Research ArticleA Posterior TAP Block Provides More Effective AnalgesiaThan a Lateral TAP Block in Patients Undergoing LaparoscopicGynecologic Surgery: A Retrospective Study

Sakatoshi Yoshiyama, Hironobu Ueshima, Ryomi Sakai, and Hiroshi Otake

Department of Anesthesiology, Showa University Hospital, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan

Correspondence should be addressed to Hironobu Ueshima; ueshimhi@yahoo.co.jp

Received 17 December 2015; Revised 29 December 2015; Accepted 13 January 2016

Academic Editor: Chih Shung Wong

Copyright © 2016 Sakatoshi Yoshiyama et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Background. There are a few papers that compared the lateral transversus abdominis plane (TAP) block with the posterior TAPblock. Our study aimed to compare retrospectively the quality of analgesia after laparoscopic gynecologic surgery using the lateralTAP block with general anesthesia versus the posterior TAP block with general anesthesia. Method. Sixty-seven adult femalepatients were included in this retrospective study. Of these patients, thirty-four patients received the lateral TAP block with generalanesthesia (lat. TAP group), and the rest of thirty-three patients received the posterior TAP block with general anesthesia (pos.TAP group). Pain scores both at rest and at movement and the use of additional analgesic drugs were recorded in the postoperativecare unit within twenty-four hours after the operation. Postoperative complications were noted. Results. Patients who received pos.TAP reported lower visual analog scale (VAS) pain scores in all points, within twenty-four hours after the operation, than patientswho received lat. TAP. Moreover, with the use of additional analgesic drugs, the incidence of nausea and vomiting during the firsttwenty-four hours after surgery was lower in the pos. TAP group than in the lat. TAP group. Conclusion. The posterior TAP blockprovided more effective analgesia than the lateral TAP block in patients undergoing laparoscopic gynecologic surgery.

1. Introduction

Laparoscopic surgery has been increasingly performed inrecent years. Intravenous morphine has been used as oneof the postoperative analgesia drugs for these laparoscopicsurgeries, but morphine causes complications such as respi-ratory depression and circulatory depression [1]. Therefore,people from old times have hesitated to use morphine aspostoperative analgesia [2].

Since the publishing of a paper on the transversusabdominis plane (TAP) block in two thousand and one [3, 4],the TAP block has been used as an analgesia for somatic painin lower abdominal surgeries and has decreased the amountof morphine used [5–7]. There are two major types of theTAP block, the lateral approach and the posterior approach.However, there are a few papers that compared the lateralTAP block with the posterior TAP block [8]. The posteriorTAP block is said to reduce postoperative morphine [8], but

the analgesia of the posterior TAP block in postoperativeperiod has not been well known. Therefore, the differencesin efficacy between the lateral TAP block and the posteriorTAP block also are still unclear. In this study, we comparedthe analgesia efficacy of the posterior TAP block with thelateral TAP block for the laparoscopic gynecologic surgeryretrospectively.

2. Materials and Methods

This retrospective study was approved by the Showa Univer-sity Hospital Institutional Review Board (approval number1895). In addition, the study was registered at the UniversityHospital Medical Information Network (UMIN ID number000019314). In this study, we investigated female patients whohad laparoscopic gynecologic surgery at Showa UniversityHospital from April, two thousand and fifteen, to Septem-ber, two thousand and fifteen. Exclusion criteria were the

Hindawi Publishing CorporationAnesthesiology Research and PracticeVolume 2016, Article ID 4598583, 5 pageshttp://dx.doi.org/10.1155/2016/4598583

2 Anesthesiology Research and Practice

Table 1: Patients demographics data: age, height, weight, operation time, and anesthesia time. Data except ASA classification expressed asmedian (twenty-fifth to seventy-fifth percentiles). ASA classification expressed the numbers.

