Efficacy of Transversus Abdominis Plane Block in the Reduction of Pain and Opioid Requirement in Laparoscopic and Robot-assisted Hysterectomy: A Systematic Review and Meta-analysis

López-Ruiz, Claudia; Orjuela, Jerutsa Catalina; Rojas-Gualdrón, Diego Fernando; Jimenez-Arango, Marcela; Ríos, José Fernando de los; Vásquez-Trespalacios, Elsa Maria; Vargas, Claudia

doi:10.1055/s-0041-1740595

Brasil

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Review Article • Rev. Bras. Ginecol. Obstet. 44 (01) • Jan 2022 • https://doi.org/10.1055/s-0041-1740595 linkcopy

Efficacy of Transversus Abdominis Plane Block in the Reduction of Pain and Opioid Requirement in Laparoscopic and Robot-assisted Hysterectomy: A Systematic Review and Meta-analysis

Eficácia do bloqueio transverso do plano abdominal na redução da dor e da necessidade de opioides em histerectomia laparoscópica e assistida por robô: Uma revisão sistemática e metanálise

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective To summarize the available evidence of TAP Block in efficacy in laparoscopic or robotic hysterectomy.

Data Sources We searched databases and gray literature for randomized controlled trials in which transversus abdominis plane (TAP) block was compared with placebo or with no treatment in patients who underwent laparoscopic or robot-assisted hysterectomy.

Method of Study Selection Two researchers independently evaluated the eligibility of the selected articles. Tabulation, Integration, and Results Seven studies were selected, involving 518 patients. Early postoperative pain showed a difference in the mean mean difference (MD): - 1.17 (95% confidence interval [CI]: - 1.87-0.46) in pain scale scores (I2=68%), which was statistically significant in favor of using TAP block, but without clinical relevance; late postoperative pain: DM 0.001 (95%CI: - 0.43-0.44; I2=69%); opioid requirement: DM 0.36 (95%CI: - 0.94-1.68; I2=80%); and incidence of nausea and vomiting with a difference of 95%CI=- 0.11 (- 0.215-0.006) in favor of TAP.

Conclusion With moderate strength of evidence, due to the high heterogeneity and imbalance in baseline characteristics among studies, the results indicate that TAP block should not be considered as a clinically relevant analgesic technique to improve postoperative pain in laparoscopic or robotic hysterectomy, despite statistical significance in early postoperative pain scale scores. Clinical Trial Number and Registry: PROSPERO ID - CRD42018103573.

Keywords: transversus abdominis plane block; pain; laparoscopic hysterectomy; robotic-assisted hysterectomy; opioid

