Research and Opinion in Anesthesia & Intensive Care Volume 2

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1 Postoperative pain management following abdominal hysterectomy in morbidly obese patients: A randomized clinical trial comparing three different methods. Ayman Rayan MD lecturer of anesthesia Minoufia University, Ayman Kasem MD lecturer of anesthesia Ain hams University,abry Ibrahim Abd Allah., MD lecturer of anesthesia Minoufia University,Hala M. Koptan MD lecturer of anesthesia Minoufia University. Abstract Objectives. In this study, we have investigated postoperative analgesia after laparotomy for abdominal hysterectomy by comparing three methods of analgesia ;epidural analgesia, TAP block or PCA with morphine for effectiveness and patient satisfaction 48 hours postoperatively. Methods. This prospective study on post-operative pain relief conducted on 120 patients who had been admitted and operated for abdominal hysterectomy AA physical status I and II morbidly obese (Body Mass Index 40) female patients between 35 and 65yr of age scheduled for elective abdominal hysterectomy. The patients of the study allocated randomly into three groups, the 1 st group was the epidural group (Group I) While the 2 nd group was TAP block group (Group II) done after end of operation ultrasound-guided placement on the other hand; the 3 rd group was the PCA group (Group III), IV morphine (bolus dose 2 mg, lock out time 15 min, 6 h maximum dose 10 mg). Hemodynamics, complications of procedures and side effects of morphine, visual analog scale (VA) and, sedation scores assessed by using postoperative Ramsay sedation scale and supplemental Lornioxicam in mg postoperatively. Results. In all the three groups, there were statistically insignificant changes in heart rate (HR) and blood pressure (BP) from the baseline value in the postoperativly. Incidence of postoperative nausea and vomiting (PONV) was 18.9% in epidural group, 8.1% in TAP block group and 53.8% in PCA group. While the incidence of pruritus was 16.2% in epidural group, 5.4% in TAP block group and 28.2% in PCA group. As regards the VA for measurement of pain postoperative between the all groups there was statistically significant increase in VA in Group II at 36h and 48h. No life-threatening hemodynamic or respiratory events occurred during the study and no local complications during epidural block or TAP block. Conclusions. We conclude that the TAP block holds considerable promise as part of a multimodal analgesic regimen for post abdominal hysterectomy analgesia. The TAP block was easy to perform, and provided reliable and effective analgesia in this study, and less complications with limitation to TAP block. Key words postoperative, pain, hysterectomy, morbidly obese. Introduction Pain is one of the primary concerns of the surgeon because of its close ties with clinical outcome and acute postoperative patient well-being. tudies have indicated such negative clinical outcomes to include decreases in vital capacity and alveolar ventilation, pneumonia, tachycardia, hypertension, myocardial ischemia, myocardial infarction, transition to chronic pain, poor wound healing, and insomnia (1) Although pain is a predictable part of postoperative experience, inadequate management of pain is common and has profound implications. Unrelieved postoperative pain may result in clinical and psychological changes that increase morbidity and mortality as well as decreasing the quality of life (2). Obesity results in multiple pathophysiological disturbances, including cardiovasvascular, respiratory, gastrointestinal, metabolic and pharmacological changes. These changes complicate perioperative anesthetic and surgical management of obese patients (3). Epidural analgesia post-laparotomy especially when using local anesthetics with opioids provides postoperative comfort. It also allows early ambulation, therefore reducing the risk of postoperative complications such as thromboembolism, ileus and respiratory problems (4). Transversus abdominis plane (TAP) block presented at 2005 as a good alternative for postoperative analgesia