|Year : 2019 | Volume
| Issue : 3 | Page : 715-721
Ultrasound-guided transversus abdominis plane block versus local anesthetic wound infiltration for postoperative analgesia after lower abdominal surgery
Manal F Abd-Almoniem, Wafaa G Ahmed, Marwa F Negm
Department of Anaesthiology, Intensive Care and Pain Management, Faculty of Medicine for Girls, Al-Azhar University University, Cairo, Egypt
|Date of Submission||20-Oct-2019|
|Date of Decision||20-Oct-2000|
|Date of Acceptance||29-Oct-2019|
|Date of Web Publication||10-Feb-2020|
MD Manal F Abd-Almoniem
Department of Anaesthiology, Intensive Care and Pain Management, Faculty of Medicine for Girls, Al-Azhar University University, Cairo
Source of Support: None, Conflict of Interest: None
Background Transversus abdominis plane (TAP) block is an effective technique to reduce postoperative pain and narcotic consumption. However, local anesthetic infiltration is commonly used as a traditional method.
Objective The aim was to compare the pain relief and frequency of analgesic requirement after lower abdominal surgeries using ultrasound-guided TAP block with that of wound infiltration with local anesthetic agent.
Patients and methods This was a randomized, prospective, comparative, and double-blinded trial. A total of 60 patients with American Society of Anesthesiologists status I/II scheduled for elective lower abdominal surgeries were included. They were classified after informed consent. The patients in group T received TAP block with 20 ml of 0.25% bupivacaine at the end of surgery using ultrasound device with a linear transducer (5–10 MHz), whereas those in group I had wound infiltration at the end of surgery with 20 ml of 0.25% bupivacaine. In postanesthesia care unit, visual analog scale was used to assess the pain postoperatively.
Conclusion Comparable short-term postoperative pain relief was provided by both ultrasound-guided TAP block and local wound infiltration, but TAP block provided better and long-lasting effects.
Keywords: lower abdominal surgeries, post-operative analgesia, transversus abdominis plane block, ultrasound guided, wound infiltration
|How to cite this article:|
Abd-Almoniem MF, Ahmed WG, Negm MF. Ultrasound-guided transversus abdominis plane block versus local anesthetic wound infiltration for postoperative analgesia after lower abdominal surgery. Sci J Al-Azhar Med Fac Girls 2019;3:715-21
|How to cite this URL:|
Abd-Almoniem MF, Ahmed WG, Negm MF. Ultrasound-guided transversus abdominis plane block versus local anesthetic wound infiltration for postoperative analgesia after lower abdominal surgery. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2020 Oct 22];3:715-21. Available from: http://www.sjamf.eg.net/text.asp?2019/3/3/715/278052
| Introduction|| |
Postoperative pain control is an important component of care in surgical patients. The aim of managing postoperative pain is to reduce the length of hospital stay and patient satisfaction, besides early mobilization and decrease in postoperative complications . Optimal postoperative pain control is difficult in abdominal surgery particularly, as anterior abdominal wall incisions can cause significant pain .
Transversus abdominis plane (TAP) block has been shown to provide effective postoperative analgesia for different types of lower abdominal surgeries. TAP block under ultrasound guidance is easy, reliable, and safe. Complications of TAP block, like liver injury and bowel hematoma, are less likely with ultrasound guidance .
Local anesthetic wound infiltration is a common postoperative analgesic method, which has been safely performed in postoperative pain control .
Bupivacaine is an amide-type, long-acting local anesthetic. It reversibly blocks specific sodium ion channels in the neuronal membrane, leading to decrease in the permeability of sodium ions and membrane stabilization, inhibition of depolarization and nerve impulse conduction, and a reversible loss of sensation .
Ultrasounds are used in the medical setting with a frequency of 1–25 MHz. Sound waves are not ionizing and are not harmful at the energy levels used for diagnostic purposes .
Ultrasound use has been rated as one of the safest method for patients, which prevents intravascular injection during regional anesthesia .
