Opioids, the related side effects [11]. In the

Opioids, NSAIDs and paracetamol are
effective post-operative analgesics but their use is not without complications
10. Inclusion of TAP block in the post-operative multi-modal analgesia
protocols has advantageously reduced the use of
the other analgesics and the related side effects 11.

  In the
first described TAP block, a blunt needle was
introduced blindly through the external and internal oblique muscles, guided by the
double- pop technique. The local anesthetic was injected
between the transverse abdominis and the
internal oblique muscles. This method has resulted in some penetrative
injuries and sometimes failure to gain the proper anesthetic effect 5. Recently, ultrasound- guided TAP block has increased
the efficacy and safety of the procedure through visualization of the needle tip and the local anesthetic injection site 12. But, the technique needs great skills also minimal complications have been described 13.

Previous randomized trials
have reported the efficacy of the ultrasound- guided TAP block as a
postoperative analgesia after open appendectomy, laparoscopic cholecystectomy,
and abdominal hysterectomy 14-16. Similarly, it has gained specific analgesic advantages
in gynecologic laparoscopic intervention, where tissue
trauma and pain were minimal to moderate 17-20.

Nevertheless, such post-operative analgesic efficacy of ultrasound- guided TAP
block was not confirmed, when compared with
trocar site local anesthetic infiltration following
laparoscopic cholecystectomy (21) and spinal
morphine after cesarean delivery 22.

Local anesthetic injection
in the neurovascular plane between the internal oblique and
transversus abdominis muscles under laparoscopic vision was first described by
Magee et al. 7. Afterward, Chetwood et al. 23
used a similar method following laparoscopic nephrectomy
which safe and time saving. In addition, laparoscopic guided TAP block
has reduced postoperative pain scores after laparoscopic
cholecystectomy 24-25 and laparoscopic ventral hernia repair 26. 

 Favuzza and Delaney 27 stated that laparoscopic guided TAP block has resulted in effective pain relief, reduction in
narcotic requirement and short postoperative hospital stay in patients who
underwent laparoscopic colorectal surgery. The Addition
of laparoscopic guided TAP block to enhanced
recovery pathway (ERP) was safe, effective and allowed
early discharge of patients following
laparoscopic colorectal surgery 28-30.

Postoperative local anesthetic injection
into trocar insertion sites after laparoscopic gynecologic surgery has   significantly reduced pain scores in
the early postoperative period compared with placebo 31. On the other hand, pain scores reduction was not significant 32. 

Various studies have compared
ultrasound- guided TAP block with trocar site local anesthetic
infiltration. The results varied from significant reduction 33 to non-significant
reduction in cumulative morphine use at 24 hours
with TAP blocks compared with local anesthetic infiltration 34. A
recent trial 35 has reported that ultrasound-
guided TAP block has no significant clinical benefit
over trocar site local anesthetic infiltration in laparoscopic
nephrectomy. Huang et al. 36 found that the combination of TAP block and
trocar sites local anesthetic infiltration provided
better analgesic effect compared with TAP block alone.

To the best of our knowledge, few numbers of trials studied the
efficacy of laparoscopic-guided TAP block. In consistence with our results,
laparoscopic- guided TAP block decreased both post-operative pain and opioid
use after laparoscopic ventral hernia repair 26. Furthermore,
it was safe and efficient analgesic in elderly patients who underwent
elective laparoscopic cholecystectomy 25. On the
contrary El Hachem et al 37 found that neither laparoscopic-guided TAP
block nor ultrasound- guided TAP block offered post-operative
analgesic superiority over trocar site local anesthetic
infiltration after four ports gynecologic
laparoscopy. Although, the local anesthetic was injected
at the end of operation similar to our study, but the difference in the
results could be attributed to dissimilarity in local anesthetic
doses or special methodology of the other
study. Patients were divided into two groups, one group
consisted of unilateral anesthesiologist-administered ultrasound-guided TAP
block, and the other group consisted of unilateral surgeon- administered
laparoscopic-guided TAP block. In both groups, the contralateral port sites
were infiltrated with local anesthetic. VAS pain score was calculated on the
block and contralateral sides, using the patients as their own controls.    

In conclusion, laparoscopic-guided
TAP block is more effective in reduction of both pain scores in the early
post-operative period and the cumulative meperidine
consumption than trocar site local anesthetic infiltration in gynecologic
laparoscopy.

The present study had some limitations, pain scores on movement were not
assessed, blinding of surgeons and anesthetists was difficult and it did not focus on side effects. So, further properly
blinded studies containing large number of
patients and using different doses of local anesthetic are required to verify
these results.