Bristol laparoscopic Associates experience of TAP block & Accelerated recovery
The evolution of an “Accelerated” recovery programme for resectional laparoscopic colorectal surgery with anastomosis; TAP, Lap and Go!
N Zafar, R Davies*, GL Greenslade*, AR Dixon
Depts., Colorectal Surgery and Anaesthesia*, Frenchay Hospital, North Bristol NHS Trust, Bristol, BS16 1LE.
Mr Tony Dixon
Consultant Colorectal Surgeon,
Frenchay Hospital, Bristol, BS16 1LE
Objective. Analyse outcomes of an evolving “Accelerated Recovery Programme” post laparoscopic colorectal resection.
Methods. Analyse a prospective electronic database; March 2000 - April 2008.
Results. 353 consecutive patients underwent 237 high anterior resections (AR), 116 right hemicolectomies (RHC); 54 (15.3%) were emergencies. 138 patients who had post-operative analgesia provided by IV paracetamol (IVP); 27 (16.3%) required additional oral morphine. Patient controlled analgesia (PCA) was used in 138. Transversus abdominis plane (TAP) blocks, supplemented by oral analgesia were used in the remaining 50 patients. The time for resumption of a normal diet was significantly reduced in TAP (median 8hrs), IVP (median 15hrs) as compared to PCA (48 hrs); P < 0.0001). Postoperative hospital stay was significantly reduced in the TAP (median 2 days), IVP (median 4days) compared to the PCA group (median 7 days); P < 0.0001. 17 (34%) TAP patients were discharged home within 24 hours of completing their surgery. There were no differences in terms of minor and major problems. The movement towards “Accelerated Recovery” was not associated with any increased risk of urinary retention, return to theatre, readmission and/or 30 day mortality.
Conclusion. Laparoscopic surgery utilising IV paracetamol and TAP blocks for peri and post-operative analgesia allows for safe effective “accelerated recovery” in an unselected patient population undergoing elective and emergency laparoscopic colorectal resection. The myth that epidural anaesthesia is necessary for enhanced recovery can now be dispelled.
Key Words: Laparoscopic colorectal surgery, enhanced recovery, TAP block, epidural anaesthesia, paracetamol, postoperative analgesia
Whilst the evidence for optimal perioperative care in colorectal surgery is abundant1-4 European peri-operative practice continues to differ from evidence-based practice5. By avoiding fasting, intravenous fluid overload and the stress response, postoperative catabolism is reduced and short-term recovery enhanced. The specific measures that can be used include avoidance of oral bowel preparation, epidural anaesthesia/analgesia continued for two postoperative days, no nasogastric tubes, intravenous fluid and in particular saline restriction and free oral intake from day one1,6. The major draw back of any enhanced recovery and early discharge programme is the high readmission rate approaching 20%7.
Whilst it is widely accepted that laparoscopic resection can improve short term patient outcomes by reducing pain, pulmonary dysfunction, intestinal ileus and general fatigue there remains disagreement as to its merits over open surgery when conducted within a properly executed enhanced recovery programme. Studies demonstrating a benefit within a setting of laparoscopic rectal resection are fewer still8. Peri-operative pain relief remains a major issue.
Conventional pain relief involves using opioids delivered either parenterally or regionally via epidural and spinal catheters. Opioid delivery by whatever route is associated with untoward systemic effects. Whilst 48hrs of epidural anaesthesia is considered integral to the success of an enhanced recovery programme, this method of delivery has recently been called into question as it exposes patients to unnecessary dangers not withstanding a significant lack of evidence supporting its use9. Parenteral paracetamol was introduction to the U.K. in 2002 with a claim that it was near equivalent to opiates in terms of analgesic effect.
We report the evolution of a new and novel process of “Accelerated Recovery” based on our experience of patient controlled analgesia, the impact of IV paracetamol and our current practice of using transversus abdominis plane (TAP) blocks10 for both intra and postoperative pain relief, augmented by IV paracetamol, in patients undergoing laparoscopic colorectal resection.
A prospectively collected, institutionally approved and password protected electronic database of all colorectal laparoscopic procedures between March 2000 and April 2008 identified 353 consecutive patients who underwent either elective or emergency right hemicolectomy and high anterior resection. Prior to the introduction of IV paracetamol in 2002, we used patient controlled analgesia (PCA) with IV morphine sulphate (1mg with a five minute lockout) for postoperative analgesia. Post 2002 we moved over to 6hrly IV paracetamol (IVP). Over the last 4 months we have used TAP blocks to provide peri and postoperative analgesia in 50 patients. Both IVP and TAP groups had access to hourly oral morphine 0.3mg/kg (maximum 20mg in any one dose) for breakthrough pain.
