
==== Front
Int J Gynecol Cancer
Int J Gynecol Cancer
ijgc
ijgc
International Journal of Gynecological Cancer
1048-891X
1525-1438
BMJ Publishing Group BMA House, Tavistock Square, London, WC1H 9JR

39122447
ijgc-2024-005404
10.1136/ijgc-2024-005404
Original Research
1506
Efficacy of locoregional analgesic techniques after laparotomy for gynecologic cancer: a systematic review
http://orcid.org/0009-0001-1176-4992
Dhondt Lieke A 1
Vereen Maya S 2
van de Laar Ralf L O 1
Stolker Robert-Jan 2
Dirckx Maaike 2
http://orcid.org/0000-0001-8899-7412
van Beekhuizen Heleen J 1
1 Department of Gynecologic Oncology, Erasmus Medical Center, Rotterdam, Netherlands
2 Department of Anesthesiology, Erasmus Medical Center, Rotterdam, Netherlands
Stockman Liz
Correspondence to Lieke A Dhondt, Department of Gynecologic Oncology, Erasmus Medical Center, Rotterdam, Netherlands; l.dhondt@erasmusmc.nl
9 2024
9 8 2024
34 9 14231430
23 2 2024
21 5 2024
© IGCS and ESGO 2024. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, an indication of whether changes were made, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Objective

To determine which locoregional techniques are effective in managing post-operative pain in major open oncologic gynecologic surgery in terms of pain scores and opioid consumption when epidural analgesia is not a feasible option.

Methods

A systematic review of the literature, based on the Preferred Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, was conducted. The ROB-2 assessment was used to assess bias. The primary outcomes were opioid consumption and post-operative pain scores. Secondary outcomes included post-operative markers such as time to mobilization and bowel movement.

Results

A total of nine studies (n=714) were included in the analysis. Eight studies had a low risk of bias. Five different forms of locoregional analgesia were described. Eight studies compared with placebo and one study compared rectus sheath block with epidural analgesia. Three of the five studies investigating transversus abdominis plane (TAP) blocks showed an improvement in pain scores and opioid consumption when compared with the placebo group. One study investigating rectus sheath blocks and another investigating paravertebral blocks demonstrated significantly less opioid consumption and improved pain scores at certain time points. The studies investigating continuous wound infiltration and superior hypogastric plexus block found no significant effect. No adverse effects of locoregional anesthesia were found.

Conclusion

Our study showed that TAP blocks, rectus sheath blocks, and paravertebral blocks may decrease opioid consumption and improve pain scores in patients undergoing open abdominal surgery for gynecologic cancer. Additionally, these techniques might serve as a viable alternative for patients with contraindications to epidural analgesia.

Pain
Anesthesia, General
Surgical Oncology
Gynecologic Surgical Procedures
Gynecology
special-featureunlocked
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pmcWHAT IS ALREADY KNOWN ON THIS TOPIC

Current literature acknowledges the opioid-sparing benefits of locoregional anesthesia. While various techniques have been introduced, their comparative efficacy remains largely unexplored.

WHAT THIS STUDY ADDS

Transversus abdominis plane blocks, rectus sheath blocks, and paravertebral blocks can be useful additions to multimodal analgesia, offering a viable alternative for epidural analgesia.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Current Enhanced Recovery After Surgery (ERAS) guidelines support the routine use of epidural analgesia. The decreased availability of epidural analgesia following gynecologic malignancy surgeries necessitates the integration of opioid-sparing locoregional analgesic methods. Alternative analgesia methods are essential for future research and align with the current trend towards optimizing post-operative recovery/mobilization and pain management.

Introduction

The management of post-operative pain is a crucial aspect of Enhaced Recovery After Surgery (ERAS). It is one of the factors that impacts the length of stay and patient satisfaction.1 2 Surgery for gynecologic malignancies often consists of major abdominal procedures resulting in significant post-operative pain.3 4 Although epidural analgesia is considered the current gold standard for laparotomy, its use has decreased in the past years due to potential adverse effects such as (post-operative) hypotension, urinary retention, and delayed mobilization.5 Furthermore, there is a growing patient population with a contraindication for epidural analgesia, mainly due to the use of anticoagulants.

