Deborah S Keller, MS, MD, Benjamin Crawshaw, MD, Bridget O Ermlich, RN, MSN, CCRP, Conor P Delaney, MD, MCh, PhD. University Hospitals-Case Medical Center, Case Western Reserve University.
BACKGROUND: Quality improvement in colorectal surgery requires implementation of tools to improve patient and financial outcomes, and assessment of results. Our objective was to evaluate the durability of transversus abdominis plane (TAP) blocks and a standardized enhanced recovery protocol (ERP) on a large series of laparoscopic colorectal resections.
METHODS: 200 consecutive laparoscopic colorectal surgery patients received bilateral TAP blocks (15 ml of 0.5 % Marcaine per side) under laparoscopic guidance at the end of their operation. All were managed postoperatively with a standardized ERP. Demographic, perioperative, and postoperative outcome variables were analyzed. The main outcome measures were length of stay (LOS), readmission, reoperation, morbidity, and mortality rates.
RESULTS: Of the 200 cases, 194 were elective and 6 emergent. The main operative indications were colorectal cancer (45%) and diverticulitis (17%). The mean age was 61.2 years and 56% were female. The mean BMI was 29.2 kg/m2 and the majority (63%) were ASA class III. The main procedures performed were segmental colectomy (64%) and low anterior resection (25%). Mean operative time was 181 minutes. Nine cases (4.5%) were converted to open. The mean and median LOS were 2.6 (SD 1.5) and 2 days (range, 1-8), respectively. 21% of patients were discharged by postoperative day (POD) 1, 41% by POD 2, and 77% by POD 3. By POD 7, 99% of patients were discharged; almost all patients (97.5%) were discharged home without the need for temporary nursing. Twenty-four patients had complications (12%). The readmission rate was 6.5% (n=13). There were 3 unplanned reoperations and no mortalities. The durability of the effect of the TAP block was further tested by comparing the first and second groups of 100 consecutive patients. With comparable demographics, there were no significant differences in readmission, complication, or reoperation rates over the entire series.
CONCLUSIONS: Adding TAP blocks to a well-implemented ERP facilitated shorter LOS with low readmission and reoperation rates. The effect appears durable and consistent in a large consecutive case series. TAP blocks may be an efficient and cost effective method for improving results after laparoscopic colorectal surgery.
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