Efficacy of Transversus Abdominis Plane Block Versus Local Injection of Pain Medication

Analgesic Efficacy of Transversus Abdominis Plane Block Versus Local Injection in Postoperative Pain Management Following Minimally Invasive Gynecological Surgery

The purpose of this study is to determine if there is a better method of administering pain medication prior to minimally invasive gynecological surgery so that postoperative pain and/or narcotic usage may be minimized. Currently, no standard of care exists regarding the use of local pain medications in minimally invasive gynecological surgery and practices vary widely among physicians, even within the same institution.

The two methods of preemptive pain medication that this study will be looking at is the transversus abdominis plane (TAP) block and the local injection of pain medication at the areas of the skin incisions. TAP block is a procedure performed by a specially trained pain management anesthesiologist in which there is an injection of a local pain medication into the abdominal wall, specifically in a space where the nerves that are responsible for postoperative pain reside. This procedure blocks the ability of the nerves to sense pain and has been found to be successful in decreasing postoperative pain in a number of procedures. The local injection of pain medications at the incision sites has also been found to be beneficial in decreasing postoperative pain. However, it is not known whether one method is superior to the other in decreasing postoperative pain or if the combination of both is best.

Patients that chose to participate are randomly (by chance) assigned to one of three groups: 1) TAP block with pain medication and local injection of normal saline (water) at the incision sites 2) TAP block with normal saline and local injection of pain medication at the incision sites or 3) TAP block with pain medication and local injection of pain medication at the port sites. These procedures are performed while the patient is asleep. Patients will be asked to record their level of pain on a standardized pain scale at one hour, six hours, and twenty-four hours after the surgery. All patients are provided with standard postoperative pain medications as needed.

The hypothesis is that patients receiving both TAP block and local injection of pain medication at the port sites will have less pain postoperatively and require a smaller amount of narcotics than those that receive either the TAP block or local injection of pain medication alone.

Study Overview

• Status: Completed
• Conditions: Pain, Postoperative
• Intervention / Treatment: Drug: ropivacaine

Detailed Description

This is a prospective, single center, double-blinded, multi-arm parallel group study conducted at a university affiliated medical center. Study approval was obtained from the Saint Barnabas Medical Center institutional review board, and written informed consent was obtained from all study participants.

Patients were randomly assigned to one of three parallel groups in a 1:1:1 ratio, to receive either: treatment transversus abdominis plane (TAP) block and placebo local injection, placebo TAP block and treatment local injection, or treatment TAP block and treatment local injection. This study took place at Saint Barnabas Medical Center in Livingston, New Jersey from May 2011 to October 2013. Patients were recruited from the offices of ten different gynecological surgeons in private practice. Two of the surgeons were gynecological oncologists, and the remainder were general obstetricians/gynecologists that perform minimally invasive gynecological surgery. The TAP blocks were administered by one of four anesthesiologists.

Patients were consented and enrolled in the study by blinded obstetrical and gynecological residents while the patients were in the preoperative area. Each patient was given a standardized informed consent packet detailing the study. Once a patient gave informed consent and was enrolled in the study, independent pharmacists were notified of their enrollment. The pharmacists then assigned participants to one of three possible interventions based on a computer-generated randomization list that was created by the principal investigator prior to commencement of patient enrollment. The pharmacist assigned patients into their appropriate intervention based upon what number participant the patient was in the study. The pharmacist then dispensed the study medications into identical 30 mL syringes labeled study drug and placed them in brown paper bags. The study medication to be administered via TAP block was placed in two 30 mL syringes and placed in a brown paper bag. The study medication to be used for local injection was placed in a single 30 mL syringe and placed in a separate brown paper bag. These bags were then brought to the operating room where they were to be administered. The bag containing the two syringes was given to the anesthesiologists performing the TAP block and the bag with the single syringe was handed to the scrub tech that then later distributed it to the surgeons. The patients, all healthcare providers, and data collectors were blinded as to group allocation. Additionally, both ropivacaine and normal saline are clear and indistinguishable from one another.

The interventions were administered in the operating room once the patients had been placed under general anesthesia, prior to skin incisions. The TAP blocks were administered under ultrasound guidance.

Patients were then prepped and draped for surgery. Prior to proceeding to skin incisions the surgeons administered 2 mL of local injection subcutaneously at the intended port site locations. If additional port sites were deemed necessary during the procedure study drug was administered in a similar fashion prior to those skin incisions being made.

Postoperatively all patients received a standardized analgesia regimen. Specifically, for mild pain, oxycodone/acetaminophen 5/325 mg one tablet orally every four hours; for moderate pain, oxycodone/acetaminophen 5/325 mg two tablets orally every six hours, and for severe pain, hydromorphone 1 mg every 3 hours intravenously.