in lower abdominal surgeries as we can block the sensory nerves of the anterior abdominal wall before they leave this plane and pierce the musculature to innervate the entire anterior abdominal wall (5). Also patient controlled analgesia (PCA) has been reported as a good alternative method for controlling postoperative pain with decreased incidence of side effects (6). In this study, we have investigated postoperative analgesia after laparotomy for abdominal hysterectomy by comparing three methods of analgesia ;epidural analgesia, TAP block or PCA with morphine for effectiveness and patient satisfaction 48 hours postoperatively. Patients and methods: This is a prospective study on post-operative pain relief conducted on patients who had been admitted and 46

2 operated for abdominal hysterectomy in the gynecology ward at Armed Forces Hospital Dhahran (AFHD) over a period of 10 months started at March With approval from the institutional human ethical committee, informed consent was obtained from 120 patients AA physical status I and II morbidly obese (Body Mass Index 40) female patients between 35 and 65yr of age scheduled for elective abdominal hysterectomy. The aim of the study was explained to the patient and an informed consent was obtained from the patient. The post-operative treatment sheet of the patient and the operation notes were reviewed for prescription of analgesia. A questionnaire was designed to record age, weight, diagnosis, type of anesthesia, surgical procedure, assessment of degree of analgesia and postoperative complications related to the anesthetic procedures and side effects of ropivacaine and morphine. Patients with a history of drug abuse, major psychiatric disorder, allergy to an analgesic, chronic pulmonary disease or patients with significant cardiac, respiratory, hepatic, renal or hematologic disorders were excluded.also patients with previous upper abdominal or recent surgery and those with preexisting chronic pain and uncooperative patients were excluded from the study. Randomization was undertaken using computergenerated codes that were maintained in sequentially numbered opaque envelopes. Anesthesia was induced with intravenously (IV) fentanyl 1.5 ug /kg, sleeping dose of propofol and esmoron 0.5 mg/kg administered to achieve muscle relaxation prior to tracheal intubation. Lungs were mechanically ventilated with end tidal CO2 maintained at mm Hg. Anesthesia was maintained by sevoflurane 1% and 70% nitrous oxide in oxygen in a semi closed circle system using pressure mode of ventilation. Routine non-invasive monitoring (ECG, Pulse oximetry and noninvasive arterial blood pressure) was performed for monitoring intraoperative and postoperative. The patients of the study allocated randomly into three groups, the 1 st group was the epidural group (Group I) in this group before induction of anesthesia, the epidural catheter was inserted under local anesthesia (LA) and activated immediately after end of operation by a test dose of 4 ml lignocaine 1% with adrenaline then ropivacaine 0.125% plus morphine 0.2 mg in each ml of the solution in top up doses 8-14 ml/6 hour or PRN. While the 2 nd group was TAP block group (Group II) done after end of operation while the patient is under general anesthesia (GA), ultrasound-guided placement of the needle in the transversus abdominis fascial plane block (TAP block) and careful aspiration to exclude vascular puncture, a test dose of 1 ml was injected to confirm needle tip placement within the fascial plane. After this, 20 ml of 0.25% ropivacaine in each side was injected through the needle, while observing closely for signs of toxicity. The TAP block was then performed on the opposite side using the same technique. On the other hand 3 rd group was the PCA group (Group III), IV morphine (bolus dose 2 mg, lock out time 15 min, 6 h maximum dose 10 mg), was started on admission to the PACU in this group. The PCA pump was removed 48 h after surgery. Hemodynamics (blood pressure, and heart rate), respiratory rate and PO2 at 30 min and 1, 2, 6, 12, 24, 36 and 48h within 48 hours.respiratory depression