If transversus abdominis plane blocks are to be used in laparoscopy then the gynaecologist is best placed to administer them.

Abstract

The role of transabdominal plane (TAP) blocks in laparoscopic surgery is unclear, and their implementation is generally left to the discretion of the anaesthetist. The anaesthetist attempts to interrupt sensory innervation across several dermatomes by instilling local anaesthetic below the fascial plane between the internal oblique and the transverse abdominis muscles. The technique may involve one or two entry points on each side of the abdomen. The ‘blind’ TAP block relies upon orientation using superficial anatomical landmarks and a ‘double pop’ sensation indicating the needle is sited correctly. Inadvertent visceral injuries have been reported as well as suboptimal placement in the majority of patients and so visualisation with ultrasound to guide needle placement has been advocated (McDermott et al. BJA 2012;108:499–502). However, the excellent visualisation of the abdominal cavity provided by laparoscopy has promoted laparoscopically delivered TAP blocks. Randomised controlled trials (RCTs) have evaluated TAP blocks across surgical practice and systematic evidence syntheses have found them to be associated with modest improvements in overall quality of recovery and corresponding reductions in postoperative pain up to 24 hours postsurgery and requirements for analgesia (Brogi et al. Can J Anaesth 2016;63:1184–96). Most data pertaining to the impact of TAP blocks on recovery from laparoscopic surgery have come from trials involving laparoscopic cholecystectomy. Data specific to gynaecological surgery are scarce, although two small RCTs evaluating ultrasound-guided TAP blocks in laparoscopic hysterectomy have been conducted, albeit with conflicting results (Kane et al. Am J Obstet Gynecol 2012;207:419.e1–5; De Oliveira GS Jr et al. Obstet Gynecol 2011;118:1230–7.). The study in BJOG by R Kargar et al. (BJOG 2019;126:647–54) reports an RCT comparing laparoscopic TAP blocks with standard port-site infiltration of local anaesthetic and placebo in women undergoing complex laparoscopic endometriosis surgery. A benefit of laparoscopically deployed TAP and port-site blocks was shown compared with placebo in pain relief up to 12 hours following surgery. However, laparoscopic TAP blocks were no more effective than conventional port-site anaesthesia. The investigators missed an opportunity to evaluate the cumulative effect of combining TAP blocks with local port-site anaesthetic. So where are we now? Well, local port-site anaesthesia should be continued but further work is needed to ascertain who may benefit from TAP blocks whether used as an alternative or in combination with port-site blockade. Confounders, such as the type and duration of laparoscopic surgery, the size of ports, patient characteristics such as obesity, and local anaesthetic regimens need to be accounted for. In addition, the question of how TAP blocks should be delivered and by whom will be of interest; blindly or ultrasound-guided by the anaesthetist or under laparoscopic guidance by the gynaecologist? I suspect most surgeons are aware that the amount of time available on operating lists for actual surgery is diminishing because of prolongation of anaesthetic times and the requirement for WHO safety check lists. Peering through the anaesthetic room the eager, optimally prepared but time-poor surgeon can become deflated observing the anaesthetist manipulating a portable ultrasound machine in order to ‘line up’ the TAP blocks. I believe the opportunity to claw this time-consuming task from our enthusiastic anaesthetic colleagues will be welcomed by most surgeons! Dr Clark reports personal fees from Bayer, personal fees from Smith & Nephew, personal fees from Hologic, outside the submitted work. A completed disclosure of interest form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.