The only study evaluating TAP block on time to first analgesic administration demonstrated an effect compared with control, WMD (95% CI) of 27.0 (15.4–38.5) minutes, P < 0.001.28 This was a high-quality study (Jadad = 5) and evaluated TAP block performed preoperatively.
None of the included studies reported on clinical manifestations of local anesthetic toxicity.
The aggregated effect of the studies examining TAP block on postoperative nausea and/or vomiting compared with placebo did not reveal a significant effect in relation to a large CI, odds ratio (95% CI) of 1.5 (0.8–2.7).28,30,31,33
The most important finding of the current investigation is the significant effect of TAP block in the reduction of postoperative pain outcomes for laparoscopic surgical procedures. TAP block reduced early pain at rest, late pain at rest, and postoperative opioid consumption. None of the included studies reported on complications due to the performance of TAP block. Taken together, our results suggest that TAP block may be an effective strategy to improve analgesic outcomes in patients undergoing laparoscopic surgical procedures.
Another important finding of the current investigation was the detection of the preoperative time as the likely optimal period for the administration of TAP block. The preoperative administration of TAP block specifically reduced early pain at rest and postoperative opioid consumption compared with postoperative administration of the block. Our results suggest some preventive analgesic properties of TAP block for early pain from laparoscopic procedures as previously reported and disputed by different investigators.18,38–40 In contrast, we did not observe the same beneficial preventive analgesic properties for late pain at rest. It is possible that the larger opioid consumption in the group that had TAP block performed postoperatively compared with the group that had the block performed preoperatively contributed to the lack of observed differences in late pain scores.
We were also able to detect a relationship between the local anesthetic dose and the effect on some of the outcomes. Studies that used higher doses of local anesthetics reported greater opioid-sparing effects and lower pain scores at 24 hours. In contrast, higher doses of local anesthetics did not result in lower pain scores during the early postoperative hours after surgery. It is important to note that higher doses of local anesthetics have been associated with mild neurotoxicity in patients receiving TAP block for cesarean delivery.41 We only included subjects who received TAP block under general anesthesia, and this fact did not allow us to detect mild neurological symptoms possibly associated with higher doses of local anesthetics.
It was interesting to note that despite a significant reduction in postoperative pain outcomes using TAP block, we were unable to find a reduction in opioid-related side effects such as postoperative nausea and vomiting. The large variation of risk profiles and the differences in the number/dosage of prophylactic antiemetic drugs among studies might have contributed to the lack of benefit from TAP block on postoperative nausea and/or vomiting.42–44 Nevertheless, few studies have reported on the beneficial effect of regional anesthesia techniques in more global recovery outcomes.45
Our group has reported on the overall effect of TAP block to improve the quality of postsurgical recovery after laparoscopic surgery.34,35 In contrast, Kane et al.32 did not detect a beneficial effect on the quality of recovery in subjects undergoing laparoscopic hysterectomy. Several methodological differences such as variations of the surgical procedure and the inclusion of obese subjects could have contributed to the lack of ability of Kane et al.32 to demonstrate an effect of TAP block on the quality of recovery. Even more importantly, Kane et al.32 administered TAP block postoperatively that may have limited the overall effect on analgesic outcomes.
It important to note that the studies included in the current meta-analysis compared TAP block with an inactive control group. Future studies comparing TAP block with other effective multimodal analgesic strategies are warranted. Because the performance of TAP block can be time-consuming and it requires a certain degree of expertise, other less invasive multimodal strategies such as perioperative systemic lidocaine, magnesium, and dexamethasone may be valuable alternatives to TAP block.46–48
Our current meta-analysis has substantial differences from previous quantitative systematic reviews.8,9,49 First, to the best of our knowledge, we included a larger number of trials and subjects in our analysis than previous authors.8,9,49 Second, we specifically examined the efficacy of TAP block for laparoscopic procedures rather than the previous analysis that focused on the efficacy of the TAP block for cesarean delivery.8,49 Last, we were able to demonstrate a preoperative timing benefit of TAP block on analgesic outcomes, as well as a linear association between local anesthetic dose and certain outcomes (opioid consumption and late pain at rest).
We detected a beneficial effect of TAP block for early/late pain at rest but not for early/late pain on movement. Pain on movement is often more severe than pain at rest.50 Complete relief of pain on movement is not commonly achieved with local or systemic analgesic techniques but frequently requires the use of more potent neuraxial techniques. Therefore, it was somewhat expected that TAP block would not be an efficient strategy to minimize postoperative pain on movement.