Each patient and their family were briefed to anticipate an early yet appropriate discharge. Our regimen was designed to be as simple as possible: three port laparoscopic surgery, small umbilical incision for specimen extraction, no post-operative drips (other than the PCA group who received 1 L Hartmann solution/24hrs whilst the PCA was in situ), drains and early mobilisation. In 2006 we abandoned, other than a phosphate enema administered one hour prior to surgery, routine pre-operative bowel cleansing and removed urinary catheters prior to extubation. Pre-operative fluids, milk excluded, were continued in all the elective patients up to one hour prior to surgery.
Anaesthesia was induced with 150-300mcg fentanyl, propofol and pancuronium; alfentanil and atracurium were used in the frail elderly. Maintenance was provided with Air/O2 and volatile anaesthetic agents. Nitrous oxide was avoided wondering whether it would diffuse into gas pockets left at the end of surgery and worsen postoperative discomfort. Intra and peri-operative fluids were restricted where appropriate to 1L Hartmann Solution. Invasive monitoring was not employed routinely. No restrictions were placed on post-operative oral fluid/diet intake, indeed elective patients were given a “cup of tea and a biscuit” in the recovery room. All were encouraged to eat as soon as possible. Early mobilisation was encouraged on the day of surgery and demanded the day after.
Bilateral TAP blocks were performed using a combination of “blind” insertion (double click) and ultrasound guidance. Using a transducer placed anterior to the anterior edge of the latissimus dorsi, between the iliac crest and inferior to the ribs behind the midaxillary line (overlying the triangle of Petit), underlying abdominal wall compartments were visualised. A 10cm bevelled 21G block needle (Pajunk, Germany) was held inferior to the transducer and passed obliquely towards the transverses abdominal plane perpendicular to the ultrasound beam. The needle tip was then guided posterior to the mid-axillary line to lie between the transversus and internal oblique muscles and so block the lateral nerve branches. Ultrasound scanning usually confirmed that the two palpable facial layer “clicks” of the “blind” block correspond to the needle piercing the external and internal oblique muscles. Once the needle tip was seen/felt to lie between the internal oblique and the transversus abdominis muscle layers, 0.375% bupivacaine was injected up to 20mls each side according to patient weight. The procedure was repeated on the opposite side.
Laparoscopic surgery commenced with one 12mm umbilical port and two right iliac-fossa operating ports (5 and 12mm) for anterior resection; two suprapubic ports (same size) for right hemicolectomy. Local anaesthetic wound infiltration was not employed. All extractions were made through the enlarged umbilical port (approx 2.5cm). Urinary catheters were removed, if appropriate on the first postoperative evening or prior to extubation in the TAP group alone.
All were written-up for 2mg morphine bolus at the discretion of the recovery nurses and in the case of the majority of IVP patients and all TAP, drips discontinued. Comfortable and awake patients were given a warm drink and a biscuit. All received supplementary multimodal analgesia including oral morphine (10mg prn), 8hrly intravenous paracetamol, NSAIDS and tramadol as tolerated. Patients were mobilised and encouraged to eat normally as they felt fit. We had no formal standardised discharge criteria. Patients were discharged, without any pressure exerted, when they felt comfortable, the stoma nurses considered it appropriate and social circumstance allowed. Each was given an advice sheet (table 1.) and information about potential postoperative problems and when to seek advice (table 2.). Patients were reviewed in outpatients at one week.
Fisher’s exact test and ?2 tests were used to analyze binary variables. The variables analyzed were continuous variables (age, time to eat after surgery, operative time and length of hospital stay). Means, medians, standard deviations and ranges were used for continuous variables. Frequency and percentages were used for categorical data. All analysis were conducted using SPSS 15.0.
353 consecutive patients underwent laparoscopic resection; 237 high anterior resections (AR), 116 right hemicolectomies (RHC). 54 (15.3%) were emergencies. Irrespective of diagnosis and procedure the patients were divided into further groups on the basis of the final analgesic treatment that they had received. Whilst 165 patients had IVP, 27 (16.3%) required additional oral morphine and were excluded leaving 138 patients who had post-operative analgesia provided by IVP alone. The same number who had a PCA. TAP blocks, supplemented by oral analgesia were used in the remaining 50 patients.
A comparison of ASA grades is reflective of our move over the last four years to offer laparoscopic resection to “all comers” (Table 3). The time for resumption of a normal diet postoperatively was significantly reduced in TAP (median 8hrs), IVP (median 15hrs) as compared to PCA (48 hrs); P < 0.0001). Postoperative hospital stay was significantly reduced in the TAP (median 2 days) IVP (median 4days) compared to the PCA group (median 7 days); P < 0.0001. More patients in the TAP group were discharged within 24hrs of their surgery; P < 0.0001. There were no differences between the three groups in terms of minor and major problems. The movement towards “Accelerated Recovery” was not associated with any increased risk of urinary retention, return to theatre, readmission and/or 30 day mortality.
