Exparel with Enhanced Recovery Protocol for Abdominal Wall Reconstruction

Michael J Jaronczyk, MD, Vladimir Daoud, MD, Craig Dennen, MD, Ibrahim Daoud, MD. St. Francis Hospital & Medical Center

Introduction: Exparel offers extended local anesthesia, which can be additive to enhanced recovery pathways. These pathways have had favorable results seen in several surgical fields. Patients experience less pain and are discharged sooner. They return to activities and tolerate a regular diet more rapidly as well. We have devised our own enhanced recovery protocol and it was amended recently. Pre-operatively, we initiate patient education and perform routine testing. On the day of surgery, we follow guidelines recommended from pathways in other fields, such as colorectal and bariatrics. Most recently, we have altered our transversus abdominis plane (TAP) block to include liposomal bupivicaine instead of 0.25% bupivicaine. Our repairs are performed in a typical Rives-Stoppa fashion with Phasix mesh and either an endoscopic external oblique release or a transversus abdominis release. Post-operatively, our patients are given early enteral nutrition and are required to ambulate. The patients are discharged when tolerating a diet and ambulating with pain controlled on an oral regimen.

Method: We have prospectively collected data on all complex abdominal wall reconstruction from a single surgeon at this institution. We defined complex abdominal wall reconstruction as a hernia repair operation with a component separation. Between September, 2015 and August, 2016, there were 16 patients who underwent this procedure. Twelve patients underwent a TAP block with 0.25% bupivicaine and were listed in B group. Four patients underwent a TAP block with Exparel and were listed in E group.

Results: E group patients were on patient-controlled analgesia (PCA) devices shorter, used less non-PCA narcotics and had shorter inpatient stays. B patients used a PCA device for a mean of 4.6 days versus 0.75 days in E group (p<0.0001). B patients received non-PCA narcotics at a mean dose of 97.5 morphine-equivalent millgrams (mg) versus 25.5 morphine-equivalent mg in E group (p=0.042). B patients had a mean inpatient stay of 5.5 days versus 3.75 days in E group (p=0.0175). All of these results were statistically significant as listed.

Conclusion: Since we have started our enhanced recovery protocol, we have seen improved patient outcomes. We have added Exparel to our algorithm and observed that it is efficacious with patient outcomes continuing to improve. Physicians and surgeons are concerned about the cost of this medication. However, the cost of this drug is far outweighed by the money conserved with shorter-term PCA usage, less narcotic consumption and fewer inpatient days.