (IQR)] were assessed using the Mann-Whitney U-test. Ordinal data were represented as median & interquartile range (IQR) and assessed using the Mann-Whitney U-test. The time to first analgesic request was assessed using the log rank test. A p -value < 0.05 was considered significant.

A total of 139 mothers (70 in the control group and 69 in the study group) were enrolled into the study (Fig.  1 ). Two mothers in the control group were lost to follow up and were excluded from the study. One subject in each group violated protocol and had to be excluded from the study. One subject in the study group had convulsions following the injection of local anaesthetic solution. She developed convulsions in the PACU approximately 20 min after performing the block. She was managed conservatively with IV midazolam (2 mg) following which she recovered. She was closely monitored for the next 24 h during which no untoward events were noted. She also had to be excluded from the study.

Flow diagram of randomisation and follow-up of enrolled participants. LSCS – lower segment caesarean section, TAP – transversus abdominis plane

Maternal and intra-operative characteristics were similar in both the groups ( p  > 0.05) (Table  1 ). The median (IQR) time to first analgesic request was 11 h (8,12) in the TAP group and 4 h (2.5,6) in the study group (Fig.  2 ). This difference was significant [ p  < 0.0001; 95% confidence interval (CI), 5.6 to 8)]. The median (IQR) number of tramadol doses consumed in the TAP group was 0 (0,1) compared to 2 (1,2) in the control group ( p  < 0.0001; 95% C.I., 1 to 2). At all points during the study, pain scores both at rest and on movement were significantly lower in the study groups compared to the placebo group ( p  < 0.0001, Fig.  3 ). Nausea scores were significantly lower ( p  < 0.05) in the study group only during the latter half (10,12,18 & 24 h) of the study. There was no difference with respect to sedation between the two groups. None of the subjects needed naloxone. The median (IQR) maternal satisfaction score was significantly higher in the TAP group compared to the control group; 2 (2,3) in the TAP group compared to 2 (2,2) in the control group ( p 0.0002; 95% C.I., 0 to 1).

Kaplan Meier graph showing the % of patients in each group not requiring supplemental analgesia over time ( p  < 0.0001, log rank test). TAP – transversus abdominis plane

Box and plot graph of pain scores (VAS) over 24 h. At each time point, the first bar represents VAS scores of pain at rest in the study group; the second bar, VAS scores of pain on movement in the study group; the third bar, VAS scores of pain at rest in the control group; and the fourth bar, VAS scores of pain on movement in in the control group. The middle line in each box represents the median value, the outer margins of the box represents the interquartile range and the whiskers represent the 10th & 90th percentile at each time point ( p  < 0.0001, Mann-Whitney U-test). VAS – visual analog scale, TAP – transversus abdominis plane

Post-operative analgesia after caesarean section is challenging since it should cater to maternal comfort and simultaneously have no adverse effects on the new born. Although neuraxial opioids provide good analgesia, they are associated with various adverse effects like nausea and pruritus which decrease overall patient satisfaction [ 1 ]. In addition, risks of delayed respiratory depression due to rostral spread of hydrophilic opioids like morphine [ 9 ] and adverse effects on the newborn [ 10 ] remain significant concerns. Therefore, techniques like TAP block have been employed to reduce opioid consumption and hence their adverse effects. TAP block as a component of multimodal analgesic regimen has considerable potential to improve the quality of pain relief and decrease analgesic requirements when used for analgesia after LSCS [ 5 ].

Our study demonstrated that supplementing a multimodal analgesic regimen with a TAP block reduces pain scores and additional analgesic requirements and hence their associated adverse effects. It also delays the time to first analgesic request and provides better satisfaction with pain relief compared with the standard regimen alone. Various trials comparing TAP block to a sham block have shown that TAP block produces superior analgesia, reduces supplemental opioid analgesic consumption and decreases the incidence of opioid induced adverse effects when used as a component of multimodal analgesic regimen for post caesarean analgesia [ 5 , 11 , 12 , 13 ].

Since neuraxial morphine has been established as the best modality for post caesarean analgesia [ 9 ], various trials have compared the analgesic efficacy of TAP block with intrathecal morphine. They noted that superior analgesia was seen with intrathecal morphine as compared to TAP block but at the expense of adverse effects [ 14 , 15 , 16 ]. Moreover, trials that supplemented TAP block to an analgesic regimen inclusive of intrathecal morphine reported no additional benefits of adding TAP block to a regimen that includes intrathecal morphine [ 16 , 17 , 18 ].

Systematic reviews and meta-analyses also reported that TAP block produces superior analgesia and reduces supplemental opioid consumption when compared to placebo in the setting of multimodal analgesia for caesarean section that excluded intrathecal morphine. However, these benefits were difficult to demonstrate when intrathecal morphine was used. They concluded that TAP block could be considered as an alternative to intrathecal morphine wherever it is contraindicated or produces undesirable adverse effects [ 19 , 20 , 21 ].

The risk of complications following TAP block remains unknown. The subject weighing 60 kg received 150 mg ropivacaine (maximum permissible dose 3 mg/kg i.e. 180 mg). We suspect this to be a case of delayed absorption of the drug though the total dose of the drug was well within the permissible limits. Although ultrasound allows real time needle visualisation, it does not guarantee that the tip of the needle is in the plane and partial intramuscular or intraperitoneal injection may have occurred. We could not get blood levels of ropivacaine as the test was unavailable at our centre. To minimise such complications in the future, measures like decreased drug concentrations (0.3% ropivacaine instead of 0.375% ropivacaine), use of adrenaline to decrease systemic absorption, visualisation of the needle tip at all times during the procedure to prevent inadvertent intramuscular/intraperitoneal injection and acquiring lipid emulsion have been incorporated into the analgesia protocol.

Very few cases of complications with TAP block have been reported in literature so far [ 22 , 23 ]. There are studies that have shown potentially toxic concentrations of local anaesthetics after TAP blocks [ 24 , 25 , 26 ]. In addition, pregnancy can predispose to local anaesthetic systemic toxicity (LAST). Various factors like the reduced dose of local anaesthetic that can cause convulsions [ 26 ], increased concentrations of free drug available due to decreased protein binding, increased venous distension of inferior vena cava (IVC) and an increased cardiac output leading to increased uptake and distribution of the drug [ 27 , 28 ] and an increased neuronal susceptibility to local anaesthetics itself can predispose to LAST in pregnant mothers [ 27 ]. Finally, the concomitant use of subarachnoid block for caesarean section could also increase the systemic absorption of the drug due to vasodilation induced by sympathetic blockade thereby predisposing to systemic toxicity [ 22 ]. It would therefore be advisable to use the lowest possible concentration of local anaesthetic necessary to achieve the desired spread for a successful block.

Finally, while randomised controlled trials demonstrate the analgesic efficacy of TAP block, they are not largely powered to identify rare complications of the block. These trials do not require large sample population to demonstrate the correlation between treatment and effect as would be required to assess the safety of the block. Hence larger safety trials are needed. Additionally, a consensus needs to be developed regarding the safe dose and concentration of local anaesthetic solution to limit the systemic toxic complications of the block without affecting its analgesic efficacy.

Though our study identified areas for future research, it had certain limitations. The sample size of our trial was insufficient to assess the safety of the block. Also, the subjects were not followed up long term for the incidence of chronic pain. While all measures to conceal the group allocation were taken, true blinding may not have been possible since subjects in the study group reported less pain.

We would like to conclude that TAP block reduces pain, prolongs the time to first analgesic request and decreases supplemental opioid analgesic requirement when used as a component of multimodal analgesic regimen for pain relief after caesarean section. However, the risk of local anaesthetic systemic toxicity remains unknown with this block. Hence larger safety trials and measures to limit this complication need to be ascertained.

Abbreviations

Body Mass Index

Confidence Interval

Interquartile Range

Intravenous

Inferior Vena Cava

Local Anaesthetic Systemic Toxicity

Lower Segment Caesarean Section

Non-Steroidal Anti Inflammatory Drugs

Patient Controlled Analgesia

Standard Deviation

Transversus Abdominis Plane

Visual Analog Scale

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Ashok Jadon, Priyanka Jain, Swastika Chakraborty, Mayur Motaka, Sudhansu Sekhar Parida, Neelam Sinha, Amit Agrawal & Asit Kumar Pati

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AJ Statistical analysis, preparation of manuscript and revision of manuscript. PJ Acquisition of data, statistical analysis and preparation of manuscript. SC Conception of study design and preparation of manuscript. MM Acquisition of data and statistical analysis. SSP Conception of study design and revision of manuscript. NS Conception of study design and revision of manuscript. AA Statistical analysis and revision of manuscript. AKP Statistical analysis and revision of manuscript. All authors have read and approved the final manuscript.

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Correspondence to Priyanka Jain .

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The trial was approved by the Ethics & Scientific Committee of TATA Motors Hospital, Jamshedpur, Jharkhand. Written informed consent was obtained from all the participants of the study.

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Jadon, A., Jain, P., Chakraborty, S. et al. Role of ultrasound guided transversus abdominis plane block as a component of multimodal analgesic regimen for lower segment caesarean section: a randomized double blind clinical study. BMC Anesthesiol 18 , 53 (2018). https://doi.org/10.1186/s12871-018-0512-x

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Received : 12 January 2018

Accepted : 25 April 2018

Published : 14 May 2018

DOI : https://doi.org/10.1186/s12871-018-0512-x

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• Transversus abdominis plane block
• Caesarean section
• Spinal anaesthesia
• Post-operative pain
• Pain management

BMC Anesthesiology

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Clinical safety and effectiveness of transversus abdominis plane (TAP) block in post-operative analgesia: a systematic review and meta-analysis

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• Published: 07 March 2017
• Volume 31 , pages 432–452, ( 2017 )

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• Ning Ma   ORCID: orcid.org/0000-0002-3191-8688 1 ,
• Joanna K. Duncan 1 ,
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• Alun L. Cameron 1  

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Transversus abdominis plane (TAP) blocks can provide analgesia postoperatively for a range of surgeries. Abundant clinical trials have assessed TAP block showing positive analgesic effects. This systematic review assesses safety and effectiveness outcomes of TAP block in all clinical settings, comparing with both active (standard care) and inactive (placebo) comparators. PubMed, EMBASE, The Cochrane Library and the University of York CRD databases were searched. RCTs were screened for their eligibility and assessed for risk of bias. Meta-analyses were performed on available data. TAP block showed an equivalent safety profile to all comparators in the incidence of nausea (OR = 1.07) and vomiting (OR = 0.81). TAP block was more effective in reducing morphine consumption [MD = 13.05, 95% CI (8.33, 51.23)] and in delaying time to first analgesic request [MD = 123.49, 95% CI (48.59, 198.39)]. Postoperative pain within 24 h was reduced or at least equivalent in TAP block compared to its comparators. Therefore, TAP block is a safe and effective procedure compared to standard care, placebo and other analgesic techniques. Further research is warranted to investigate whether the TAP block technique can be improved by optimizing dose and technique-related factors.

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Acknowledgements

In addition to the article’s author, the systematic review was undertaken with the assistance of Dr. Yasoba Atukorale, Robyn Lambert, and Deanne Forel.

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Ma, N., Duncan, J.K., Scarfe, A.J. et al. Clinical safety and effectiveness of transversus abdominis plane (TAP) block in post-operative analgesia: a systematic review and meta-analysis. J Anesth 31 , 432–452 (2017). https://doi.org/10.1007/s00540-017-2323-5

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Bilateral transversus abdominis plane (TAP) block reduces pain and the need for additional analgesics after elective cesarean section under opioid-free spinal anesthesia: findings from a randomized clinical trial

• Massimo Antonio Innamorato 1   na1 ,
• Alessandro Vittori   ORCID: orcid.org/0000-0002-2377-3765 2   na1 ,
• Silvia Natoli 3 , 4 ,
• Paolo Perna 1 ,
• Ilaria Farinelli 5 ,
• Emiliano Petrucci 6 ,
• Marco Baciarello 7 ,
• Elisa Francia 2 ,
• Franco Marinangeli 8 ,
• Elena Giovanna Bignami 7 &
• Marco Cascella 9  

Journal of Anesthesia, Analgesia and Critical Care volume  3 , Article number:  20 ( 2023 ) Cite this article

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Cesarean section (CS) is the most frequently performed obstetric procedure globally, and postoperative pain remains a prominent concern. This study aimed to evaluate the effectiveness of the bilateral transversus abdominis plane (TAP) block in addressing this issue.