Although we detected a significant reduction in opioid consumption and pain at rest when TAP block was compared with control, the clinical impact of our findings remains to be examined. Recently, patient-centered outcomes such as quality of recovery scores have been used as a valid measurement of clinical impact for other analgesic interventions.51–54 Future studies examining TAP block should incorporate patient-centered outcomes into their designs to provide additional information regarding the clinical impact of TAP block on recovery of surgical patients.
Our investigation should be interpreted within the context of its limitations. Although we limited the type of surgical procedures and anesthesia techniques to minimize heterogeneity, we observed high heterogeneity in our analysis. Some of the variation in the effect size could be explained by different doses of the local anesthetic administered. Because studies have not directly compared the time of block administration, our subgroup analysis (preoperative versus postoperative administration of TAP block) should only be interpreted as observational and as hypothesis-generating for future studies. Only a large randomized trial can confirm or refute our findings. Another limitation of our study is that we did not register the review protocol on a registry database of systematic reviews. Registration of systematic reviews may prevent reporting bias. Nevertheless, our primary outcomes were identical to previous systematic reviews reported by our group on postoperative pain outcomes.55
In summary, we have detected a beneficial effect of TAP block on analgesia outcomes after laparoscopic surgery. The preoperative period seems to be the optimal time for administration of the block. Dose effects of local anesthetics used for TAP block were detected for late pain and opioid consumption outcomes. None of the included studies reported on the systemic effects related to local anesthetic toxicity. TAP block should be considered an effective analgesic technique to ameliorate postoperative pain after laparoscopic surgical procedures.
1. Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012;115:1060–8
2. White PF, White LM, Monk T, Jakobsson J, Raeder J, Mulroy MF, Bertini L, Torri G, Solca M, Pittoni G, Bettelli G. Perioperative care for the older outpatient undergoing ambulatory surgery. Anesth Analg. 2012;114:1190–215
3. Choi EM, Na S, Choi SH, An J, Rha KH, Oh YJ. Comparison of volume-controlled and pressure-controlled ventilation in steep Trendelenburg position for robot-assisted laparoscopic radical prostatectomy. J Clin Anesth. 2011;23:183–8
4. Lau S, Vaknin Z, Ramana-Kumar AV, Halliday D, Franco EL, Gotlieb WH. Outcomes and cost comparisons after introducing a robotics program for endometrial cancer surgery. Obstet Gynecol. 2012;119:717–24
5. De Oliveira GS Jr, Fitzgerald P, Streicher LF, Marcus RJ, McCarthy RJ. Systemic lidocaine to improve postoperative quality of recovery after ambulatory laparoscopic surgery. Anesth Analg. 2012;115:262–7
6. De Oliveira GS Jr, Ahmad S, Fitzgerald PC, Marcus RJ, Altman CS, Panjwani AS, McCarthy RJ. Dose ranging study on the effect of preoperative dexamethasone on postoperative quality of recovery and opioid consumption after ambulatory gynaecological surgery. Br J Anaesth. 2011;107:362–71
7. Abdallah FW, Chan VW, Brull R. Transversus abdominis plane block: a systematic review. Reg Anesth Pain Med. 2012;37:193–209
8. Siddiqui MR, Sajid MS, Uncles DR, Cheek L, Baig MK. A meta-analysis on the clinical effectiveness of transversus abdominis plane block. J Clin Anesth. 2011;23:7–14
9. Abdallah FW, Halpern SH, Margarido CB. Transversus abdominis plane block for postoperative analgesia after Caesarean delivery performed under spinal anaesthesia? A systematic review and meta-analysis. Br J Anaesth. 2012;109:679–87
10. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62:e1–34
11. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17:1–12
12. Macintyre PE, Ready LBMacintyre PE, Ready LB. Pharmacology of opioids. Acute Pain Management: A Practical Guide. 20012nd ed St Louis, MO: W.B. Saunders:15–49
13. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005;5:13
14. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–88
15. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315:629–34
16. De Oliveira GS Jr, Chang R, Kendall MC, Fitzgerald PC, McCarthy RJ. Publication bias in the anesthesiology literature. Anesth Analg. 2012;114:1042–8
17. Rosenthal R. The file drawer problem and tolerance for null results. Psychol Bull. 1979;86:638–41
18. Barreveld A, Witte J, Chahal H, Durieux ME, Strichartz G. Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth Analg. 2013;116:1141–61
19. Lee YY, Ngan Kee WD, Fong SY, Liu JT, Gin T. The median effective dose of bupivacaine, levobupivacaine, and ropivacaine after intrathecal injection in lower limb surgery. Anesth Analg. 2009;109:1331–4
20. Hessian EC, Evans BE, Woods JA, Taylor DJ, Kinkel E, Bjorksten AR. Plasma ropivacaine concentrations during bilateral transversus abdominis plane infusions. Br J Anaesth. 2013;111:488–95
21. Corvetto MA, Echevarría GC, De La Fuente N, Mosqueira L, Solari S, Altermatt FR. Comparison of plasma concentrations of levobupivacaine with and without epinephrine for transversus abdominis plane block. Reg Anesth Pain Med. 2012;37:633–7
22. Børglum J, Jensen K, Christensen AF, Hoegberg LC, Johansen SS, Lönnqvist PA, Jansen T. Distribution patterns, dermatomal anesthesia, and ropivacaine serum concentrations after bilateral dual transversus abdominis plane block. Reg Anesth Pain Med. 2012;37:294–301
23. Sandeman DJ, Bennett M, Dilley AV, Perczuk A, Lim S, Kelly KJ. Ultrasound-guided transversus abdominis plane blocks for laparoscopic appendicectomy in children: a prospective randomized trial. Br J Anaesth. 2011;106:882–6
24. Ortiz J, Suliburk JW, Wu K, Bailard NS, Mason C, Minard CG, Palvadi RR. Bilateral transversus abdominis plane block does not decrease postoperative pain after laparoscopic cholecystectomy when compared with local anesthetic infiltration of trocar insertion sites. Reg Anesth Pain Med. 2012;37:188–92
25. Bharti N, Kumar P, Bala I, Gupta V. The efficacy of a novel approach to transversus abdominis plane block for postoperative analgesia after colorectal surgery. Anesth Analg. 2011;112:1504–8
26. Griffiths JD, Middle JV, Barron FA, Grant SJ, Popham PA, Royse CF. Transversus abdominis plane block does not provide additional benefit to multimodal analgesia in gynecological cancer surgery. Anesth Analg. 2010;111:797–801
27. Freir NM, Murphy C, Mugawar M, Linnane A, Cunningham AJ. Transversus abdominis plane block for analgesia in renal transplantation: a randomized controlled trial. Anesth Analg. 2012;115:953–7
28. Albrecht E, Kirkham KR, Endersby RV, Chan VW, Jackson T, Okrainec A, Penner T, Jin R, Brull R. Ultrasound-guided transversus abdominis plane (TAP) block for laparoscopic gastric-bypass surgery:a prospective randomized controlled double-blinded trial. Obes Surg. 2013;23:1309–14
29. Sinha A, Jayaraman L, Punhani D. Efficacy of ultrasound-guided transversus abdominis plane block after laparoscopic bariatric surgery: a double blind, randomized, controlled study. Obes Surg. 2013;23:548–53
30. Walter CJ, Maxwell-Armstrong C, Pinkney TD, Conaghan PJ, Bedforth N, Gornall CB, Acheson AG. A randomised controlled trial of the efficacy of ultrasound-guided transversus abdominis plane (TAP) block in laparoscopic colorectal surgery. Surg Endosc. 2013;27:2366–72
31. Petersen PL, Stjernholm P, Kristiansen VB, Torup H, Hansen EG, Mitchell AU, Moeller A, Rosenberg J, Dahl JB, Mathiesen O. The beneficial effect of transversus abdominis plane block after laparoscopic cholecystectomy in day-case surgery: a randomized clinical trial. Anesth Analg. 2012;115:527–33
32. Kane SM, Garcia-Tomas V, Alejandro-Rodriguez M, Astley B, Pollard RR. Randomized trial of transversus abdominis plane block at total laparoscopic hysterectomy: effect of regional analgesia on quality of recovery. Am J Obstet Gynecol. 2012;207:419.e1–5
33. Hosgood SA, Thiyagarajan UM, Nicholson HF, Jeyapalan I, Nicholson ML. Randomized clinical trial of transversus abdominis plane block versus placebo control in live-donor nephrectomy. Transplantation. 2012;94:520–5
