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Journal of Minimally Invasive Gynecology. Vol 00, No 00, 00 2023
Table 3
Association between TAP block administration and timing and postoperative patient outcomes
TAP block vs No TAP block
Preop vs Postop TAP block
No TAP block
(n = 1966)
TAP block (combined
pre and postoperative)
(n = 1016)
p-value Preoperative
TAP block
(n = 854)
Postoperative
TAP block
p-value
(n = 162)
Opioid MME used postoperatively
Nausea medication administrations
Time to discharge
38.5 (17.5-71.8)
1.0 (1.0-2.0)
30.5 (15.0-57.0)
1.0 (1.0-2.0)
6.3 (4.2-12.8)
5.5 (4.2-18.4)
.002*
.384
<.001*
30.5 (15.0-57.5)
30.0 (15.0-51.6)
.752*
+
1.0 (1.0-2.0)
2.0 (1.0-2.0)
.298*
5.3 (4.1-16.8)
6.2 (4.6-21.8)
.001*
Maximum postoperative NRS pain score
6.0 (4.0-8.0)
6.0 (5.0-8.0)
.199
6.0 (5.0-8.0)
6.0 (4.0-8.0)
.494f
Minutes to maximum pain score
136.0 (56.0-283.0)
125.0 (60.0-220.0)
.1879
124.0 (59.0-216.0)
133.0 (67.0-253.0) .067
MME = morphine milliequivalents; NRS = numerical rating scale; TAP = transversus abdominis plane.
All results are presented as median (interquartile range) due to skewed distributions.
* Linear mixed effects regression controlling for BMI and age with CPT as a random effect.
t
Generalized linear mixed effect regression with CPT as a random effect.
I
Linear mixed effects regression controlling for BMI with CPT as a random effect.
ŷ Linear mixed effects regression controlling for BMI, age, and endometriosis diagnosis with CPT as a random effect.
Linear mixed effect regression with CPT as a random effect.
§
patients who did not receive a TAP block required more
milliequivalents of morphine to achieve the same postoper-
ative pain scores than those who did receive a TAP block
(at any time point).
Discussion
This study found that receipt of a TAP block, regardless
of timing, was associated with a statistically significantly
lower administration of morphine milliequivalents postoper-
atively than patients who did not receive a TAP block,
although postoperative pain scores did not differ among
these groups. This suggests that patients in the TAP block
group required fewer morphine milliequivalents to achieve
the same pain levels. While the difference is only slightly
more than one 5 mg dose of oxycodone, this still minimizes
patient exposure to opioids at a time when opioid addiction
and abuse is increasing daily. Specifically regarding the tim-
ing, pre- versus postoperative TAP block did not change
postoperative opioid consumption or pain scores. TAP
blocks were further associated with a significantly shorter
time to discharge than no TAP blocks, with preoperative
TAP block timing also associated with a shorter time to dis-
charge than postoperative TAP block administration. It is
important to note that while the difference is statistically sig-
nificant, the time between both groups differs by less than an
hour and may contribute more to a financial rather than clin-
ical difference. This data can be used to guide counseling of
patients undergoing minimally invasive hysterectomy for
benign indications with regard to pain management and
postoperative care. It suggests that clinicians can be flexible
in performing the TAP block either pre or postoperatively,
without compromising postoperative opioid consumption or
pain scores. However, we acknowledge that due to the
retrospective nature of our study, there are unaccounted for
differences between patients selected to receive a TAP
block, which may have impacted postoperative opioid
requirements. The subanalysis comparing preoperative ver-
sus postoperative TAP block recipient outcomes addresses
these differences and maintains the finding of a statistically
shorter time to discharge following hysterectomy.
Our results differ from much of the existing literature
regarding TAP block use in laparoscopic hysterectomy
patients. A 2016 randomized control trial (RCT) by Ghisi
et al. [20] compared postoperative patient-controlled anal-
gesia (PCA) to a combination of preoperative TAP block
administration with postoperative PCA use in patients
undergoing total laparoscopic hysterectomy, with no differ-
ences found in morphine consumption in the first 24 hours.
Another RCT by Torup et al. [21] found no difference in
morphine consumption or pain scores in the first 24 hours
when comparing preoperative TAP block to a sham block
in patients undergoing a robotic-assisted laparoscopic hys-
terectomy [21]. A 2020 systematic review and meta-analy-
sis of eligible RCTs evaluating TAP blocks in laparoscopic
and robotic hysterectomy patients found no difference in
pain scores or opioid consumption, while a 2019 systematic
review and meta-analysis found reduced morphine con-
sumption in hysterectomies completed via abdominal
approach but not laparoscopically [22,23]. From this
research, however, it remains unclear whether preoperative
timing of TAP block use, compared to postoperative admin-
istration, represents the most clinically relevant timing.
A systematic review of TAP blocks in laparoscopic sur-
geries (not limited to gynecological cases) reported a
decrease in pain at rest and opioid consumption in patients
who received a TAP block and also found that preoperative
TAP block timing had greater effects on pain and opioid