Circumcision in children: postoperative analgesic efficiency of transversus abdominis plan block vs caudal epidural block: a prospective observational study

Background and objective: Circumcision is one of the most common operations and can cause postoperative pain, fear, and anxiety for children. This study aims to compare the effects of transversus abdominis plane (TAP) block and caudal epidural (CE) anesthesia on postoperative analgesia after circumcision in providing postoperative pain control.

Methods: Eighty boys aged 1 to 14 years who underwent elective circumcision surgery under general anesthesia either with USG-guided TAP block or with CE block for postoperative analgesia were enrolled consecutively to this prospective observational study equally in each group. Postoperative pain scores and need for rescue analgesia were recorded and compared between the two groups.

Results: There was no statistically significant difference between the groups in mean age and Aldrete scores (p > 0.05). Body mass index (BMI) of the caudal block group was statistically lower than the TAP group (p < 0.05). While there was no statistically significant difference between the groups in 30th-minute VAS values (p > 0.05), the CE block group's 1st, 2nd, 4th, 8th, 12th, 18th, and 24th hour VAS values were statistically lower than the TAP block group's (p < 0.05).

Conclusion: USG-guided TAB block under general anesthesia was not associated with lower postoperative pain scores and delayed rescue analgesia need compared with CE block in patients who underwent elective circumcision surgery. CE block provided superior analgesia than the USG-guided TAP block after elective circumcision surgery in this study.

Circumcision; Caudal epidural block; Transversus abdominis plane block; Postoperative pain

[1] Zavras N, Tsamoudaki S, Ntomi V, Yiannopoulos I, Christianakis E, Pikoulis E. Predictive Factors of Postoperative Pain and Postoperative Anxiety in Children Undergoing Elective Circumcision: a Prospective Cohort Study. Korean Journal of Pain. 2015; 28: 244–253.

[2] Wang J, Zhao S, Luo L, Liu Y, Zhu Z, Li E, et al. Dorsal penile nerve block versus eutectic mixture of local anesthetics cream for pain relief in infants during circumcision: a meta-analysis. PLoS ONE. 2018; 13: e0203439.

[3] Sethi N, Pant D, Dutta A, Koul A, Sood J, Chugh PT. Comparison of caudal epidural block and ultrasonography-guided transversus abdominis plane block for pain relief in children undergoing lower abdominal surgery. Journal of Clinical Anesthesia. 2016; 33: 322–329.

[4] Zhu C, Wei R, Tong Y, Liu J, Song Z, Zhang S. Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis. Regional Anesthesia & Pain Medicine. 2019; 44: 259–267.

[5] Mai CL, Young MJ, Quraishi SA. Clinical implications of the transversus abdominis plane block in pediatric anesthesia. Paediatric Anaesthesia. 2012; 22: 831–840.

[6] Gupta A, Kumar A, Dogra N, Aggarwal S. Ultrasound-guided transversus abdominis plane block versus caudal block for postop-erative analgesia in children undergoing inguinal hernia surgery: a comparative study. Journal of Anaesthesiology Clinical Pharmacology. 2020; 36: 172–176.

[7] Aldrete JA. The post-anesthesia recovery score revisited. Journal of Clinical Anesthesia. 1995; 7: 89–91.

[8] Bryskin RB, Londergan B, Wheatley R, Heng R, Lewis M, Barraza M, et al. Transversus Abdominis Plane Block Versus Caudal Epidural for Lower Abdominal Surgery in Children: A double-blinded randomized controlled trial. Anesthesia & Analgesia. 2015; 121: 471–478.

[9] Baeriswyl M, Zeiter F, Piubellini D, Kirkham KR, Albrecht E. The analgesic efficacy of transverse abdominis plane block versus epidural analgesia: a systematic review with meta-analysis. Medicine. 2018; 97: e11261.

[10] Urits I, Ostling PS, Novitch MB, Burns JC, Charipova K, Gress KL, et al. Truncal regional nerve blocks in clinical anesthesia practice. Best Practice & Research Clinical Anaesthesiology. 2019; 33: 559–571.

[11] İpek CB, Kara D, Yılmaz S, Yeşiltaş S, Esen A, Dooply SSSL, et al. Comparison of ultrasound-guided transversus abdominis plane block, quadratus lumborum block, and caudal epidural block for perioperative analgesia in pediatric lower abdominal surgery. Turkish Journal of Medical Sciences. 2019; 49: 1395–1402.

[12] Karnik PP, Dave NM, Shah HB, Kulkarni K. Comparison of ultrasound-guided transversus abdominis plane (TAP) block versus local infiltration during paediatric laparoscopic surgeries. Indian Journal of Anaesthesia. 2019; 63: 356–360.

[13] Sternlicht A, Shapiro M, Robelen G, Vellayappan U, Tuerk IA. Infiltration of liposome bupivacaine into the transversus abdominis plane for postsurgical analgesia in robotic laparoscopic prostatectomy: a pilot study. Local and Regional Anesthesia. 2014; 7: 69–74.

[14] Escudero-Fung M, Lehman EB, Karamchandani K. Timing of Transversus Abdominis Plane Block and Postoperative Pain Manage-ment. Local and Regional Anesthesia. 2020; 13: 185–193.

[15] Desai N, Chan E, El-Boghdadly K, Albrecht E. Caudal analgesia versus abdominal wall blocks for pediatric genitourinary surgery: systematic review and meta-analysis. Regional Anesthesia & Pain Medicine. 2020; 45: 924–933.

[16] Shahait M, Lee DI. Application of TAP Block in Laparoscopic Urological Surgery: Current Status and Future Directions. Current Urology Reports. 2019; 20: 20.

[17] Long JB, Birmingham PK, De Oliveira GS, Schaldenbrand KM, Suresh S. Transversus abdominis plane block in children: a multicenter safety analysis of 1994 cases from the PRAN (Pediatric Regional Anesthesia Network) database. Anesthesia and Analgesia. 2014; 119: 395–399.

[18] Tsai H, Yoshida T, Chuang T, Yang S, Chang C, Yao H, et al. Transversus Abdominis Plane Block: an Updated Review of Anatomy and Techniques. BioMed Research International. 2017; 2017: 8284363.

[19] Yu N, Long X, Lujan-Hernandez JR, Succar J, Xin X, Wang X. Transversus abdominis-plane block versus local anesthetic wound infiltration in lower abdominal surgery: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiology. 2014; 14: 121.

[20] Ozen V, Yigit D. Caudal epidural block versus ultrasound-guided dorsal penile nerve block for pediatric distal hypospadias surgery: a prospective, observational study. Journal of Pediatric Urology. 2020; 16: 438. e1–438. e8.

[21] Ozen V, Yigit D. A comparison of the postoperative analgesic effectiveness of low dose caudal epidural block and us-guided dorsal penile nerve block with in-plane technique in circumcision. Journal of Pediatric Urology. 2020; 16: 99–106.