Abdominoplasty is a common aesthetic procedure. It aims to improve the abdominal wall contour by the removal of the redundant skin and fat from the abdominal region, including rectus sheath plication and umbilicus transposition. The procedure can be combined with liposuction for further improvement of contour [6].
Patients undergoing such type of surgery usually suffer from preoperative emotional stress and anxiety due to expected postoperative pain
Pain following abdominal surgeries has two components: somatosensory pain originating from the cutaneous, subcutaneous, and muscular layers of the incision site and visceroperitoneal inflammatory pain of viscera and deeper peritoneal layers[7].
Abdominoplasty is an extraperitoneal surgical procedure devoid of the visceroperitoneal pain component. Besides the extensive incision, most of the pain is initially related to the fascial plication of the abdominal wall [8].
Hence, adequate pain management during the postoperative period is of great importance.
Previous studies on postoperative pain management after abdominoplasty have failed to achieve effective analgesia beyond the recovery room. So many investigators have been searching for a safe and reliable analgesic technique[9].
This study showed the effectiveness of the TAPB assisted technique for pain control after abdominoplasty. The TAP block was used as a method of analgesia in most varieties of abdominal surgeries[10]. The TAPB has been administrated to provide an early postoperative analgesic effect and so reduce the analgesic requirements.
The transversus abdominis plane block (TAPB) is a regional anesthetic technique that targets the injection of the local anesthetic (LA) in the neurovascular plane between the transversus abdominis muscle and the internal oblique muscle[11].
There are various techniques to perform a TAP block (subcostal, lateral, and posterior) each one provides different dermatomes coverage, the exact technique should be selected according to the surgical incision and technique undergoing.
The subcostal TAP covers from T6 to T9 dermatomes and is usually suitable for upper abdominal surgeries. Lateral TAP block gives coverage from T10 to T12 dermatomes while the posterior TAP approach covers from T9 to T12, L1, and is shown to provide longer analgesia duration with some visceral analgesic effect [12].
The usage of ultrasound-guided TAP block is not devoid of its challenges, especially in obese patients with the redundant abdominal wall and thick fat folds. Difficult patient positioning, unsuccessful identification of the anatomic landmarks, and lack of suitable equipment require more experience and multiple attempts could be made before achieving a successful block. Additional obstacles could be due to the postoperative tissue edema, the presence of drains, and wound dressing [13, 14].
The postoperative analgesic consumption in this study; morphine and pethidine consumption were significantly lower in the TAPB group in comparison to the non-blocked group, where our results show that for morphine 4.38 ± 2.04 to 6.97 ± 1.97 and pethidine 20.69 ± 25.06 to 208.62 ± 85.64 respectively.
Our results were in agreement with the results of Araco et al, 2010[15]. who found that it reduces the stress response and facilitates earlier rehabilitation and recovery, also the results of Abo-Zeid MA,2018 who noticed that the direct bilateral TAPB offered a longer postoperative analgesia duration and lesser morphine consumption when compared with rectus sheath block (RSB) and subcutaneous infiltration (SCI)[16].
Abd El‑Hamid AM, Afifi EE (2016), concluded that patients with TAP block had lower pain scores and less total postoperative morphine requirements compared with local anesthetic wound infiltration after open inguinal hernia repair [17]. Feng [18] also described a combination of intercostal, pararectus, iliohypogastric, and ilioinguinal nerve blocks for abdominoplasty, her work showed substantial improvements in pain scores and a reduction in narcotic use.
Hebbard P. 2008, described a modification of subcostal TAP block (oblique subcostal TAP block). The purpose of covering the anterior abdominal wall dermatomes from T6 to T12 and L1 performing one needle prick only using a longer needle to inject local anesthesia in the TAP plane from the subcostal region to iliac crest. But it’s difficult to perform, therefore it has not gained popularity. The difficulty is to reach the lower dermatomes and to provide good coverage for the lower abdominal wall[19].
On the other side, Azawietal (2016) found that local anesthetic wound infiltration was superior to the TAP block concerning postoperative analgesia after laparoscopic nephrectomy [20]. J. Kessler, also found that TAP block did not improve postoperative quality of recovery (QoR-40) for patients undergoing total laparoscopic hysterectomy[21].In contrast, the use of TAP block in patients undergoing more minor gynecological laparoscopic surgery led to faster readiness for discharge and was associated with a better quality of recovery. Similar results were shown for patients undergoing abdominoplasty [22].
Regarding the VAS in this study; total VAS in the recovery room, 1st day, 2nd day and 3rd day postoperative were significantly lower in the TAPB group in comparison to the non-blocked group, where our results show that for VAS in recovery room 0.34 ± 0.94 to 11.66 ± 2.62, VAS 1st day 2.69 ± 3.04 to 12.76 ± 1.72, VAS 2nd day 3.17 ± 3.27 to 12.28 ± 2.25 and VAS 3rd day 2.07 ± 2.59 to 11.31 ± 2.22 respectively.
Regarding the patient time to start ambulation out of bed in this study, it was significantly shorter in the TAPB group in comparison to the non-blocked group. Where it was 4.62 ± 1.08 hours and 12.41 ± 5.04 hours respectively. Effective pain management and early ambulation are both linked together and had a recognized impact on recovery from major surgery [23]. The resumption of ambulation sooner in the immediate recovery period has been well established in reducing the incidence of thromboembolism. Several authors have suggested that there is a relationship between reduced mobility and increased risk of venous thromboembolism (VTE), proportional to the degree and length of time for which the patient is confined to bed [24, 25, 26].
Our results were in agreement with the results of Rolando, who found that liposomal bupivacaine injections for regional blocks in abdominoplasty with rectus plication indicate that patients resumed both earlier ambulation and normal activity [27].
Regarding the patient time to start utilizing spirometry in this study, it was significantly shorter in the TAPB group in comparison to the non-blocked group, where our results show that it was 4.27 ± 1.09 hours and 11.45 ± 5.05 hours respectively.
General anesthesia and postoperative pain carry a risk of developing postoperative pulmonary complications including impaired respiratory drive, cough, and reduced immune system. It was found that residual neuromuscular blockade can be a major problem in the Canadian RECITE study (56.5% with a train of four ratios < 0.9 on arrival in PACU) [28].
Adequate reversal of muscle relaxants and adequate analgesia is vital to reduce postoperative pulmonary complications. Also, to allow patients to breathe deeply, cough, and mobilize. Chest physiotherapy, early ambulation, sitting up positioning, deep breathing, and coughing exercises may reduce postoperative pulmonary complications.
The patients’ need for mechanical ventilatory support (CPAP) in this study was significantly lower in the TAPB group compared to the non-blocked group, where our results show that no patients in the TAPB group needed ventilatory support and for the non-blocked group it was 0.31 ± 0.66.