When epidural analgesia is not feasible, systemic opioids in combination with other analgesics are commonly used peri-operatively. The current trend for post-operative pain management is the use of multimodal post-operative analgesia.6 However, the opioid epidemic and post-operative opioid-related complications have prompted us to be critical and careful when prescribing opioids. All these factors have resulted in a search for opioid-sparing locoregional techniques such as continuous wound infiltration and various abdominal wall blocks (rectus sheath blocks and transversus abdominis plane (TAP) blocks).7 These techniques may be useful alternatives as a contribution to multimodal systemic analgesia. However, the optimal block with regard to pain scores and opioid consumption in this patient category has not yet been extensively researched.

This study aims to determine which locoregional technique is effective in managing post-operative pain in major open oncologic gynecologic surgery in terms of pain scores and opioid consumption when epidural analgesia is not a feasible option or preferred by the patient.

Methods

A systematic review of the literature, based on the Preferred Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, was conducted. The checklist is shown in Online Supplemental File 1 8 The protocol for this review was registered in PROSPERO (CRD42023460486). The search was conducted in Medline, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar (100 top-ranked) and was executed in September 2023 using the following keywords: Laparotomy, Gynecological cancer, and Anesthesia. The inclusion criteria were: randomized controlled trial, adult patients scheduled for laparotomy for gynecologic oncologic surgery, receiving locoregional analgesia compared with epidural anesthesia or placebo. The full search for each database is shown in Online Supplemental File 2.

10.1136/ijgc-2024-005404.supp1 Supplementary data

10.1136/ijgc-2024-005404.supp2 Supplementary data

The title and abstract of the obtained records as well as subsequently full-text articles were independently screened for eligibility by two researchers (LAD and MSV) using Endnote. Disagreements were resolved through consultation with a third researcher (MD). The quality assessment of eligible studies was independently conducted by both researchers (LAD and MSV) using the Risk-of-bias version 2 (ROB-2) assessment. Data extraction was executed by two researchers (LAD and MSV). Extracted data included various aspects including sample size, age, type of locoregional anesthesia, pain scores, opioid consumption, and secondary outcomes.

The primary outcomes evaluated were opioid consumption and post-operative pain scores. Secondary outcomes included time to mobilization, bowel mobility, and patient satisfaction.

Results

The search resulted in a total of 828 articles, which was reduced to 538 articles after de-duplication. Of these, 460 were excluded based on title and abstract. The remaining 78 articles were assessed for eligibility for inclusion based on full text. A total of nine articles met all the inclusion criteria and are included in this review (Figure 1). The nine included studies were published between 2005 and 2023 and resulted in a total sample size of 714 patients. Five studies included surgery using midline laparotomy, two studies using mostly midline laparotomy and a small percentage Pfannestiel incision and two studies did not specify the surgical approach (Table 1).

Figure 1 Flowchart showing the inclusion process for the articles identified in the search, detailing the stages and reasons for exclusion. After extensive screening, a total of nine studies were included in the review.

