Background: Multimodal opioid-sparing analgesia has been well established as a component of enhanced recovery after surgery protocols for colorectal surgery patients. Commonly used regional anesthesia techniques include transversus abdominis plane block, rectus sheath blocks, or continuous wound infiltration /catheters. Another proposed technique is the quadratus lumborum block, which has been suggested to provide better visceral analgesia. It resembles a posterior approach to the transversus abdominis plane block, and its target are the ventral rami of the spinal nerve roots (including the subcostal and ilio-hypogastric nerves), which pass between the quadratus lumborum and its anterior fascia.
Objective: We aim to evaluate the efficacy of an intraoperative quadratus lumborum block and compare it to other regional anesthetic techniques used for colorectal surgery patients within the same institution.
Design: Retrospective, observational study.
Setting: Tertiary care academic medical center.
Patients: Adult patients who underwent minimally invasive (laparoscopic or robotic) colectomy or low anterior resection, from September 2022 to September 2024.
Intervention: Intraoperative transversus abdominis plane vs. transversus abdominis plane + quadratus lumborum block vs. no regional block. The anesthetic agent used was 0.25% bupivacaine without epinephrine (1 mg/kg). When performing a quadratus lumborum block, approximately two thirds of the total dose was administered in the quadratus lumborum spaces.
Main outcome measures: Cumulative opioid dose, quantified in morphine milligram equivalents, subjective pain scores, and need for intravenous hydromorphone were evaluated in the post-anesthesia care unit, postoperative day 1 and postoperative day 2, and compared between patients getting transversus abdominis plane + quadratus lumborum block, transversus abdominis plane block alone, and no regional block. Length of stay, early mobilization, and return of bowel function, were also evaluated and compared between groups.
Results: A total of 224 patients were included (mean age 60.1 ± 13 years; 46.8% male); 82.1% underwent laparoscopic surgery, and 93.7% were opioid-naïve. Forty-three patients (19.2%) received no regional block, 69 (30.8%) received transversus abdominis plane block alone, and 112 (50.0%) received transversus abdominis plane + quadratus lumborum block. Postoperative opioid use did not differ in the post-anesthesia care unit or postoperative day 1. On postoperative day 2, opioid requirements were lower in the transversus abdominis plane + quadratus lumborum block group compared with transversus abdominis plane block alone (median 7.5 vs. 18.8 mg; p = 0.030), and pain scores were lower (median 4 vs. 5; p = 0.014). Median length of stay was shorter with transversus abdominis plane + quadratus lumborum block (2 days vs. 3 days; p < 0.001). On multivariable analysis, transversus abdominis plane + quadratus lumborum block was independently associated with lower postoperative day 2 pain scores (β -0.94, 95% CI: -1.82 to -0.06; p = 0.036) and earlier return of bowel function (β -0.60 days, 95% CI: -1.09 to -0.12; p = 0.015).
Limitations: This retrospective, single-institution study is subject to selection bias. Perioperative management was not fully standardized, including variability in ketorolac administration not captured in adjusted analyses, which may have influenced results. Discharge practices also varied across providers, potentially affecting length of stay.
Discussion: A surgeon-administered quadratus lumborum block, in addition to the traditional transversus abdominis plane block, in the setting of an enhanced recovery after surgery program, for patients undergoing minimally invasive colorectal resections, is a feasible option with favorable outcomes. There appears to be an association with lower, patient reported, pain scores and earlier return of bowel function. Randomized studies should be done to confirm the transversus abdominis plane + quadratus lumborum block benefits in minimally invasive colorectal surgery. See Video Abstract.
Keywords: Enhanced recovery after surgery; Laparoscopic surgery; Outcomes; Pain; Regional anesthesia; Robotic surgery.
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