Transversus Abdominis Plane (TAP) Block for Laparoscopic Cholecystectomy
For laparoscopic cholecystectomy, bilateral TAP block with 20 ml of 0.375% ropivacaine on each side is recommended as an effective component of multimodal analgesia to improve pain control and reduce opioid usage.
Technique and Administration
Dosage Recommendations:
- Volume: 18-20 ml per side (bilateral administration)
- Concentration: 0.375-0.5% ropivacaine or bupivacaine
- Approach: Ultrasound-guided subcostal TAP block is preferred for laparoscopic cholecystectomy
Ultrasound Guidance:
- Use a high-frequency linear ultrasound probe
- Employ in-plane needle guidance technique
- Visualize the three muscle layers (external oblique, internal oblique, and transversus abdominis)
- Ensure proper spread of local anesthetic between the internal oblique and transversus abdominis muscles
Evidence for Efficacy
TAP blocks have strong evidence supporting their use in laparoscopic procedures. According to ERAS Society guidelines, local anesthetic TAP blockade as a supplement to standard analgesia improves pain control and reduces opiate usage 1. This recommendation carries a high level of evidence with a strong grade of recommendation.
Multiple studies demonstrate that ultrasound-guided TAP blocks for laparoscopic cholecystectomy:
- Reduce intraoperative opioid requirements 2
- Decrease postoperative pain scores, particularly while coughing 3
- Reduce postoperative morphine consumption by approximately 50% 2, 3
- Provide analgesia for approximately 4-8 hours with standard local anesthetics 4
Subcostal vs. Posterior Approach
For laparoscopic cholecystectomy specifically, the subcostal approach is superior to the posterior approach. Research shows that the subcostal TAP block provides better static pain scores over 24 hours postoperatively compared to the posterior approach 5. This is likely because the subcostal approach better targets the upper abdominal dermatomes affected during laparoscopic cholecystectomy.
Optimization Strategies
Adjuvants:
- Adding dexmedetomidine (0.5 μg/kg) to ropivacaine can significantly prolong analgesia duration from approximately 290 minutes to 485 minutes 6
- This combination also reduces 24-hour opioid consumption without major adverse effects
Timing:
- Administer TAP block either after induction of anesthesia or at the end of surgery before emergence
- Both timings have shown efficacy, though post-surgical administration may be more practical in many settings
Integration with Multimodal Analgesia
TAP blocks should be part of a multimodal analgesic approach:
- Baseline analgesia with paracetamol and NSAIDs (unless contraindicated) 1
- TAP block as regional anesthetic component
- Rescue opioids only if needed
Considerations and Cautions
- Ensure proper training in ultrasound-guided techniques
- Be aware of the limited duration of action (8-10 hours) with standard local anesthetics 1
- Monitor for potential complications including vascular puncture, peritoneal perforation, or local anesthetic systemic toxicity
- For minimally invasive surgery like laparoscopic cholecystectomy, TAP blocks are preferred over epidural analgesia 1
TAP blocks represent an effective component of multimodal analgesia for laparoscopic cholecystectomy, with clear benefits in reducing pain scores and opioid requirements, ultimately contributing to enhanced recovery and improved patient outcomes.