Eficácia do bloqueio transverso do plano abdominal na redução da dor e da necessidade de opioides em histerectomia laparoscópica e assistida por robô: Uma revisão sistemática e metanálise

López-Ruiz, Claudia; Orjuela, Jerutsa Catalina; Rojas-Gualdrón, Diego Fernando; Jimenez-Arango, Marcela; Ríos, José Fernando de los; Vásquez-Trespalacios, Elsa Maria; Vargas, Claudia

doi:10.1055/s-0041-1740595

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Revista Brasileira de Ginecologia e Obstetrícia

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Sumário

Review Article • Rev. Bras. Ginecol. Obstet. 44 (01) • Jan 2022 • https://doi.org/10.1055/s-0041-1740595 copiar

Eficácia do bloqueio transverso do plano abdominal na redução da dor e da necessidade de opioides em histerectomia laparoscópica e assistida por robô: Uma revisão sistemática e metanálise

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

Objetivo

Resumir as evidências disponíveis sobre a eficácia do bloqueio TAP em histerectomia laparoscópica ou robótica.

Fontes de Dados

Pesquisamos bancos de dados e literatura cinza por ensaios clínicos randomizados nos quais o bloqueio do plano transverso do abdome (TAP na sigla em inglês) foi comparado com placebo ou com nenhum tratamento em pacientes que foram submetidos a histerectomia laparoscópica ou assistida por robô.

Métodos

de Seleção de Estudos Dois pesquisadores avaliaram independentemente a elegibilidade dos artigos selecionados. Tabulação, Integração e Resultados Sete estudos foram selecionados envolvendo 518 pacientes. A dor pós-operatória precoce apresentou diferença nasmédias (DM) de: -1 17 (intervalo de confiança [IC] de 95%: - 1 87-0 46) nos escores da escala de dor (I2=68%) o que foi estatisticamente significativo a favor do uso do bloqueio TAP mas sem relevância clínica; dor pós-operatória tardia: DM 0001 (IC95%: - 043-044; I2=69%); necessidade de opioides: DM0 36 (95%CI: - 0 94-168; I2=80%); e incidência de náuseas e vômitos com diferença de 95% CI=- 011 (- 0215-0006) a favor do TAP.

Conclusão

Com moderada força de evidência devido à alta heterogeneidade e ao desequilíbrio nas características basais entre os estudos os resultados indicam que o bloqueio do TAP não deve ser considerado como uma técnica analgésica clinicamente relevante para melhorar a dor pós-operatória em histerectomia laparoscópica ou robótica apesar da significância estatística nas pontuações da escala de dor pósoperatória inicial.

Número e Registro do Ensaio Clínico: PROSPERO ID - CRD42018103573.

Palavras-chave:
bloqueio do plano transverso do abdome; dor; histerectomia laparoscópica; histerectomia robótica assistida; opioide