With specific reference to the TAP group, only four required intraoperative morphine, the remainder a modest doses of fentanyl; median dose 150mcg (100-300mcg). 24 received oral morphine (10 – 100mg); median dosage 30mg whilst the remaining 52% received a combination of intravenous/oral paracetamol and NSAID alone. One proctocolectomy patient who developed an exacerbation of their obstructed pulmonary disease underwent a successful TAP block for rescue analgesia on day 3. 17 (34%) TAP patients were discharged home within 24 hours of completing their surgery.
Enhanced recovery programmes utilising thoracic epidural (high sympathetic blockade) analgesia as championed11, 12 over recent years are becoming the current “buzz words” in “trendy” colorectal practice. So much so that they are fast becoming the norm and shaping modern practice. An effective epidural is thought to attenuate the neuro-humoral stress response to surgery, potentially improving postoperative cardio-respiratory function, reducing complications and mortality13, 14; the latter by as much as 30%14. However, in the highly powered MASTER trial, the largest multi-centre, non-blinded, RCT of 888 high-risk patients undergoing major abdominal surgery15, there was no significant difference in mortality or major morbidity. The MASTER group calculated, provided that the epidurals worked, for every 15 patients treated one episode of respiratory failure would be prevented. An audit of UK practice has shown that the majority of epidurals are ineffective16.
A well-recognised phenomenon of a good epidural is hypotension secondary to vasoparesis. We have shown that once an epidural block has been established, colonic mucosal and inferior mesenteric artery blood flow relate more to mean arterial pressure rather than cardiac output and more importantly that volume replacement failed to restore splanchnic flow and that a vasopressor was required17. In a busy general ward with a high turnover of both emergency and elective patients this is neither practical nor safe. Whilst no one can argue that good intraoperative fluid control is essential and poor practice will influence outcome, there is little evidence that intraoperative fluid loading per se will improve postoperative blood pressure control. Pre-loading and vasopressors also require invasive monitoring, which again is not without complication. The process of setting up an epidural and monitoring is also demanding of time. In the “sit-down time” required of an epidural, we could complete a laparoscopic right hemicolectomy18.
In our quest for simplifying perioperative management protocols, avoidance of unnecessary interventions and complications whilst achieving and maintaining low pain scores we have avoided epidurals. Initially we used patient controlled opiate infusions only to abandon this in favour of IV paracetamol and NSAIDs augmented by oral analgesia. This change of practice was associated with a significantly earlier return to normal diet and hospital discharge and without any increased risk of morbidity or mortality i.e., overall recovery was not compromised.
Rafi19 described “blind” TAP block via the triangle of “Petit” in 2001. The triangle comprise latissimus dorsi posteriorly, external oblique anteriorly and the iliac crest inferiorly. TAP blocks have a wide application in intermediate abdominal surgery e.g., appendicectomy, hernia repair and gynaecological surgery. They are also effective in patients undergoing major colonic resection via a midline laparotomy. In their small randomised, double-blind trial of 32 patients McDonnell et al reported10 that postoperative visual analogue pain scores were significantly reduced at all postoperative pain points during the first 24 hours along with PCA morphine requirements. This and our experience of its use for postoperative pain rescue would suggest that it could also provide effective alternative analgesia when an epidural is contraindicated or refused. Only four of our patients were given parenteral morphine during surgery, the remainder requiring only modest doses of fentanyl at a third of the dose that we would normally have expected to use. The analgesic effect also extended into the immediate 6hr postoperative period. One particular advantage of this method is that by avoiding parenteral opiates, postoperative nausea was not a problem and patients were quickly able to tolerate a normal diet.
The success of this block is dependent on identifying the plane between internal oblique and the transversus abdominis muscles. Whilst a “blind” technique are very effective and easy to perform, the correct plane been identified by two subtle “pops” as the blunt needle passes through two fascial planes, effective placement is much more challenging in the obese or in the elderly where muscle layers are thinner. Cadaveric studies have demonstrated that the injection of methylene blue via the triangle of Petit using the "double pop" technique results in reliable deposition into the transversus abdominis plane. In volunteers, the injection of local anaesthetic and contrast produced a reliable sensory block and demonstrated deposition throughout the transversus abdominis plane. The sensory block produced by lidocaine 0.5% extended from T7 to L1 and receded over 4 to 6 hours. This finding was supported by magnetic resonance imaging studies that showed a gradual reduction in contrast in the transversus abdominis plane over time. It was Hubbard’s recent description21 of ultrasound guided TAP block that prompted us move on from “blind TAP” and to explore its use in laparoscopic colorectal resection.