We performed a randomized trial in women with term pregnancies who underwent elective CS with spinal anesthesia. The women were randomized (1:1) to receive bilateral TAP or postoperative systemic analgesics (control group). The primary outcome was the effect on postoperative pain assessed using the numeric rating score (NRS) at 2, 6, 12, and 24 h in the postoperative period.

At 2 and 6 h after the surgical procedure, there was a significant reduction in both resting (rNRS p  = 0.004) and movement-related pain (dNRS p  = 0.0001, p  = 0.001 respectively). However, at 12 h, a reduction of dNRS was demonstrated ( p  = 0.0001), while no benefit was observed at rest. The percentage of women with NRS ≤ 4 was higher after the block at 2 h for both resting and movement-related pain (rNRS p  = 0.010; dNRS p  = 0.0001); at 6 and 12 h, it was only significant for dNRS ( p  = 0.002). Rescue doses of analgesics were significantly higher in the control group at 2, 6, and 12 h ( p  = 0.01, p  = 0.0383, p  = 0.0003 respectively). No complications with the procedure were recorded.

Bilateral TAP block has the potential to alleviate postoperative pain and reduce the need for additional analgesics after CS.

Trial registration

This study is registered with ClinicalTrials.gov, number (NCT02801968), registered 28 May 2016, https://clinicaltrials.gov/ct2/show/NCT02801968?term=NCT02801968&draw=2&rank=1

Cesarean section (CS) is a widely practiced surgical procedure worldwide, with approximately 20% of women currently undergoing this method of delivery [ 1 ]. Moreover, since the incidence of CS is increasing in recent decades [ 2 ], it is important to define optimal strategies for perioperative management.

One crucial aspect is the management of postoperative pain as moderate-to-severe pain is reported in up to 80% of women [ 3 ]. This represents a significant challenge given that providing women who undergo a CS with optimal postoperative analgesia is crucial for effective pain control and has wide-ranging positive impacts. Effective pain relief, for example, improves mobility, facilitating recovery and engagement in daily activities [ 4 ]. Furthermore, a fruitful pain management strategy also promotes successful breastfeeding, contributing to the health and well-being of both the mother and the neonate. Additionally, adequate pain control enhances the maternal bond with the neonate, enabling mothers to engage in crucial activities such as skin-to-skin contact, holding and caring for their infants, and establishing a deep emotional connection. Moreover, inadequate pain control could also lead to the development of chronic pain in approximately 12% of patients [ 5 ] and trigger postpartum depressive syndromes [ 6 ]. Therefore, optimal pain management supports the development of a strong and loving relationship between mother and neonate and can prevent the occurrence of postoperative complications.

There are several approaches utilized to enhance post-cesarean analgesia and ensure adequate pain management. These include the systemic administration of opioids, the use of non-steroidal anti-inflammatory drugs (NSAIDs), regional anesthetic techniques (spinal with low-dose intrathecal morphine or other opioids, and epidural anesthesia), regional nerve blocks, wound infiltration or continuous wound infusion, and the implementation of patient-controlled analgesia [ 7 ]. Multimodal analgesic approaches involve combining different medications and techniques to target pain from various angles. Consequently, synergistic pain relief can be achieved with lower doses and reduced side effects [ 8 ].

Following a CS, women may experience both somatic pain, originating from the abdominal wall incision, and visceral pain caused by the uterus. The predominant source of discomfort is often the abdominal wall, which is of somatic origin. Transversus abdominis plane (TAP) block is a regional anesthesia technique that involves injecting a local anesthetic into the transversus abdominis (TA) plane. It is a triangular fascial plane located between the internal oblique (IO) and the TA muscles. The interstitial space mentioned encompasses the intercostal, subcostal, iliohypogastric, and ilioinguinal nerves. Since these nerves innervate the anterior and lateral abdominal wall as well as the parietal peritoneum, this block can provide targeted pain relief to the incision site and surrounding areas, reducing the need for systemic analgesics and improving postoperative comfort [ 9 ].

We performed a prospective, randomized trial comparing postoperative pain relief after TAP block versus systemic analgesia in patients undergoing elective CS with opioid-free spinal anesthesia. We hypothesized that TAP block would provide better pain control compared with systemic administration of opioids and non-opioid agents.

Materials and methods

The study was approved by the Research Ethics Committee of the institution (Ethical Committee Area Vasta Romagna), opinion 1574, on April 13, 2016 and it was registered with ClinicalTrials.gov, number (NCT02801968). It was carried on in accordance with the Helsinki Declaration. This investigation adheres to the Consolidated Standards of Reporting Trials (CONSORT) guidelines [ 10 ].

Trial design and procedures

From June 1, 2016, through June 30, 2016, we conducted a single-center randomized clinical trial at the Obstetric Anesthesia Unit, Santa Maria Hospital, Ravenna, Italy. Enrollment for the study included women who were at least 18 years old and had term pregnancies with a gestational age ranging from 37 to 42 weeks. These women were scheduled to undergo elective CS under spinal anesthesia. Details of the inclusion and exclusion criteria can be found in Table  1 .

All women then received intrathecal hyperbaric bupivacaine hydrochloride 12.5 mg (0.5%). After the end of the surgery, eligible women were randomized in a blinded 1:1 ratio and assigned to a treatment group:

Bilateral TAP block for postoperative analgesia. The TAP block was performed under ultrasound (US) guidance with a 6–15 MHz linear transducer. Patients were scanned in the supine position between the inferior margin of the 12th rib and the iliac crest, along the midaxillary line to find the best visualization of the obliquus externus, OI, and TA muscles. A 150-mm 20 G needle (Ultraplex ®, B. Braun Milano, Milan, Italy) was used to inject 0.5% ropivacaine (20 mL on each side). Postoperative analgesia was provided with tramadol (100 mg IV) q8h and acetaminophen 1000 mg q8h. Rescue doses with analgesics were allowed (ketorolac 30 mg, max 90 mg/day).

Standard systemic intravenous postoperinative analgesia with IV tramadol 100 mg q8h, acetaminophen 1000 mg q8h, and ketorolac 30 mg prn q8h.

The primary endpoint of the study focused on evaluating the impact of the intervention on postoperative pain levels. Pain intensity was assessed using the numeric rating score (NRS) at specific time points within the postoperative period, including 2, 6, 12, and 24 h. We recorded pain intensity both at rest (rNRS) and during voluntary contraction of the abdominal muscles (dynamic, dNRS). Furthermore, the percentage of women with an NRS score of 4 or lower was also considered.

The secondary objective of the study was to assess the postoperative consumption of the nonsteroidal anti-inflammatory drug (NSAID) ketoprofen, patient satisfaction, and the occurrence of block-related side effects including local anesthetic systemic toxicity due to intravascular injection, neurologic injury (e.g., nerve trauma from the needle), visceral trauma, and vascular injury.

Patients’ overall satisfaction was registered 24 h postoperatively. Participants were asked to assess their level of satisfaction based on their experience by using a three-tier scale including “very satisfied,” indicating a high degree of contentment; “satisfied,” indicating a general sense of satisfaction; and “dissatisfied,” indicating a lack of satisfaction or dissatisfaction.

Sample size calculation and statistical analysis

The null hypothesis of the study postulated that there would be no significant reduction in pain intensity 12 h after the surgical procedure. In order to ascertain a ~ 70% difference in intensity with a risk of type I error ≤ 5% and of type II error ≤ 20%, we calculated that a sample size of 31 per group was necessary. Data were reported as median (interquartile range, IQR) or number (percentage of the group). Group results were compared with t tests, Mann–Whitney, and χ 2 tests, according to data distribution. Data manipulation and analysis were done in Microsoft Excel, SPSS Statistics 20, and MedCalc.

A total of 65 women scheduled for CS were screened for eligibility. Of these, 62 met the criteria for inclusion in the study. Three women were excluded due to refusal of the regional analgesic technique ( n  = 2) and due to chronic use of analgesics ( n  = 1). After allocation, all the women completed the study (Fig.  1 ).

CONSORT flow diagram

There were no significant differences in baseline characteristics between the two groups (Table  2 ).

Primary endpoint

Postoperative resting and dynamic pain.

Two hours after the completion of the surgical procedure, compared to the control group, the TAP block group reported a statistically significant reduction in NRS values both at rest ( p  = 0.004) and during movement ( p  = 0.0001).

In 6 h, a statistically significant reduction in NRS values was observed both at rest ( p  = 0.001) and during movement ( p  = 0.004).

After 12 h, the mean NRS value at rest did not show significant differences between the two groups ( p  = 0.058); however, the mean NRS value during movement (dNRS) was significantly lower in the TAP block group ( p  = 0.0001).

At 24 h, no significant difference in pain was observed between the two groups, both at rest ( p  = 0.067) and during movement ( p  = 0.218) (Table  3 ).

Pain control in the two groups (NRS ≤ 4)

Following the end of the intervention, 2 h later, 95% of women in the TAP block group reported an NRS value ≤ 4 at rest compared to 78% in the control group ( p  = 0.010) (Fig.  2 ).

Pain at rest. Legend: A value below 4 on the NRS scale was considered. On the y axis, the percentage of patients. * p  < 0.05; ** p  < 0.01; *** p  < 0.001; **** p  < 0.0001

During movement, 79% of the patients in the TAP block group had an NRS ≤ 4 compared to 35% in the control group ( p  = 0.0001) (Fig.  3 ).

Pain during voluntary contraction of the abdominal muscles. Legend: A value below 4 on the NRS scale was considered. On the y-axis, the percentage of patients. * p  < 0.05; ** p  < 0.01; *** p  < 0.001; **** p  < 0.0001

At 6 h, the proportion of patients with an NRS ≤ 4 at rest at 6 h was very similar in the two groups, 96% and 93% respectively ( p  = 0.553) (Fig.  2 ), while during movement, the TAP block group had a proportion of patients with an NRS ≤ 4 of 64% compared to 30% in the control group, with a statistically significant difference ( p  = 0.002) (Fig.  3 ).

After 12 h, all the patients in the TAP block group (100%) reported an NRS ≤ 4 at rest 12 h after the surgical procedure compared to 93% in the control group ( p  = 0.154) (Fig.  2 ). During movement, 48% of the patients in the TAP block group had an NRS ≤ 4 compared to only 30% in the control group ( p  = 0.002) (Fig.  3 ).

After 24 h, all the patients in the TAP block group reported an NRS ≤ 4 at rest 24 h after the surgical procedure compared to 96% in the control group ( p  = 0.313). During movement, 74% of the patients in the TAP block group had an NRS ≤ 4 compared to 70% in the control group ( p  = 0.775) (Fig.  3 ).

Secondary endpoint

The use of NSAIDs differed significantly between the two groups after the administration of the block at 2, 6, and 12 h. In the TAP block group, no patients required additional analgesia 2 h after the surgical procedure, while in the control group, NSAIDs were administered to a total of 6 patients ( p  = 0.01). At 6 h, the consumption of ketoprofen differed significantly between the two groups ( p  = 0.0383), as well as at 12 h ( p  = 0.0003). There was no difference between the two groups at 24 h ( p  = 0.640) (Figs. 4 and 5 ).

Postoperative rescue doses of ketoprofen. Legend: * p  < 0.05; ** p  < 0.01; *** p  < 0.001; **** p  < 0.0001

Patients’ overall satisfaction registered 24 h postoperatively

There were no complications during the performance of the TAP blocks.

Bilateral US-guided TAP block combined with opioid-free spinal anesthesia, as compared with a regimen of systemic opioids and no-opioid analgesics, mitigated the intensity of postoperative pain following CS. At 2 and 6 h after the surgical procedure, there was a significant reduction in both resting and movement-related pain. However, at 12 h a reduction in pain during movement was demonstrated, while no benefit was observed at rest. The proportion of women experiencing NRS scores of 4 or lower was higher in the block group at 2 h for both resting pain and pain during movement. At 6 and 12 h, a significant difference was observed only for pain during movement. These findings strongly confirm results from evidence-based analyses [ 11 , 12 ] and suggest further investigations to refine the technique, molecules, and dosages to be used.

