Liposomal Bupivacaine Blocks Cut Opioid Use and Speed Recovery in Elderly Laparoscopic Hernia Repair
核心洞察
A single-center randomized controlled trial found that combined TAP and rectus sheath blocks with liposomal bupivacaine reduced 48-hour perioperative opioid consumption by 29.17% versus no block in patients aged 70 and older.
Mean morphine-equivalent use was 17 mg with liposomal bupivacaine, 18 mg with plain bupivacaine and 24 mg in controls, with estimated mean differences of -7.24 mg and -5.53 mg respectively.
Only 2.0% of liposomal bupivacaine patients required rescue analgesia versus 18.4% of controls, and time to first ambulation was shortened by 5.86 hours.
Ultrasound-guided dual-plane regional blockade with liposomal bupivacaine significantly reduced perioperative opioid consumption and accelerated early recovery in elderly patients undergoing laparoscopic inguinal hernia (搜索) repair, according to a triple-blind randomized controlled trial conducted at Zhongshan Hospital, Fudan University in Shanghai, China.
The trial, registered with the Chinese Clinical Trial Registry (ChiCTR2400086990) and approved by the hospital ethics committee (B2024-226R), enrolled 147 patients aged 70 years or older scheduled for elective laparoscopic transabdominal preperitoneal (TAPP) repair between July 16, 2024 and July 31, 2025. Participants were randomized 1:1:1 to liposomal bupivacaine (LB), standard plain bupivacaine (BP), or a control group receiving no block, with allocation concealed in sequentially numbered opaque sealed envelopes and outcome assessment performed by blinded personnel.
Opioid-Sparing Effect and Sensitivity Analyses
The primary outcome — total perioperative opioid consumption expressed as intravenous morphine equivalents through 48 hours after surgery — was reduced in both active groups. Mean (SD) morphine-equivalent use was 24 (7) mg in controls, 18 (7) mg with plain bupivacaine, and 17 (6) mg with liposomal bupivacaine. Compared with control, estimated mean differences were −5.53 mg (95% CI −8.08 to −2.99) for BP and −7.24 mg (95% CI −9.80 to −4.69) for LB, corresponding to relative reductions of 25.00% and 29.17%, respectively. Standardized effects were Hedges' g −0.85 for BP and −1.06 for LB, indicating moderate-to-large effects favoring the active groups.
The authors reported that sensitivity analyses based on summary statistics showed the 48-hour reduction was robust to alternative distributional assumptions and uncertainty in variance. Parametric bootstrap under normal and log-normal data-generating processes yielded mean-difference estimates and 95% CIs consistent with the primary Welch analysis. Stress tests inflating or deflating group standard deviations by ±20% and contamination models introducing a 5% heavy-tail component left the direction and statistical significance unchanged (BP vs control: Pr[Δ<0] ≈ 0.99–1.00; LB vs control: Pr[Δ<0] ≈ 1.00).
Analgesia Duration, Pain Scores and Recovery Metrics
Time to first rescue analgesia differed significantly across groups, with the cumulative probability of not requiring rescue analgesia highest in the LB group and lowest in controls (log-rank P = 0.04). Patients in the LB group showed fewer early requests for rescue analgesia within the first 15 hours postoperatively.
At 8 hours postoperatively, pain scores were significantly lower in the LB group than in controls both at rest (1.08 ± 0.27 vs 1.54 ± 0.64; P < 0.001) and on movement (2.18 ± 0.47 vs 2.80 ± 0.94; P = 0.019). The BP group also had lower resting pain scores than controls (P = 0.007) but did not differ significantly on movement (P = 0.614).
Fewer LB patients required rescue analgesia (1/49, 2.0%) compared with controls (9/49, 18.4%; P = 0.011), with an odds ratio of 0.10 (95% CI 0.01–0.84). The BP-versus-control difference was not statistically significant (OR 0.31; P = 0.082).
Time to first ambulation was shorter in the LB group (14.1 ± 2.5 h) and BP group (16.7 ± 6.5 h) than in controls (20.0 ± 6.2 h), with mean differences of −5.86 h (P < 0.001) and −3.34 h (P = 0.006). Time from cessation of anesthesia to extubation was markedly shorter in both block groups (2.00 [1.00–4.00] min for LB and 2.00 [1.00–2.50] min for BP) than in controls (6.00 [5.00–8.00] min; P < 0.001).
Postoperative hospital stay was reduced to a median of 1.00 [1.00–1.00] days in both the LB and BP groups versus 2.00 [1.00–2.00] days in controls (P < 0.001), and overall hospitalization was also shorter (LB 3.00 [2.00–3.00] days; BP 3.00 [3.00–3.00] days; control 4.00 [3.00–4.00] days; P < 0.001).