The aim was to compare the analgesic efficacy of TAP block guided by ultrasound with that of local wound infiltration after lower abdominal surgeries under general anesthesia by using visual analog scale (VAS) to evaluate pain intensity (the primary outcome), as well as hemodynamics of the patient [heart rate (HR) and blood pressure (BP)], first requirement of rescue dose of opioid, total opioid consumption, opioid-related adverse effects, and complications related to the used procedure (the secondary outcome).
| Patients and methods|| |
This randomized, prospective double-blind clinical study was carried out at Al-Zahraa University Hospital, Cairo, Egypt, between February 2018 and February 2019. After obtaining approval from Hospital Ethics Committee, written informed consents were obtained from 60 patients who were scheduled for lower abdominal surgeries under general anesthesia. Patients were aged between 20 and 60 years, of both sex, with American Society of Anesthesiologists I or II. Exclusion criteria were as follows: patients who refused to participate in the study, American Society of Anesthesiologists physical status greater than or equal to 3, cardiac diseases, allergy to the drugs used in the study, coagulation abnormality, history of alcohol or drug abuse, uncontrolled diabetes mellitus or hypertension, local infection at the site of block, obese (BMI>30 kg/m2), and pregnant women.
Patients were classified randomly using closed envelops into two groups; each one contained 30 patients. Ultrasound-guided TAP block group (using Sonoscape A5 US device manufactured by SonoScape Medical Corp., Shenzhen, China, with straight array probe 5–10 MHz) (group T), received 0.25% bupivacaine (Sunny Pharmaceutical Company, Badr, Cairo, Egypt) in 20 ml saline at the end of surgery after skin closure. Wound infiltration group (group I) received wound infiltration with 0.25% bupivacaine in 20 ml saline at the end of surgery after peritoneal closure.
In the OR, standard monitoring included ECG, pulse oximetry, noninvasive BP measurement, and capnography, which were applied to the patient using Drager (Drager Medical GmbH, Lubeck, Germany) (Vista 120) monitor. General anesthesia was maintained using (Drager −Primus) anesthetic machine. Patients were instructed to use to the VAS for pain assessment postoperatively.
Anesthetic technique was as follows: in the recovery unit, 18 or 20 G cannula was inserted, and all patients were premedicated with midazolam 2 mg and metoclopramide 10 mg intravenously. Induction of general anesthesia in each group was performed by injection of fentanyl 1 µg/kg intravenously, propofol 2 mg/kg intravenously, and atracurium 0.5 mg/kg with insertion of ETT of suitable size and connection to mechanical ventilator. The respiratory rate and tidal volume were adjusted to maintain the end tidal CO2 within 10% variation from baseline values. intravenously fluid therapy, transfusions, and other procedures followed the usual standards.
Maintenance of anesthesia was performed using 50% oxygen with isoflurane 1–2% and 0.1 mg/kg atracurium as top-up doses for muscle relaxation. Hemodynamic variables within 10% of baseline values were maintained.
Neostigmine was given to reverse neuromuscular block at the end of procedure by dose of 0.05 mg/kg with atropine 0.01 mg/kg intravenously. At the end of the surgery, ETT extubation was done and then the patient was transferred to postanesthesia care unit (PACU).
For postoperative analgesia, all patients received diclofenac (75 mg) intramuscular per 12 h. Patients were strongly advised that they should ask for additional analgesia if needed at any time after surgery. If pain was not relieved by diclofenac, pethidine (50 mg) intramuscularly was administered. Nausea and vomiting were treated using intramuscular metoclopramide 10 mg if needed.
Assessment parameters in PACU included the following: VAS at 0, 2, 4, 8, 12, and 24 h was used to assess the pain intensity, hemodynamics of the patient (HR and BP), first requirement of rescue dose of opioid, total number of patients who used opioid, opioid-related adverse effects, and complications related to the used procedure.
Data were collected, revised, coded, and entered to the Statistical Package for the Social Sciences (IBM SPSS) version 18 (SPSS Inc. Released 2009, PASW Statistics for Windows, Version 18.0, Chicago: SPSS Inc., IBM Corp. Released 2010. IBM SPSS). Moreover, qualitative variables were presented as number and percentages. The comparison between groups with qualitative data was done by using χ2.
The comparisons between two independent groups with quantitative data and parametric distribution were done by using Paired t-test.
- P value greater than 0.05 is considered nonsignificant.
- P value less than or equal to 0.05 is considered significant.
- P value less than or equal to 0.01 is considered highly significant.
| Results|| |
There was no statistically significant difference between the two groups regarding demographic data (age, sex, or BMI), as shown in [Table 1].
|Table 1 Demographic data description of the patients included in the study|
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Moreover, there was no statistically significant difference between the two groups regarding the type of operations done in our study (P=0.083).
