The Effect of Transversus Abdominis Plane Block with Liposomal Bupivacaine on Length of Stay after Total Abdominal Hysterectomy
Transversus abdominis plane (TAP) blocks are gaining popularity as a regional technique in major abdominal surgery, as they have been shown to be effective in reducing post-operative pain. Total abdominal hysterectomy (TAH) is associated with high levels of incisional pain, and TAP blocks may decrease post-operative pain and opioid consumption. However, the data for TAP blocks for patients undergoing TAH is inconclusive. Carney et al (1) found that bilateral TAP blocks effectively reduced morphine consumption and decreased pain scores in women undergoing TAH. Similarly, Bhattacharjee et al (3) found TAP blocks provided effective pain relief. Conversely, Gharaei et al (4) compared TAP blocks to placebo and did not find a significant difference in pain scores; Rojskjaer et al found no decrease in opiate consumption and minor decreases in immediate post-operative pain scores (2).
Notably, these studies were performed with conventional local anesthetics. Liposomal bupivacaine (Exparel) has been approved for infiltration techniques, and the literature suggests it may provide an extended duration of pain relief when compared to standard local anesthetics when used for TAP blocks, although none of the available studies are specific to TAH.
We began using liposomal bupivacaine for TAP blocks for TAH in June 2015. Anecdotally, time to discharge was decreased and pain control improved, so we designed a retrospective study to confirm these findings.
This was a retrospective study examining the efficacy of TAP block with liposomal bupivacaine versus routine general anesthesia for decreasing time to hospital discharge, PACU pain scores, opiate consumption and length of stay, as well as ward pain score and 12-hour opiate consumption in women undergoing TAH. IRB approval was obtained prior to data collection. A list of women who underwent TAH in 2015 was obtained and compared against our acute pain service database to generate a list of women who received a bilateral TAP block with liposomal bupivacaine for their TAH (10 mL liposomal bupivacaine with 20 mL 0.25% bupivacaine for a total of 30 mL per side). Data was collected from our inpatient electronic medical record and anesthesia records. Informed consent was obtained prior to general anesthesia and TAP block.
There were 38 subjects in group 1, TAP block, and 34 subjects in group 2, no TAP block. One subject from group 1 was excluded due to an excessive value in the time to discharge.
Standard descriptive data was calculated for each group, and then inferential statistics were calculated (Table 1). The Mann-Whitney U was utilized for all data except age. There were no significant differences in time to hospital discharge, post-operative pain scores or post-operative hydromorphone consumption between the groups.
TAP block with liposomal bupivacaine did not significantly decrease hospital length of stay, post-operative pain scores or opiate consumption. However, our study is limited by its retrospective nature. Several confounding factors were likely at play, including the use of routine post-operative pain regimens and standard discharge planning for both groups. Further randomized controlled trials are necessary to determine the utility of liposomal bupivacaine in TAP blocks for hysterectomies.