Study	Country	Type of surgery	Inclusion criteria	Exclusion criteria	Outcomes	Comparison group	Number TAP / ControlSequence generation and concealment	Blinding	Anesthetic drug dose (mg)	ASA	TAP block technique
Calle et al. (2014) ¹⁵15 Calle GA, López CC, Sánchez E, Ríos JFDL, Vásquez EM, Serna E, et al. Transversus abdominis plane block after ambulatory total laparoscopic hysterectomy: randomized controlled trial. Acta Obstet Gynecol Scand. 2014;93(04):345-350. Doi: 10.1111/aogs.12351 https://doi.org/10.1111/aogs.12351...	ColombiaPrado Clinic and CES University, Medellin	Laparoscopic	Patients with ASA surgical risk classification types 1 and 2; had no contraindications for administration of local anesthetics, NSAIDs, or acetaminophen; had an adequate level of understanding, i.e., being able to communicate by telephone and understand a numerical scale.	Change in the standard anesthetic technique, hospitalization following hysterectomy, previous medical history of allergy to local anesthetics, and not being able to be reached by telephone	Pain scale scores (VAS) at 24, 48, and 72 hours after surgery, opioid requirement after surgery	Placebo	100 / 97Sequence was generated using computer-generated randomization list in blocks, which were placed in sealed envelopes	Triple blind: Patient, surgeon, and data analyst	Bupivacaine 0.25%(96)	I, II	Laparoscopic-guided
De Oliveira et al. (2011) ¹³13 De Oliveira GS Jr,Milad MP, Fitzgerald P, Rahmani R,McCarthy RJ. Transversus abdominis plane infiltration and quality of recovery after laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol. 2011;118(06):1230-1237. Doi: 10.1097/AOG.0-b013e318236f67f https://doi.org/10.1097/AOG.0-b013e31823...	United States of AmericaNorthwestern University, Chicago	Laparoscopic	Healthy women undergoing laparoscopic hysterectomy	Patients with previous history of allergy to local anesthetics, long-term use of opioid analgesics or corticosteroids, and pregnancy	Quality of Recovery (QoR-40) at 24h; pain numeric scale score at 30 minutes, 60 minutes, and 24 hours; time to opioid requirement and cumulative opioid consumption at 24 hours, and number of postoperative antiemetics	Placebo	22 / 23Individuals were randomized into three groups using a computer-generated table of random numbers, and group assignments were sealed in sequentially numbered envelopes	Double blind: patients, anesthesia care providers	Ropivacaine 0.5%100	I, II	Ultrasound
Ghisi et al. (2016) ¹⁶16 Ghisi D, Fanelli A, Vianello F, Gardini M, Mensi G, Colla LL, et al. Transversus abdominis plane block for postoperative analgesia in patients undergoing total laparoscopic hysterectomy: a randomized, controlled, observer-blinded trial. Anesth Analg. 2016;123 (02):488-492. Doi: 10.1213/ANE.0000000000001267 https://doi.org/10.1213/ANE.000000000000...	ItalyInstituti Ospitalieri Cremona	Laparoscopic	Patients between 18 and 70 years old, undergoing elective total laparoscopic hysterectomy	Chronic opioid therapy in the previous 3 months before surgery, conversion to open surgical technique, BMI > 30 kg/m² or < 18 kg/m², postoperative recovery in intensive care unit, chronic therapy with antidepressants, known diagnosis of epilepsy or therapy with antiepileptic drugs, bilirubin level > 3.0 mg/dL, aspartate aminotransferase and/or alanine aminotransferase > 250 IU, creatinine level >1.4 mg/dL, pregnancy or lactation, known allergy to any drug used in the study, local infection at the block site, and drug or alcohol addiction.	Postoperative pain at rest and during movement using NRS of 0 to 10, at 2, 4, 6, and 24 hours. Morphine requirement 24 hours, incidence of postoperative nausea and vomiting (PONV) using the Apfel score	No block	22 / 22Patients were randomized into two groups using computer-generated sequence of numbers placed in sealed envelopes	Single blind: observer (data collection)	Levobupivacaine 0.375%(75)	I - III	Ultrasound
Guardabassi et al. (2017) ¹⁸18 Guardabassi DS, Lupi S, Agejas R, Allub JM, García-Fornari G. Efficacy of ultrasound-guided transversus abdominis plane block in laparoscopic hysterectomy. Clinical trial. Rev Esp Anestesiol Reanim. 2017;64(05):257-261. Doi: 10.1016/j.redar.2016.12.004 https://doi.org/10.1016/j.redar.2016.12....	ArgentinaHospital Italiano de Buenos Aires	Laparoscopic	Patients between 18 and 70 years old; BMI < 35 kg/m²; undergoing total laparoscopic hysterectomy	Previous medical history of allergy to local anesthetics; psychiatric disorders or dementia, abdominal wall infection; chronic use of analgesics, chronic pain syndrome; diagnosed peripheral neuropathy; known allergy to analgesics or corticoids.	Pain NRS: non-randomized study scores at 60 minutes, 2, 8, and 24 hours after surgery; opioid consumption during the first 24 postoperative hours; adverse effects on quality of sleep of the first night after surgery; episodes of nausea and vomit; Ramsay sedation scale	No block	20 / 20Non-probability sampling of consecutive case series.Random assignment using sealed envelopes	Single-blind: Data analysts	Ropivacaíne 0.5%(75)	I, II	Ultrasound
Bava et al. (2016) ¹⁷17 Bava EP, Ramachandran R, Rewari V, Chandralekha , Bansal VK, Trikha A. Analgesic efficacy of ultrasound guided transversus abdominis plane block versus local anesthetic infiltration in adult patients undergoing single incision laparoscopic cholecystectomy: A randomized controlled trial. Anesth Essays Res. 2016;10 (03):561-567. Doi: 10.4103/0259-1162.186620 https://doi.org/10.4103/0259-1162.186620...	ChinaDepartment of Anesthesiology and Operation, Hospital of People's Liberation Army. Xi'an	Laparoscopic and LAVH	Women scheduled for elective laparoscopic hysterectomy with benign lesions	Patients with preoperative use of analgesics were excluded due to potential impact on postoperative analgesia requirement; BMI > 30 kg/m²; coagulopathy; contraindication for peripheral nerve block; any drug allergy	Pain, with NRS: 30 and 60 minutes, 4, 8, 12, and 24 hoursPONV, Ramsay sedation scaleSatisfaction scores	No block	35 / 36Computer-generated randomization list in blocks, placed in sealed envelopes	Double-blind: blinded to patients and data analysts, but not to members of the surgical and anesthesia care teams	Ropivacaine 0.375%(112.5)	—	Ultrasound
Kane et al. (2012) ¹⁴14 Kane SM, Garcia-Tomas V, Alejandro-Rodriguez M, Astley B, Pollard RR. Randomized trial of transversus abdominis plane block at total laparoscopic hysterectomy: effect of regional analgesia on quality of recovery. Am J Obstet Gynecol. 2012;207(05): 419.e1-419.e5. Doi: 10.1016/j.ajog.2012.06.052 https://doi.org/10.1016/j.ajog.2012.06.0...	United States of AmericaMetrohealth Medical Center, Case Western Reserve University, Cleveland	Laparoscopic and single-port	All women undergoing laparoscopic hysterectomy by a single surgeon between April and September 2011 were approached to participate in this study.	Patients on chronic pain narcotic medications, or if they had allergy to local anesthetic.	Numeric visual analog scales for pain and opioid requirement at 2 and 24 hours after surgery; quality of recovery (QoR-40 survey) at postoperative day 1	No block	28 / 29Computer-based block randomization	Single-blind: blinded to data analysts	Ropivacaine 0.5% with epinephrine(100)	—	Ultrasound