was defined as respiratory rate less than 8 breaths per min and / or PaCO2 more than 45 mmhg. Complications of anesthesia procedures ultrasoundguided TAP block may include failure of the block, intramuscular hematoma and abscess, visceral puncture or perforation and epidural block including failure of the block, as well as systemic complications were recorded. Undesirable effects from morphine use as postoperative nausea and vomiting (PONV), sedation, respiratory depression and itching were also monitored and recorded. These assessments were performed within 48 h after end of surgical procedure. Rescue antiemetic prochlorperazine(compazine) was offered to any patient who complained of nausea or vomiting while when itching occurred diphenhydramine (Benadryl) usually provided relief. Analgesia was assessed at rest at 30 min and 1, 2, 6, 12, 24, 36 and 48h after surgery by an observer using a 100-mm VA assessed by using a self-rating visual analog scale (VA) ranging from 0 to 10, where 0 = no pain and 10 = worst possible pain assessed immediately postoperative edation scores were assigned by the investigator using postoperative Ramsay sedation scale 1 6(1= Patient is anxious and agitated or restless, or both, 2= Patient is cooperative, oriented and tranquil,3=patient responds to commands only,4 =Patient exhibits brisk response to light glabellar tap or loud auditory stimulus,5=patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus and 6=Patient exhibits no response) measured at 30 min and 1, 2, 6, 12, 24, 36 and 48h. Routine post anesthesia care unit (PACU) management included recording of vital signs on admission. Oxygen (40% FIO2) was administered on admission and discontinued half an hour before discharge. After total recovery from anesthesia (awareness was tested as the ability to open their eyes, grip a finger, and breathe deeply on request).patients were instructed to receive 8 mg IM lornoxicam (Xefo 8 mg, Nycomed) when VA was >3, and total amounts of lornoxicam administered to each group were recorded. Any other supplemental analgesics given during the perisurgical period were recorded. The aim of this study was to assess the efficacy of acute postoperative pain management through comparing three methods of postoperative pain control in morbidly obese patients (BMI > 40) undergoing abdominal hysterectomy. tatistical analyses were performed using a standard statistical program (igmastat 3.5, ystat oftware, an Jose, CA). Demographic data were analyzed using tudent s t-test or Fisher s exact test. The data were 47

3 tested for normality using the Kolmogorov-mirnov normality test. Repeated measurements (pain scores) were analyzed by repeated measures analysis of variance if normally distributed, with further paired comparisons at each time interval performed using the t-test. For non-normally distributed data, between groups comparisons at each time point were made using Wilcoxon s ranked sum test. Normally distributed data were presented as (mean ±D), nonnormally distributed data were presented as median Results A total of 120 patients who had laparotomy for abdominal hysterectomies were approached 113 patients were finally enrolled in this study; 7 patients were excluded for multiple causes. 3 patients refused continuous participation in the study and 2 patients in epidural group complained from failed block and 2 patients excluded after enrollment due to postoperative analgesic protocol violations. (interquartile range), and categorical data were presented as raw data and frequencies. The all analyses were set as P=0.05 and the Bonferroni correction for multiple comparisons were used if appropriate. tatistical data was analyzed by using student's t-test and Mann-Whitney U-test; correlation coefficients were calculated to evaluate the effect of age on scores of pain. The scores of pain were analyzed t-test. The remaining one hundred and thirteen patients were finally enrolled in this study, 37 patients were underwent epidural analgesia, 37 patients underwent TAP block and 39 patients allocated in PCA group. The characteristics of these patients are shown