34. De Oliveira GS Jr, Milad MP, Fitzgerald P, Rahmani R, McCarthy RJ. Transversus abdominis plane infiltration and quality of recovery after laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol. 2011;118:1230–7
35. De Oliveira GS Jr, Fitzgerald PC, Marcus RJ, Ahmad S, McCarthy RJ. A dose-ranging study of the effect of transversus abdominis block on postoperative quality of recovery and analgesia after outpatient laparoscopy. Anesth Analg. 2011;113:1218–25
36. Ra YS, Kim CH, Lee GY, Han JI. The analgesic effect of the ultrasound-guided transverse abdominis plane block after laparoscopic cholecystectomy. Korean J Anesthesiol. 2010;58:362–8
37. El-Dawlatly AA, Turkistani A, Kettner SC, Machata AM, Delvi MB, Thallaj A, Kapral S, Marhofer P. Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth. 2009;102:763–7
38. Katz J, Clarke H, Seltzer Z. Review article: Preventive analgesia: quo vadimus? Anesth Analg. 2011;113:1242–53
39. Kissin I. A call to reassess the clinical value of preventive (preemptive) analgesia. Anesth Analg. 2011;113:977–8
40. Clarke H, Bonin RP, Orser BA, Englesakis M, Wijeysundera DN, Katz J. The prevention of chronic postsurgical pain using gabapentin and pregabalin: a combined systematic review and meta-analysis. Anesth Analg. 2012;115:428–42
41. Griffiths JD, Le NV, Grant S, Bjorksten A, Hebbard P, Royse C. Symptomatic local anaesthetic toxicity and plasma ropivacaine concentrations after transversus abdominis plane block for Caesarean section. Br J Anaesth. 2013;110:996–1000
42. De Oliveira GS Jr, Castro-Alves LJ, Ahmad S, Kendall MC, McCarthy RJ. Dexamethasone to prevent postoperative nausea and vomiting: an updated meta-analysis of randomized controlled trials. Anesth Analg. 2013;116:58–74
43. De Oliveira GS Jr, Castro-Alves LJ, Chang R, Yaghmour E, McCarthy RJ. Systemic metoclopramide to prevent postoperative nausea and vomiting: a meta-analysis without Fujii’s studies. Br J Anaesth. 2012;109:688–97
44. Habib AS, Gan TJ. Postoperative nausea and vomiting: then & now. Anesth Analg. 2012;115:493–5
45. Catro-Alves LJ, De Azevedo VL, De Freitas Braga TF, Goncalves AC, De Oliveira GS Jr. The effect of neuraxial versus general anesthesia techniques on postoperative quality of recovery and analgesia after abdominal hysterectomy: a prospective, randomized, controlled trial. Anesth Analg. 2011;113:1480–6
46. Kang JG, Kim MH, Kim EH, Lee SH. Intraoperative intravenous lidocaine reduces hospital length of stay following open gastrectomy for stomach cancer in men. J Clin Anesth. 2012;24:465–70
47. Albrecht E, Kirkham KR, Liu SS, Brull R. Peri-operative intravenous administration of magnesium sulphate and postoperative pain: a meta-analysis. Anaesthesia. 2013;68:79–90
48. Waldron NH, Jones CA, Gan TJ, Allen TK, Habib AS. Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis. Br J Anaesth. 2013;110:191–200
49. Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth. 2012;59:766–78
50. Srikandarajah S, Gilron I. Systematic review of movement-evoked pain versus pain at rest in postsurgical clinical trials and meta-analyses: a fundamental distinction requiring standardized measurement. Pain. 2011;152:1734–9
51. Gornall BF, Myles PS, Smith CL, Burke JA, Leslie K, Pereira MJ, Bost JE, Kluivers KB, Nilsson UG, Tanaka Y, Forbes A. Measurement of quality of recovery using the QoR-40: a quantitative systematic review. Br J Anaesth. 2013;111:161–9
52. Bertoglio S, Fabiani F, Negri PD, Corcione A, Merlo DF, Cafiero F, Esposito C, Belluco C, Pertile D, Amodio R, Mannucci M, Fontana V, Cicco MD, Zappi L. The postoperative analgesic efficacy of preperitoneal continuous wound infusion compared to epidural continuous infusion with local anesthetics after colorectal cancer surgery: a randomized controlled multicenter study. Anesth Analg. 2012;115:1442–50
53. Kim SY, Kim JM, Lee JH, Song BM, Koo BN. Efficacy of intraoperative dexmedetomidine infusion on emergence agitation and quality of recovery after nasal surgery. Br J Anaesth. 2013;111:222–8
54. Wongyingsinn M, Baldini G, Stein B, Charlebois P, Liberman S, Carli F. Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial. Br J Anaesth. 2012;108:850–6
55. De Oliveira GS Jr, Agarwal D, Benzon HT. Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials. Anesth Analg. 2012;114:424–33