Effects of transversus abdominis plane blocks after hysterectomy: a meta-analysis of randomized controlled trials

Figures & data

Figure 1 PRISMA flow diagram of study identification and selection process.

Note: Reproduced from PLoS Medicine (OPEN ACCESS) Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097.⁴⁴

Figure 2 Distribution of bias in the included trials.

Notes: Green = low risk of bias. Red = high risk of bias. Yellow = unclear risk of bias.

Figure 3 Cochrane collaboration’s risk of bias summary: evaluation of risk of bias items for each included study.

Notes: Green = low risk of bias. Red = high risk of bias. Yellow = unclear risk of bias.

Table 1 Characteristics of the included studies

Year	Authors	Group (n)	Age (years) (mean or median)	BMI (kg/m^2)/weight (kg) (mean or median)	Surgery	Anesthesia	Blocking time	Block solution	Pain assessment	Primary outcome
2008	Carney et al^Citation7	TAP: 24, Sham: 26	TAP: 54, Sham: 50	TAP: 26, Sham: 27	TAH	GA	Pre	0.75% RP (1.5 mg/kg)	VAS (10)	MC
2011	Amr and Amin^Citation21	TAP (pre): 23, TAP (post): 23, Sham: 22	TAP (pre): 54, TAP (post): 52 Sham: 51	TAP (pre): 80, TAP (post): 82, Sham: 82	TAH	GA	Pre and post	0.375% BP (20 mL)	VAS (100)	MC
2011	Atim et al^Citation22	TAP: 18, Sham: 18, INF: 19	TAP: 47, Sham: 44, INF: 40	TAP: 71, Sham: 67, INF: 65	TAH	GA	Post	0.25% BP (20 mL)	VAS (10)	PP
2011	De Oliveira et al^Citation23	TAP (0.25% RP): 21, TAP (0.5% RP): 22, Sham: 23	TAP (0.25% RP): 46, TAP (0.5% RP): 45, Sham: 47	TAP (0.25% RP): 27, TAP (0.5% RP): 25, Sham: 27	LH	GA	Pre	(0.25%–0.5%) RP (20 mL)	NRS (10)	QoR-40
2012	Kane et al^Citation10	TAP: 28, NC: 28	TAP: 46, NC: 44	TAP: 31, NC: 30	LH	GA	Pre	0.5% RP+EP (20 mL)	VAS (100)	QoR-40
2013	Gharaei et al^Citation24	TAP: 21, NC: 21	TAP: 64, NC: 65	TAP: 71, NC: 72	TAH	GA	Post	0.2% RP (0.5 mg/kg)	VAS (10)	PP
2014	Bhattacharjee et al^Citation25	TAP: 45, Sham: 45	TAP: 46, Sham: 45	TAP: 53, Sham: 53	TAH	GA	Pre	0.25% BP (0.5 mL/kg)	VAS (100)	PP
2014	Calle et al^Citation26	TAP: 100, Sham: 97	TAP: 44, Sham: 43	TAP: 25, Sham: 26	LH	GA	Post	0.25% BP (20 mL)	VAS (10)	PP
2014	Marais et al^Citation27	TAP: 15, Sham: 15	TAP: 47, Sham: 48	TAP: 25, Sham: 28	TAH	GA	Pre	0.25% BP (20 mL)	VAS (10)	MC
2015	Røjskjaer et al^Citation28	TAP: 23, Sham: 23	TAP: 49, Sham: 47	TAP: 28, Sham: 25	TAH	GA	Pre	0.75% RP (20 mL)	VAS (100)	MC
2015	Torup et al^Citation29	TAP: 34, Sham: 31	TAP: 53, Sham: 57	TAP: 24, Sham: 29	RH	GA	Pre	0.5% RP (20 mL)	VAS (100)	MC
2016	Ghisi et al^Citation11	TAP: 22, NC: 22	TAP: 46, NC: 48	TAP: 59, NC: 61	LH	GA	Pre	0.375% LBP (20 mL)	NRS (10)	MC
2016	Moyo et al^Citation30	TAP+Dxm: 16, Sham: 16	TAP+Dxm: 41, Sham: 47	TAP+Dxm: 24, Sham: 24	AH	GA	Pre	0.25 % BP (20 mL), Dxm (4 mg)	VAS (10)	PP

Abbreviations: AH, abdominal hysterectomy; BP, bupivacaine; Dxm, dexamethasone; EP, epinephrine; GA, general anesthetic; INF, surgical site infiltration; LBP, levobupivacaine; LH, laparoscopic hysterectomy; MC, morphine consumption; NC, no block; PP, postoperative pain; Post, postoperation; Pre, preoperation; QoR-40, quality of recovery score; RH, robotic-assisted hysterectomy; RP, ropivacaine; SA, spinal anesthesia; Sham, sham block; TAH, total abdominal hysterectomy, TAP, transversus abdominis plane block; VAS, visual analogue scale; NRS, numerical rating scale.