Lat. TAP group (𝑛 = 34) Pos. TAP group (𝑛 = 33) 𝑃

Age (years) 40 (35–45) 41 (36–27) 0.65Height (cm) 159.5 (153.5–163) 158.5 (155–162.5) 0.74Weight (kg) 56 (48–60) 52.5 (49–60.5) 0.81ASA classification (I/II/III) 8/25/1 7/24/2 —Operation time (minutes) 120 (80–170) 110 (75–185) 0.98Anesthesia time (minutes) 160 (115–205) 150 (120–220) 0.98

conversion from laparoscopic surgery to open surgery andsecondary surgery.

Perioperative data of the subjected patients were collectedretrospectively, including age, height, weight, American Soci-ety of Anesthesiologists (ASA) classification, operation time,anesthesia time, surgery contents, visual analog scale (VAS)pain scores and the number of additional analgesic drugsused, and the complications (i.e., nausea and vomiting)within twenty-four hours after the operation. VAS pain scoreswere measured at one, two, six, twelve, and twenty-fourpostoperative hours during rest and at twelve and twenty-four postoperative hours during movement of sitting upin bed. The researchers were two nurses. They were usedto measure the VAS. In my hospital, all patients move tothe intensive care unit (ICU) after laparoscopic gynecologicsurgery. Each patient who performed laparoscopic gyne-cologic surgery moved regularly to the ICU measures atone, second, six, twelve, and twenty-four postoperative hoursduring rest and at twelve and twenty-four postoperative hoursduring movement by nurses being in the ICU.The additionalanalgesic drug was fifteen mg of intravenous pentazocinewhen the patient complained about pain. The frequency ofcomplications such as nausea and vomiting were counted asthe number of patients injected with ten mg of intravenousmetoclopramide. We compared those data between twogroups of patients, who received the lateral TAP block withgeneral anesthesia and the posterior TAP block with generalanesthesia.

The lateral TAP block: forty mL of 0.375% levobupiva-caine (20mL into each side) was injected in the TAP to thelateral abdominal wall in the midaxillary line, between thelower costal margin and iliac crest [8].

The posterior TAP block: forty mL of 0.375% levobupiva-caine (20mL into each side) was injected in the TAP in thearea of the triangle of Petit [8].

Each anesthesiologist decides on the type of the TAPblock by himself or herself. There have been no rules on howthe type of the TAP block is decided upon, but anestheticrecord has been written. The volume and concentration ofTAP block are decided for all cases.

Statistical analysis was performed utilizing JMP® 11(SAS Institute Inc., Cary, NC, USA). Patient demographics,VAS pain scores, the number of additional analgesic drugsinjected, and the frequency of complications were analyzedby using the Mann-Whitney 𝑈 test, Student’s 𝑡-test, and 𝜒2test, retrospectively. Data of age, height, weight, operation

time, anesthesia time, and VAS pain score were expressedas a median (twenty-fifth to seventy-fifth percentiles) (cm),number of additional analgesic drugs injected expressed asaverage (standard deviation), and the intravenous metoclo-pramide expressed as frequencywith percentages (%), andweused Fisher’s exact test.The level of significance for both testswas set at 𝑃 < 0.05.

3. Results

During the study period, seventy-three patients underwentlaparoscopic gynecologic surgery. Of these patients, thirty-four patients received the lateral TAP block under generalanesthesia (lat. TAP group) and thirty-three patients receivedthe posterior TAP block under general anesthesia (pos. TAPgroup). Six patients (two patients in lat. TAP group andfour patients in pos. TAP group) were excluded from thestudy because of the criteria. Table 1 is the comparison ofpatient’s demographics, ASA classification, operation time,and anesthesia time. Surgery contents were shown in Table 2.VAS pain scores of lat. TAP group at one, two, six, twelve, andtwenty-four postoperative hours during rest were 3.0 (3–4.5),4.0 (3.5–5), 4.5 (4–6), 3.5 (3-4), and 3.0 (3-4), respectively,while those of pos. TAP group at one, two, six, twelve, andtwenty-four postoperative hours during rest were 2.0 (1.5–2),2.0 (1.5–2.5), 2.8 (2–3.5), 2.0 (1-2), and 2.0 (1-2), respectively(Table 3, Figure 1). As shown in Table 3, VAS pain scores ofpos. TAP group were significantly lower than those of lat.TAP group in all test periods. VAS pain scores of lat. TAPgroup at twelve and twenty-four postoperative hours duringmovement were 3.0 (3-4) and 5.0 (4–7), while those of pos.TAP group at twelve and twenty-four postoperative hoursduring movement were 2.0 (1-2) and 3.0 (2.5–3.5) (Figure 2).As compared with those of lat. TAP group, VAS pain scores ofpos. TAP group scores were significantly lower in both timeperiods (Table 3). The amounts of additional pentazocine inpos. TAP group (1.4 (0.5)) were significantly lower than thosein lat. TAP group (3.0 (1.1)). Metoclopramide was injected for17.6% patients in lat. TAP group, and for 6.1% patients in pos.TAP group, and the difference was significant (Table 4).