The TAP block is an effective and safe locoregional anesthesia technique used in numerous surgical procedures with excellent results [ 13 ]. Several studies have shown that this strategy may reduce pain after CS in the context of multimodal analgesia including intrathecal or systemic morphine and other opioids [ 6 , 14 ]. However, in our protocol, the intraoperative administration of agents belonging to this class of drugs was not planned. This data is of utmost importance considering the potential short-term and long-term side effects attributed to perioperative opioids [ 15 , 16 , 17 ]. For example, while low-dose intrathecal morphine is widely regarded as the preferred method for postoperative pain management following a CS section performed under spinal anesthesia, it carries the risk of undesired opioid-related side effects including pruritus, nausea, vomiting, urinary retention, and sedation [ 18 ].

During the initial hours after the cesarean section, the implementation of the TAP block procedure exhibited a notable improvement in analgesic efficacy, effectively alleviating both resting and movement-related pain experienced by the mothers. This substantial pain relief provided a considerable advantage, contributing to overall comfort and well-being. However, it is particularly noteworthy that the most significant impact of the procedure was observed at the 12-h mark, specifically in relation to pain experienced during movement. This finding carries paramount importance as it underscores the potential of the TAP block technique to facilitate and enhance maternal activities, particularly during critical moments of mother-infant integration. By effectively reducing pain during movement, the TAP block can offer mothers a greater degree of mobility and physical comfort, enabling them to actively engage in essential tasks such as breastfeeding and caring for their newborns. These activities, which are crucial for establishing a strong maternal bond, are often hindered by postoperative pain [ 4 ].

In our study, the superiority of TAP over the control group decreased at the 12 h and the 24th hour. However, the assessment of the pain indices reveals that both enrollment groups achieved satisfactory levels of pain control (Table  3 ). This highlights the effectiveness of a multimodal approach. In fact, during these intervals, there were fewer rescue doses administered (Fig.  4 ) and a higher percentage of patients reported NRS < 4 (Figs.  2 and 3 ). This data is noteworthy because, according to several studies, intrathecal morphine provides superior analgesia compared to TAP blocks up to 24 h after CS [ 19 , 20 ].

Despite the use of ropivacaine has likely resulted in a longer duration of analgesic effect, the decrease in the usage of supplementary analgesic medications is significant in the TAP group at 2, 6, and 12 h, after which the block no longer ensures pharmacological savings. Other authors have employed plain bupivacaine; however, it has a short duration of analgesia (approximately 5–8 h) [ 6 ]. In other experiences, liposomal bupivacaine has been utilized [ 21 ]. This is another viable alternative to increase the duration of the block; however, this drug is not always readily available, and its use does not appear to be associated with cost reduction [ 22 ].

In contrast to the findings of previous studies [ 23 ], which reported improvements in perceived quality among patients, our research did not observe a similar outcome. This discrepancy could potentially be attributed to the methodology employed in our study. It is possible that the use of a more comprehensive and validated tool, such as a detailed questionnaire or a Likert scale, would have provided a more accurate assessment of patients’ perceptions.

Study limitations

This study is limited to a single center, meaning that the findings may be influenced by specific characteristics and practices unique to that particular institution. While efforts were made to include a diverse study population, the generalizability of the results may be influenced by this limitation. Nevertheless, the procedure was performed by experienced anesthesiologists using a standardized technique.

This study acknowledges a limitation in the lack of data regarding general postoperative complications such as nausea and vomiting, and pruritus. In a recent investigation, these complications were most frequent in the study group of TAP plus spinal anesthesia, compared to general anesthesia, and peridural anesthesia, combined or not with the regional block [ 6 ]. On the other hand, the correlation between the decrease in opioid usage and a reduction in opioid-related side effects is not consistently supported by the evidence and remains inconclusive [ 19 ]. To address this gap, future research should consider incorporating comprehensive assessment and reporting of these complications. This could involve implementing standardized protocols for monitoring and documenting postoperative symptoms. Additionally, collecting patient-reported outcomes and conducting follow-up assessments can provide valuable insights into the occurrence and impact of these complications.

One limitation of our study is the reliance on opioids (tramadol) for postoperative pain control. However, it is important to note that cesarean delivery involves not only somatic pain originating from the abdominal incision but also visceral pain due to the manipulation of the uterus and other internal organs. This dual nature of pain presents a challenge in effectively managing postoperative pain with a single intervention. Although the TAP block has shown promising results in reducing somatic pain, it primarily targets the nerves innervating the abdominal wall and may not adequately address the visceral pain component. Therefore, relying solely on the TAP block for pain management may not provide optimal relief for the comprehensive pain experience after cesarean delivery.

Conclusions

In the context of multimodal analgesia that excludes intraoperative opioids, the TAP block procedure demonstrates its efficacy in providing analgesia during the early hours after a CS. The impact on relieving pain during movement highlights its potential to support and enhance critical maternal activities. The reduced use of analgesic drugs is a significant advantage, potentially minimizing the acute and long-lasting associated side effects. Additional research is necessary to enhance and optimize the TAP-based multimodal strategy, explore different molecules, and determine appropriate dosages.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from Massimo Antonio Innamorato on reasonable request.

Abbreviations

Body mass index

• Cesarean section

Dynamic numeric rating scale

International normalized ratio

Internal oblique

Numeric rating score

Resting numeric rating score

Non-steroidal anti-inflammatory drug

Transversus abdominis

Transversus abdominis plane

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Acknowledgements

The authors would like to thank the study participants for the cooperation.

This work was supported also by the Italian Ministry of Health with “Current Research funds”.

Author information

Massimo Antonio Innamorato and Alessandro Vittori contributed equally to this work as two formal first authors.

Authors and Affiliations

Department of Neuroscience, Santa Maria Delle Croci Hospital, AUSL Romagna, Pain Unit, 48121, Ravenna, Italy

Massimo Antonio Innamorato & Paolo Perna

Department of Anesthesia and Critical Care, ARCO Roma, Ospedale Pediatrico Bambino Gesù IRCCS, 00165, Rome, Italy

Alessandro Vittori & Elisa Francia

Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, 00133, Rome, Italy

Silvia Natoli

IRCCS Maugeri Pavia, 27100, Pavia, Italy

Department of Anesthesia and Critical Care, Ospedale Maggiore Carlo Alberto Pizzardi, 40133, Bologna, Italy

Ilaria Farinelli

Department of Anesthesia and Intensive Care Unit, San Salvatore Academic Hospital of L’Aquila, 67100, L’Aquila, Italy

Emiliano Petrucci

Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, 43126, Parma, Italy

Marco Baciarello & Elena Giovanna Bignami

Department of Anesthesiology, Intensive Care and Pain Treatment, University of L’Aquila, 67100, L’Aquila, Italy

Franco Marinangeli

Department of Anesthesia and Critical Care, Istituto Nazionale Tumori-IRCCS, Fondazione Pascale, 80131, Naples, Italy

Marco Cascella

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Contributions

M.A.I. and A.V. contributed equally to the work as two formal first authors. Conceptualization, M.A.I., A.V. and M.C..; methodology, M.A.I.,A.V.,S.N., M.B.,P.P.,I.F. and M.C..; software, M.A.I., A.V. and M.C.; validation, M.A.I., A.V., M.B. and M.C. ; formal analysis, M.A.I., A.V. and M.C.; investigation, M.A.I., A.V., S.N., P.P., I.F., E.P., E.F., M.C., F.M., E.G.B and M.C.; resources, M.A.I. and P.P.; data curation, M.A.I, A.V., P.P. I.F., M.B. and M.C.; writing-original draft preparation, M.A.I., A.V., M.B. and M.C.; writing—review and editing, M.A.I., A.V., S.N., P.P., I.F., M.B., E.P., E.F., F.M, E.G.B. and M.C.; visualization A.V. and M.C..; supervision, A.V, S.N., E.G.B. and M.C..; project administration: M.A.I., A.V., S.N., F.M., E.G.B. and M.C. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Alessandro Vittori .

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The study was approved by the Research Ethics Committee of the institution (Ethical Committee Area Vasta Romagna), opinion 1574, on April 13, 2016; all study participants signed the informed consent. All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards.

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Innamorato, M.A., Vittori, A., Natoli, S. et al. Bilateral transversus abdominis plane (TAP) block reduces pain and the need for additional analgesics after elective cesarean section under opioid-free spinal anesthesia: findings from a randomized clinical trial. J Anesth Analg Crit Care 3 , 20 (2023). https://doi.org/10.1186/s44158-023-00106-6

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DOI : https://doi.org/10.1186/s44158-023-00106-6

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The efficacy of TAP block versus ilioinguinal block for post-cesarean section pain management: A systematic review and meta-analysis

Affiliation.

• 1 Department of Anesthesia, School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia.
• PMID: 34430749
• PMCID: PMC8367791
• DOI: 10.1016/j.heliyon.2021.e07774

Background: Controversy still exists regarding the analgesic efficacy of transverse abdominis plane (TAP) block versus ilioinguinal or iliohypogastric (IL/IH) nerve block for postoperative pain management following cesarean section. This meta-analysis aimed to perform relatively credible pooled results on the efficacy of the TAP versus IL/IH nerve block for postoperative pain management after cesarean section.

Methods: Databases such as: PubMed/MEDLINE, Google scholar, and google were systematically searched. studies compared the analgesic efficacy of TAP versus IL/IH nerve block for postoperative pain management following cesarean section were included. Data were extracted by three reviewers independently by using Microsoft Excel and then exported to STATA™ 16 version statistical software for analysis. We used a random-effects model meta-analysis and the mean difference of analgesic efficacy with a 95 ​% confidence interval was reported based on Preferred Reporting Items for systematic reviews and meta-analysis (PRISMA).

Results: Five studies with a total of 390 (196 in TAP and 194 in IL/IH) study participants were included in this meta-analysis. No statistically significant difference was observed between the TAP and IL/IH groups in time to first rescue analgesic request, total postoperative analgesic consumption in milligrams of intravenous tramadol equivalence, and post pain severity score at different points of time both rest and movement.

Conclusion: This meta-analysis revealed that both approaches have similar postoperative analgesic efficacy following cesarean section. we recommend that the clinician may consider either approach for post-cesarean section pain management.

Keywords: Cesarean section; IL/IH block; Meta-analysis; TAP block.

© 2021 The Author(s).

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Conflict of interest statement

The authors declare no conflict of interest.

PRISMA flow diagram showing search…

PRISMA flow diagram showing search strategies.

Time to first rescue analgesia…

Time to first rescue analgesia request in minute.

Subgroup analysis by nerve block…

Subgroup analysis by nerve block techniques.

Subgroup analysis by study design.

Intravenous equivalent total tramadol consumption…

Intravenous equivalent total tramadol consumption at 24 h postoperatively.

Intravenous equivalent total tramadol consumption at 48 h postoperatively.

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The new trending pain-free cesarean section: TAP block versus IV PCA

• Sondos M. Salem 1 ,
• Mazen Abdel-Rasheed 1 ,
• Mohammad A. Gouda 2 &
• Sameh Salama 1  

Bulletin of the National Research Centre volume  45 , Article number:  132 ( 2021 ) Cite this article

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Women's pain satisfaction post-cesarean section remains a challenge. Accurate assessment of pain severity of post-cesarean section helps to choose the most appropriate anesthetic approach, drug, and dose, as well as improvement of treatment of postoperative pain. Our objective was to compare the efficacy of ultrasound-assisted transversus abdominis plane (TAP) block versus IV patient-controlled analgesia (PCA) in the first 24 h postoperative in women who underwent cesarean section. The primary outcome was postoperative pain at 2, 4, 6, 12, and 24 h. The secondary outcomes were intestinal mobility, early mobilization, nausea, vomiting, heart rate, and respiratory rate.

A cross-sectional study has been conducted on 70 women who are planned for elective cesarean section. They were divided into 2 groups; “group A” ( n  = 35), women who received TAP block, and “group B” ( n  = 35), those who received PCA. Pain score, heart rate, respiratory rate, intestinal motility, nausea, and vomiting have been assessed 2, 4, 6, 12, and 24 h postoperatively. The degree of pain was significantly lower in “group B” than in “group A” in all time intervals ( p  < 0.001). Heart rate was significantly higher in women in “group B” compared to those in “group A” only at 2 and 4 h postoperative ( p  < 0.001). Nausea and vomiting were also significantly higher in women in “group B” compared to those in “group A” ( p value 0.03 and 0.04, respectively). Regarding intestinal motility, it was audible in “group A” earlier than in “group B.”