Although Laparoscopic colorectal surgery can permit an earlier recovery and discharge from hospital, early discharge is not always routinely achieved. The other problem with enhanced recovery programmes is their high rates of readmission (10-20%) and complications6,7,8,11,12. Other groups have embraced the concept of “accelerated recovery” and have avoided the use of epidurals, analgesia provided by a PCA; 70% were discharged within 3 days of surgery. 20% of their patients experienced a complication within 30 days. It was perhaps not surprising that it was those patients who were in a position to be discharged early i.e., by day 2 who had the lowest rate of complications and readmissions 22. This was our experience also.
Given the analgesic efficacy of TAP, its ease of performance, including its utility in emergency patients and the absence of any perceived complications, we would argue that TAP perfectly complements quick and properly executed laparoscopic colorectal resection performed under modern light anaesthesia and allows for safe “accelerated recovery” which in many patients will be before the scheduled removal, at 48hrs of the potentially dangerous thoracic epidural, considered by many to be essential for enhanced recovery. This observational study also supports the use of the intravenous paracetamol for perioperative analgesia in laparoscopic colonic resection and coupled with “TAP, LAP and GO” is a step towards good patient care and a way to meet the challenge of increasing workload on NHS.
The results of laparoscopic colonic resection are assured only if we modulate the perioperative care of our patients (including the type and duration of anaesthesia -analgesia) with the requirements of procedure and patient alike. We believe that with the current enthusiasm for enhanced recovery and laparoscopic surgery it is time to look more critical at the available evidence for epidural anaesthesia and weigh up the associated risks, benefits and alternatives and convey them to our patients.
Table 1. Discharge instructions
DISCHARGE INSTRUCTIONS – LAPAROSCOPIC COLON RESECTION
For your own safety, it is important that you do not drive, drink alcohol or make important decisions for the first 48 hours after surgery.
Unrestricted, so long as you don’t experience too much pain. Keep yourself active, i.e., don't take to your bed once you get home. Avoid driving until the majority of your pain has gone. You should be able to return to your usual activities, including work in 2-3 weeks.
Your dressings will be removed before you go home. Leave the pieces of tape on your wounds for a week; soak them off in the bath. You can shower or bathe the 1st postoperative day. Expect some bruising and localised tenderness.
Drink plenty of water and stick to a light diet for 2-3 days after your operation. Avoid high fibre foods for the first few weeks.
Continue your normal tablets. For pain, take two paracetamol tablets by mouth every 6 hours and if prescribed, an anti-inflammatory e.g., Diclofenac 75mg twice a day.
Expect to feel reasonably well quite quickly (average 3-5 days). If you don’t, please consider phoning the ward or the cancer specialist nurse. Remember you may tire very easily. After all it is still major surgery!
You will usually be discharged within 24 - 48hrs of your operation. If you are not feeling particularly well or have questions, please speak to us!
The ward will make you an appointment for 1-2 weeks after discharge. This allows us to see how you are and talk through any further treatments that we feel may be required.
Table 2. When to seek medical advice
WHEN TO SEEK MEDICAL ADVICE
Please call the ward, your GP, the on-call surgical team or call in at A&E if you develop any of the following:
Chills and or persistent fever over 39 C
Pulse >100 or respiratory rate >30
Fresh rectal bleeding
Increasing abdominal swelling
Persistent nausea and or vomiting so that you are unable to eat or drink liquids
Persistent cough or shortness of breath
Redness or purulent drainage from an incision
Painful swollen calf or leg
Explain that you feel unwell, that you have had a resent laparoscopic resection and that you need a senior surgical review.
Table 3: Comparison of the three groups of patients.
PCA (N=138) IVP (N= 138) TAP (N = 50)
Median age yrs 62 67 65
ASA I 50 (36%) 21 (15%) 8 (16%)
ASA II 62 (45%) 69 (50%) 20 (40%)
ASA III 24 (17%) 43 (31%) 22 (44%)
ASA IV 2 ( 2%) 5 ( 4%) 0
Median time to diet 48 (12-552) 15 (0-72) 8 (2-72) p<0.0001
& range (hrs)
Median Length stay 7 (2-46) 4 (1-24) 2 (1- 30) p<0.0001
& range (days)
Discharge <24hrs 0 9 (6.5%) 17 (34%)p<0.0001
Anastomotic leak 3 (2.2%) 4 (2.7%) 3 (6%)
Ileus 6 0 1
Wound sepsis 9 4 2
Retention of urine 2 1 3 (6%)
SB obstruction 1 2 0
Death (30 day) 1 3 1
Return to theatre 4 (2.9%) 6 (4.3%) 3 (6%)
Readmission 6 (4.3%) 8 (5.8%) 2 (4%)
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