L. M. Deppe2, C. Kasal2, K. Mathis1, D. W. Larson1 1Mayo Clinic Rochester,Colon And Rectal Surgery,Rochester, MN, USA 2Mayo Clinic Health System,Red Wing, MN, USA
Introduction:
Data has suggested value of TAP (transversus abdominus plane) neural blockade in
procedure related pain management as part of an enhanced recovery surgical program. Our goal was to
retrospectively analyze pain management using combined bupivacaine and liposomal bupivacaine as
part of a rural community laparoscopic colorectal and surgical program.
Methods:
Records of consecutive laparoscopic segmental colectomy and enterectomy patients
managed with an enhanced recovery program whose procedures were performed by four community
surgeons over an eighteen month period were reviewed under IRB approval. Patients who returned to
the operating room within thirty days were excluded from analysis. In place of an intrathecal block, an
ultrasound (US) guided bilateral TAP block was performed by the operating surgeon using 266 mg of
liposomal bupivacaine and 50 mg of 0.25% bupivacaine with epinephrine using the technique previously
described. Comparison was performed to previously published results of an enhanced recovery program
(which we also adopted) utilized by our Rochester, Minnesota based colorectal surgical system
colleagues.
Results:
Twenty four patients were included in analysis. Two patients were excluded; one requiring reexploration
for hemorrhage after anticoagulation and another with an anastomotic leak (who eventually
succumbed to respiratory failure). Three enterectomies were included (for malignancy and
inflammatory bowel disease) as well as twelve right hemicolectomies and nine sigmoid/left
hemicolectomies (eighteen for neoplasia and the remainder for diverticulitis). We found compliance
with enhanced recovery elements varied greatly and was generally surgeon dependent. No TAP block
site related reactions were noted. Median length of stay was three days, consistent with previously
published academic institutional results. Our ASA 1-2 population was 58%, comparing favorably with
published experience by our colorectal team which was 81%. Mean body mass index and median oral
morphine equivalents were 30.6 kg/m2 versus 26.9 kg/m2 and 4.5 mg versus 37.5 mg respectively.
Forty-six percent of patients never took an opiate versus a rate of 26% by our academic colleagues. There
were no readmissions within thirty days, although one patient did develop a deep incisional surgical site
infection. Though not formally timed, performing the above block was felt to add approximately five minutes to case length.
Conclusion:
Incorporating a surgeon performed US guided TAP block as part of an enhanced recovery
program resulted in similar length of stay, favorable oral morphine equivalent utilization and avoidance
of narcotic compared to published data utilizing an intrathecal block. Further study is indicated to
directly compare surgeon directed TAP block versus intrathecal injection for post-operative pain
management.