Gastrointestinal
Effect of local wound infiltration and transversus abdominis plane block on morphine use after laparoscopic colectomy: a nonrandomized, single-blind prospective study

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Abstract

Background

Recently, nonopioid-based treatment modalities have been used to improve analgesia and decrease opioid-related side effects after surgery. Transversus abdominis plane (TAP) block and local infiltration of the surgical wound are commonly used multimodal analgesia techniques after abdominal surgery; however, few studies have compared the effectiveness of a TAP block with that of local infiltration of surgical wounds in patients who have undergone laparoscopic colorectal surgery.

Materials and methods

Sixty patients undergoing laparoscopic colorectal surgery participated in this prospective comparative study. All patients were allocated to 1 of 2 groups as follows: the TAP group or the infiltration group. Patients in the TAP group received bilateral TAP blocks at the end of the surgery. Patients in the infiltration group received local infiltration of anesthetics in the surgical wounds after closure of the peritoneum. All patients received postoperative analgesia with morphine as a patient-controlled analgesia. Opioid consumption and pain scores were recorded at 2, 6, 24, and 48 h after the operation.

Results

The characteristics of patients in the TAP group (n = 30) and local infiltration group (n = 29) were comparable. Pain scores while coughing and at rest were not different between the two groups. Postoperative morphine use was significantly reduced in the TAP group compared with that in the local infiltration group at 2–6 h (2.9 ± 1.9 mg versus 4.5 ± 3.2 mg, P = 0.02), 6–24 h (5.5 ± 3.3 mg versus 10.2 ± 8.4 mg, P = 0.00), the first 24 h (16.6 ± 6.6 mg versus 24.0 ± 9.7 mg), and 48 h (23.6 ± 8.2 mg versus 31.8 ± 12.5 mg, P = 0.00). No differences in rescue analgesic use or side effects were noted between the groups.

Conclusions

Compared with local anesthetic infiltration, bilateral TAP blocks decreased the cumulative morphine use at 24 h and 48 h postoperatively in patients who had undergone laparoscopic colorectal surgery.

Introduction

Postoperative analgesia is important in multimodal approaches to postoperative recovery [1]. Although the laparoscopic approach reduces incisions and pain associated with colorectal surgery [2], postoperative pain continues to be a problem. Opiate-based analgesia is commonly used to reduce postoperative pain, but it can delay postoperative recovery of gastrointestinal mobility and increase postoperative nausea and vomiting (PONV). Recently, nonopioid-based treatment modalities have been introduced to improve analgesia and decrease opioid-related side effects [3].

Transversus abdominis plane (TAP) blocks and local infiltration of surgical wounds are currently used in multimodal postoperative pain treatment. TAP block is performed by injecting a local anesthetic solution between the internal oblique and transversus abdominis muscles to block the sensory nerves arising from the lower six thoracic and first lumbar nerve roots and produce a regional abdominal wall nerve block [4]. Unlike the epidural block, the TAP block does not produce an unwanted motor block, hypotension, and urinary retention. Wound infiltration using local anesthetics is another minimally invasive and low-cost treatment modality with few adverse effects. Local infiltration is effective after minor surgical procedures, but the effectiveness of this method in extensive surgeries has been inconsistent [5].

To our knowledge, no prospective trial has compared the use of TAP block and local infiltration of anesthetics in surgical wounds of patients after laparoscopic colorectal surgery. Therefore, we performed this prospective, single-blind controlled study to compare the effects of TAP block and local infiltration of anesthetics on pain scores and postoperative morphine use in patients who underwent laparoscopic colorectal surgery.

Section snippets

Patients

After the Kyungpook National University Medical Center's medical ethics committee approved this prospective comparative study, we recruited patients aged 20–75-y-old who were scheduled to undergo elective laparoscopic colectomy under general anesthesia. Patients with a history of allergy to local anesthetics or systemic opioids, impaired kidney function, coagulopathy, chronic pain syndrome, chronic opioid use, and those weighing <40 kg or >80 kg were excluded. A member of the research team

Results

We assessed 78 patients for eligibility and excluded 18 patients. A total of 12 patients did not meet the inclusion criteria (2 patients had an allergy to local anesthetics, 4 patients had a history of chronic opioid use, 6 patients had a chronic pain syndrome such as spinal stenosis or osteoarthritis), and 6 patients refused to participate in this study. Sixty patients scheduled to undergo elective laparoscopic colorectal resection were enrolled in the trial. All operations were performed by a

Discussion

Postoperative analgesia decreases the physiologic response to stress and improves surgical outcomes with reduced morbidities [7]. Reducing intravenous opiate use as a consequence of reduced postoperative pain also has the benefit of decreasing the incidence of side effects associated with these drugs, such as nausea, vomiting, and gastrointestinal paralysis [8]. To reduce these opioid-related side effects, contemporary postoperative care aims to decrease opioid use using a nonopioid analgesic

Conclusion

In conclusion, our results suggested that, compared with local anesthetic infiltration, the postoperative bilateral TAP block decreased morphine use for postoperative pain management in laparoscopic colorectal surgery. Further studies are required to determine the efficacy of TAP block and local infiltration using a preemptive model and as a part of multimodal analgesia in laparoscopic colorectal surgery to translate findings into clinical practice.

Acknowledgment

This work was supported by the Kyungpook National University Research Fund, 2012.

Authors' contributions: J.-S.P. obtained funding. J.-S.P., G.-S.C., K.-H.K., and J.Y. participated in the conception and design of the study. J.-S.P., Y.J., and J.Y. wrote the article. J.-S.P., K.-H.K., Y.J., S.P., and J.Y. critically revised the article. H.J. collected, analyzed, and interpreted the data.

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