in table(1). tatistical analysis revealed no significant differences between groups regarding demographic data, and duration of the operative procedure. Table (1) Demographic data and operative data of three groups: Age (years) 45.5± ± ±3.6 > 0.05 Height (cm) 155.6± ± ±5.2 > 0.05 Body Mass Index 42.3± ± ±3.1 > 0.05 AA I-II > 0.05 Duration of surgery 57.7± ± ±7.4 > 0.05 (min.) In all the three groups, there were statistically insignificant changes in heart rate (HR) and blood pressure (BP) from the baseline value in the postoperative period, only three patients in epidural group complained from decreased systolic blood pressure, the minimum systolic blood pressure recorded was 82 mmhg and fall was transient and responded to dose of 5 mg ephedrine IV as shown Table (2) There was statistically insignificant variation in respiratory rate and PO2 in the three groups. Table (2) changes in respiratory rate in the three groups: 30 min postoperative 17.1±1.5 17± ±1.9 > h 16.3± ± ±1.3 > h 15.4±1.5 16,4± ±1.7 > h 17.1± ± ±1.3 > h 15.3± ± ±2.5 > h 17.5± ± ±1.2 > h 14.7± ± ±1.9 > h 15.5± ± ±1.5 > 0.05 Table (3) changes in PO2 in the three groups: 30 min postoperative 98.6± ± ±0.92 > h 99.5± ± ±0.94 > h 98.6± ± ±0.83 > h 99.7± ± ±0.65 > h 98.4± ± ±0.48 > h 98.2± ± ±0.72 > h 98.6± ± ±0.73 > h 99.2± ± ±0.63 > 0.05 Table (4) Max fall in systolic BP in the three groups: 30 min postoperative 19.6± ± ±5.5 > h 19.3± ± ±6.8 >

4 2 h 18.7± ± ±8.8 > h 19.5± ± ±6.7 > h 17.8± ± ±7.4 > h 18.9± ± ±7.1 > h 19.3± ± ±7.7 > h 19.4± ± ±6.4 > Group I Group II Group III Fig (1) Max fall in systolic BP in the three groups: 30 min postop. 1h postop. 2h postop. 6h postop. 12h postop. 24h postop. Table (5) Changes in HR in the three groups: 30 min postoperative 13.6± ± ±3.4 > h 14.5± ± ±4.5 > h 12.7± ± ±3.5 > h 13.3± ± ±2.4 > h 14.4± ± ±2.3 > h 11.9± ± ±3.7 > h 12.5± ± ±4.2 > h 13.7± ± ±2.4 >

5 Group I Group II Group III min postop. Fig (2) Changes in HR in the three groups: 1h postop. 2h postop. 6h postop. 12h postop. 24h postop. Table (6) Nausea, vomiting and pruritus: (%) vomiting Nausea or 18.9% 8.1% 53.8% 0.05 < (%) Pruritus 16.2% 5.4% 28.2% 0.05 < Nausea and vomiting (%) Pruritus (%) Group I Group II Group III Fig (3) Nausea, vomiting and pruritus: Incidence of postoperative nausea and vomiting (PONV) was 18.9% in epidural group, 8.1% in TAP block group and 53.8% in PCA group. While the incidence of pruritus was 16.2% in epidural group, 5.4% in TAP block group and 28.2% in PCA group. o statistically extremely significant increase in PCA group in comparison to other groups while there was significant increase in epidural group in comparison to TAP block group as regards PONV and itching.all patients complained of nausea and vomiting, 8 mg of zofran IV stat, while in patients complained of pruritus hydrocortisone 100 mg IV. 50

6 No life-threatening hemodynamic or respiratory events occurred during the study and no local complications during epidural block or TAP block. No need to naloxone injection in epidural group or in TAP block group, while there were three patient of PCA group needed naloxone 0.4 mg IV. The mean time of insertion of epidural catheter (from local infiltration untill fixation of the catheter) in epidural group was (14.4±3.7 min). The mean time of performing bilateral ultrasound-guide TAP block in TAP block group was (19.6±7.4 min). Table (7) the amount of postoperative analgesic (Lornioxicam in mg) Groups Group I(n=37) Group II(n=37) Group III(n=39) P value Lornioxicam (mg) 0.43± ± ± > I vs. II P I vs. III P < < P II vs. III Values are (mean ± D). Group I = Epidural gr.,group II = TAP block gr. group III= PCA gr. ignificant * P< 0.05 Very significant **P< 0.01 Extremely significant ***P< Group I Group II Group III Lornioxicam (mg) Fig (4) the amount of postoperative analgesic (Lornioxicam in mg) Table (8) Postoperative Ramsay sedation score (1-6) Variables Group I Group (n=37) (n=37) II Group III(n=39) P value 30 min postoperative 1.4± ± ± > I vs. II was sign. 1 h 2.45± ± ± > I vs. III was very sign. II vs. III was extremely > 2 h 2.44± ± ±1.2 > 0.05 I vs. II was N. 6 h 1.9± ± ±2.3 > 0.05 I vs. II was N. 51

