A Unique Approach To Transversus Abdominis Plane Block Provides Early Opioid-sparing Pain Control In Open Aortic Surgery
Amber S. Hussain, D.O.1, Gayatri S. Pillai, BS1, Sahaj S. Shah, BA1, Heather S. Hussain, ScD2, Robert W. Abdu, DO1, Evan J. Ryer, MD1, Gregory G. Salzler, MD1, James R. Elmore, MD1.
1Geisinger Medical Center, Danville, PA, USA, 2Independent Data Analyst, Alexandria, VA, USA.
OBJECTIVES: Several approaches have been described for Transversus Abdominis Plane (TAP) blocks without a clear consensus on technique optimization or standardized nomenclature. In this paper, we propose a unique ultrasound-guided TAP block technique to achieve targeted analgesia of T6-L1 segmental nerves for long midline abdominal incisions.
METHODS: This is a retrospective single-center review of patients who underwent open aortic surgery between January 2016 and December 2021. Patients were grouped into TAP block, epidural, or general anesthesia alone. Morphine Milligram Equivalent (MME) at 48, 72, and 120 hours postoperatively, vasopressor requirements, time to extubation, and ICU and hospital length of stay are compared between groups.
RESULTS: Of 89 open abdominal aortic surgeries performed for aneurysmal disease, 63 met inclusion criteria. Mean age was 69 years, 69.8% male and 98.4% white. Rupture, intraoperative death, and the need for additional procedures, including thromboembolectomy, renal bypass, and other abdominal surgery, were excluded. Our specific ultrasound-guided TAP block technique was done in 17 patients (27%). A total of 266 mg/20 mL liposomal bupivacaine (EXPAREL®) dilute to 60 mL is injected in 10 mL aliquots into the transversus abdominis plane at three anterolateral abdominal wall points bilaterally. Thirty-two patients (50.8%) were treated with an epidural, and 14 (22.2%) underwent general alone. There were no differences in group characteristics. Mean MME₄₈ is 140.5±121.7 (95% CI 63.2-217.8) in the general anesthesia group, 51.1±71.9 (95% CI 14.1-88) in TAP, and 9.3±17.3 (95% CI 3.1-15.5) in epidural group (p<0.001). MME₇₂ and MME₁₂₀ are significant (p<0.001). Subgroup comparisons between TAP versus general exhibit a difference in MME₄₈ (p=0.038), but not after. Epidural anesthesia is effective compared to TAP and general anesthesia up to 72 hours (∆MME₁ p=0.045, p=0.015). There is no difference in MME beyond 72 hours (∆MME₂ p=0.82, 0.58, 0.94), vasopressor requirements, time to extubation, and ICU and hospital LOS across all groups (Figure 1).
CONCLUSIONS: TAP block provides early effective pain control with significant opioid-sparing effects compared to general anesthesia alone in the first 48 hours postoperatively. The analgesic effect is still less than epidural anesthesia; however, all groups equilibrate with no difference in MME beyond postoperative day three. 
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