4. Discussion

This study suggests that the posterior TAP block couldprovide better analgesia than the lateral TAP block forlaparoscopic gynecologic surgery in perioperative period.

Anesthesiology Research and Practice 3

Table 2: Surgery contents. 𝑃 calculated by using Fisher’s exact test.

Lat. TAP group (𝑛 = 34) Pos. TAP group (𝑛 = 33) 𝑃

Total hysterectomy 6 5 0.8Uterine myomectomy 14 12 0.82Oophorectomy 8 7 0.68Tubectomy 5 8 0.37The others 1 1 1.00

Table 3: Postoperative VAS scores during both rest and movement: data expressed as median (twenty-fifth to seventy-fifth percentiles).

Lat. TAP group (𝑛 = 34) Pos. TAP group (𝑛 = 33) 𝑃

VAS at rest (h)1 3.0 (3.0–4.5) 2.0 (1.5–2.0) <0.00012 4.0 (3.5–5.0) 2.0 (1.5–2.5) <0.00016 4.5 (4.0–6.0) 2.5 (2.0–3.5) <0.000112 3.5 (3.0–4.0) 2.0 (1.0–2.0) <0.000124 3.0 (3.0–4.0) 2.0 (1.0–2.0) <0.0001

VAS at movement (h)12 3.0 (3.0–4.0) 2.0 (1.0–2.0) <0.000124 5.0 (4.0–7.0) 3.0 (2.5–3.5) <0.0001

Table 4: Postoperative dates except someVAS scores: data of the amounts of additional pentazocine expressed as average (standard deviation)and amounts of the intravenous metoclopramide expressed as frequency with percentages (%).

Lat. TAP group (𝑛 = 34) Pos. TAP group (𝑛 = 33) 𝑃

The amounts of additional pentazocine 15mg 3.0 (1.1) 1.4 (0.5) <0.0001The number of people who used intravenous metoclopramide 10mg 17.6 6.1 0.02

LateralPosterior

(Hours)

VAS

scor

es (c

m)

10

8

6

4

2

00 10 20 30

Figure 1: Postoperative VAS scores at one, two, four, six, twelve,and twenty-four postoperative hours during rest: data expressed asa median (twenty-fifth to seventy-fifth percentiles).

Better analgesia enabled us to decrease the incidence ofcomplications and the usage of additional analgesics.

For the TAP block, reported by Rafi et al, injecting localanesthetic in the lumbar triangle of Petit can provide betterpostoperative analgesia in lower abdominal surgery [3]. Rafi’stechnique of TAP block was a landmark technique, which

10

8

6

4

2

012 24

VAS

scor

es (c

m)

(Hours)LateralPosterior

Figure 2: Postoperative VAS scores twelve and twenty-four postop-erative hours duringmovement: data expressed as amedian (twenty-fifth to seventy-fifth percentiles).

has the risk of complications such as organ injury, mistakenpuncture of superficial circumflex iliac perforator, and nerveinjury which were pointed out [9, 10]. The breakthrough inthe technique happened when the ultrasound-guided TAPblock was reported by Manatakis et al., which could predictimproving patient’s security [11]. However, the efficacy of

4 Anesthesiology Research and Practice

the TAP block performed by the ultrasound-guided tech-nique was ineffective because an injection site may not havebeen the lumbar triangle of Petit [12, 13]. The new approachcalled the posterior TAP block was introduced to improve theefficacy. On the other hand, the previous approach was calledthe lateral TAP block. The injection site of the posterior TAPblock is almost the same as that of the TAP block reportedby Rafi.This study showed that the posterior TAP block is aneffective analgesia for lower abdominal surgery.

The prime cause of postoperative pain for laparoscopicgynecologic surgery is said to derive from the visceral painin the uterus and the vagina. The posterior TAP block isbelieved to relieve the visceral pain and this theory is provedwith the result of this study. Walter et al. reported thatlocal anesthetic spread to the thoracic paravertebral space inthe posterior TAP block [14]. The reach of local anestheticsinto the thoracic paravertebral space may result in blockingthe sympathetic nerve and relieving the visceral pain. Theeffective analgesia in perioperative period by the posteriorTAP block enabled us to decrease the amounts of additionalanalgesia and the frequency of complications such as nauseaand vomiting.

The injection site of the posterior TAP block in this studywas the lumbar triangle of Petit, but several other approachesof the posterior TAP blocks including quadratus lumborumblockade have been reported in recent years [15, 16]. Thedifference among these posterior TAP blocks is still notknown in detail, which needs further investigations.

There were some limitations of this study. VAS scoreswere affected by additional analgesic drug. If a patientrequired additional analgesic drug at, say, 1 hour after surgery,then it would be expected to have an impact on the VASscore at the 2-hour time point. In the future, we must solvethis problem. This study also was a retrospective study,not a randomized control study. We also do not know theappropriate volume and concentration for the TAP blocks. Inthis study, we focused only on the first 24 hours after surgerybecause the TAP block was not a continuous administrationbut a single shot. Some surgeries require analgesia longer than24 hours. These problems are left for the future study.

In conclusion, we found that the posterior TAP blockcould provide more effective analgesia than the lateralTAP block in patients undergoing laparoscopic gynecologicsurgery.

Conflict of Interests

The authors have no financial relationships to this study.

Authors’ Contribution

Sakatoshi Yoshiyama contributed to study implementa-tion, statistical analysis, and paper preparation. HironobuUeshima contributed to study design and paper preparation.Ryomi Sakai contributed to data collection and offeredcriticism of both data interpretation and paper preparation;Hiroshi Otake contributed to study and paper preparation.

References

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[6] P. L. Petersen, P. Stjernholm, V. B. Kristiansen et al., “Thebeneficial effect of transversus abdominis plane block afterlaparoscopic cholecystectomy in day-case surgery: a random-ized clinical trial,” Anesthesia and Analgesia, vol. 115, no. 3, pp.527–533, 2012.

[7] S. Pather, J. A. Loadsman, P. D. Gopalan, A. Rao, S. Philp,and J. Carter, “The role of transversus abdominis plane blocksin women undergoing total laparoscopic hysterectomy: a ret-rospective review,” Australian and New Zealand Journal ofObstetrics and Gynaecology, vol. 51, no. 6, pp. 544–547, 2011.

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[11] D. K. Manatakis, N. Stamos, C. Agalianos, M. A. Karvelis, M.Gkiaourakis, and D. Davides, “Transient femoral nerve palsycomplicating ‘blind’ transversus abdominis plane block,” CaseReports in Anesthesiology, vol. 2013, Article ID 874215, 3 pages,2013.

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[13] J. Ortiz, J. W. Suliburk, K. Wu et al., “Bilateral transversusabdominis plane block does not decrease postoperative painafter laparoscopic cholecystectomy when compared with localanesthetic infiltration of trocar insertion sites,” Regional Anes-thesia and Pain Medicine, vol. 37, no. 2, pp. 188–192, 2012.

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Anesthesiology Research and Practice 5

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