389: Laparoscopic TAP block Vs opioids for shoulder tip and surgical pain after gynecological laparoscopy

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Acute postsurgical pain, Pharmacological treatments, Assessment and Measurement of Pain/Nociception, Treatment/management

Background and Aims: Postoperative pain following laparoscopic gynecological surgeries (LGS) could extends beyond the surgical site. LGS is considered minimally invasive. However, shoulder tip pain (STP) is a particularly distressing complication. It is thought to result from diaphragmatic irritation caused by carbon dioxide insufflation. Currently no standard preventive method is available.. The transverse abdominis plane (TAP) block is effective for treating anterior abdominal wall pain. Its role in STP, however, remains uncertain. Laparoscopic-guided TAP (LTAP) block has been described primarily in gastrointestinal surgery. Data on its use in gynecological laparoscopy are limited.

Methods: This was conducted as a prospective, non-randomized cohort study at a tertiary care teaching hospital in Sri Lanka from May to August 2025. Women undergoing LGS for benign indications were included in either LTAP block or conventional multimodal opioid based analgesia after matching for age and comorbidities. LTAP was administered bilaterally using 20ml of 0.125% bupivacaine under direct laparoscopic visualization. STP was assessed at 6,12, and 24 hours postoperatively using Visual Analogue Scale. Incidence and severity of STP were recorded. Secondary outcomes included incisional pain, backache, opioid consumption, postoperative nausea and vomiting (PONV), mobilization time, and length of hospital stay.

Results: 114 patients were analyzed, with 57 in each group. The incidence of STP was significantly lower in LTAP group at 6 and 12 hours postoperatively (p<0.001), with a trend toward reduction at 24 hours. STP severity scores were also significantly lower in the LTAP group at all assessed time points (p<0.05). Incisional pain scores and cumulative opioid requirement were markedly reduced in LTAP group (p<0.001). Although the incidence of postoperative backache was similar between groups, the severity was significantly higher among LTAP patients. No significant differences were observed in PONV, time to mobilization and hospital stay.

Conclusions: LTAP block significantly reduces both the incidence and severity of STP following LGS, despite its lack of direct anatomical coverage of the phrenic nerve. These findings suggest an indirect analgesic benefit, possibly through improved control of somatic pain and reduced central sensitization. LTAP block also demonstrated a clear opioid-sparing effect without increasing postoperative complications aligning well with ERAS protocols. As a surgeon-delivered technique, LTAP block is particularly suited to real-world practice in low- and middle-income settings. Incorporating LTAP block into multimodal analgesic strategies may improve postoperative comfort, especially for patients troubled by STP after laparoscopy

References: 1. Park SJ. Postoperative Shoulder Pain after Laparoscopic Surgery. J Minim Invasive Surg. 2020 Mar 15;23(1):3-4. doi: 10.7602/jmis.2020.23.1.3. PMID: 35600729; PMCID: PMC8985641.
2. Favuzza J, Delaney CP. Laparoscopic-guided transversus abdominis plane block for colorectal surgery. Dis Colon Rectum. 2013;56(3):389–91. https://doi.org/10.1097/DCR.0b013e318280549b.

Presenting Author: Ashani Ratnayake
Submitting Author: Ashani Ratnayake

Senior Author: Ashani Ratnayake

IASP 2026 Global Year theme of Neuropathic Pain: No

• Sampath Gnanarathne: MBBS, MD, FRCOG - Faculty of Medicine , University of Peradeniya
• Ashini Uhanovita: MBBS - Faculty of Medicine, University of Peradeniya