Table 1 Study characteristics of included studies

Author, Year	Study design	Time of inclusion, country	Intervention	Control	N	Age	Type of surgery	Primary outcome of study	Follow-up	
Bakshi, 201614	RCT	2013,
India	Surgically placed rectus sheath catheters (ropivacaine)	Placebo catheter	74	18–75	Midline laparotomy	Opioid consumption at 24 and 48 hours	48 hours	
Bernard, 20239	RCT	2020–2021,
Canada	Single-shot surgical TAP block (bupivacaine)+IV-PCA	Placebo shot+IV-PCA	79	Adult	Midline laparotomy	Total morphine mg equivalents consumption at 24 hours	48 hours	
Griffiths, 201010	RCT	2008–2009,
Australia	Single-shot TAP block (ropivacaine)	Placebo shot	65	Adult	Midline laparotomy. 4 Pfannen-stiel	Incidence of NRS >5 at 2 hours and total post-operative morphine consumption at 2 and 24 hours	24 hours	
Kuniyoshi, 202115	RCT	2016–2017,
Japan	Pre-incision rectus sheath catheters (levobupivacaine)	Epidural (levobupivacaine)	73	20–80	Midline laparotomy	NRS at rest and movement or coughing up to 36 hours	36 hours	
Kushner, 200516	RCT	2002–2004,
USA	Subcutaneous wound infiltration catheters (bupivacaine)	Placebo catheter	80	Adult	Mostly midline laparotomy. 85% bupivacaine vs 75% placebo group	Mean NRS over 5 days	5 days	
Melnikov, 201211	RCT	2010,
Norway	Single-shot thoracic paravertebral or TAP block (ropivacaine)	Placebo shot	58	Adult	Midline laparotomy	Cumulative IV opioid at 24 hours	48 hours	
Subramanian, 201917	RCT	not specified,
India	Superior hypogastric plexus block (bupivacaine)+wound infiltration	Wound infiltration	60	18–60	Laparotomy	Pain scores	48 hours	
Yoshida, 201613	RCT	2014–2016,
Japan	Oblique subcostal TAP block catheters (ropivacaine)	Single-shot oblique subcostal TAP block (ropivacaine)+placebo catheter	80	20–80	Midline laparotomy	Cumulative morphine consumption after 24 hours	50 hours	
Zhang, 202312	RCT	2021–2022,
China	Single-shot TAP block (ropivacaine 0.375%, compound lidocaine 0.4% or 0.6%)	Placebo singe shot	145	20–60	Laparotomy	Pain up to 72 hours	72 hours	
IV-PCA, intravenous patient-controlled analgesia; NRS, numeric rating scale; RCT, randomized controlled trial; TAP, transversus abdominis plane.

Using the ROB-2 assessment, eight of the nine studies showed a low risk of bias. One study showed some concerns due to uncertainty about the allocation of intervention concealment and carers being aware of the intervention given (Table 2).

Table 2 Risk of bias (ROB)-2 assessment

Study ID	Experimental	Comparator	D1	D2	D3	D4	D5	Overall	
Bakshi	Rectus block	Placebo	+	+	+	+	+	+	
Bernard	TAP block	Placebo	+	+	+	+	+	+	
Griffith	TAP block	Placebo	+	+	+	+	+	+	
Kuniyoshi	Rectus block	EDA	+	+	+	+	+	+	
Kushner	Continuous wound infiltration	Placebo	+	+	+	+	+	+	
Melnikov	TAP or paravertebral block	Placebo	+	+	+	+	+	+	
Subramanian	Superior hypogastric block	Placebo	!	!	+	+	+	!	
Yoshida	TAP block	Placebo	+	+	+	+	+	+	
Zhang	TAP block	Placebo	+	+	+	+	+	+	
+, low risk; !, some concerns; −, high risk.

D1, randomisation process; D2, deviations from the intended interventions; D3, missing outcome data; D4, measurement of the outcome; D5, selection of the reported result.

EDA, epidural analgesia; TAP, transversus abdominis plane.

Locoregional Analgesia Techniques

Five different forms of locoregional analgesia were described (TAP blocks, paravertebral blocks, rectus sheath blocks, continuous wound infiltration, and superior hypogastric blocks). Five studies described the use of TAP blocks compared with placebo.9–13 Melnikov et al compared either thoracic paravertebral blocks or TAP blocks with placebo.11 Two studies reported on the effect of continuous rectus sheath blocks, comparing them with either epidural analgesia or placebo.14 15 Kushner et al described the efficacy of continuous wound infiltration compared with placebo and Subramanian et al compared the efficacy of a superior hypogastric plexus block with placebo.16 17

Pain

Eight of the nine studies described the outcome of pain using the numeric rating scale (NRS), while one study reported on this using the Wisconsin Brief Pain Inventory.16 Three of five studies reporting on TAP blocks compared with placebo found a significant decrease in NRS.11–13 In the study by Melnikov et al, the assessment of NRS at various intervals during rest and during coughing showed a significant reduction in both TAP block and paravertebral block across all time points, except at rest at 48 hours where only the paravertebral block had a significantly lower NRS.11 Zhang et al compared different local anesthetics and concentrations with placebo and found lower NRS at rest at 3 hours in the 0.375% ropivacaine group versus placebo. They also found that the use of 0.4% and 0.6% compound lidocaine led to reduced NRS at rest until 12 hours post-operatively.12 Yoshida et al found significantly reduced pain scores in the intervention group during coughing at 1 hour and 24 hours after catheter placement,13 while Bernard et al and Griffiths et al found no significant decrease in pain scores compared with placebo (Table 3).9 10

