Laparoscopic gynecologic surgery is less invasive than open surgery, but many patientsstill experience pain after the procedure. M-TAPA and EXOP are ultrasound-guided regionalanesthesia techniques used to reduce abdominal pain. Previous research suggests thatM-TAPA provides effective pain relief on the anterior abdominal wall, while EXOP may helpreduce pain in the lateral abdominal region. This study aims to determine whethercombining M-TAPA with EXOP provides better postoperative pain control than using M-TAPAalone. The study will compare pain scores during the first 24 hours after surgery, theneed for rescue analgesic medication, and recovery quality using the QoR-15questionnaire. All procedures are part of routine clinical care, and no experimentaldrugs or devices are used.
In routine practice at our institution, anesthesia clinicians performing gynecologic
laparoscopic procedures administer either modified thoracoabdominal nerve block through
perichondrial approach (M-TAPA Block) alone or a combination of M-TAPA and external
oblique muscle plane (EXOP) blocks, based solely on individual clinician preference. The
researcher does not influence this decision. Among the eligible patients, those receiving
either M-TAPA or M-TAPA + EXOP will be included and evaluated observationally. Block
types other than these two will not be included.
All postoperative visits and clinical follow-ups are routinely conducted by the
hospital's pain management team. The researcher does not intervene in these clinical
processes and is only responsible for obtaining informed consent, recording demographic
variables, documenting the type of block performed, administering the QoR-15
questionnaire, and evaluating sensory block distribution using the pinprick test.
Preoperative evaluation and necessary laboratory testing are carried out according to
standard hospital practice by the attending anesthesiologist. The researcher obtains
informed consent, records demographic data, and administers the preoperative QoR-15
questionnaire.
In the operating room, standard monitoring (non-invasive blood pressure, ECG, heart rate,
and oxygen saturation) is applied, intravenous access is established, and crystalloid
infusion is initiated. Anesthesia induction is performed using propofol, an opioid, and a
neuromuscular blocking agent, followed by endotracheal intubation. General anesthesia is
maintained with sevoflurane in an oxygen-air mixture. Laparoscopic surgery is performed
with gradual CO₂ insufflation, maintaining intra-abdominal pressure below 12 mmHg.
For postoperative analgesia, all patients routinely receive 1 g intravenous paracetamol
and 100 mg tramadol. After surgery, neuromuscular blockade is reversed and patients are
transferred to the post-anesthesia care unit (PACU).
After surgery, patients are monitored in the PACU and transferred to the ward once their
Aldrete score is ≥9. All patients receive 1 g intravenous paracetamol every 8 hours as
per routine protocol. Postoperative pain is assessed by the pain team using the 0-10
Numeric Rating Scale (NRS).
Postoperative nausea and vomiting (PONV) are assessed and intravenous ondansetron 4 mg is
administered for PONV ≥2. Patients without PONV are encouraged to mobilize early and
resume oral intake. Discharge is permitted once symptoms resolve; however, all patients
remain hospitalized for at least 24 hours.
As an additional study-related procedure, the researcher evaluates dermatomal spread
using the pinprick test and administers the QoR-15 questionnaire at 24 hours.
Procedure: Modified Thoracoabdominal Nerve Block Through Perichondrial Approach
A bilateral modified thoracoabdominal nerve block through the perichondrial approach
(M-TAPA) is performed under ultrasound guidance in the supine position prior to
extubation as part of routine clinical practice. After aseptic preparation, a linear
ultrasound probe is positioned at the level of the 10th rib in the sagittal plane. The
needle is advanced to the fascial plane between the internal oblique and transversus
abdominis muscles. Following negative aspiration and confirmation of correct plane
identification with hydrodissection, 20 mL of 0.25% bupivacaine is injected bilaterally
(total volume 40 mL). The procedure is performed by anesthesiologists experienced in
gynecologic surgery, without researcher involvement in clinical decision-making
Other Name: M-TAPA Block
Procedure: Modified Thoracoabdominal Nerve Block Through Perichondrial Approach And External Oblique Muscle Plane Block
Following completion of the bilateral M-TAPA block, an external oblique muscle plane
(EXOP) block is performed under ultrasound guidance as part of routine clinical practice.
The ultrasound probe is positioned over the lateral abdominal wall between the costal
margin and iliac crest. After negative aspiration and confirmation of correct plane
identification with hydrodissection, 20 mL of 0.125% bupivacaine is injected on each side
into the fascial plane superficial to the external oblique muscle (total volume 80 mL).
Other Name: M-TAPA + EXOP Block
Inclusion Criteria:
- Patients scheduled for laparoscopic gynecologic surgery
- Age 18-90 years
- ASA physical status I-III
Exclusion Criteria:
- Contraindications to block procedures (coagulopathy, anticoagulant therapy, local
infection at needle insertion site, etc.)
- Severe cardiac, renal, hepatic, hematologic, neurologic, or psychiatric disease
- Allergy to amide-type local anesthetics
- Chronic pain, narcotic or alcohol dependence
- BMI ≥ 35 kg/m²
- Pregnancy
- Refusal to participate
- Conversion from laparoscopy to laparotomy
SBÜ Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi
Istanbul, Bakirkoy, Turkey (Türkiye)
Şeyma Nur Güner Zengin, MD
+90 212 414 71 71
snurguner@gmail.com
Güneş Özlem Yıldız, Associate Professor
+90 212 414 71 71
drgunesim@hotmail.com
Not Provided