TAP block beats port-site infiltration after laparoscopic cholecystectomy

Design

Three-arm open-label randomised controlled trial

Population

180 adults having elective laparoscopic cholecystectomy for gallstones

Primary outcome

VAS pain at multiple time points and positions

Effect

Rescue tramadol 8.3% (L-TAP) and 13.3% (S-TAP) vs 41.7% (port-site), p < 0.001

A three-arm, open-label randomised trial at a single tertiary centre allocated 180 patients having elective laparoscopic cholecystectomy for gallstones, 60 to each of: low-pressure pneumoperitoneum with a laparoscopic-guided transversus abdominis plane block; standard pressure with the same block; or standard pressure with port-site infiltration. All received regular intravenous paracetamol, with tramadol as rescue.

Both block groups had lower pain scores than port-site infiltration at several early time points. Rescue tramadol was needed by 8.3% with low pressure plus block and 13.3% with standard pressure plus block, against 41.7% with infiltration (p < 0.001). Shoulder-tip pain was 3.3% with low pressure plus block against 20.0% with infiltration. Next-day discharge was 96.7%, 95.0% and 86.7%.

The block is placed by the surgeon under laparoscopic view, needs no ultrasound or extra anaesthetic time, and is cheap. The trial did not name a single primary endpoint and was not blinded, and the arms differed in local anaesthetic dose and timing, so the extra gain from low pressure cannot be separated cleanly.

• Consider a surgeon-placed laparoscopic-guided TAP block in place of port-site infiltration for elective cholecystectomy.
• Rescue opioid use fell from about four in ten patients to about one in ten with the block.
• Adding low-pressure pneumoperitoneum was associated with the least shoulder-tip pain.
• The technique needs no ultrasound machine, which suits units without regional anaesthesia support.
• Stay within the maximum safe local anaesthetic dose when combining a block with port-site infiltration.

Why it matters

A two-minute surgeon-placed block may move day-case cholecystectomy closer to opioid-free recovery without new equipment.

Don't overread it

The trial was open-label without a single primary endpoint, so the size of the pain-score differences should be read cautiously.

The statistics, in plain English

Rescue tramadol in 8.3% against 41.7% is an absolute difference of about 33 points, so roughly one patient in three spared rescue opioid. With many pain comparisons tested, some isolated differences could be chance; the rescue analgesia result is the most robust.

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