Comparison of Laparoscopic-Assisted Transversus Abdominis Plane Block and Trocar-Site Local Anesthetic Infiltration After Laparoscopic Appendectomy: A Randomized Controlled Trial.

BACKGROUND AND

objectiveAbdominal wall blocks are increasingly used for pain control following laparoscopic appendectomy. This study aimed to compare the analgesic efficacy of a transversus abdominis plane (TAP) block performed by the surgical team under direct laparoscopic visualization with trocar-site infiltration using an equal total dose of local anesthetic (LA). MATERIALS AND

methodsSixty patients who underwent laparoscopic appendectomy for uncomplicated acute appendicitis between August 2017 and January 2018 were prospectively randomized in a 1:1 ratio into two groups. In the TAP group (n = 30), 15 mL of 0.25% bupivacaine was administered bilaterally under direct laparoscopic visualization before appendectomy. In the LA group (n = 30), 5 mL of 0.5% bupivacaine was infiltrated at each trocar site before incision. The total bupivacaine dose was standardized to 75 mg in both groups. Pain intensity was measured using the visual analog scale (VAS) at postoperative hours 0, 2, 6, 12, and 24. The two groups were compared in terms of rescue analgesic consumption; time to first mobilization, first passage of flatus, and initiation of oral intake; nausea and vomiting; complications; and length of hospital stay.

resultsThe groups were comparable in terms of age, sex, body mass index, and American Society of Anesthesiologists (ASA) score (all p > 0.05). VAS scores were significantly lower in the TAP group at all measured time points (hour 0, p = 0.005; hour 2, p = 0.022; hour 6, p = 0.020; hour 12, p = 0.020; and hour 24, p = 0.001; effect sizes, r = 0.34-0.49). In the TAP group, 19 of 30 patients (63.3%) required no rescue analgesia during the first 24 hours, compared with 11 of 30 (36.7%) in the LA group (p = 0.039); the total number of nonsteroidal anti-inflammatory drug (NSAID) doses per patient was significantly lower in the TAP group (p = 0.023). Although opioid requirements were numerically lower in the TAP group, the difference did not reach statistical significance (2/30, 6.7% vs. 7/30, 23.3%; p = 0.071). Oral intake was initiated earlier in the TAP group (median, 8.0 vs. 10.0 hours; p = 0.018). The median length of hospital stay was 24.0 hours in the TAP group and 32.0 hours in the LA group (p = 0.002), and the proportions of patients discharged within 24 hours were 16 of 30 (53.3%) and 3 of 30 (10.0%), respectively (p < 0.001). No differences were observed between the groups in mobilization, passage of flatus, or the frequency of nausea and vomiting. No complications related to block administration were observed.

conclusionsA surgeon-performed TAP block under laparoscopic visualization provides lower pain scores and reduces analgesic consumption during the first 24 hours following laparoscopic appendectomy compared with trocar-site infiltration using an equal dose of LA. As it requires neither additional equipment nor ultrasonographic expertise, this technique represents a feasible option in emergency surgical practice.