7 12 h 1.6± ± ±1.9 > 0.05 I vs. II was N. 24 h 1.5± ± ±2.1 > 0.05 I vs. II was N. 36 h 1.6± ± ±2.5 > 0.05 I vs. II was N. 48 h 1.2± ± ±1.6 > 0.05 I vs. II was N Group I Group II Group III Fig (5) Postoperative Rmasay sedation score There was statistically increase in Ramasay sedation score in Group I in comparison to Group II and III. Table (9) Postoperative changes of VA (0-10) Variables Group I (n=37) Group (n=37) II Group (n=39) III P value 30 min postoperative 1.1± ± ±0.92 < I vs. II was extremely > 0.05 I vs. III was N II vs. III was very 0.01 < 52

8 1 h 1.8± ± ±0.7 > 0.05 I vs. II was N 2 h 2.1± ± ±1.2 < I vs. II was extremely > 0.05 I vs. III was N. 6 h 2.5± ± ±0.92 < I vs. II was extremely I vs. III was extremely < > 0.05 II vs. III was N. 12 h 1.6± ± ±1.9 > 0.05 I vs. II was N. > 0.05 I vs. III was N. > 0.05 II vs. III was N. 24 h 1.1± ± ±1.2 < 0.05 I vs. II was. II vs. III was very 0.01 < 36 h 1.5± ± ±1.4 < I vs. II was extremely > 0.05 I vs. III was N. 48 h 1.28± ± ±1.1 < I vs. II was extremely > 0.05 I vs. III was N Group I Group II Group III min postop. 1h postop. 2h postop. 6h postop. 12h postop. 24h postop. Fig (6) Changes of VA values in the postoperative period VA pain scores shown in figure (9) at 30 min, 1, 2, 6, 12, 24, 48 h in epidural group the majority of VA scores was lower in this group and no patients need supplemental Lornioxicam; while in TAP block group there was higher in VA in 13 patients mainly after 36 h postoperative need supplemental of Lornioxicam IV., on the other hand in PCA group VA scores were lower than TAP group. In PCA the VA scores were lowest within 48 h, the difference was significant increase in TAP block group 53

9 36 h and 48 h in comparison to the other the two patients otherwise there was no significant difference. There were statistically significant changes in PCA group with morphine and the other two groups as regards the side effects related to the morphine (itching, nausea and vomiting). Discussion: This randomized, controlled trial demonstrated how to supplement a standard multimodal analgesic regimen via a comparison between three methods of postoperative analgesia during the 1st 48 hours postoperative after laparotomy for hysterectomy in morbidly obese patients. Any method of postoperative analgesia must meet three basic criteria; it must be simple, safe, and clinically appropriate and evidence based (7). Although IV PCA morphine facilitates a greater degree of patient control and thereby results in high patient satisfaction levels, the analgesia produced is often incomplete, and opioid-mediated side effects remain common (1). Hysterectomy is the most common gynecological operation in women.the indicators of hysterectomy are as follows: 1) Benign disease such as leiomyomas, endometriosis, chronic infection and adnexal mass. 2) Acute condition such as pregnancy catastrophe; severe postpartum hemorrhage, severe infection. 3) Cancer or premalignant disease such as preinvasive cancer, adjacent or distant cancer. 4) Discomfort (chronic or recurrent) such as chronic pelvic pain, pelvic relaxation, stress incontinence, abnormal uterine bleeding 5) Uterine rupture, ectopic pregnancy, uterine prolapse (8). TAP technique can produce effective analgesia for up to 36 h. The reasons for the prolonged duration of analgesic effect after TAP blockade may relate to the fact that the TAP is relatively poorly vascularized, and therefore drug clearance may be slowed. The disposition of drug injected into the TAP is currently being studied. Therefore, the TAP block seems to be effective for patients undergoing surgery involving either midline or lower abdominal incision. There are a number of limitations to this study. First, the study limited assessment of postoperative analgesia to the first 48 postoperative hours. econd, all blocks were performed by the same anesthetist. Although this was done to decrease variability in the performance of the block, this approach may limit the extent to which our findings can be generalized. The use of ultrasound in TAP block to confirm needle