• Study Type: Interventional
• Enrollment (Actual): 220
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • New Jersey
    • Livingston, New Jersey, United States, 07039
      • Saint Barnabas Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• Female
• Undergoing gynecological robotic and/or laparoscopic surgery
• Overnight hospitalization expected

Exclusion Criteria:

• Fibromyalgia
• Chronic pelvic pain
• Relevant drug allergy
• Conversion to laparotomy
• Pregnant

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Treatment TAP, placebo local injection; Treatment TAP block was 30 mL 0.5% ropivacaine bilaterally. Placebo local injection was 2 mL of 0.9% normal saline at each port site.	Drug: ropivacaine; Treatment local injection was 2 mL of 0.5% ropivacaine at each port site. Treatment TAP was 30 mL of 0.5% ropivacaine bilaterally.; Other Names: Naropin
Active Comparator: Placebo TAP, treatment local injection; Placebo TAP was 30 mL of 0.9% normal saline bilaterally. Treatment local injection was 2 mL of 0.5% ropivacaine at each port site.	Drug: ropivacaine; Treatment local injection was 2 mL of 0.5% ropivacaine at each port site. Treatment TAP was 30 mL of 0.5% ropivacaine bilaterally.; Other Names: Naropin
Active Comparator: Treatment TAP, treatment local injection; Treatment TAP was 30 mL of 0.5% ropivacaine bilaterally. Treatment local injection was 2 mL of 0.5% ropivacaine at each port site.	Drug: ropivacaine; Treatment local injection was 2 mL of 0.5% ropivacaine at each port site. Treatment TAP was 30 mL of 0.5% ropivacaine bilaterally.; Other Names: Naropin

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Postoperative Pain on a Visual Analogue Pain Scale at One Hour Postoperatively	A Visual Analogue Scale was used. The scale range was 0 to 10 in increments of one. 0 was no pain and 10 was worst pain possible.	one hour postoperatively
Postoperative Pain on a Visual Analogue Pain Scale at Six Hours Postoperatively	A Visual Analogue Scale was used. The scale range was 0 to 10 in increments of one. 0 was no pain and 10 was worst pain possible.	six hours postoperatively
Postoperative Pain on a Visual Analogue Pain Scale at Twenty-four Hours Postoperatively	A Visual Analogue Scale was used. The scale range was 0 to 10 in increments of one. 0 was no pain and 10 was worst pain possible.	twenty-four hours postoperatively

Secondary Outcome Measures

Outcome Measure	Time Frame
Time Until First Request for Pain Medication	up to twenty-four hours postoperatively
Total Narcotic Usage in Morphine Equivalents	up to twenty-four hours postoperatively

Collaborators and Investigators

• Sponsor: Liberman, Eric, D.O.
• Investigators: Principal Investigator: Eric C Liberman, D.O., St. Barnabas Medical Center; Principal Investigator: Thad Denehy, M.D., St. Barnabas Medical Center

Publications and helpful links

General Publications

• Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia. 2001 Oct;56(10):1024-6. doi: 10.1046/j.1365-2044.2001.02279-40.x. No abstract available.
• Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Anesth Analg. 2008 Dec;107(6):2056-60. doi: 10.1213/ane.0b013e3181871313.
• Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care. 2007 Aug;35(4):616-7. No abstract available.
• El Hachem L, Small E, Chung P, Moshier EL, Friedman K, Fenske SS, Gretz HF 3rd. Randomized controlled double-blind trial of transversus abdominis plane block versus trocar site infiltration in gynecologic laparoscopy. Am J Obstet Gynecol. 2015 Feb;212(2):182.e1-9. doi: 10.1016/j.ajog.2014.07.049. Epub 2014 Aug 1.
• 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 Nov;207(5):419.e1-5. doi: 10.1016/j.ajog.2012.06.052. Epub 2012 Jun 29.

Study record dates

Study Major Dates

• Study Start: May 1, 2011
• Primary Completion (Actual): October 1, 2013
• Study Completion (Actual): October 1, 2013

Study Registration Dates

• First Submitted: December 8, 2014
• First Submitted That Met QC Criteria: December 9, 2014
• First Posted (Estimate): December 10, 2014

Study Record Updates

• Last Update Posted (Estimate): April 14, 2015
• Last Update Submitted That Met QC Criteria: April 10, 2015
• Last Verified: April 1, 2015

More Information

Terms related to this study

• Keywords: Anesthetics, Local; Nerve block; Surgical procedures, Minimally invasive
• Additional Relevant MeSH Terms: Pathologic Processes; Postoperative Complications; Pain; Neurologic Manifestations; Pain, Postoperative; Physiological Effects of Drugs; Central Nervous System Depressants; Peripheral Nervous System Agents; Sensory System Agents; Anesthetics; Anesthetics, Local; Ropivacaine
• Other Study ID Numbers: 11-02