A Dose-Ranging Study of the Effect of Transversus Abdominis Block on Postoperative Quality of Recovery and Analgesia After Outpatient Laparoscopy

BACKGROUND: Postoperative pain can delay functional recovery after outpatient surgery. Multimodal analgesia can improve pain and possibly improve quality of recovery. In this study, we evaluated the dose-dependent effects of a preoperative transversus abdominis plane (TAP) block on patient recovery using the Quality of Recovery 40 (QoR-40) questionnaire after ambulatory gynecological laparoscopic surgery. Global QoR-40 scores range from 40 to 200, representing very poor to outstanding quality of recovery, respectively. METHODS: Healthy women undergoing outpatient gynecological laparoscopy were randomly allocated to receive a preoperative TAP block using saline, ropivacaine 0.25%, or ropivacaine 0.5%. Needle placement for the TAP blocks was performed using ultrasound guidance and 15 mL of the study solution was injected bilaterally by a blinded investigator. QoR-40 score and analgesic use were assessed 24 hours postoperatively. The primary outcome was global QoR-40 score at 24 hours after surgery. Data were analyzed using the Kruskal-Wallis test. Post hoc pairwise comparisons were made using the Dunn test with P values and 95% confidence intervals Bonferroni corrected for 6 comparisons. RESULTS: Seventy-five subjects were enrolled and 70 subjects completed the study. The median (range) for the QoR-40 score after the TAP block was 157 (127-193), 173 (133-195), and 172 (130-196) for the saline group and 0.25% and 0.5% ropivacaine groups, respectively. The median difference (99.2% confidence interval) in QoR-40 score for 0.5% bupivacaine (16 [1-30], P = 0.03) and 0.25% bupivacaine (17 [2-31], P = 0.01) was more than saline but not significantly different between ropivacaine groups (-1 [-16 to 12], P = 1.0). Increased global QoR-40 scores correlated with decreased area under the pain score time curve during postanesthesia recovery room stay (rho = -0.56, 99.2% upper confidence limit [UCL] = -0.28), 24-hour opioid consumption (rho = -0.61, 99.2% UCL = -0.34), pain score (0-10 scale) at 24 hours (rho = -0.53, 99.2% UCL = -0.25), and time to discharge readiness (rho = -0.65, 99.2% UCL = -0.42). The aforementioned variables were lower in the TAP block groups receiving ropivacaine compared with saline. CONCLUSIONS: The TAP block is an effective adjunct in a multimodal analgesic strategy for ambulatory laparoscopic procedures. TAP blocks with ropivacaine 0.25% and 0.5% reduced pain, decreased opioid consumption, and provided earlier discharge readiness that was associated with better quality of recovery. (Anesth Analg 2011; 113: 1218-25)