TAP blocks vs wound infiltration in laparoscopic colectomies Results of a Randomised Controlled Clinical Trial Kim Gorissen Frederic Ris Martijn Gosselink Ian Lindsey Dept of Colorectal Surgery Dept of Anaesthetics Dept of Statistics Anwar Rashid James Shorthouse Nick Crabtree Adrian Smith OXFORD UNIVERSITY HOSPITALS
Rationale Adequate pain relief is essential in ERAS Surgical trauma Recovery Surgical outcomes Multimodal analgesic regiments golden standard
However.. Epidural Opioids NSAIDS Reduced mobility Technical failure rates Local complications Evidence? Reduced splanchnic blood flow PONV, prolonged ileus Sedation, urinary retention, respiratory depression Interference ERAS Increased leakage rates
TAP block Substantial proportion pain is caused by surgical trauma skin & parietal peritoneum Local field block Peripheral nerve block
Innervation anterior abdominal wall Th 6- L1 Iliohypogastric Ilioinguinal
Transverse Abdominal Plane block Th 6- L1 Iliohypogastric Ilioinguinal TAP block
Evidence TAP blocks TAP reduces 24h morphine consumption a Possible faster recovery However Mainly gynaecologic surgery Very limited observational data (open) colorectal 1 RCT in laparoscopic colectomy, TAP vs control b NO comparison of TAP vs simple wound infiltration a Charlton S et al, Cochrane database 2010 b Walter CJ. Surg. Endos 2013
Methods Single centre, randomised, double blinded trial TAP vs WOUND INFILTRATION Inclusion Right hemicolectomy or High anterior resection ASA 1-3 Elective surgery Exclusion Previous colorectal resections, chronic abdominal pain Opioid tolerance, allergy or intolerance BMI > 35 or weight <50kg
Methods 1:1 randomisation Sample size calculation assuming 40% reduction in morphine Power 80 Significance 5% 36 Each arm
Results Randomised N=72 Allocated to TAP-block N=36 Allocated to Local Anaesthetic N=35 TAP block employed N=36 Wound infiltration employed N=35 Operative procedure employed N=32 Operative procedure employed N=32 Complete ward follow-up N=28 Complete ward follow-up N=28 Analysed N=28 Analysed N=28
Results Randomised N=72 Allocated to TAP-block N=36 Allocated to Local Anaesthetic N=35 TAP block employed N=36 Wound infiltration employed N=35 Operative procedure employed N=32 Operative procedure employed N=32 Complete ward follow-up N=28 Complete ward follow-up N=28 Analysed N=28 Analysed N=28
Results: Patients characteristics TAP-block (N = 28) Local Anaesthetic (N = 28) P- value Mean age - yr (CI) 67.6 (62.8 72.9) 68.0 (61.7 73.1) P=0.885 Mean BMI (CI) 26.9 (22.4 27.3) 28.9 (24.4 29.3) P=0.104 Gender Male Female ASA classification I II III Diagnosis of cancer 16 (57) 12 (43) 8 (29) 18 (64) 2 (7) 15 (54) 13 (46) 4 (14) 23 (82) 2 (1) P=0.788 P=0.280 21 (75) 25 (89) P=0.216 Previous Surgery 8 (29) 6 (22) P=0.239
Results: Patients characteristics TAP-block (N = 28) Local Anaesthetic (N = 28) P- value Mean age - yr (CI) 67.6 (62.8 72.9) 68.0 (61.7 73.1) P=0.885 Mean BMI (CI) 26.9 (22.4 27.3) 28.9 (24.4 29.3) P=0.104 Gender Male Female ASA classification I II III Diagnosis of cancer 16 (57) 12 (43) 8 (29) 18 (64) 2 (7) NS 15 (54) 13 (46) 4 (14) 23 (82) 2 (1) P=0.788 P=0.280 21 (75) 25 (89) P=0.216 Previous Surgery 8 (29) 6 (22) P=0.239
Results: Procedural variants TAP-block (N = 28) Local Anaesthetic (N = 28) P- value Surgical procedure Lap Right hemi Lap High anterior 9 (32) 19 (68) 5 (18) 23 (82) P=0.116 Wound length median cm (IQR) 6 (5-7) 5(4-6) P=0.188 Duration operative procedure median minutes (IQR) Postoperative complications 200 (150 230) 205 (160 240) P=0.990 3 (11) 5 (18) P=0.226
Results: Procedural variants TAP-block (N = 28) Local Anaesthetic (N = 28) P- value Surgical procedure Lap Right hemi Lap High anterior 9 (32) 19 (68) NS 5 (18) 23 (82) P=0.116 Wound length median cm (IQR) 6 (5-7) 5(4-6) P=0.188 Duration operative procedure median minutes (IQR) Postoperative complications 200 (150 230) 205 (160 240) P=0.990 3 (11) 5 (18) P=0.226
Results: Cumulative Morphine 50 45 40 35 30 25 20 15 10 5 0 47.3 46.7 30.9 31 TAP block LA 24h 48h
Pain at rest 10 8 6 4 2 0 6h 12h 24h 48h TAP WOUND INFILTRATION TAP-block Local Anaesthetic P value n Median (IQR) n Median (IQR) Mann-Whitney test 24 h 25 2 (1-3) 25 2 (1-5) 0.672 48h 21 1 (0.5 4.5) 23 2 (0-3) 0.820
Pain at movement 10 8 6 4 2 0 6h 12h 24h 48h TAP TAP-block WOUND INFILTRATION Local Anaesthetic n Median (IQR) n Median (IQR) Mann-Whitney test 24h 22 5 (2-7) 24 4 ( 2-7) 0.808 48h 21 2 (1.5 5) 22 2 (1-5) 0.941
Days TAP-block Local Anaesthetic Nausea 24h 21 0 (0 0.5) 23 0 (0 0) 0.924 Nausea 48h 15 0 (0-0) 18 0 (0-0.25) 0.899 Mobilisation 26 1 (0.5 2) 28 1 (0.5 2) 0.908 Discharge 24 4.5 (3 9) 28 4.5 (3 8) 0.910
Conclusion TAP may seem like great idea BUT wound infiltration = EQUALLY EFFECTIVE (AND) Easy Quick Reliable
Conclusion TAP may seem like great idea BUT has NO benefit
Questions