Conclusions

Both TAP block and PCA are effective in postoperative pain relief after cesarean section; however, PCA is more superior, especially for visceral pain. Nevertheless, TAP block has the privilege of avoiding systemic action of opioids used in PCA. PCA can easily be applied while TAP block needs more training and an intraoperative ultrasound machine. Complications and side effects of both were minimal when adjusting the doses.

Recent literature has reported that worldwide, including Egypt, there has been a dramatic surge in the cesarean delivery rate (Mobarak and Sultan 2019 ). Such surge is accompanied by increased women's awareness and demands for pain-free techniques during and after the surgery. This motivates obstetricians to use new approaches and methodologies rather than the routine methods of postoperative analgesia. Normally, uncomplicated cesarean section (CS) may result in moderate to severe pain during the first 48 h following surgery (Gerbershagen et al. 2013 ). Hence, pain relief is critical, as it affects both the mother and her care for the newborn. Moreover, insufficient pain control may badly influence recovery, mother–infant bonding, which in turn could lead to more persistent postsurgical pain. Women undergoing cesarean delivery have further compelling reasons to receive sufficient pain relief since early mobilization represents an essential factor that decreases the risk of thrombo-embolic disease, which is known to be increased throughout pregnancy and puerperium. Relieving pain in such women improves their care for the newborn and helps them breastfeed efficiently (DiNicola 2011 ).

There are many various methods to control postoperative pain. However, searching for the best method is still ongoing. Several techniques have been used. Nevertheless, using opioids throughout different routes is still the gold standard (Taneja et al. 2017 ).

In cesarean delivery, TAP block represents a convenient primary analgesic for women not receiving neuraxial morphine for any reason. TAP block is an assisting analgesic technique used to decrease either the use of opioids during the intraoperative period or the use of systemic analgesics for postoperative pain management. The TAP block is a field block of the thoracolumbar nerves, running in the fascial plane between the internal oblique muscle and the transversus abdominis muscles. The anterior primary rami course between the internal oblique and the transversus abdominis muscles and subsequently branch into the lateral and anterior cutaneous nerves at approximately the midaxillary line (Tsai et al. 2017 ).

Patient-controlled analgesia “PCA” results in greater patient satisfaction, as it is more effective to relieve pain than non-patient opioid injections (McNicol et al. 2015 ). Moreover, PCA is recommended for women in labor pain. Pain accompanying contractions, particularly when intensified by the use of induction agents, i.e., oxytocin, can be effectively controlled and minimized (Srivastava et al. 2009 ). The purpose of using PCA is to effectively control pain at a desired dose and schedule. This is done by allowing patients to administer a predetermined bolus dose of medication on demand. Each bolus could be administered alone or together with another medication. However, PCA is used for the treatment of acute, chronic, postoperative, and labor pain. The most commonly used drugs are opioids and local anesthetics, although other analgesics can be used (Mann et al. 2005 ).

Our objective was to compare the efficacy of ultrasound-assisted transversus abdominis plane (TAP) block versus IV patient-controlled analgesia (PCA) in the first 24 h postoperative in women who underwent cesarean section. The primary outcome was postoperative pain at 2, 4, 6, 12, and 24 h. The secondary outcomes were intestinal mobility, early mobilization, nausea, vomiting, heart rate, and respiratory rate.

Our study is a pilot cross-sectional study. It is a multicentric study as it was conducted in 3 different private hospitals (El-Nada, Al-Safwa, and Al-Zohour hospitals) at 6th October City, Giza, Egypt, from January 2020 to September 2020. The medical board of Al-Zohour hospital endorsed the ethical approval for this study.

Seventy pregnant women with repeated elective cesarean sections were included if they fulfilled the following criteria: age from 20 to 35 years, gestational age from 37 to 39 weeks, body mass index (BMI) 20–30 kg/m 2 , hemoglobin level above 11 g/dl, and history of previous CS to have a previous experience with postoperative pain. Women with only one previous cesarean section and no contraindication for vaginal delivery have been offered vaginal delivery after cesarean section, and those who denied have been included in the study.

Pregnant women with any of the following medical disorders have been excluded from the study; diabetes, hypertensive disorders with pregnancy, coagulation disorders, depression, chronic pelvic pain, allergy to analgesic drugs, and any psychological disorders.

Participating women were classified into 2 groups: “group A” ( n  = 35), women who received TAP block, while “group B” ( n  = 35) received PCA. Pregnant women were recruited to participate in the study from the outpatient antenatal clinic when the elective CS was scheduled. The following were done for the participating women: complete medical history, obstetric history, routine antenatal and preoperative investigations checked, antenatal fetal growth monitoring by ultrasound and Doppler when needed. All women asked for new trends in relieving pain as TAP block or PCA were counseled preoperatively, and oral explanation, using no medical jargon, was given to all women, and written consent was taken.

All women were operated on under spinal anesthesia by a consultant obstetrician. All women had uncomplicated cesarean sections with minimal blood loss < 500 ml. After the end of the operation, consultant anesthetist under aseptic precautions introduced TAP block under ultrasound guidance with a single injection as follows: The needle was introduced in the plane of the ultrasound probe directly under the probe and advanced until it reached the plane between the internal oblique and transversus abdominis muscles. The probe followed the needle entry point in order to avoid intraperitoneal injection, intramuscular, or even intravascular injections. Aspiration was done before injection to ensure that all local anesthetic (LA) was in the right plane.

Upon reaching the plane, 2 ml of saline was injected to confirm the correct needle position (hydro-dissection), after which 20 ml of local anesthetic solution is injected. We used 0.2% isobaric marcaine and 0.5% lidocaine (Sigma Tec pharmaceutical, Egypt) in order to decrease local anesthetic systemic toxicity (LAST) and to take advantage of the synergistic effect of both drugs, marcaine 8 ml and lidocaine 5 ml. Then, 7 ml saline was injected. The transversus abdominis plane is visualized expanding with the injection (appears as a hypoechoic spread) (Tsai et al. 2017 ).

For women chose to have PCA for postoperative pain relief, an elastomeric PCA pump single-use with 300 ml capacity was used. A basal 8 ml/hour infusion of analgesic-containing infusion with a button was used to give an additional bolus dose of 1 ml with a lockout time of 15 min. Nalbuphine 80 mg (Amoun pharmaceutical), ketolac 120 mg (Amriya pharm, Egypt), and granitryl 3 mg (Egyphar, Egypt) were used. The rest of the bottle was normal saline.

Postoperative follow-up of all women was done at those intervals: 2 h (after cessation of the effect of spinal anesthesia), 4 h, 6 h, 12 h, and 24 h postoperatively. The following data were recorded: nausea, vomiting, pain score, heart rate, respiratory rate, uterine contractility by fundal level, intestinal mobility, time to start mobilization, need for additional analgesics. Maternal pain score was evaluated and documented in the patients' notes in the maternity ward. A numeric rating scale (NRS) was used. The pain was rated at 2, 4, 6, 12, and 24 h after surgery. The pain scale ranged from 0 (= no pain) to 10 (= worst pain imaginable) (Safikhani et al. 2018 ).

Statistical analysis

Statistical Package for the Social Sciences “SPSS” v. 25 was used to perform all statistical analyses. Quantitative parameters were expressed as mean ± standard deviation, while numbers and percentages were used for categorical variables. To compare group 1 with group 2, we used the independent samples t test, while differences in frequencies were analyzed using the chi-square test. p value < 0.05 was considered to be statistically significant.

The present study results revealed that no significant differences were detected between both groups regarding age, BMI, and the number of previous cesarean sections (Table 1 ). Although pain sensation degree (using NRS) is decreased in both groups along the first 24 h postoperative, the NRS values were significantly lower in the PCA group “group B” than in the TAP block group “group A” ( p  < 0.001) (Table 2 ).

Heart rate was significantly higher in women in “group B” compared to those in “group A” at 2 and 4 h postoperatively ( p  < 0.001); however, there is no significant difference between both groups in other time periods ( p  > 0.05). Concerning respiratory rate, there is no significant difference between both groups in all time periods ( p  > 0.05). On the contrary, nausea, and vomiting were significantly higher in women in “group B” compared to those in “group A” (P value 0.03 and 0.04, respectively) (Table 3 ).

Regarding intestinal motility, it was observed to be audible in “group A” earlier than “group B.” At 2 h postoperative, intestinal motility was found significantly audible in “group A” than in “group B,” while there is no significant difference between both groups at 6 and 24 h postoperative (Table 4 ).

Surgery and anesthesia represent critical healthcare services, aiming to minimize the risk of mortality and disability. Moreover, anesthetic measures help to reduce the incidence and intensity of acute pain during and immediately after surgery (Gan 2017 ).

As the cesarean section rate increased steeply all over the world, obstetricians and anesthetists should search for optimal pain management techniques to improve postoperative outcomes and patient satisfaction. Accurate assessment of pain severity of post-cesarean section helps to choose the most appropriate anesthetic approach, drug, and its dose, as well as improvement of treatment of postoperative pain. However, the ideal route and dose of the postoperative analgesia after CS are still debatable.

This study was conducted on 70 women who had at least one previous CS without TAP block or PCA, so they can compare their past experience of pain with the pain-relieving techniques used in this study. We selected all our women with an age range of 20–25 years (in their reproductive age). The BMI was chosen to be 20–30 kg/m 2 in order not to have any weight influence on postoperative mobility that could affect our results. We have excluded women with systemic medical disorders that could affect their heart rates, intestinal mobility, or their perception and expression of pain.

Women were classified into “group A” received TAP block, and “group B” received PCA. Data analysis showed no significant differences between both groups regarding age, BMI, and the number of previous cesarean sections. However, the PCA was superior in postoperative pain relief rather than TAP block.

In our study, we used 0.2% isobaric marcaine and 0.5% lidocaine in order to decrease local anesthetic systemic toxicity (LAST) and to take advantage of the synergistic effect of both drugs and marcaine 8 ml, lidocaine 5 ml; then, 7 ml saline was injected. The toxicity of local anesthesia in truncal regional anesthesia blocks can exceed a systemic threshold. This had been confirmed in a recent meta-analysis done by Rahiri et al. via assessing the systemic concentrations of local anesthesia after perioperative single-shot TAP or rectus sheath block. They discovered that 8.6% of patients had systemic concentrations that were higher than the widely agreed threshold for LAST (Rahiri et al. 2017 ).

However, the anesthesiologists are facing the challenge of finding a balance between utilizing a LA, which provides effective analgesia while minimizing the risk of LAST. Higher sensitivity can increase the risk of LAST in pregnancy as a result of altered physiology. However, reduced protein binding, higher vascularity, cardiac activity, and tissue blood flow, as well as increased neuronal susceptibility to LA, can all be clarified. Because of the consequences of pregnancy, TAP block for CS necessitates the administration of significant amounts of local anesthesia agent bilaterally in such a highly vascular region (Tsen et al. 1999 ; Ng et al. 2018 ).

In the present study, after a detailed explanation about techniques' pros and cons, both techniques have been accepted by women. NRS is one of the most commonly used pain scales in medicine. It is highly recommended, as the optimal response scale, to assess pain among adult patients without cognitive impairment (Safikhani et al. 2018 ).

The present study revealed that, although pain sensation degree (using NRS) is decreased in both groups along the first 24 h postoperative, the NRS values were significantly lower in PCA group “group B” than in TAP block group “group A” ( p  < 0.001) (Table 2 ).

The meta-analysis carried out by Champaneria et al. ( 2016 ) evaluated and compared TAP block for acute pain relief following CS to normal/control practice. The study concluded that, for pain at rest and pain with movement, TAP block was more efficient than control, i.e., TAP block significantly controls pain at rest when compared with placebo or no TAP block (Champaneria et al. 2016 ).

