Ultrasound Guided Posterior Quadratus Lumborum Block for Improved Postoperative Analgesia in Minimally Invasive Gynecologic Surgery
Conditions: Post-operative Pain, Gynecologic Surgery, Regional Anesthesia
Sponsor: Pedram Bral

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TITLE:  Ultrasound guided posterior quadratus lumborum block for improved 
postoperative analgesia in minimally invasive gynecologic surgery 
 
 
 
Date:  June 19, 2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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TITLE 
 
Ultrasound guided posterior quadratus lumborum block for improved postoperative 
analgesia in minimally invasive gynecologic surgery 
 
 
INTRODUCTION 
 
The overall decrease in morbidity associated with advances in minimally invasive 
surgery has transformed the concept of postoperative management, with lower 
complication rates, earlier mobilization, rapid postoperative recovery, and earlier 
discharge from the hospital. However, at times, laparoscopic surgery is associated 
with higher postoperative pain than traditional laparotomy in the immediate 
postoperative period; often requiring significantly higher doses of pain medication 
within the first 4 hours after surgery. In general, laparoscopic procedures could be 
associated with longer operative times; however, minimally invasive surgeons are 
presented with the most challenging patients- often morbidly obese, prior history of 
several surgical procedures in the abdomen and pelvis, and/or adhesive disease.  
Overall operative time is increased, including time under general anesthesia and 
amount of surgical dissection, which makes control of postoperative pain all the more 
problematic. 
 
BACKGROUND AND SIGNIFICANCE 
 
The challenge to achieve adequate analgesia has led to the development of directed, 
multi-modal protocols specific to management of post-laparoscopy pain in effort to 
decrease the amount of additional administration of narcotic medication. While 
several non-opioid regiments have been found to be effective, opioid medications still 
play a significant role in early postoperative analgesia. Given the adverse side effects 
of narcotic medications, regional blocks utilizing local anesthetic agents and has been 
shown to improve overall pain control in this time period.  
 
 
Truncal abdominal nerve blocks are useful for pain control in abdominal and pelvic 
surgeries. More recently, the utilization of the quadratus lumborum (QL) block has 
effectively alleviated somatic and visceral pain in the upper and lower abdomen. The 
QL block provides analgesia spanning from the T4 to L1 dermatomal levels in the 
thoracolumbar plane to provide a broad sensory level analgesic effect. The approach 
involves injecting local anesthetic under ultrasound guidance into the plane posterior 
to the quadratus lumborum muscle and middle layer of thoracolumbar fascia. 
 

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Given the utility of the QL block in controlling somatic pain, this study aims to 
determine whether the QL block is an effective analgesic adjunct in the control of 
postoperative pain period, specifically with regards to patients undergoing 
laparoscopic gynecologic surgery. 
 
 
 
STUDY OBJECTIVES 
 
this study aims to determine whether the posterior QL blocks is an effective analgesic 
adjunct in the control of postoperative pain period, specifically with regards to 
patients undergoing laparoscopic gynecologic surgery. 
 
HYPOTHESIS  
 
The patients receiving QL blocks will have lower post-operative pain scores and will 
need less oral supplemental pain killers.  
 
Subjects:  
 
Women aged 18 to 65 presenting for scheduled laparoscopic or robotic total or 
supracervical hysterectomy for benign indication.  
 
Eligibility Criteria:  
Patient will be eligible for recruitment if between the ages of 18 to 65 scheduled to 
undergo laparoscopic or robotic total or supracervical hysterectomy for benign 
indications. Only surgery for benign pathology will be considered to enrollment. No 
Malignancy cases will be included.  
 
 
Exclusion criteria:  
1. History of adverse reaction or allergy to Bupivacaine or liposomal 
bupivacaine 
 
2. Medical contraindication to placement of QL block.  
 
3. Suspicion of possible reproductive cancer with contraindication of 
morcellation of uterine tissue.  
 
4. Significant medical condition or laboratory result that in the opinion of the 
Investigator indicate an increased vulnerability to study subject which exposes 
the subject to an unreasonable risk as a result of participating. 
 
5.  Any clinically significant condition uncovered during the surgery, such as 
excessive bleeding or decompensation, that might render the subject medically 
unstable to continue the study or complicate the subject's intraoperative or 
postoperative course. 
 

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6. Pregnant patients 
 
7. Less than 40Kg weight.  
 
 
 
 
Design:  
 
Prospective Cohort observational study. All patients that meet criteria for 
participation in this study will be screened: patients scheduled to undergo a 
laparoscopic hysterectomy for benign conditions by attending physicians in the 
division of Minimally Invasive Gynecologic Surgery. Based on surgeon’s preference, 
and patient’s consent, the patient is offered a QL block or not. Our aim is to follow 
the patient’s pain scores post op and amount of oral pain medication used whether 
they received QL block or not. If the patient received the QL block then they will be 
considered part of the study arm. If the patient did not receive the QL block then 
they will be considered part of the control arm.  
 