Study (ref)	Randomization process	Deviation from planned intervention	Data on loss of results	Measurement of outcomes	Selection of reported outomes	Overall bias
Calle et al. (2014)¹⁵15 Calle GA, López CC, Sánchez E, Ríos JFDL, Vásquez EM, Serna E, et al. Transversus abdominis plane block after ambulatory total laparoscopic hysterectomy: randomized controlled trial. Acta Obstet Gynecol Scand. 2014;93(04):345-350. Doi: 10.1111/aogs.12351 https://doi.org/10.1111/aogs.12351...	Low	Low	Low	Low	Low	Low
De Oliveira et al. (2011)¹³13 De Oliveira GS Jr,Milad MP, Fitzgerald P, Rahmani R,McCarthy RJ. Transversus abdominis plane infiltration and quality of recovery after laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol. 2011;118(06):1230-1237. Doi: 10.1097/AOG.0-b013e318236f67f https://doi.org/10.1097/AOG.0-b013e31823...	Low	Low	Low	Low	Low	Low
Ghisi et al. (2016)¹⁶16 Ghisi D, Fanelli A, Vianello F, Gardini M, Mensi G, Colla LL, et al. Transversus abdominis plane block for postoperative analgesia in patients undergoing total laparoscopic hysterectomy: a randomized, controlled, observer-blinded trial. Anesth Analg. 2016;123 (02):488-492. Doi: 10.1213/ANE.0000000000001267 https://doi.org/10.1213/ANE.000000000000...	Low	Low	Low	Low	Low	Low
Guardabassi et al. (2017)¹⁸18 Guardabassi DS, Lupi S, Agejas R, Allub JM, García-Fornari G. Efficacy of ultrasound-guided transversus abdominis plane block in laparoscopic hysterectomy. Clinical trial. Rev Esp Anestesiol Reanim. 2017;64(05):257-261. Doi: 10.1016/j.redar.2016.12.004 https://doi.org/10.1016/j.redar.2016.12....	Some concern	Low	Low	Low	Low	Some concern
Bava et al. (2016)¹⁷17 Bava EP, Ramachandran R, Rewari V, Chandralekha , Bansal VK, Trikha A. Analgesic efficacy of ultrasound guided transversus abdominis plane block versus local anesthetic infiltration in adult patients undergoing single incision laparoscopic cholecystectomy: A randomized controlled trial. Anesth Essays Res. 2016;10 (03):561-567. Doi: 10.4103/0259-1162.186620 https://doi.org/10.4103/0259-1162.186620...	Low	Low	Low	Low	Low	Low
Torup et al. (2015)²¹21 Torup H, BøgeskovM, Hansen EG, Palle C, Rosenberg J, Mitchell AU, et al. Transversus abdominis plane (TAP) block after robot-assisted laparoscopic hysterectomy: a randomised clinical trial. Acta Anaesthesiol Scand. 2015;59(07):928-935. Doi: 10.1111/aas.12516 https://doi.org/10.1111/aas.12516...	Low	Low	Low	Low	Low	Low
Kane et al. (2012)¹⁴14 Kane SM, Garcia-Tomas V, Alejandro-Rodriguez M, Astley B, Pollard RR. Randomized trial of transversus abdominis plane block at total laparoscopic hysterectomy: effect of regional analgesia on quality of recovery. Am J Obstet Gynecol. 2012;207(05): 419.e1-419.e5. Doi: 10.1016/j.ajog.2012.06.052 https://doi.org/10.1016/j.ajog.2012.06.0...	Low	Low	Low	Some concern	Low	Some concern

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[1] Address for correspondence
Claudia López-Ruiz, MD, Gynecologist, Laparoscopist, MSc in Epidemiology, Minimally Invasive Surgery, Department of Gynecology and Obstetrics, Clínica del Prado, Cl. 19A #4425, Medellín, Antioquia, Colômbia (e-mail: cclopezruiz@gmail.com).