Similarly, a meta-analysis by Mishriky et al. ( 2012 ) showed that post-cesarean TAP block is associated with lower pain scores at rest (6 and 12 h) and with movement (6 and 12 h) (Mishriky et al. 2012 ). So, TAP block appears to be beneficial for postoperative analgesia based on this available evidence. Overall, the studies concluded that TAP block reduces the need for opioids and can reduce pain scores in the first 12 h following CS. Regarding the effectiveness of TAP block to control pain following cesarean delivery, our findings are in agreement with other previous studies as participant women already had a past experience with postoperative pain during their previous cesarean sections. However, those studies did not compare TAP block with PCA for post-cesarean pain relief. They compared the TAP block technique to the routine postoperative medications given post-cesarean.

In 2018, Ng et al. carried out a meta-analysis to evaluate the efficacy of a high dose of TAP block versus a low one given. The results of their meta-analysis revealed that both groups (low-dose and high-dose groups) showed similar postoperative analgesia and opioid-sparing effects (opioid consumption, time-to-first request, 24 h pain scores). As a result, it was concluded that there would be no enhanced advantage of local anesthetic above a certain dosage threshold. Furthermore, low-dose approaches for post-cesarean TAP block can reduce the risk of local anesthetic toxicity while maintaining analgesic efficacy (Ng et al. 2018 ). This comes in concordance with our results.

In our study, women who received IV PCA “group B” had pain scores significantly lower than those in those TAP block “group A” after 2, 4, and 6 h. Nalbuphine has been chosen rather than morphine to reduce the well-known side effects of morphine, e.g., respiratory depression, pruritus, and postoperative nausea vomiting. Nalbuphine, on the other hand, being μ antagonist and ƙ agonist, has a ceiling effect in its respiratory depression; hence, it is considered to be safer than morphine. The incidence of adverse effects like pruritus and PONV is lower with nalbuphine than morphine (Gal et al. 1982 ). Yeh et al. (2008) used different combinations of morphine and nalbuphine and found no difference in PCA requirements in the postoperative period in patients undergoing open gynecological surgeries (Yeh et al. 2008 ).

The superiority of PCA over TAP block regarding pain relief and patient satisfaction might be due to the effect of combinations of PCA drugs systemically, affecting visceral pain, in contradiction with TAP block, which acts on somatic pain only in the anterior abdominal wall. On the contrary to our results, Erbabacan et al. ( 2015 ) concluded that, in lower abdominal surgeries, 30 mL of TAP block is as effective as intravenous PCA in pain treatment. In addition, comparing intravenous PCA with TAP block revealed that the latter is regarded as a more superior approach since it can avoid the systemic actions of morphine used for PCA and as its analgesic effect starts earlier (Erbabacan et al. 2015 ). However, this study was carried out on lower abdominal surgeries, not cesarean sections that exclude the pain from postoperative uterine contractions.

The results of the present study revealed that heart rate was significantly higher in women in “group B” compared to those in “group A” at 2 and 4 h postoperative ( p  < 0.001); however, there is no significant difference between both groups in other time periods ( p  > 0.05). This might be due to the vasodilating effect of nalbuphine used in IV PCA. Thus, our findings were consistent with those concluded by Erbabacan et al. ( 2015 ), where heart rate values were found to be significantly lower in the TAP block group than in the PCA group. However, this can be attributed to less sympathetic system activation accompanied by less pain sensation in patients. Although findings do not support such effect due to the absence of significant difference between the mean values of arterial pressure, this effect can be attributed to the vasodilation effect of morphine used in PCA (Erbabacan et al. 2015 ). Despite this statistical finding, this did not affect the patients' general condition by clinical observation and was not felt by the women.

Comparing the effect of TAP block and IV PCA on respiratory rate, our study revealed no statistically significant differences that might be explained by the low pain score in both groups.

Regarding nausea and vomiting, they were found to be significantly higher in women in “group B” compared to those in “group A” (Table 3 ). This difference may be related to the dose of nalbuphine given in the PCA group. Reductions in postoperative nausea and vomiting, antiemetic requirements have been demonstrated. In disagreement with our results, Siddiqui et al. (2011) published a meta-analysis to evaluate the clinical effectiveness of TAP block on nausea alone and found no significant reduction in nausea score. However, this might be attributed to the different doses used (Siddiqui et al. 2011 ). Similarly, Mäkelä et al. ( 2019 ) carried out a study on 205 patients and evaluated oxycodone, which has an emetic effect, and concluded that the IV PCA patients experienced more nausea at 4 h and more vomiting at 8 h ( p  = 0.001 and p  = 0.01, respectively) (Mäkelä et al. 2019 ). Those studies disagreed with our results, but we can explain this by using different doses than we used in our study.

In our study, 3 cases from “group A” (TAP block) required additional analgesics taken intramuscularly. Using PCA or TAP block to relieve pain after CS minimizes the need for additional analgesics.

Uterine contractility can be detected by fundal level palpation. In our study, 5 patients out of 70 from both groups were recorded to have a fundal level above the umbilicus when compared to others (65/70) who all had a fundal level below the umbilicus. Furthermore, no significant differences were recorded between IV PCA and TAP block on uterine contractility.

Regarding intestinal motility, auscultation using a stethoscope was done at 2, 6, and 24 h intervals. It was observed to be audible in “group A” earlier than “group B.” At 2 h postoperative, intestinal motility was found significantly audible in “group A” than in “group B,” while there is no significant difference between both groups at 6 and 24 h postoperative (Table 4 ). This might be attributed to the systemic effect of PCA drugs. In the Cochrane review, Charoenkwan and Matovinovic ( 2014 ) concluded that after major gynecological surgery, early postoperative feeding is safe and enables earlier recovery of bowel function, a shorter hospital stay, and higher satisfaction (Charoenkwan and Matovinovic 2014 ).

Regarding early mobilization of women in the studied groups, PCA with its sedative effect played a role in delaying patient mobilization when compared to those receiving TAP block. Similarly, Mäkelä et al. ( 2019 ) found that the mean time of mobilization was 17 h, which is longer when compared with a 6-h recommendation (Mäkelä et al. 2019 ).

It has been reported that complications and common side effects of the PCA approach are connected to the essential mechanism of the procedure and the medications used. The most common complications of PCA pumps comprise failure to use anti-reflux valves, “run-away” pumps, PCA by proxy, incorrect syringe placement, and machine tampering (Pastino and Lakra 2021 ).

Although TAP block in cesarean delivery is useful as a primary mode of analgesia in women not receiving neuraxial morphine for any reason, difficulties in performing the block might occur due to anatomical changes after cesarean delivery. However, to perform the block, the ultrasonographic anatomy is ideally recommended to solve this problem, even following cesarean delivery. The main drawback of TAP block is that it does not provide visceral analgesia. As a result, this may explain why certain studies have failed to demonstrate TAP block's dominance over other modalities.

TAP block is a minimally invasive technique with a very high safety profile. However, still it may encounter possible complication as needle trauma, intraperitoneal injection, neural ischemia, inadvertent intravascular injection, local anesthetic toxicity, infection, femoral nerve palsy, and poor/failed block. However, with proper training, only a few cases of serious events were reported in the literature (Walker 2010 ).

We searched in the literature and found out that most of the research published on both techniques was done on surgeries other than CS. So we believe that our study would open more research on this point, especially with the dramatic increase in CS rates and persistent demand for pain-free surgeries.

Limitations of the study

Firstly, women chose the type of analgesia according to patient discretion, so no randomization was done. Also, the number of cases was limited, but the reason was that the study was carried out in private hospitals, and both techniques could add a financial burden on the women having CS, so a considerable number of our patients did not agree to participate in the study.

Control of pain after cesarean section is considered a dramatic request from women nowadays. TAP block versus IV PCA was studied due to the effectiveness of both maneuvers in relieving postoperative pain. However, IV PCA was superior on TAP block due to its visceral effect, while TAP block was preferred to avoid systemic action of opioids used in PCA. PCA can be easily applied, while TAP block needs hand skills. Complications and side effects of both types were minimal when adjusting doses of drugs used.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Transversus abdominis plane

Patient-controlled analgesia

Cesarean section

Numeric rating scale

Body mass index

Local anesthesia

Local anesthetic systemic toxicity

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Acknowledgements

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Reproductive Health and Family Planning Research Department, Medical Research Division, National Research Centre, Al Bohouth Street, Dokki, PO Box 12622, Giza, Egypt

Sondos M. Salem, Mazen Abdel-Rasheed & Sameh Salama

Anesthesia Department, Ahmed Maher Teaching Hospital, Cairo, Egypt

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SS concerned with research idea, study design, data collection, and manuscript writing. SMS concerned with data collection and manuscript writing. MA concerned with data analysis and manuscript writing; MG concerned with data collection. All authors read and approved the final manuscript.

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Salem, S.M., Abdel-Rasheed, M., Gouda, M.A. et al. The new trending pain-free cesarean section: TAP block versus IV PCA. Bull Natl Res Cent 45 , 132 (2021). https://doi.org/10.1186/s42269-021-00588-w

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Received : 27 May 2021

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DOI : https://doi.org/10.1186/s42269-021-00588-w

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Efficacy of laparoscopic-guided transversus abdominis plane block for patients undergoing robotic-assisted gynaecologic surgery

A randomised control trial.

Rajanbabu, Anupama; Puthenveettil, Nitu 1, ; Appukuttan, Akhila; Asok, Anjitha

Departments of Gynaecological Oncology, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

1 Departments of Anaesthesia and Critical Care, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Address for correspondence: Dr. Nitu Puthenveettil, Department of Anaesthesia and Critical Care, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India. E-mail: [email protected]

Received June 13, 2019

Received in revised form August 22, 2019

Accepted August 26, 2019

Background and Aims: 

Transverse abdominis plane (TAP) block has been used regularly as part of multimodal analgesia for caesarean sections and other lower abdominal surgeries. Adequate postoperative analgesia provided with regional blocks allows faster postoperative recovery and better patient satisfaction. In our study, we are comparing the analgesic efficacy of laparoscopic-guided TAP block with port infiltration using a local anaesthetic in patients undergoing gynaecologic robotic surgeries.

Methods: 

After obtaining approval from the hospital ethics committee, Central Trial Registry of India (CTRI) clearance and written informed consent from patients, this prospective double-blinded randomised control trial was conducted on patients undergoing robotic-assisted gynaecologic surgery under general anaesthesia. Group B patients received bilateral TAP block under direct laparoscopic vision with 15 ml of 0.1% ropivacaine on each side and Group C patients received routine port site infiltration with 30 ml of 0.1% ropivacaine. Postoperative pain score was measured till 24 hours, need for rescue analgesics, complications associated were noted. Independent two sample 't' test, Mann Whitney u test, Chi-square and Fisher's exact test were used for statistical analysis.

Results: 

Pain score was significantly lower in Group B patients up to 24h ( P < 0.001). The use of rescue analgesic was also significantly less in group B compared to Group C ( P < 0.001). No adverse events were noted in both groups.

Conclusion: 

Laparoscopic-guided TAP block is effective and superior to port site infiltration in providing postoperative analgesia in patients undergoing robotic-assisted gynaecologic surgery.

INTRODUCTION

Postoperative pain is a major concern for patients undergoing any surgery. Patients undergoing robotic-assisted gynaecologic surgery have much lesser pain and shorter hospital stay when compared to patients undergoing open surgeries. But methods to reduce the pain further will allow faster postoperative recovery and better patient satisfaction. By transversus abdominis plane (TAP) block, the sensory nerves of the anterior abdominal wall from T6 to L1 are blocked. TAP block has been used regularly as part of multimodal analgesia for caesarean, lower abdominal surgeries.[ 1 2 3 ] It is also used in laparoscopic surgeries to reduce postoperative pain and opioid requirements.[ 4 5 6 7 ] Studies have examined the effectiveness of TAP block on relieving postoperative pain in laparoscopic procedures with conflicting results. Many studies showed reduction in postoperative pain and opioid consumption with TAP block.[ 8 9 10 ] In contrast, a study on TAP block performed for laparoscopic appendectomies did not show any improvement in pain scores.[ 11 ] In this study, we are comparing the analgesic efficacy of laparoscopic-guided TAP block with port infiltration in gynaecologic robotic surgeries. Secondary objectives were to find the difference in postoperative use of rescue analgesics, adverse effects due to analgesic use, nausea and vomiting, time to first feed, time to discharge from recovery and hospital between the two modalities.