Study	Country	Type of surgery	Inclusion criteria	Exclusion criteria	Outcomes	Comparison group	Number TAP / ControlSequence generation and concealment	Blinding	Anesthetic drug dose (mg)	ASA	TAP block technique
Calle et al. (2014) ¹⁵	ColombiaPrado Clinic and CES University, Medellin	Laparoscopic	Patients with ASA surgical risk classification types 1 and 2; had no contraindications for administration of local anesthetics, NSAIDs, or acetaminophen; had an adequate level of understanding, i.e., being able to communicate by telephone and understand a numerical scale.	Change in the standard anesthetic technique, hospitalization following hysterectomy, previous medical history of allergy to local anesthetics, and not being able to be reached by telephone	Pain scale scores (VAS) at 24, 48, and 72 hours after surgery, opioid requirement after surgery	Placebo	100 / 97Sequence was generated using computer-generated randomization list in blocks, which were placed in sealed envelopes	Triple blind: Patient, surgeon, and data analyst	Bupivacaine 0.25%(96)	I, II	Laparoscopic-guided
De Oliveira et al. (2011) ¹³	United States of AmericaNorthwestern University, Chicago	Laparoscopic	Healthy women undergoing laparoscopic hysterectomy	Patients with previous history of allergy to local anesthetics, long-term use of opioid analgesics or corticosteroids, and pregnancy	Quality of Recovery (QoR-40) at 24h; pain numeric scale score at 30 minutes, 60 minutes, and 24 hours; time to opioid requirement and cumulative opioid consumption at 24 hours, and number of postoperative antiemetics	Placebo	22 / 23Individuals were randomized into three groups using a computer-generated table of random numbers, and group assignments were sealed in sequentially numbered envelopes	Double blind: patients, anesthesia care providers	Ropivacaine 0.5%100	I, II	Ultrasound
Ghisi et al. (2016) ¹⁶	ItalyInstituti Ospitalieri Cremona	Laparoscopic	Patients between 18 and 70 years old, undergoing elective total laparoscopic hysterectomy	Chronic opioid therapy in the previous 3 months before surgery, conversion to open surgical technique, BMI > 30 kg/m² or < 18 kg/m², postoperative recovery in intensive care unit, chronic therapy with antidepressants, known diagnosis of epilepsy or therapy with antiepileptic drugs, bilirubin level > 3.0 mg/dL, aspartate aminotransferase and/or alanine aminotransferase > 250 IU, creatinine level >1.4 mg/dL, pregnancy or lactation, known allergy to any drug used in the study, local infection at the block site, and drug or alcohol addiction.	Postoperative pain at rest and during movement using NRS of 0 to 10, at 2, 4, 6, and 24 hours. Morphine requirement 24 hours, incidence of postoperative nausea and vomiting (PONV) using the Apfel score	No block	22 / 22Patients were randomized into two groups using computer-generated sequence of numbers placed in sealed envelopes	Single blind: observer (data collection)	Levobupivacaine 0.375%(75)	I - III	Ultrasound
Guardabassi et al. (2017) ¹⁸	ArgentinaHospital Italiano de Buenos Aires	Laparoscopic	Patients between 18 and 70 years old; BMI < 35 kg/m²; undergoing total laparoscopic hysterectomy	Previous medical history of allergy to local anesthetics; psychiatric disorders or dementia, abdominal wall infection; chronic use of analgesics, chronic pain syndrome; diagnosed peripheral neuropathy; known allergy to analgesics or corticoids.	Pain NRS: non-randomized study scores at 60 minutes, 2, 8, and 24 hours after surgery; opioid consumption during the first 24 postoperative hours; adverse effects on quality of sleep of the first night after surgery; episodes of nausea and vomit; Ramsay sedation scale	No block	20 / 20Non-probability sampling of consecutive case series.Random assignment using sealed envelopes	Single-blind: Data analysts	Ropivacaíne 0.5%(75)	I, II	Ultrasound
Bava et al. (2016) ¹⁷	ChinaDepartment of Anesthesiology and Operation, Hospital of People's Liberation Army. Xi'an	Laparoscopic and LAVH	Women scheduled for elective laparoscopic hysterectomy with benign lesions	Patients with preoperative use of analgesics were excluded due to potential impact on postoperative analgesia requirement; BMI > 30 kg/m²; coagulopathy; contraindication for peripheral nerve block; any drug allergy	Pain, with NRS: 30 and 60 minutes, 4, 8, 12, and 24 hoursPONV, Ramsay sedation scaleSatisfaction scores	No block	35 / 36Computer-generated randomization list in blocks, placed in sealed envelopes	Double-blind: blinded to patients and data analysts, but not to members of the surgical and anesthesia care teams	Ropivacaine 0.375%(112.5)	—	Ultrasound
Kane et al. (2012) ¹⁴	United States of AmericaMetrohealth Medical Center, Case Western Reserve University, Cleveland	Laparoscopic and single-port	All women undergoing laparoscopic hysterectomy by a single surgeon between April and September 2011 were approached to participate in this study.	Patients on chronic pain narcotic medications, or if they had allergy to local anesthetic.	Numeric visual analog scales for pain and opioid requirement at 2 and 24 hours after surgery; quality of recovery (QoR-40 survey) at postoperative day 1	No block	28 / 29Computer-based block randomization	Single-blind: blinded to data analysts	Ropivacaine 0.5% with epinephrine(100)	—	Ultrasound

Study (ref)	Randomization process	Deviation from planned intervention	Data on loss of results	Measurement of outcomes	Selection of reported outomes	Overall bias
Calle et al. (2014)¹⁵	Low	Low	Low	Low	Low	Low
De Oliveira et al. (2011)¹³	Low	Low	Low	Low	Low	Low
Ghisi et al. (2016)¹⁶	Low	Low	Low	Low	Low	Low
Guardabassi et al. (2017)¹⁸	Some concern	Low	Low	Low	Low	Some concern
Bava et al. (2016)¹⁷	Low	Low	Low	Low	Low	Low
Torup et al. (2015)²¹	Low	Low	Low	Low	Low	Low
Kane et al. (2012)¹⁴	Low	Low	Low	Some concern	Low	Some concern

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[TFN1] Abbreviations: ASA, American Society of Anesthesiology; BMI, body mass index; NRS, non-randomized study; NSAIDS, nonsteroidal anti-inflammatory drugs; PONV, Postoperative nausea and vomiting.