Visual analogue scale
VAS was assessed at 0, 2, 4, 8, 12, and 24 h postoperatively. There was no statistically significant difference in the VAS between the two groups at 0, 2, 4, and 8 h postoperatively, as P value was greater than 0.0.5, but on 12 and 24 h postoperatively, there was a significant difference between the two groups, where it was much lower in group T than in group I, as shown in [Table 2].
|Table 2 The average visual analog scale for both groups in the six evaluation periods|
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HR was assessed at 0, 2, 4, 8, 12, and 24 h postoperatively where 0 h starts from the time of arrival at PACU. Assessment was continued until reaching 24 h postoperatively. There was no statistically significant difference in the heart rate between the two groups at 0, 2, 4, 8, and 12 h postoperatively, as P value was greater than 0.05. At 24 h postoperatively, there was a highly significant difference between the two groups, as P value was less than 0.01, which means the mean heart rate for group I is statistically greater than that of group T, as shown in [Figure 1].
|Figure 1 The mean of heart rate for both groups in the six evaluation periods.|
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Mean arterial blood pressure
Mean arterial blood pressure (MAP) was assessed at 0, 2, 4, 8, 12, and 24 h postoperatively. There was no statistically significant difference in the MAP between the two groups at 0, 2, 4, and 8 h postoperatively, as P value was greater than 0.05. At 12 and 24 h postoperatively, there was a significant difference between the two groups, as P value was less than 0.05, which means the mean MAP for group I is statistically greater than that of group T, as shown in [Figure 2].
|Figure 2 Comparison of mean arterial blood pressure for both groups in the six evaluation periods.|
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First request of rescue dose of opioid
The average time needed for first request of opioid in group T is significantly greater than that in group I, as P value was less than 0.05, as shown in [Figure 3].
|Figure 3 Comparing first request of nonopioid and opioid analgesia between the two groups.|
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Total number of patients who used opioid and mean dose of opioid consumption
There was no significant difference between the both groups regarding total number of patients who used opioid (P=0.126). However, the mean dose of opioid consumption was less in group T than group I (60 vs 70 mg), and the difference between both groups was also nonsignificant.
Opioid adverse effects and complications related to the used procedure
There was no significant difference between both groups in developing any of opioid adverse effects like nausea and vomiting, and also there were no complications reported in our study in both groups (P>0.05).
| Discussion|| |
Control of postoperative pain is an essential component of surgical patient care plan. Unrelieved pain is inhumane and immunosuppressive, and it is associated with both local wound and systemic complications such as delayed wound healing, transition to chronic pain, low vital capacity and alveolar ventilation, pneumonia, deep vein thrombosis, hypertension, and myocardial ischemia and infarction. Good pain control allows early mobilization and fast recovery; it decreases hospital stay and costs .
Postoperative pain management can be improved by using a multimodal approach, which results in pain relief with minimal adverse effects, enhanced recovery protocols, along with minimally invasive surgeries .
In the present study, we included 60 patients categorized into two groups comparing the postoperative analgesic efficacy and safety of ultrasound-guided TAP block with local anesthetic wound infiltration when added to the routine components of multimodal analgesia such as NSAIDs, acetaminophen, and small doses of opioids if needed.
Our study found that there was a significantly lower pain score in the TAP group at 12 and 24 h postoperatively (P<0.05). However, no significant difference was detected at any other time point, which suggests that TAP block is effective for relatively longer periods. Local anesthetic infiltration is limited to a short period of pain control, and then the effects decrease to a minimum by 8 h postoperatively.
The results of this study are in line with the observations of Yu et al. , in their meta-analysis study. They collected data from four previous studies done on 196 patients. They agreed with our study that there was no significant difference between both groups in VAS at any time postoperatively, except at 24 h, where there was a significant difference between both groups, as it was less in TAP group than in the wound infiltration group, but this study only evaluated the VAS at 2, 4, and 24 h postoperatively, with no data on the VAS at 8 and 12 h postoperatively.
In parallel to the previous study, a systematic review done by Guo et al.  collected data from nine studies with 500 participants, and the results agreed with us as they showed no significant difference on the first hour postoperatively, but it showed less VAS on 8 and 24 h.
In contrast, the study done by Görkem et al.  classified participants into five groups (control group, TAP placebo, TAP block, wound infiltration placebo, and wound infiltration) and compared the VAS on 0, 6, 12, 18 h postoperatively. They found a significant difference on 0, 6, 12, and 18 h postoperatively, where the TAP group had lesser VAS than any other group in the research including wound infiltration group, but they did not evaluate the VAS on 24 h postoperatively. The difference in the results may be owing to the administration of intravenous anesthesia, which was done at the end of surgery before extubation, whereas in our study, the intravenous anesthesia was given with the induction of the general anesthesia. Moreover, in our study, we used fentanyl as intravenous anesthesia, whereas in this study, they used a combination of morphine and sufentanil. In addition, the total number of the patients in this study was 216, whereas in our study was only 60 patients.