This prospective double-blinded randomised control trial was conducted after obtaining approval from the hospital ethics committee (dated 12-11-2018), CTRI clearance (CTRI/2018/12/016612) and written informed consent from patients undergoing robotic-assisted gynaecologic surgery under general anaesthesia from December 2018 to May 2019. The study was conducted in accordance with the principles of the 2013 Declaration of Helsinki. Forty patients between 18-70 years belonging to American Society of Anaesthesiologist physical class I and II were included in the study. Patients not willing for TAP block, allergic to ropivacaine, surgery duration of more than 3 hours and conversion to open surgery were excluded from the study. The recruited patients were divided into two equal groups B and C by closed envelope technique [ Figure 1 ]. Group B patients received bilateral laparoscopic-guided TAP block using 15 ml of 0.1% ropivacaine on each side and group C patients received routine port site infiltration with 30 ml of 0.1% ropivacaine.

Standardised general anaesthesia protocol was followed. All patients received oral ranitidine 150 mg, metoclopramide 10 mg and alprazolam 0.5 mg as premedication on the morning of surgery. In the operating theatre, patients were induced with IV midazolam 2 mg, propofol 1-2 mg.kg −1 and fentanyl 2-3 μg.kg −1 . All patients were intubated and anaesthesia was maintained using O 2 , air and isoflurane 0.5-1.5%. In group B patients, the TAP block was performed by a single consultant surgeon. After inserting the first 10-mm-trocar and examining the abdominal cavity, a puncture with an 18-gauge needle was performed using classic landmark technique. Localisation of the needle was done under direct laparoscopic vision and the needle's tip was positioned at the fascial space between the internal oblique and the transverses abdominis muscle. 15 ml of 0.1% ropivacaine was injected after aspiration to avoid intravascular injection. Transverse abdominis muscle can be seen bulging away from the internal oblique laparoscopically when the injection is correctly placed [ Figure 2 ]. The procedure was performed bilaterally. Group C patients received laparoscopic port site infiltration preoperatively with 30 ml of 0.1% ropivacaine.

All patients were then positioned in Trendelenburg position as required for gynaecologic laparoscopic surgery. Towards the end of surgery patients in both groups received IV ondansetron 4 mg and paracetamol 1 gm. On completion of surgery, residual muscle relaxation was reversed with IV neostigmine 0.05 mg.kg −1 and glycopyrrolate 10 μg.kg −1 . Patients were then extubated and shifted to the recovery room. All patients were shifted to the room once their modified Aldrete score was more than 9. Six hours after surgery all patients received oral paracetamol 650 mg 8 th hourly. Patients were given rescue analgesia with IV tramadol 1 mg.kg −1 along with 4 mg ondansetron as antiemetic if the patient complained of pain. The total dose of tramadol given in the first 24 h was noted for both groups.

Anaesthetist in charge of the recovery room, who was unaware to which group the patient belonged, monitored the pain score. The postoperative parameters recorded were mean blood pressure, heart rate, numeric pain score, nausea and vomiting. These parameters were recorded on arrival to recovery, 4, 8 and 12 hours. 24-hour pain score was obtained telephonically. Patients were asked to rate pain experienced by them using a ten-point numeric pain scale (0 - no pain, 10 - worst possible pain). The severity of nausea and vomiting was rated using a scale (0-none, 1-present). Any local complications related to the procedure were also recorded.

As there was no previous similar study on gynaecologic robotic surgery, a pilot study was done. Based on this, the mean pain score after gynaecologic robotic surgery was compared among block and control groups at 12 h and 24 h, (0.20 ± 0.632, 3.70 ± 2.797) and (0.20 ± 0.632, 3.60 ± 2.797), with a 95% confidence interval at 80% power, the minimum sample size comes to 5 and 6 samples in each group respectively. But we assigned 20 patients in each group as too small a sample size increases the likelyhood of a Type II error which can skew the results. For all the continuous variables, the results are given in mean ± SD and categorical variables as a percentage. To compare the mean difference of numerical variables between groups, independent two samples't' test was applied for parametric data and Mann-Whitney u test for non-parametric data. To obtain the association of categorical variables, Chi-square and Fisher's exact test was applied. A P value <0.05 was considered as statistically significant. Statistical analysis was done using IBM SPSS 20.0 (SPSS Inc, Chicago, USA).

A total of 40 patients were enrolled in this study. Distribution of patients in both groups were similar with respect to demographics, American Society of Anesthesiologists' physical status, and duration of surgery. The intraoperative fentanyl consumption was comparable between the two groups. There was a significant difference in pain scores between the two groups with the patients receiving TAP block having lower scores up to 24 h ( P < 0.001) [ Figure 3 ]. The postoperative heart rate and mean arterial pressure did not show any significant difference between the groups [Figures 4 and 5 ]. The demand for rescue analgesic was less in group B compared to group C (15% vs. 90%), and this difference was also statistically significant ( P < 0.001). On comparing the incidence of postoperative nausea and vomiting, there was no significant difference between the two groups [ Table 1 ]. All patients were ambulated at 3-4 hours in the postoperative period and none of them were over sedated. We did not encounter any complications associated with the procedure in both groups.

This randomised controlled trial has demonstrated decreased pain scores and reduced requirement of rescue analgesics with laparoscopically-guided TAP block in patients undergoing minimally invasive robotic gynaecologic surgeries. But there was no difference in ICU stay or discharge from hospital. None of the patients in our study group had any adverse effects associated with the block or port site infiltration.

TAP block is a non-dermatomal field block. Transversus abdominis plane is a potential space between transverse abdominis and internal oblique muscle. TAP block can be performed by blind insertion of local anaesthetic using anatomical landmarks, ultrasound guidance or under laparoscopic guidance. Studies have shown that TAP blocks performed by either blind or under ultrasound guidance are effective in providing analgesia in laparoscopic surgeries.[ 4 5 7 8 9 ] Blind TAP blocks are performed after locating the triangle of Petit using the double pop loss of resistance technique.[ 12 ] It is associated with a high incidence of penetrative injuries and a higher failure rate. Ultrasound-guided TAP blocks became popular because of their effectiveness and safety profile compared to blind TAP blocks.[ 12 13 ] But it needs great skill and the availability of ultrasound machines in the operation theatre. Also at times, we might encounter difficulty in identification of muscle planes. In laparoscopic-guided TAP block, local anaesthetic is injected into the transversus abdominis plane by a semi-blind technique. It can be easily performed by the surgeon under direct vision of the laparoscope without the need for any additional skills.[ 14 15 16 ] The presence of an internal bulge which can be visualised laparoscopically confirmed the correct placement of the drug. Recently, robotic-assisted gynaecologic surgeries are becoming popular in centres where robotic facilities are available. Patients undergoing robotic-assisted surgery have less pain than patients undergoing laparoscopy or open surgery. This advantage may be due to the endowristed instruments reducing port movement on the abdominal wall. But these patients may also complain of pain. The inadequate treatment of acute postoperative pain can delay discharge, and lead to the development of chronic pain, which is difficult to treat. Adequate postoperative analgesia provided with blocks will allow faster postoperative recovery and better patient satisfaction. We used laparoscopic-guided approach to perform TAP block as it is associated with less risk of visceral injury, is easy to perform with shorter procedure time and has a high success rate.[ 10 ]

Many studies on laparoscopic TAP block used bupivacaine as a local anaesthetic.[ 17 ] But we have used ropivacaine because it is safer and is equally effective.[ 18 19 ] Studies have demonstrated pain relief, lesser narcotic use and shorter hospital stay with the use of laparoscopic-guided TAP.[ 14 16 20 ] But unlike Tihan et al .,[ 10 ] we could not demonstrate any improvement in time to discharge from hospital. This may be due to the fact that our patients in both groups were already day care patients and were discharged before 24 hours.

Laparoscopic TAP block provided analgesia up to 24 hours, which reduced the requirement of postoperative opioids. This reduces the incidence of opioid-induced side effects like sedation and nausea and vomiting. But in our study even though there was a significantly increased consumption of tramadol in the control group, which received only port infiltration, the incidence of postoperative nausea and vomiting was not significantly different between the two groups. The use of antiemetic, ondansetron along with tramadol could have prevented our patients from excessive emesis.

This study is limited by the fact that it is from a single institution and also the TAP block was administered by a single operating surgeon. Various additives and liposomal bupivacaine have been shown to prolong the duration of analgesia produced by TAP block. This should be studied further to see if there is an increased benefit to patients.

Laparoscopic-guided TAP block is effective in reducing postoperative pain in patients undergoing robotic gynaecologic surgeries and is superior to port site infiltration.

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Ultrasound-guided quadratus lumborum block versus transversus abdominis plane block in patients undergoing total abdominal hysterectomy

• Amin M. Alansary 1 ,
• Ayman M. Kamaly 1 ,
• Hatem S. Abdel Hamid 1 ,
• Yassmin M. Aboelanean   ORCID: orcid.org/0000-0003-2635-5259 1 &
• Ahmed W. Ezzat 1  

Ain-Shams Journal of Anesthesiology volume  14 , Article number:  22 ( 2022 ) Cite this article

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Ultrasound (US)-guided quadratus lumborum block (QLB) and transversus abdominis plane block (TAP) are used as a part of multimodal analgesia for postoperative pain after abdominal procedures, as they improve postoperative pain.

QLB group showed significantly better visual analog score (VAS) scores from 6 h till 24 h postoperative. Time for the first request for pethidine was significantly longer in the QLB group (398.3 ± 23.7 min) than in the TAP group (80.3 ± 20.7 min), ( p < 0.0001 and its total consumption was significantly lesser ( p = 0.007) in the QLB group (68.33 ± 66.28) than in TAP group (120.0 ± 76.11). Also, the sensory level was higher in the QLB group (8.3 ± 0.63 segments) than in the TAP group (6.2 ± 0.79 segments), ( p < 0.001). Moreover, only 2 patients (6.67%) in the QLB group experienced nausea and/or vomiting versus 9 (30%) in TAP group with significant value.

Conclusions

QLB was more effective in providing visceral and somatic pain analgesia after total abdominal hysterectomy (TAH) in comparison to TAP block, QLB resulted in wider sensory blockade compared to TAP block with less incidence of postoperative nausea and/or vomiting.

Enhanced recovery after surgery is a multimodal perioperative care pathway that promotes preoperative organ function and reduces the stress response generated by surgical trauma to achieve and improve speedy recovery (Shida et al., 2015 ). Opioids, the popular painkiller, have several side effects such as sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, pruritis, and respiratory depression (Woodhouse & Mather, 1998 ). As a result, various approaches are required to control postoperative pain and reduce opioid usage and adverse effects (Ng et al., 2002 ). The sensory nerves of the anterolateral abdominal wall, T6-L1, that travel to innervate the abdomen are blocked during the TAP block (Almarakbi & Kaki, 2014 ). After lower abdominal surgery, a TAP block can provide effective analgesia (Wegner et al., 2017 ).

QLB block is classified anatomically into 3 groups: QLB 1 (Lateral approach) provides analgesia from T7 to L1 (Abrahams & Derby, 2016 ). QLB 2 is conducted by injection medication at the site posterior to the quadratus lumborum muscle from the posterior abdominal wall (Blanco et al., 2015 ). QLB 3, also referred to as transmuscular quadratus lumborum block, aimed at the anterior border of quadratus lumborum and posterior to psoas major, so that the anesthetic can spread to the thoracic paravertebral space (Hansen et al., 2016 ).

In comparison to the TAP block, Blanco’s QLB has an advantage in extending the local anesthetic agent beyond the transversus abdominis plane to the thoracic paravertebral area. This increased distribution of local anesthetic agents causes significant analgesia and prolongs the effect of the injected local anesthetic solution (Blanco et al., 2016 ).

This study aims to compare the effect of ultrasound-guided bilateral QLB versus bilateral ultrasound-guided TAP block on intraoperative and postoperative analgesia in patients undergoing total abdominal hysterectomy under general anesthesia, compare sensory level between QLB and TAP groups, and compare the incidence of postoperative nausea and vomiting.

