The important finding of this study is the positive effect of the transversus abdominis plane infiltration on postoperative quality of recovery in patients undergoing laparoscopic hysterectomy. This effect was present for all quality of recovery dimensions for the 0.5% ropivacaine group when compared with placebo, and it was also present for pain, physical comfort, and emotional subcomponents of the QoR-40 questionnaire for the 0.25% ropivacaine group. Individuals in the 0.5% ropivacaine group had lower pain scores and decreased opioid consumption when compared with placebo and achieved higher scores in the global QoR-40 questionnaire. Individuals in the 0.5% ropivacaine group were also able to meet discharge criteria from postanesthesia recovery unit faster than individuals in the saline group. The use of higher-dose ropivacaine (0.5%) for the transversus abdominis infiltration does not seem to provide clinically meaningful advantages on patient postoperative quality of recovery at 24 hours when compared with lower-dose (0.25%) ropivacaine after laparoscopic hysterectomy.
Beneficial effects of a transversus abdominis plane infiltration have been shown after other laparoscopic procedures. El-Dawlatly et al10 demonstrated reducing opioid consumption in patients undergoing laparoscopic cholecystectomy who received a transversus abdominis plane infiltration of local anesthetics. In colorectal resections, Conaghan et al11 demonstrated a reduction on postoperative opioid consumption without increased complications after a transversus abdominis plane infiltration. Although reduced opioid analgesic requirements have been shown after a transversus abdominis plane infiltration, previous studies have not evaluated the effect of reduced opioid consumption on quality of patient recovery after surgery. In this study, we found an inverse linear relationship between 24-hour opioid consumption and quality of recovery. The global QoR-40 scores achieved by using the transversus abdominis plane infiltration are similar to previously reported scores in outpatient laparoscopic surgery.12 These findings suggest that patients who received this technique had similar postoperative quality of recovery as patients who normally underwent outpatient surgery for other surgical procedures.
Other methods of analgesia using local anesthetics have been used to improve postoperative analgesia after laparoscopic gynecological surgery. Wound injection of local anesthetics and intraperitoneal local anesthetic instillation have been studied but have shown less consistent analgesic effectiveness after laparoscopic surgery than the transversus abdominis plane infiltration. The reported analgesic effect of intraperitoneal local anesthetics instillation for laparoscopic surgery have ranged from considerable pain reduction13 to no reduction in pain.14 Local anesthetic infiltration to the surgical wound has a short-lived (2–6 hours) duration of action and there is lack of evidence that it decreases postoperative pain.15,16 More importantly, there is also lack of evidence that these techniques can lead to a better functional recovery to patients.
It is important to note that patient recovery after hysterectomy can be affected by individual personality characteristics. Person et al17 demonstrated that women with high stress coping abilities have a better outcome in general well-being than women with low stress coping capacity. This finding is suggestive that better analgesia and reduced opioid use alone are not sole factors in quality of postoperative recovery after hysterectomy.
There are constraints to the routine use of the transversus abdominis plane infiltration of local anesthetics. The procedure requires the use of ultrasonography for accurate delivery of drug and patient safety.18 It can also be time-consuming, especially for those who are inexperienced. Although never reported, and minimized by the use of ultrasound guidance, potential serious risks with the performance of the procedure include intestinal and liver puncture. Local anesthetic toxicity is also a potential risk, but no cases have been reported so far.
There are limitations to our study. The individuals in this study were not managed as outpatients; they were discharged at the discretion of the surgeon and most were admitted overnight for observation. Therefore, we cannot determine the efficacy of use of the transversus abdominis plane infiltration in managing individuals for outpatient hysterectomy directly. We did not obtain ropivacaine blood levels to evaluate the systemic effect of the transversus abdominis plane infiltration. Because the individuals received general anesthesia, we were unable to assess the distribution of the analgesia produced by the infiltration. Finally, the study was underpowered to detect a difference in opioid consumption or global quality of recovery 40 score between the ropivacaine 0.25% and 0.5% groups.
In conclusion, we demonstrated that the preoperative transversus abdominis plane infiltration leads to a better quality of recovery and analgesia in patients undergoing laparoscopic hysterectomy. There is an association between postoperative analgesia and functional recovery of these patients. Individuals in the 0.5% ropivacaine group meet discharge criteria faster for release from postanesthesia care unit than the ones in the saline group.
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