Table 3 Primary outcomes pain and opiod consumption of included studies

Author, Year	N	Intervention vs control	Opioid consumption (intervention vs control)	Pain (intervention vs control)	
Bakshi, 201614	74	Surgically placed rectus sheath catheters (ropivacaine) vs placebo	Mean (SD) morphine consumption:
24 hours: 8.8 (8.3) mg vs 27.3 (10.0) mg, 95% CI 14.3 to 22.8 (p=0.001)
48 hours: 14.8 (11.0) mg vs 42.4 (16.8) mg, 95% CI 20.9 to 34.3 (p=0.001)	Median NRS scores 48 hours:
At rest: 3 (2–3) vs 5 (5–6) (p=0.001)
With movement: 4 (4–5) vs 7 (6–8) (p=0.001)	
Bernard, 20239	79	Single-shot TAP block (bupivacaine) vs placebo	No significant decrease in intervention group:
24 hours: 98.0±59.2 vs 100.8±44.0 morphine mg equivalents (p=0.85)	No significant differences between groups in mean pain scores:
4 hours: 3.1±2.4 (0–10 scale) vs 3.1±2.0 (p=0.93)	
Griffiths, 201010	65	Single-shot TAP block (ropivacaine) vs placebo	No significant difference in post-operative morphine consumption:
2 hours: 13.5 mg vs 11.87 mg (p=0.53)
24 hours: 34.0 mg vs 36.1 mg (p=0.76)	No significant differences in proportion of patients with inadequate analgesia at 2 hours:
At rest: 39% vs 22% (p=0.13)
Coughing: 61% vs 53% (p=0.54)	
Kuniyoshi, 202115	73	Pre-incision rectus sheath catheters (levobupivacaine) vs epidural (levobupivacaine)	Frequency of use of rescue analgesics (IV-PCA): 11.0 vs 14 vs (p=0.53)	Intervention group non-inferior at rest up to 36 hours.
Intervention neither inferior nor non-inferior to control at movement at 4, 6, 8 and 12 hours	
Kushner, 200516	80	Subcutaneous wound infiltration catheters (bupivacaine) vs placebo	75 mg IV and 107 mg total morphine equivalent vs 60 mg IV and 86 mg total (p=0.40 IV; p=0.25 total)	The Brief Pain Inventory score for current pain: 2.8 vs 3.14 (p=0.46)	
Melnikov, 201211	58	Single-shot thoracic paravertebral block or TAP block (ropivacaine) vs placebo	Difference in intervention groups vs control group at 24 and 48 hours (p<0.05).
Difference in favor of the paravertebral group vs the TAP block group at 24 and 48 hours (p<0.05)	At rest: Significant decrease in NRS up to 24 hours (p<0.05). Paravertebral group significantly less at 48 hours.
Coughing: Significant difference at all time intervals up to 48 hours (p<0.05)	
Subramanian, 201917	60	Superior hypogastric plexus block (bupivacaine)+wound infiltration vs wound infiltration	Difference in morphine consumption:
48 hours: 36.03 mg vs 54.33 mg (p<0.0001) 33.6%	Significant difference in pain scores at 0 hours (p=0.033), 2 hours (p<0.0001), 6 hours (p<0.0001), 12 hours (p<0.0001) and 24 hours (p=0.003).
At 48 hours: (p=0.085)	
Yoshida, 201613	80	Oblique subcostal TAP block catheters (ropivacaine) vs single-shot oblique subcostal TAP block (ropivacaine)+catheter (placebo)	Cumulative morphine consumption (median (IQR))
24 hours: 0.25 (0.11–0.48) vs 0.44 (0.24–0.73), 95% CI difference in medians −0.30 to −0.03 (p=0.01)	Significantly reduced pain scores during coughing at 1 hour (p=0.04) and 24 hours (p=0.04).
Not significant at other timepoints	
Zhang, 202312	145	Single-shot TAP (ropivacaine 0.375%, compound lidocaine 0.4% or 0.6%) vs placebo	Sufentanil usage lower in all groups compared with placebo.
48 hours: 0.6% compound lidocaine: 24.2 (5.4) mg vs 45.6 (7.5) mg (p<0.001)	Pain scores at rest:
0.375% ropivacaine at 3 hours: mean (SD) 2.4 (1.2) vs 3.0 (1.0), (p=0.036).
0.4% and 0.6% compound lidocaine at 12 hours: 2.8 (0.9) vs 2.1 (0.9) and 2.0 (0.9), (p=0.016) and (p=0.006)	
IV-PCA, intravenous patient-controlled analgesia; NRS, numeric rating scale; TAP, transversus abdominis plane.