position decreasing complications relating to peritoneal puncture. The management of patient complaining of morbid obesity and management of postoperative pain in this type of the patient was a challenge. As considered morbidly obese patient with drawbacks of it on his health and the type of the procedure for post-laparotomy undergone abdominal hysterectomy and postoperative period is significant situation need good management, early ambulation for protection against DVT. As regards the VA for measurement of pain postoperative between the all groups there was statistically significant increase in VA in Group II at 36h and 48h. Abdominal hysterectomy is a major surgical procedure followed by postoperative discomfort and pain, so postoperative analgesia must be effective to facilitate early ambulation and prevention of postoperative morbidity. The analgesic regimen should be safe, effective and with minimal side effects (9). The analgesic regimen needs to meet the goals of providing safe, effective analgesia, with minimal side effects. ince postsurgical pain treatment relies on the subjective nature of the patient s pain perception, new methods of pain treatment have been developed such as continuous epidural analgesia or patient-controlled analgesia. These methods have partially replaced the more traditional approach of on-demand parenteral administration of opioids (10) (11). Epidural administration of morphine seems ideal for morbidly obese patients working at the spinal level and is quite effective in treating incisional pain without narcotic depression of the higher centers of the central nervous system (12). In our study, the analgesia was satisfactory in all patients who received morphine epidurally even the supplemental analgesia was significantly decreased in agreement with the study was done by Brodsky and Merrell(13). Central nervous system depression following the epidural administration of narcotics is less than that following similar dosage of intravenously given narcotics (14). In our study ultrasound-guided TAP block appears to be safe (injecting local anesthetic into an intermuscular plane), but case reports have indicated that visceral injury can occur with both ultrasound- and landmarkguided TAP blockade. Using an ultrasound-guided technique, we did not observe any visceral injury or local anesthetic toxicity in our group of patients this is in agreement with the study done by McDonnell et al., 2007(15). In our study the incidence of nausea and vomiting in epidural group was 18.9% and 53.8% in PCA group with morphine, this in contrast of the meta-analysis done by the incidence was 30.3% and 33.4% respectively in both groups (16) while the study done by tanley et al 1996(17) the incidence of nausea and vomiting was 36% in using morphine epidurally for postoperative pain management. In this study the incidence of pruritus was 16.2% in epidural group and 28.2 % in PCA group with morphine, this in contrary of the meta-analysis done by Christopher et al where the incidence was 30.9% and 17.1% respectively in both groups (16) while the study done by tanley et al 1996(17) the incidence of pruritus was 46% in using morphine epidurally for postoperative pain management. 54

10 Pain by VA in epidural group during 1st 48h was lower and no patients needed supplemental Lornioxicam; while in TAP block group there was higher VA in 13 patients mainly after 36 h postoperative who needed supplemental Lornioxicam IV., on the other hand in PCA group VA scores were lower than TAP group, this is in agreement with result of the study done McDonnellet al., 2007(18). Although IV PCA morphine facilitates a greater degree of patient control, and thereby results in high patient satisfaction levels, the analgesia produced is often incomplete, and opioid-mediated side effects remain common (1). In conclusion, we found that pain relief from epidural analgesia postoperatively in morbidly obese patients was highly satisfactory and that these patients required significantly less supplemental analgesia in comparison to the other two groups (TAP block group and PCA). There were no differences in respiratory function postoperatively between study groups. References Breivik H. Postoperative pain management: why is it difficult to show that it improves outcome?eur J Anaesthesiol. 