The QL block is best thought of as a volume or compartment block in that volumetric 
spread of LA along the fascial plane is associated with efficacy in blocking the 
thoracolumbar nerves between T7-L1. It can be reasonably assumed that this 
compartment is the same across patients and is not affected by the amount of 
subcutaneous or central fat present in the obese patient.  
 
 
If a block is to be performed, the QL block will be performed using a 21G x 100mm 
Stimuplex needle under ultrasound guidance using a curvilinear probe.  Subjects will 
be positioned in the semi-lateral position to facilitate access into the plane posterior 
to the quadratus lumborum muscle and middle layer of thoracolumbar fascia. The QL 
block will be administered via an in-plane approach and local anesthetic will be 
injected between the quadratus lumborum muscle and the middle layer of the 
thoracolumbar. The QL block will be in the operating room after induction prior to 
starting the scheduled surgical procedure. If the block is performed, it will include 
20ml of 0.25% bupivacaine and 5ml of liposomal bupivacaine (Exparel) per side. The 
block will be done bilaterally therefore a total of 40ml of 0.25% bupivacaine  and 
10ml of liposomal bupivacaine (Exparel) will be administered.   
Patients will be pre-medicated with Midazolam. Routine monitoring will be performed 
including electro-cardiography, non-invasive blood pressure monitoring, heart rate 
oxygen saturation and end-tidal carbon dioxide and capnograph will be performed. 
General anesthesia will be induced with Propofol 1-2 mg/kg and analgesia will be 
provided with Fentanyl 2 mcg/kg. General anesthesia will be maintained using the 
Sevoflurane titrated to effect as determined by the anesthesia team caring for the 
patient Rocuronium will be administered during the duration of the case to provide 
muscle relaxation for the duration of the procedure, with an induction dose of 0.6 
mg/kg and titrated to 1-2 twitches assessed by continuous twitch monitor. Reversal 
of neuromuscular blockade will be achieved using 0.06 mg/kg of Neostigmine and 
0.012mg/kg of Glycopyrrolate or 2mg/kg of sugamadex.   

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Possible allergic type reactions of receiving bupivacaine include urticaria, pruritis, 
erythema, angioedema, tachycardia, sneezing, nausea, vomiting, dizziness, and 
syncope. Overdosage or rapid absorption lead to systemic toxicity manifestation that 
need immediate counter measures related to the central nervous system and 
cardiovascular system. There is also risk of nerve injury given the location of the 
regional block. Routine precaution is taken by the surgical and anesthesia team to 
avoid overdosing. Any reactions or overdosing will be managed accordingly. The 
study will not alter the subjection to possible adverse reaction as this is an 
observational study.  
 
Data Collection Procedures:  
 
As this is an observational (prospective cohort) study, there will be no randomization 
or blinding done. We will be observing the patient’s post op pain scores and amount 
of pain medication used  
 
Postoperatively, patients will be transferred to the PACU for monitoring.  
The amount, timing and type of additional pain medications necessary at 1 and 3 
hours after surgery will be recorded. Pain levels will be documented at the same 1- 
and 3-hours intervals, and scored utilizing a 1-10 Numeric Rating Scale (NRS).  The 
NRS is a verbal assessment, asking patients to quantify their pain on 1- 10 scale. It 
has previously been shown in studies to be a simple, valid alternative to the visual 
analog scale (VAS).  
 
Study subjects will receive a telephone call 24 hours after surgery and asked about 
how much additional medication they have taken for pain control, as well as their 
pain level utilizing the same 1-10 NRS assessment.  
 
Our primary outcome is difference in pain scores at 3 hours. Our secondary outcome 
is difference in pain scores, at 1 hour, 24 hours, difference in additional medication 
taken orally for pain control, and adverse effects if any.  
 
Sociodemographic and clinical data of study subjects will also be obtained, including 
age, body mass index, history of abdominal and pelvic surgeries, history of pelvic 
adhesive diseases such as endometriosis, duration of surgery, and duration of stay 
postoperatively in PACU. 
  
Data Analysis:  the mean difference between pain scores at 1 hour, 3 hour, and 24 
hour, and the difference in the amount of oral pain medication used will be assessed 
as below.  
 
Expected Outcomes: Our study aims to show that patients receiving a preoperative 
QL block will have lower post-operative pain scores and will need less oral pain 
medication 
 
 
 

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