They explained the reason why TAP block provided lower postoperative pain than wound infiltration as it has better pain control effect. With TAP block, the anesthetic directly blocks the afferent nerves before these nerves enter the anterior abdominal wall. Visceral pain relief may be owing to posteromedial diffusion of the anesthetic along the facial plane.
Moreover, there is controversy in the finding of the study done by Amjad et al. , which compared the VAS at 0, 2, 4, 6 h postoperative between both groups and showed significant lower VAS in TAP block group than in wound infiltration group. In this study, TAP block was done after induction of anesthesia and before surgical incision, whereas this protocol was not done in our study. We performed TAP block in our study at the end of surgery and before extubation, so there was time lag between the both studies.
In contrast to our study, an Indian study done by Ranjit and Shrestha  showed significant difference between both groups, where VAS was much lower in TAP group, with statistical difference at 0, 2, 4, and 8 h postoperatively, but on 12 and 24 h postoperatively, it was lower in TAP group, but there was no significant difference between both groups. The total number of the patients in this study was 45 patients, whereas our study was done on 60 patients, which may be the cause of difference.
In our study, there is a significant difference between both groups in the first request of opioid (P>0.05), and the average time needed for first request of opioid in TAP group is significantly greater than that in wound infiltration group.
A Pakistanian study done by Amjad et al.  found there was no statistically difference between both groups in requirements of analgesia and opioids; however, the time needed for first call of analgesia was longer in TAP group.
The systematic review done by Guo et al.  showed different results from our study. It showed no significant difference between both groups in analgesic requirements or the time needed for receiving first dose of analgesia. The reason in this controversy may be owing to the nature of the systematic review study, which collected the data from nine studies including 500 participants, whereas we have only 60 participants in our study, which is too small to compare.
Our study results reported that total numbers of patients who used opioid were less in the TAP group, with no statistical difference between both groups.
In parallel to our study, a Turkish study done by Görkem et al.  showed there was no statistical difference between groups in the total opioid consumption, whereas TAP group was less opioid consumption.
In addition to the previous study, an Indian study done by Ranjit and Shrestha  used oral tablets of tramadol as a rescue dose of opioid in case of severe intolerable pain. Their results showed lower opioid consumption in the TAP group compared with the wound infiltration group, but there was no statistical difference between both groups, which is in agreement with our study.
The study done by Yu et al.  disagrees with us. Their results showed that there is no difference between both groups regarding total opioid consumption. However, this study is a meta-analysis study done on a large population, whereas our study was done only on 60 patients, and they used morphine for rescue dose of opioid, which is more potent than pethidine, which was used in our study.
In our study, there is no significant difference between both groups in developing any of opioid adverse effects like nausea and vomiting.
The results of this study are consistent with the observations reported by Yu et al.  in their meta-analysis study, which showed no significant difference between both groups regarding postoperative nausea and vomiting.
The systematic review done by Guo et al. , showed the same results, as there was no significant difference between both groups in developing postoperative nausea and vomiting.
In this study, there was no statistically significant difference in the heart rate between the two groups at 0, 2, 4, 8, and 12 h postoperatively, but on 24 h postoperatively, there was a significant difference between the two groups, as the TAP group showed lower heart rates than in the wound infiltration group.There was no statically difference in the mean arterial BP between the two groups in 0, 2, 4, and 8 h postoperatively, but on 12 and 24 h postoperatively, there was a significant difference between the two groups, as the TAP group showed lower BP readings than in the wound infiltration group.
The study done by Paul et al.  reported that pre-incisional TAP block attenuates hemodynamic responses to surgical stress and decreases intraoperative fentanyl requirements, which seem to be consistent with our study.
In our trial, there are no complications reported in both groups, which agrees with the study done by Ranjit and Shrestha  and the study done by Guo et al. . They reported the same results, as there were no complications in their work; however, not many studies have discussed this point, and it needs to be reassessed in the upcoming researches.
| Conclusion|| |
Ultrasound-guided TAP block is better than traditional local wound infiltration for postoperative analgesia in patients undergoing lower abdominal surgeries, as it provides better analgesic effect, as shown in patient’s hemodynamics and VAS. It decreases the need for rescue opioid analgesia and so its adverse effects.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]