Ethical approval for this study (FMASU M D 237/2019) was provided by the Ethics committee of Ain Shams University hospital, Abbasia, Cairo, Egypt on 20 August 2019. Written informed consent was obtained from all subjects. This trial followed the CONSORT statement. This prospective randomized interventional study was conducted at Ain-Shams University gynecology and obstetrics hospital in the operating rooms from September 2019 to January 2021

Sixty adult female patients American Society of anesthesiologists (ASA) Physical Status Class I and II, scheduled for TAH were randomized into two equal groups (TAP group and QLB group). Randomization was performed using a computer-generated random number table in opaque sealed envelopes with a 1:1 allocation ratio by an anesthesiologist not directly involved in the trial.

Group TAP ( n = 30): where each patient received general anesthesia plus bilateral TAP block.

Group QLB ( n = 30): where each patient received general anesthesia plus bilateral QL block.

Inclusion criteria

Female, aged ≥ 45–≤ 60 years.

ASA physical status classes I and II.

Scheduled for total abdominal hysterectomy.

Exclusion criteria

Included patients who refused to participate in this study.

Had a body mass index (BMI) of more than 30 kg/m.

ASA physical status more than II, or had major disease, e.g., cardiac, renal, respiratory, neurologic, or hepatic.

Patients using anticoagulants or with coagulopathy.

Infection at the site of injection.

Allergy or contraindications to local anesthetics.

Anesthesia and surgical procedure

On arrival of the patients to the operating room, electrocardiography (ECG), noninvasive blood pressure, and pulse oximetry were applied. Baseline parameters such as systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MABP), heart rate (HR), and arterial oxygen saturation (SpO2) were recorded. An intravenous (IV) line was inserted, and IV fluid started. For both groups, general anesthesia was induced with IV injection of fentanyl (1 μg/kg) and propofol (2 mg/kg) then, atracurium (0.5 mg/kg) was injected for endotracheal intubation then capnography was connected, and mechanical ventilation was used to maintain the end-expiratory CO2 (ETCO2) values between 34 and 36 mmHg. Anesthesia was maintained with isoflurane 1–2% in a 40% oxygen-air mixture. An incremental dose of atracurium (0.1 mg/kg) was given every 30 min or when needed. After endotracheal intubation, stabilization of the patient’s vital data, and before the start of the surgery, the anesthesiologist (who was blinded to the collected data until the end of the study) performed the block techniques and administered the medication. Both blocks were performed under complete aseptic precautions using an ultrasound machine with a high-frequency linear probe covered with a sterile sheath (Sonoscape® SSI 6000, Chinawith12 6 MHz high-frequency linear probe) and 100 mm needle (BBraun Medical Inc., Bethlehem, PA, USA).

Intraoperative fentanyl 50 ug was given if the HR or the blood pressure or both increase > 20% of the baseline. Isoflurane was discontinued on completion of the surgical procedure, and neostigmine 0.04 mg/kg plus atropine 0.02 mg/kg was administered to reverse the effect of atracurium. After emergence from anesthesia and achieving an appropriate level of consciousness, the patient was discharged from the operating room to the postanesthesia care unit (PACU).

Then, we recorded postoperative total dose of pethidine used/24 h, VAS for pain at 0, 2, 4, 6, 12, 18, and 24 h postoperatively also blood pressure and heart rate 0, 30 min, 2, 4, 6, 12, 18 and 24 h were recorded, the total dose of fentanyl used intraoperative, the number of patients needed rescue analgesia and any side effect. The sensory level between QLB and TAP groups was compared. Also, the incidence of postoperative nausea and vomiting between both groups was compared.

When VAS score was 3 or more, the patient request, heart rate > 110 beats per minute and or mean arterial blood pressure > 20% from the baseline, 50 mg pethidine was given intravenously. No other analgesic drugs were given except pethidine. The total amount of pethidine consumed in 24 hours was recorded.

Patient-reported outcomes

Primary outcome.

The total dose of pethidine used postoperatively/patient rescue analgesia for 24 h.

Secondary outcome

VAS for pain (recorded at 0, 2, 4, 6, 12, 18, and 24 h postoperative).

Incidence of postoperative adverse effects.

The number of patients needed rescue analgesia.

Assessment of sensory level in both groups.

The total dose of fentanyl used intraoperatively.

Sample size calculation

The sample size was calculated using the STATA® version 10 programs, setting the alpha error 5% and power at 90%. Results from a previous study (Yousef, 2018 ) showed that 77% of TAP group cases needed analgesia postoperatively compared to 27% of the QL group. Calculation according to these values produced a sample size of 30 patients per group taking into account a 20% dropout rate.

Statistical analysis

Data were analyzed using Statistical Package for Social Science (SPSS) version 22.0. Quantitative data were expressed as mean ± standard deviation (SD). Qualitative data were expressed as frequency and percentage. The following tests were used: Independent-samples t test of significance was used when comparing between two means, chi-square ( χ 2 ) test of significance was used to compare proportions between two qualitative parameters, Mann-Whitney U test: for two-group comparisons in non-parametric data, the confidence interval was set to 95% and the margin of error accepted was set to 5%. So, we set the significance level at a p value < 0.001 was considered significant.

Seventy-two patients were eligible for the study, 2 patients did not meet inclusion criteria and ten patients denied consenting for the study. So, 60 patients were enrolled in the study: 30 patients in each group (Fig. 1 ).

Consort patient flowchart

Postoperative vital data in the form of MABP and HR were compared in the 2 groups and there were no statistical differences between the groups at 1st 6 h then TAP block group had more increase in blood pressure and HR further on (Fig. 2 ). The 2 groups were not statistically different for demographic data (Table 1 ). MABP and HR were significantly higher in the TAP group than in the QLB group with a p value less than 0.05.

Comparison between both groups as MABP and HR

At PACU arrival till the first 6 h postoperative, the QLB group exhibited better clinical pain scores than the TAP block group, however without statistically significant difference between the two groups. Then, QLB group started to show better VAS scores with significant differences till 24 h postoperative (Table 2 ). Sensory level was higher in the QLB group than in the TAP group (Table 3 ). 

As regards the total dose of narcotics used in each group, intraoperative fentanyl showed no difference between the two groups, but postoperative pethidine consumption was more in the TAP group than the QLP group ( P < 0.001) (Table 4 ).

Nausea and vomiting were also examined between the groups and there was a significant difference as the TAP group had more postoperative nausea and vomiting mostly related to more narcotic consumption and more pain score.

Table 5 shows the statistically significant difference between groups as regards nausea and vomiting.

One of the most prevalent medical procedures that cause considerable postoperative pain is hysterectomy (Wright et al., 2013 ). Poor pain control after abdominal hysterectomy is linked to a longer hospital stay and recovery time, as well as psychological changes, quality of life, and patient satisfaction (Blanton et al., 2017 ). Postoperative pain control after hysterectomy prevents the development of chronic pain (Katz & Seltzer, 2009 ).

In postoperative treatment, adequate and safe postoperative analgesia is critical (Baik et al., 2014 ). Unfortunately, the usage of opioids has side effects such as nausea and vomiting, as well as the risk of long-term dependence (Clarke et al., 2014 ). The sensory afferent nerves that run between the abdominal muscles are blocked by the TAP block, which reduces surgical incisional pain (McDonnell et al., 2007 ).

The current study also calculated and compared the standard deviation for each of the two groups analyzed, as well as the postoperative VAS score, initial time to rescue analgesia, and total amount of opioids (pethidine) administered in the first 24 h. When compared to the QLB group, TAP block patients showed higher values. The effects of QLB and TAP blocks in this study resulted in a lower incidence and severity of postoperative pain, as well as a lower incidence of total opioid demand. QLB was found to be more effective than TAP block in this clinical trial. The QLB approach was found to be superior to the TAP block approach in terms of analgesia (pethidine), total pethidine consumption, and VAS score. TAP patients had higher pain ratings and were the first to request assistance.

Also, there is less incidence of postoperative nausea and vomiting in the QLB group. The current study’s findings were congruent with Yousef’s findings on the same topic, in which she compared QLB and TAP blocks on 60 females undergoing total abdominal hysterectomy under general anesthesia and separated them into two groups. The findings corroborated our findings in terms of total opioid use and pain control duration in the first 24 h after QLB duration (Yousef, 2018 ).

The findings of this study backed up Blanco et al.’s findings from 2016, which revealed that the QLB provides longer-lasting analgesia than the TAP block. Furthermore, their findings demonstrate that using QLB as the default approach can dramatically minimize opiate consumption and deleterious effects after cesarean delivery (Blanco et al., 2016 ).

Furthermore, the findings backed with Blanco et al.’s findings from 2016, which looked at the effects of QLB versus placebo on patient-controlled analgesia (PCA) morphine doses and postcesarean demand. Six and twelve hours after surgery, patients who took QLB had considerably lower morphine intake than control groups. They also required much less morphine at all times following the Caesarean procedure. The VAS scores in the QLB group were considerably higher than in the control group (Blanco et al., 2016 ).

Aditianingsih et al. investigated the analgesic impact of recurrent QLB versus continuous epidural analgesia after laparoscopic nephrectomy in terms of total opioid dose, hemodynamic changes, and postoperative nausea and vomiting, QLB used the same total amount of opioids as epidural analgesia to control pain in 65 patients in the first 24 h after surgery, with no difference in the incidence of postoperative nausea and vomiting (Aditianingsih et al., 2019 ).

However, Borys et al. found that the TAB or QL block did not manage postoperative persistent pain, such as neuropathic pain. They measure postoperative pain for the first, third, and sixth months after CS surgery, but we did not address these topics here whoever was successful in managing pain in the first 24 h postoperatively using the QLB approach, as previously mentioned (Borys et al., 2019 ).

Our results showed that QLB was more effective in providing analgesia after TAH in comparison to TAP block and even more time covering to rescue opioids, sensory level was higher in the QLB group than in the TAP group with less incidence of postoperative nausea and/or vomiting.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

• Quadratus lumborum block

Transversus abdominis plane

Total abdominal hysterectomy

American Society of anesthesiologists

Electrocardiography

Systolic blood pressure

Diastolic blood pressure

Mean arterial blood pressure

Arterial oxygen saturation

End-tidal co2

Score visual analog score

Postanesthesia care unit

Statistical Package for Social Science

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Amin M. Alansary, Ayman M. Kamaly, Hatem S. Abdel Hamid, Yassmin M. Aboelanean & Ahmed W. Ezzat

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Study supervision: HA, AK. Drafting the article: AA and YA. Conception and design: AA and YA. Statistical analysis: AK and HA. Acquisition of data: AE and AA. Analysis and interpretation of data: AE and AA. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Administrative/technical/material support: all authors. All authors read and approved the final manuscript.

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Correspondence to Yassmin M. Aboelanean .

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Ethical approval for this study (FMASU M D 237/2019) was provided by the Ethics committee of Ain Shams University hospital, Abbasia, Cairo, Egypt on 20/8/2019. Written informed consent was obtained from all subjects.

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Alansary, A.M., Kamaly, A.M., Abdel Hamid, H.S. et al. Ultrasound-guided quadratus lumborum block versus transversus abdominis plane block in patients undergoing total abdominal hysterectomy. Ain-Shams J Anesthesiol 14 , 22 (2022). https://doi.org/10.1186/s42077-022-00224-3

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DOI : https://doi.org/10.1186/s42077-022-00224-3

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• v.7(8); 2021 Aug

The efficacy of TAP block versus ilioinguinal block for post-cesarean section pain management: A systematic review and meta-analysis

Associated data.

Data will be made available on request.

Controversy still exists regarding the analgesic efficacy of transverse abdominis plane (TAP) block versus ilioinguinal or iliohypogastric (IL/IH) nerve block for postoperative pain management following cesarean section. This meta-analysis aimed to perform relatively credible pooled results on the efficacy of the TAP versus IL/IH nerve block for postoperative pain management after cesarean section.

Databases such as: PubMed/MEDLINE, Google scholar, and google were systematically searched. studies compared the analgesic efficacy of TAP versus IL/IH nerve block for postoperative pain management following cesarean section were included. Data were extracted by three reviewers independently by using Microsoft Excel and then exported to STATA™ 16 version statistical software for analysis. We used a random-effects model meta-analysis and the mean difference of analgesic efficacy with a 95 ​% confidence interval was reported based on Preferred Reporting Items for systematic reviews and meta-analysis (PRISMA).