Bakshi et al compared rectus sheath blocks with placebo and found a significant decrease in worst median NRS at 48 hours at rest and during movement.14 Kuniyoshi et al found that, compared with epidural analgesia, rectus sheath blocks demonstrated non-inferiority at rest up to 36 hours and even superiority at 24 hours post-operatively. Moreover, they found that rectus sheath blocks were neither inferior nor non-inferior to epidural analgesia at movement at different time points.15

Subramanian et al compared superior hypogastric plexus block plus continuous wound infiltration with continuous wound infiltration alone and found significantly lower pain scores up to 24 hours post-operatively.17 Kushner et al compared continuous wound infiltration with placebo and found no significant differences in mean 5-day Wisconsin Brief Pain Inventory scores nor in the least or worst pain experienced.16

Opioid Consumption

Three studies found a significant reduction in opioid consumption.11–13 Melnikov et al found that patients receiving TAP blocks required significantly less ketobemidon (an opioid with N-methyl-D-aspartate antagonist properties) at 6 hours post-operatively, as well as in both intervention groups at 24 and 48 hours.11 Similarly, Yoshida et al found lower cumulative morphine consumption 24 hours after catheter placement in the intervention group.13 Furthermore, Zhang et al reported that all intervention groups needed significantly less sufentanil than the placebo group at different time intervals.12 However, two studies did not find any significant decrease in opioid consumption.9 10

Bakshi et al found a significant reduction in the mean morphine consumption in the intervention group at both 24 hours and 48 hours.14 Kuniyoshi et al found that, compared with epidural analgesia, there was no significant difference in the effective frequency of use of rescue analgesics (IV patient-controlled anesthesia).15 Subramanian et al found a significant decrease in morphine consumption in the group receiving superior hypogastric plexus block up to 48 hours post-operatively,17 and Kushner et al found no significant differences in opioid consumption with the use of continuous wound infiltration.16

Secondary Outcomes

Secondary outcomes, including length of stay, time to mobilization, and adverse analgesic events are shown in Table 4. Not all studies reported on these outcomes. Two studies found a significantly earlier time to mobilization,14 17 two studies showed improved bowel motility and a decrease in post-operative nausea and vomiting,12 14 and three studies showed higher patient satisfaction in the block groups.11 12 14 No serious adverse events related to locoregional techniques were reported.

Table 4 Secondary outcomes of included studies between intervention and control group