Safety, Satisfaction and Confounding Adjustment
The incidence of postoperative adverse events, including dizziness, nausea and vomiting, and poor wound healing, was low and comparable across groups (P = 0.472), with no serious complications reported. Analgesia satisfaction was high in all groups with no significant difference (overall P = 0.068); 100.0% of LB patients reported the highest satisfaction score, compared with 97.9% in the BP group and 91.8% in controls. Haemodynamic parameters showed no statistically significant between-group differences and no group-by-time interaction on mixed-effects modeling.
Median surgical duration was significantly longer in the LB group (44 [34–60] min) than in controls (34 [25–45] min; P = 0.017), with the BP group intermediate (40 [29–56] min). The investigators acknowledged that longer surgery times could influence postoperative outcomes but noted that the LB group still demonstrated reduced opioid consumption and improved recovery. Additional sensitivity analyses adjusting for surgery duration did not alter the overall conclusions for opioid consumption, pain scores, or recovery metrics.
Mechanistic Rationale and Positioning in the Literature
The authors attributed the analgesic benefits to the extended-release formulation and the anatomical coverage of dual-plane blockade. Liposomal bupivacaine is encapsulated in multivesicular liposomes that allow gradual release of bupivacaine over 72–96 hours, sustaining analgesia well beyond the typical 6–8 hour duration of plain bupivacaine. Combining transversus abdominis plane (TAP) and rectus sheath blocks provides wider somatic analgesia of the lower abdominal wall, covering both lateral and midline incisions used in laparoscopic hernia repair.
The trialists contrasted their findings with prior work: Fayezizadeh et al reported that TAP blocks with liposomal bupivacaine reduced opioid requirements and pain scores in open abdominal wall reconstruction, and Aasbø et al demonstrated improved analgesia after liposomal bupivacaine infiltration in open inguinal hernia (搜索) repair without a regional block. In contrast, Nedeljkovic et al found no significant advantage of liposomal bupivacaine over plain bupivacaine for TAP blocks after caesarean delivery, which the authors suggested may reflect differences in surgical type, block technique, or population characteristics. They noted that most prior studies involved younger adults or non-standardized regional techniques, and few focused specifically on older adults or combined TAP and rectus sheath blocks.
The investigators stated that although a universally accepted Minimal Clinically Important Difference for 48-hour postoperative morphine consumption remains undefined, a reduction of 6–7 mg of intravenous morphine equivalents over 48 hours represents a meaningful decrease in cumulative opioid load in a geriatric population with heightened opioid sensitivity, aligning with Enhanced Recovery After Surgery principles. They also noted that while liposomal bupivacaine has a higher acquisition cost, a 1-day reduction in length of stay could offset this expense, though a formal cost-effectiveness analysis was beyond the study's scope.
Limitations
The authors identified several limitations: the trial was single-center, potentially limiting generalizability; complete blinding of the anesthetist performing the block was not feasible, although outcome assessors were blinded; no pharmacoeconomic analysis was included, leaving the higher acquisition cost of liposomal bupivacaine a potential barrier to adoption; and follow-up was limited to the in-hospital period, so longer-term outcomes such as persistent postoperative pain or functional recovery were not assessed. They concluded that further multicenter trials with longer follow-up are warranted to confirm the results and evaluate cost-effectiveness.
Supporting Evidence in Bariatric Surgery
Separately, a randomized controlled trial published in the European Journal of Medical Research (He Y, Yin D, Wu Z; 2026;31:530) compared bupivacaine liposome injectable suspension (BLIS) with ropivacaine for transversus abdominis plane block in 60 adults undergoing elective laparoscopic sleeve gastrectomy within a standardized ERAS protocol including patient-controlled analgesia and multimodal analgesia. The primary outcome was pain scores over 72 hours; secondary outcomes included opioid and NSAID rescue use, motor function, sleep quality, and adverse events.
Patients in the BLIS group reported lower pain scores from 4 to 72 hours postoperatively compared with ropivacaine recipients, and had approximately 75% less need for rescue NSAIDs (6.7% vs 30%) along with fewer patient-controlled analgesia compressions. Both groups ambulated within 24 hours, and there were no significant differences in sleep quality, deep sleep percentages, or adverse event rates. The authors noted that BLIS did not significantly alter functional recovery metrics such as ambulation time, sleep patterns, or hospital stay, but described the sustained pain relief and reduced medication needs as clinically meaningful, particularly for patients with obesity-related respiratory compromise or obstructive sleep apnea (搜索).