Five studies with a total of 390 (196 in TAP and 194 in IL/IH) study participants were included in this meta-analysis. No statistically significant difference was observed between the TAP and IL/IH groups in time to first rescue analgesic request, total postoperative analgesic consumption in milligrams of intravenous tramadol equivalence, and post pain severity score at different points of time both rest and movement.

This meta-analysis revealed that both approaches have similar postoperative analgesic efficacy following cesarean section. we recommend that the clinician may consider either approach for post-cesarean section pain management.

Meta-analysis; Cesarean section; TAP block; IL/IH block

1. Introduction

A cesarean section is a surgical approach to giving birth that can prevent maternal and newborn mortality when used for clinical indication. Globally, its rate has increased progressively [ 1 , 2 ]. In Ethiopia the current cesarean section rate is about 30 ​% [ 3 ]. Cesarean section commonly induces moderate to severe pain for 48 h and with 11.8 ​% incidence of chronic pain [ 4 ]. Post-operative pain treatment aims to provide subjective comfort, inhibit nociceptive impulses, and blunt the neuroendocrine response to pain thus enhancing early restoration of body function [ 5 ].

Untreated pain can increase pulse rate, cardiac work, and oxygen consumption, and also it can reduce physical activity and leads to venous stasis and an increased risk of deep vein thrombosis. Furthermore, it may lead to post-operative ileus, nausea, vomiting, urinary retention and may result in prolonged hospital stay [ 6 , 7 , 8 , 9 ]. Adequate analgesia is used to protect the peri-operative complications like deterioration of the circulatory, respiratory and central nervous system from the effects of noxious stimuli [ 10 , 11 ].

A systemic approach is a commonly practiced analgesia option that could be associated with side effects like pruritus, nausea, and vomiting, sedation, and respiratory depression. It also affects the feto-maternal bond, early breastfeeding of the newborn, and maternal satisfaction [ 11 ].

Recently, transversus abdominis plane (TAP) and ilioinguinal/iliohypogastric (IL/IH) nerve blocks are getting more consideration as a possible alternative to provide effective post-cesarean section pain management option [ 10 , 12 , 13 , 14 ]. Both TAP and IL/IH nerve blocks are targeting the ilioinguinal and iliohypogastric nerves. The difference between TAP and IL/IH nerve blocks is the former is a compartment block, while the latter is a truncal block.

Controversy still exists regarding the analgesic efficacy of transverse abdominis plane (TAP) block versus ilioinguinal or iliohypogastric (IL/IH) nerve block for postoperative pain management following cesarean section [ 15 , 16 , 17 , 18 , 19 , 20 ].

Therefore, to reconcile this controversy, we perform this meta-analysis to summarize the existing evidence comparing the analgesic efficacy of TAP and IL/IH blocks in parturients undergoing cesarean section.

2.1. Study setting and search strategies

This systematic review and meta-analysis was conducted to estimate the effectiveness of TAP block versus IL/IH nerve block in a parturient who gives birth by cesarean section. Databases such as: Hinari, PubMed/MEDLINE, Google scholar, and google search were used to identify potential studies. A hand search was applied to identify additional literature by using key terms and cross-references. All searches were limited to the English language and studies were published within ten years. The search was performed on 28-31/3/2021 from all databases. Medical subject heading or entry terms “Pregnant Women” OR “Gravidity” OR “Mothers” OR “Obstetrics” OR “Women” OR “Female” AND “TAP block” OR “transverse abdominis plane block” AND “II/IH block” OR “II/IH block” OR “ilioinguinal block” OR “hernia block” AND “time to first analgesia request” OR “total analgesia consumption’’ OR “pain severity score” were used. The results were further restricted by free full text and human species. This meta-analysis was registered in PROSPERO with a registration number of CRD42020144553.

2.2. Eligibility criteria

We used PICO ( P opulation: parturient who gave birth by cesarean section, I ntervention: TAP block, C ontrol: II/IH block/hernia block, O utcome: analgesic efficacy in terms of time to first analgesic request, total analgesic consumption, and pain severity score) approach to include and exclude studies.

2.2.1. Inclusion criteria

This systematic review and meta-analysis included articles that met the following criteria: All studies conducted on the efficacy of TAP block versus ilioinguinal block for post-cesarean section pain management and articles published with the English language which has free full text were included.

2.2.2. Exclusion criteria

Studies that did not report time to first analgesic request, total postoperative analgesic consumption, and postoperative pain severity scores were excluded. Studies lacking appropriate data and failure to reply from the corresponding authors within three weeks were excluded too.

2.3. Outcome measurement

The main outcome of interest for this meta-analysis was to estimate the mean difference of TAP block versus ilioinguinal block for post-cesarean section pain management in terms of time to first analgesic request, total postoperative analgesic consumption, and postoperative pain severity scores. The pooled results were summarized by using mean difference with 95 ​% confidence interval.

2.4. Quality assessment and data extraction

The quality of the studies was critically appraised by the Joanna Briggs institute assessment tool established for randomized controlled trial and cohort studies [ 21 ]. The quality of all the included studies was graded as “high quality”.

Authors’ names with a year of publication, study design, type of anesthesia, block approach, sample size, postoperative analgesia regimen, and outcome variables were extracted. The titles and abstracts of all identified literature in the searches were reviewed by three authors. Included studies were reviewed by three authors independently, and decisions were made regarding selection/rejection. The disagreements arising were resolved by the discussion of all the authors.

2.5. Statistical analysis

Microsoft Excel spreadsheet was used to extract the necessary information from each study. The extracted data was imported to STATA™ version 16.0 software for analysis. The mean differences of time to first analgesic request, total postoperative analgesic consumption in milligram of intravenous tramadol equivalent, and severity of postoperative pain scores in NRS were determined by the random-effects model using DerSimonian-Laird weight [ 22 ]. The effect size or mean difference with a 95 ​% confidence interval was presented using forest plots or tables.

2.6. Heterogeneity and publication bias

The I 2 statistic test was used to evaluate the presence of heterogeneity between studies [ 22 ]. Subgroup analysis by using study design (cohort versus Randomized controlled trial), and nerve block approach (landmark versus Ultrasound-guided technique) was performed to minimize heterogeneity. Since the number of included studies were small, we did not conduct publication bias analysis [ 23 ].

3.1. Search strategy

In this systemic review and meta-analysis, a total of 335 articles were identified through different databases search. One hundred twenty-three (123) articles were left after removing duplication. The remaining 123 articles were screened for their title and abstract based on which 117 articles were excluded. From the remaining six articles, one article was excluded for reasons. Finally, five potential articles had been included for qualitative and quantitative synthesis ( Figure 1 ) [ 24 ].

PRISMA flow diagram showing search strategies.

3.2. Characteristics of included studies

In this systematic review and meta-analysis, a total of 390 parturient were included from five studies with a sample size ranging from 32 [ 19 ] to 124 [ 17 ]. The time to first analgesic request among the included studies varied from 409 ± 206 min [ 18 ] to 1327 ± 960 min [ 17 ] in the TAP group while it varied from 300 ± 204.44 min [ 19 ]to 1504 ± 834 min [ 17 ] in IL/IH group. Regarding study design, three studies employed an RCT [ 15 , 18 , 19 ] and the remaining two were cohort studies [ 16 , 17 ] ( Table 1 ).

Table 1

Characteristics of studies included in the systematic review and meta-analysis of the efficacy of TAP block versus ilioinguinal block for post-cesarean section pain management, 2021.

CSE: Combined spinal-epidural, IV: Intravenous, IL/IH: Ilioinguinal/Iliohypogastric, PCA: Patient control analgesia, RCT: Randomized control trial, TAP: Transversus abdominis plane.

3.3. Meta-analysis

3.3.1. time to first analgesia request.

Five studies with a total of 390 (196 in TAP and 194 in IL/IH) study participants were included to estimate the mean difference time to first rescue analgesia request following cesarean section. The mean difference among included studies was -14.97 with 95 ​% CI (-157.13, 127.20). There was a significant heterogeneity across the included studies (I 2 = 75.98 ​%, P = 0.001). Therefore, random effect models were used to determine the mean difference between groups among study participants. The overall mean difference of first-time rescue analgesic requests was not statistically significant between groups ( Figure 2 ).

Time to first rescue analgesia request in minute.

3.4. Subgroup analysis

Subgroup analysis was done to detect the potential source of heterogenicity by using the nerve block technique (landmark versus ultrasound-guided) and study design (cohort versus randomized control trial). After subgroup analysis, landmark technique and cohort study design showed the lowest heterogenicity, while the highest heterogenicity was detected in the randomized control trial group (Figures  3 and ​ and4 4 ).

Subgroup analysis by nerve block techniques.

Subgroup analysis by study design.

3.4.1. Total postoperative analgesia consumption in intravenous tramadol equivalent

All studies report total analgesic consumption within 24 hours, while only two studies report within 48 hours. The total postoperative analgesia consumption in intravenous tramadol equivalent was calculated [ 25 ]. The mean difference of total analgesia consumption at different cut-off time points within 24 and 48 h were not statistically significantly different between the TAP and IL/IH groups (p-values >0.05) (Figures  5 and ​ and6 6 ).

Intravenous equivalent total tramadol consumption at 24 h postoperatively.

Intravenous equivalent total tramadol consumption at 48 h postoperatively.

3.4.2. Pain severity score

Pain severity score was assessed by numeric rating scale both at rest and movement at different cut-off time points for 48 h postoperatively. The mean difference of pain severity score at different time points both at rest and movement had no statistically significant difference between groups (p-values >0.05). Pain severity score during rest at 2 h and 24 h has no statistically significant heterogenicity within studies (Tables  2 and ​ and3 3 ).

Table 2

The mean difference of pain severity score at rest between TAP and IL/IH nerve block.

CI: Confidence interval, MD: Mean difference.

Table 3

The mean difference of pain severity score at movement between TAP and IL/IH nerve block.

4. Discussion

Currently, there is no single gold standard for post-C/S pain management modality. There are several options and choices are made by resource availability, institutional protocols, and individual preferences [ 26 ].

Transverse abdominis plane block and ilioinguinal/iliohypogastric nerve blocks have been used as part of multimodal analgesia for postoperative pain management after cesarean section. However, their relative efficacy is still uncertain. This systemic review and meta-analysis revealed that there was no statistically significant difference between the two blocks in terms of time to first rescue analgesic request, total postoperative analgesic consumption, and pain severity score at different points of time both at rest and movement.

The mean difference of time to first rescue analgesia request for TAP and IL/IH block in minutes among included studies was -14.97 with 95 ​% CI: -157.13, 127.20, p-value 0.84. Even though the time to first rescue analgesia request for TAP block is 14.97 more than the IL/IH block, there is no statistically significant difference between the blocks. In line with our study primary studies found that the time to first rescue analgesia request has no statistically significantly different between groups [ 15 , 17 ]. This might be due to their comparative effectiveness in analgesic duration.

The mean difference of total analgesic consumption in milligram of intravenous tramadol equivalent at 24 and 48 h among included studies were -25.13, 95 ​% CI: -57.42, 7.16, p-value 0.13 and -394.44 95 ​% CI: -107.61, 282.72, p-value 0.25 respectively. The statistical insignificance might be justified by their comparable postoperative pain severity score at different points in time.

The mean difference of postoperative pain severity score in NRS at 2,4,6,8,12,24, and 48 h among included studies were not statistically significant between groups both at rest and movement, p-values > 0.05. In line with our finding, a meta-analysis done by Zhou Y et al. 2019 following hernia repair surgery showed a similar result concerning postoperative pain severity score [ 27 ].

5. Conclusion

This meta-analysis found no significant differences in the time to first request for rescue analgesia, postoperative analgesic consumption, and post-operative pain score following cesarean section between TAP block and IL/IH block.

6. Limitation

This systematic review and meta-analysis showed the pooled efficacy of the two abdominal field blocks with limited number of studies.

Declarations

Author contribution statement.

Tikuneh Yetneberk: Conceived and designed the experiments; Performed the experiments.

Diriba Teshome: Analyzed and interpreted the data.

Basazinew Chekol: Contributed reagents, materials, analysis tools or data; Wrote the paper.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

Declaration of interests statement.

The authors declare no conflict of interest.

Additional information

No additional information is available for this paper.

Acknowledgements

We would like to give our thanks to our colleagues who supported us in the whole process of this paper work.