Pre Operative Transversus Abdominis Plane Block Laparoscopic Gynecological Surgery
Condition: Pain; Surgery
Study type: Interventional

Summary: 
      The use of pre-operative transversus abdominis plane block will reduce pain after outpatient
      laparoscopic gynecological surgery and improve quality of recovery.
    

Detailed description: 
      75 subjects will be randomly allocated into 3 groups, using a computer generated table of
      random numbers. Group A (study group) will receive a bilateral TAP block using 15 cc of 0.5%
      ropivacaine on each side. Group B (control group) will receive 15 cc of sterile normal
      saline. Group C (study group 2) will receive a bilateral TAP block using 15 cc of 0.25%
      ropivacaine on each side.

      Subjects will be premedicated with intravenous (IV) midazolam 0.04 mg/kg. Routine ASA
      monitors will be applied. Anesthesia will be induced with remifentanil infusion started at
      0.1 mcg/kg/minute titrated to keep blood pressure within 20% of the baseline and propofol 1.0
      -2.0 mg/kg. Tracheal intubation will be facilitated with rocuronium (0.6 mg/kg) or
      succinylcholine (1-2mg /kg). After induction, a bilateral TAP block will be performed in both
      groups, under ultrasound guidance with a transportable ultrasound device (SonoSite, Bothell,
      WA, USA) and a linear 6-13 MHz ultrasound transducer .Once the EOAM, IOAM and TAM are
      visualized at the level of the anterior axillary line between the 12th rib and the iliac
      crest, the puncture area and the ultrasound probe will be prepared in a sterile manner. Then
      the block will be performed with a 21 G 90mm StimuQuik needle( Arrow International, Reading,
      PA, USA ) utilizing an "in- plane" ultrasound-guided technique by three investigators (GDO
      ,AP). Once the tip of the needle is placed in the space between the IOAM and TAM, and after
      negative aspiration of blood, 15 cc of 0.5% ropivacaine, 15 cc of 0.25% ropivacaine or
      sterile normal saline will be administered under direct ultrasonographic guidance. The
      contralateral block will be performed in the same fashion. Anesthesia will be maintained with
      sevoflurane titrated to maintain a bispectral index (BIS) between 40-60 , remifentanil
      infusion started at 0.1mcg/kg/min titrated to keep blood pressure within 20 % of baseline
      values , and rocuronium that will be administered at the discretion of the anesthesiologist.
      Upon termination of the surgery, neuromuscular blockade will be antagonized with a
      combination of neostigmine 0.05mg/kg and glycopyrrolate 0.01 mg/kg. Subjects will also
      receive ketorolac 30 mg IV after discontinuation of remifentanil for postoperative pain
      control. Ondansetron 4 mg IV will be administered to prevent postoperative nausea and
      vomiting. Subjects will be assessed in the OR after extubation for their pain using a
      numerical rating scale and if pain greater than 4/10 they will receive hydromorphone(10 mcg
      /kg IV) Subjects will receive IV Hydromorphone in divided doses as needed to achieve a verbal
      rating score for pain <4 out of 10 In PACU.They will also receive metoclopramide (20 mg IV )
      as rescue antiemetic in PACU. The primary and secondary outcomes will be assessed by an
      independent observer who will be blinded to group allocation (CA, AP, SA, YV, RJM and PF). A
      study team representative will telephone the participant at 24 hours, to complete the
      modified quality of recovery (QOR40) survey and ask the following:

        1. How much pain they are experiencing 0-10

        2. How and what kind of pain medications have been used since discharge.

        3. If they have had any nausea

        4. What kind of nausea relief medications have been used since discharge
    

Intervention name(s): Transversus abdominis plane block
Intervention type(s): Procedure
Intervention description(s): A regional block performed in the transversus abdominis plane of the abdomen, used to provide anesthesia and analgesia for the abdominal region.
Other intervention name(s): TAP block
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary purpose: Prevention
Keywords: Pain; TAP block; Laparoscopic; Gynecologic