Figure 4 Forest plots of the effect of TAP block group vs control group.

Notes: (A) Mean 24-hour morphine consumption. (B) Time to first request for analgesic. (C) Rate of nausea and vomiting.
Abbreviations: h, hours; TAP, transversus abdominis plane.

Table 2 Pain score results at different times of postoperation of TAP vs NC/SB

Outcomes	Subgroup	Studies included	No. of patients (Exp/Con)	Weighed mean (95% CI)	P-value	Heterogeneity
						P-value	I^Citation2 test
Pain score at rest at 2 hours	AH	6	148/126	−1.41 (−2.57, −0.26)	0.002	<0.0001	97%
	LH/RH	3	84/84	−0.83 (−1.52, −0.14)	0.02	0.73	0%
Pain score at rest at 6–8 hours	AH	6	146/125	−1.29 (−1.91, −0.68)	<0.0001	<0.0001	91%
	LH/RH	2	56/53	−0.61 (−1.51, 0.29)	0.19	0.06	73%
Pain score at rest at 12 hours	AH	3	91/69	−1.25 (−2.23, −0.27)	0.01	0.05	67%
Pain score at rest at 24 hours	AH	5	124/104	−0.73 (−1.33, −0.14)	0.02	<0.0001	91%
	LH/RH	5	227/201	−0.64 (−1.45, 0.16)	0.12	0.0006	80%
Pain score at rest at 48 hours	AH	3	91/69	−1.27 (−1.91, −0.62)	0.0001	0.05	67%
Pain score on movement at 2 hours	AH	5	127/105	−1.91 (−3.30, −0.53)	0.007	<0.0001	98%
	LH/RH	2	56/53	0.22 (−0.62, 1.06)	0.61	0.56	0%
Pain score on movement at 6–8 hours	AH	5	125/104	−1.39 (−2.16, −0.63)	0.0004	<0.0001	91%
	LH/RH	2	56/53	0.98 (0.58, 1.38)	<0.0001	0.81	0%
Pain score on movement at 12 hours	AH	2	70/48	−1.60 (−1.93, −1.28)	<0.0001	0.86	0%
Pain score on movement at 24 hours	AH	5	124/104	−1.12 (−1.91, −0.33)	0.005	<0.0001	93%
	LH/RH	2	56/53	0.11 (−0.68, 0.90)	0.78	0.78	0%
Pain score on movement at 48 hours	AH	2	70/48	−1.62 (−2.14, −1.10)	<0.0001	0.24	27%

Abbreviations: AH, abdominal hysterectomy; Con, control group; Exp, experimental group; LH, laparoscopic hysterectomy; NC, no block; RH, robotic-assisted hysterectomy; SB, sham block; TAP, transversus abdominis plane block.

Table 3 Sensitivity analysis of studies for laparoscopic hysterectomy

Outcomes	Studies included	References	No. of patients (Exp/Con)	Weighed mean (95% CI)	P-value	Heterogeneity
						P-value	I^Citation2 test
Mean 24-hour morphine consumption	3	^Citation10,Citation11,Citation23	71/73	−0.04 (−2.72, 2.64)	0.98	1.00	0%
Pain score at rest at 2 hours	2	^Citation10,Citation11	50/50	−1.00 (−1.81, −0.19)	0.02	1.00	0%
Pain score at rest at 24 hours	4	10,11,23,26	171/170	−0.44 (−1.21, 0.23)	0.20	0.04	64%

Abbreviations: Con, control group; Exp, experimental group.

Figure 5 Representative funnel plots for TAP block group vs control group. Notes: (A) Mean 24-hour morphine consumption; (B) Rest pain score at 2 hours; (C) Rate of nausea and vomiting.

Abbreviations: h, hours; MD, mean difference; SE, standard error; TAP, transver-sus abdominis plane.

Figure S1 Forest plots of pain score at different times postoperation for TAP block group vs control group.

Note: (A) Rest pain score at 2 hours; (B) rest pain at 6–8 hours; (C) rest pain score at 12 hours; (D) rest pain score at 24 hours; (E) rest pain score at 48 hours; (F) movement pain score at 2 hours; (G) movement pain score at 6–8 hours; (H) movement pain score at 12 hours; (I) movement pain score at 24 hours; and (J) movement pain score at 48 hours.

Abbreviations: h, hours; TAP, transversus abdominis plane.

Figure S2 Funnel plots for TAP block group vs control group.

Note: (A) Time to first request for analgesic; (B) rest pain at 6–8 hours; (C) rest pain score at 12 hours; (D) rest pain score at 24 hours; (E) rest pain score at 48 hours; (F) movement pain score at 2 hours; (G) movement pain score at 6–8 hours; (H) movement pain score at 12 hours; (I) movement pain score at 24 hours; and (J) movement pain score at 48 hours.

Abbreviations: h, hours; TAP, transversus abdominis plane.

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