1998;15(6): Carr DB, Goudas LC. Acute pain. Lancet 1999; 353: Karayiannakis AJ, Makki GG, Montazioka A, Karouson D, Karatzos G. Postoperaive pulmonary function after laparoscopic and open cholecystectomy. British Journal of Anesthesia 1996;77: Mathias, Carvalho JCA. Anesthesia regional. Rev. Bras. Anesthesiol 1993; 43: McDonnell JG, O Donnell B, Curely G, Heffornan A, Power C, Laffey JG. The analgesic efficacy of transversusabdominis plane block after abdominal surgery: A prospective randomized controlled trial. Anesth. Analg. 2007; 104: White PF. Use of patient-controlled analgesia for management of acute pain. JAMA 1988;259: Beilin B, havit Y, Trabekin E, Mordashev B, Mayburd E, Zeidel A. The effects of postoperative pain management on immune response to surgery. AnesthAnalg 2003; 97: Jones, H.W., III Chapter 31: Hystrectomy. In J.A. Rock & H.W. Jones III (Eds), TeLinde s operation gynecology (9 th ed., pp ) Philadelphia; Lippincott Williams &Willkins. Leong WM, Lo WK, Chiu JW. Analgesic efficacy of continuousdelivery of bupivacaine by an elastomeric balloon infusor afterabdominal hysterectomy: a prospective randomised controlledtrial. Aust N Z J ObstetGynaecol 2002;42: Rosaeg OP, Lindsay MP. Epidural opioid analgesia after caesarean section: a comparison of patientcontrolled analgesia with meperidine and single bolus injection of morphine. Can J Anaesth 1994;41(11): Cohen BE, Hartman MB, Wade JT, Miller J, Postoperative pain control after lumbar spine fusion. Patient-controlled analgesia versus continuous epidural analgesia. pine 1997; 22: We conclude that the TAP block holds considerable promise as part of a multimodal analgesic regimen for post abdominal hysterectomy analgesia. The TAP block was easy to perform, and provided reliable and effective analgesia in this study, and no complications due to the TAP block were detected. There are limitations to TAP block. First, the study limited assessment of postoperative analgesia to the first 48 postoperative hours. econd, all blocks were performed by the same investigator. Although this was done to decrease variability in the performance of the block, this approach may limit the extent to which our findings can be generalized. Fourth, the study was not large enough to assess safety. No ideal way between the three methods as following side effects of morphine in PCA group, difficult technique in epidural group and on the other hand TAP block is one-shot technique leading to most probably needs supplemental analgesia. Jorgensen BC, Andersen HB, Engquist A: Influence of epidural morphine on postoperative pain, endocrinemetabolic, and renal responses to surgery-a controlled study. ActaAnaesthesiolcand 1982 Jan; 26: Brodsky JB, Merrell RC: Epidural administration of morphine postoperatively for morbidly obese patients. West J Med 1984 May; 140: ) Bromage PR, Camporesi E, Chestnut D: Epidural narcotics for postoperative analgesia. AnesthAnalg (Cleve) 1980 Jul; 59: McDonnell JG, O Donnell B, Curley G, Heffernan A, Power C,Laffey JG. The analgesic efficacy of transversusabdominis planeblock after abdominal surgery: a prospective randomized controlled trial. AnesthAnalg 2007;104:193 7 Christopher L. Wu, M.D., eth R. Cohen, B.., Jeffrey M. Richman, M.D., Andrew J. Rowlingson, B.A., Genevieve E. Courpas, B.A., Kristin Cheung, M.D., Elaina E. Lin, B.A., pencer. Liu, M.D. Efficacy of Postoperative Patient-controlled and Continuous Infusion Epidural Analgesia versus Intravenous Patient-controlled Analgesia with Opioids. Anesthesiology 2005; 103: tanley G, Appadu B, Mead M, Rowbotham DJ. Dose requirements, efficacy and side effects of morphine and pethidinedelivered by patient-controlled analgesia after gynaecologicalsurgery. Br J Anaesth 1996;76:484 6 McDonnell JG, O Donnell BD, Farrell T, Gough N, Tuite D,Power C, Laffey JG. Transversusabdominis plane block: cadaveric and radiological evaluation. RegAnesth Pain Med2007;32: