Transversus Abdominis Bilateral Plane Block in Total Laparoscopic Hysterectomy : A Randomized Controlled Trial

Overview

The ambulatory management after laparoscopic hysterectomy is a reality in our service, where 90% of hysterectomies are laparoscopically done and 80% of these are managed on an ambulatory basis with shorter hospital stay ;less than 12 hours. (OALOS 9.41 + / - (1.79) range from 5 to 12 hours and POLE 5.38 + / - (1.8) range from 2 to 9 hours) So far the immediate analgesic management has been made systemically, and the satisfaction reported by patients was high, even though some patients require longer stay in recovery and need higher doses of analgesics before their discharge criteria, allowing an optimal ambulatory management. There are several treatment options that theoretically could be used but the results have been variable and have failed to demonstrate the expected benefit. The Transversus Abdominis Plane Block consists in the deposition of local anesthetic in the plane between the internal oblique and transverse abdominal, looking to infiltrate the spinal nerves at this level, so the innervation to the skin, muscles and the parietal peritoneum will be interrupted. The TAP Block was first described in 2001 , based on anatomy marks techniques of the peripheral nerves and was developed and evaluated later by McDonnell et al.

The blockage in the abdominal transverse plane (TAP Block) with local anesthetic has demonstrated efficacy and safety in patients with various types of abdominal surgery by laparotomy as both laparoscopically. The blockage in the abdominal transverse plane is a single entry in the triangle of Petit, to access a greater number of nerves that allow a wider spread of analgesia. The innervation of the anterolateral abdominal wall is given by the anterior branches of spinal nerves T7 to L1 (these include the intercostal nerves T7 at 11, the nerve subcostal nerve T12 and ilio hypogastric and ilio inguinal L1 The anterior divisions of the nerves T7 to T11 continues from the intercostal space and enter the abdominal wall between the internal oblique and transversus abdominis, reaching the rectus abdominis, which pierce and innervate the skin of the anterior abdominal region. In its course also innervate the external oblique muscle via the lateral cutaneous branch is divided into anterior and posterior innervating the external oblique and dorsal latium The anterior branch of T12 is connected to the ilio hypogastric nerve and gives branch to the piriformis muscle, the lateral cutaneous branch pierces the internal and external oblique muscles and descends over the iliac crest innervate the anterior part of the buttocks. The ilio hypogastric nerve,L1, is divided between the internal oblique and transversus abdominis near the iliac crest in two anterior and lateral cutaneous branches, the first innervate the skin of the buttocks and the second the hypogastric region. The ilio inguinal nerve communicates with the ilio hypogastric nerve between the internal oblique and transversus abdominis, near the anterior iliac crest and innervates the anterior and medial thigh and part of the skin covering the genitals. The aim of the nerve block is to deposit local anesthetic in the plane between the internal oblique and transverse abdominal looking to infiltrate the spinal nerves at this level, so the skin innervation on muscle and parietal peritoneum will interrupted. Obviously if the surgery goes through the peritoneal cavity, visceral pain will not be interrupted. This block is indicated in any lower abdominal surgery and has been used effectively in laparoscopic surgery, so far no work described in LH, this block allows analgesia from T7 to L1 even with minimal side effects, low cost, without altering surgical time, and low risk. Among the complications described above, a puncture of the liver in a patient with liver elongated and some small punctures without serious consequences. The ambulatory management could be more efficient with the use of blockage in the abdominal transverse plane (TAP Block) with local anesthetic. In order to study the benefits that the TAP Block could offer to our patients, we suggest a randomized controlled trial comparing the blockage in the abdominal transverse plane with placebo.