Author, Year	Length of stay	Time to mobilization	Post-operative nausea and vomiting	Bowel motility	Urinary retention	Satisfaction	Adverse event	
Bakshi, 201614	Not reported	Intervention 9.0 (2.2) hours vs placebo 11.9 (2.5) hours (p<0.001)	Less in intervention group (p<0.001)	Earlier flatus in intervention vs control: 6 (17%) vs 33 (92%) (p<0.001)	Not reported	Better in intervention group (p<0.001)	Local site discomfort with no infection (n=1)	
Bernard, 20239	No significant differences	Not reported	No significant differences	No significant differences	Not reported	Not reported	Not reported	
Griffiths, 201010	Not reported	Not reported	No significant differences	Not reported	Not reported	No significant differences	None	
Kuniyoshi, 202115	Not reported	Not reported	No significant differences	Not reported	Not reported	Not reported	Epidural group: hypotension, motor block, sensory disturbance. None in rectus sheath group	
Kushner, 200516	No significant differences	Not reported	Not reported	No significant differences	Not reported	Not reported	Excessive leakage of catheter (n=1) where removal occured.	
Melnikov, 201211	Not reported	Not reported	Low in all groups. Control needed more antiemetics early post-operatively	Not reported	Not reported	Satisfied with analgesia:
Paravertebral 84%
TAP 79%
Placebo 50%	None	
Subramanian, 201917	Not reported	Intervention group 23.53 (±1) hours vs placebo 25.03 (±1.8) hours (p<0.001)	Not reported	Not reported	No significant difference	Not reported	None	
Yoshida, 201613	Not reported	No significant differences	No significant differences	No significant differences	Not reported	Not reported	None	
Zhang, 202312	Compound lidocaine 0.6% vs placebo: 5.9 (1.4) vs 6.9 (1.5) days (p<0.034)	No significant differences	Less in 0.6% compound lidocaine group vs placebo (p=0.009)	Compound lidocaine 0.4% 24.5 hours vs placebo 29.2 hours (p=0.021)
Compound lidocaine 0.6% 24.1 hours vs 29.2 hours (p=0.009)	No significant difference	Satisfaction 72 hours vs placebo:
Compound lidocaine 0.6% (p<0.001)
Ropivacaine (p=0.002)
Compound lidocaine 0.4% (p=0.046)	None	
TAP, transversus abdominis plane.

Discussion

Summary of Main Findings

We found five studies reporting a positive result regarding pain and opioid consumption with the use of locoregional techniques in patients undergoing major open surgery for gynecologic malignancies. TAP blocks, rectus sheath blocks, and paravertebral block showed a significant improvement in pain scores and decreased opioid use when compared with placebo, and rectus sheath block was non-inferior compared with epidural analgesia.11–15 No significant effect of continuous wound infiltration was found.16 Furthermore, two studies indicated a significantly earlier time to mobilization,14 17 two showed improved bowel motility and a decrease in post-operative nausea and vomiting,12 14 and three studies demonstrated higher patient satisfaction in the block groups.11 12 14

Results in the Context of Published Literature

Three studies have described a positive outcome with the use of TAP blocks compared with placebo as either a single-shot technique, continuous block, or the use of a long-acting local anesthetic.11–13 Each of these demonstrated a significant decrease in opioid consumption and pain scores, Yoshida et al being the only study uing the oblique sub-costal TAP approach and Zhang et al using different concentrations of compound lidocaine (a long-acting local anesthetic mixture of lidocaine, menthol, and glycerin) only registered for use in China.

The aim of using catheters or long-acting local anesthetics is to ensure a prolonged analgesic effect. Catheter-related problems such as displacement can, however, deter the use of them.18 Liposomal bupivacaine is a long-acting local anesthetic registered in the USA since 2011, the EU since 2020, and the UK since 2021, and may be a viable alternative to locoregional catheters.19 20 However, none of the included studies have investigated the effect of liposomal bupivacaine.21 Meyer et al did study the use of liposomal bupivacaine versus standard bupivacaine in wound infiltration in open gynecologic surgery and found no significant effect on opioid use,22 neither was the effect of continuous wound infiltration in our review. More research is warranted on the use of liposomal bupivacaine in locoregional blocks, since it is more widely registered than compound lidocaine, before conclusions can be drawn. There is insufficient data from this review to support the use of locoregional catheters as the follow-up of outcomes was too short to demonstrate a benefit over the single-shot technique.

In two studies the effect of single-shot TAP block versus placebo was investigated and produced no significant results.9 10 In both studies the accuracy of block placement could have influenced the outcome. Bernard et al investigated the use of surgically placed TAP blocks via a transperitoneal approach using the fascial ‘pop’ technique without ultrasound guidance.9 As demonstrated by Bakshi et al, ultrasound guidance can be used to verify and correct needle placement in blocks.14 The negative outcome of single-shot TAP blocks by Griffiths et al was not surprising as its effect is not expected to be present at 24 hours post-operatively. Furthermore, the placement as described by Griffiths et al might not have been accurate enough for optimal analgesia. As described by Tsai et al, the posterior approach to the TAP block anesthetizes the lateral cutaneous branches of the main thoracolumbar nerves and thereby improves analgesia of the lateral and paramedian abdominal wall.23 This effect could be missed if the needle position is too ventral and might have an impact on analgesia and opioid consumption.

Melnikov et al found that thoracic paravertebral blocks were superior to TAP blocks with regard to opioid consumption. This superiority could be accounted for by the possible visceral analgesia provided by paravertebral blocks.24 Ultrasound-guided rectus sheath blocks are indicated for umbilical surgery or midline laparotomy.25 Needle placement and injection of local anesthetic just ventral to the posterior rectus sheath provides analgesia in the midline from T7 to T12.25 Bakshi et al described the use of surgically placed rectus sheath catheters, whose needle position was verified and corrected by ultrasound guidance, with significant effect on pain and opioid consumption. This study highlights the importance of correct catheter placement.14 The other study investigating rectus sheath catheters demonstrated non-inferior pain scores when compared with epidural analgesia with similar opioid consumption in both groups,15 which could be seen as an advantage and make rectus sheath catheters a viable alternative when epidural analgesia is not feasible. Subramanian et al described the use of a superior hypogastric plexus block as an alternative to a neuraxial technique and demonstrated a significant decrease in opioid consumption and a reduction in pain scores. This technique is usually used for the management of chronic pelvic pain and is not usually part of the armamentarium of the peri-operative anesthesiologist.17

Severe acute post-operative pain occurring within 2 weeks after surgery is a predictor for the development of chronic post-surgical pain.26 27 However, the included studies had a maximum follow-up of 5 days and did not encompass opioid use or NRS scores during the first 2 weeks post-operatively. Consequently, these studies could not provide insights into the role of these analgesic techniques in chronic post-surgical pain. Furthermore, none of the included studies assessed pre-operative pain or opioid use. Future research incorporating a follow-up period of 2 weeks and assessment of pre-operative pain and opioid use could support the use of locoregional analgesic techniques and determine its role in chronic post-surgical pain.

As not all studies reported on the secondary outcomes, no definite conclusions of the advantage of locoregional techniques over placebo or epidural analgesia concerning length of stay, incidence of post-operative nausea and vomiting, opioid-related adverse events, or bowel motility could be made. However, the available data suggest that locoregional techniques may have a positive effect on bowel mobility, time to mobilization, and a decrease in post-operative nausea and vomiting which can have an enhanced effect on recovery in the post-operative period, adding to the positive effect of reduced pain and opioids.

Strength and Weaknesses

The study population has been limited to women undergoing oncologic gynecologic surgery, which limits the generalizability of the results. However, this focused approach can be considered a strength as it provides robust evidence specifically for this patient group. We did not include studies comparing different locoregional techniques or studies comparing different local anesthetic compositions if they did not include either an epidural group or a placebo group, so we could have missed important findings. Furthermore, standardized pain management changed within the timeframe of the selected papers. Moreover, meta-analysis was not possible since data were heterogenous and some data needed were not presented in the published studies. Efforts to obtain the information from authors proved unsuccessful.

Implications for Further Research

More research is needed to confirm the positive effect of TAP, rectus sheath, and paravertebral blocks and to compare these techniques with each other in order to determine the best locoregional analgesia technique. It is recommended to incorporate a follow-up period of at least 2 weeks and to consider assessing pre-operative pain and opioid use in further research to strengthen the evidence supporting the use of locoregional analgesic techniques and to determine their role in chronic post-surgical pain.

Conclusion

This review found that TAP, rectus sheath, and paravertebral blocks, when placed correctly, can decrease opioid consumption and improve pain scores. It also showed that these locoregional techniques, as part of a multimodal analgesic regime, may enhance recovery during the early post-operative period in patients undergoing open abdominal surgery for gynecologic cancer. Additionally, these techniques might serve as a viable alternative for patients with contraindications for epidural analgesia. Further research is warranted to strengthen and prove these results and to compare these modalities with each other.

The authors wish to thank MFM Engel from the Erasmus MC Medical Library for developing and updating the search strategies.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Not applicable.

Contributors: All authors contributed to the realization and conceptualization of this paper. LAD and MSV performed the search, screened the articles, extracted the data and did the quality assessment and wrote down the results. All authors have thoroughly read, revised, and approved several versions of the manuscript and agreed to this submission. The guarantor of this paper is LAD.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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